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International Journal of Clinical and Experimental Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nhyp20

Dissociative Phenomena and the Question of Responsibility Seymour L. Halleck

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University of North Carolina School of Medicine , Chapel Hill Published online: 31 Jan 2008.

To cite this article: Seymour L. Halleck (1990) Dissociative Phenomena and the Question of Responsibility, International Journal of Clinical and Experimental Hypnosis, 38:4, 298-314, DOI: 10.1080/00207149008414529 To link to this article: http://dx.doi.org/10.1080/00207149008414529

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DISSOCIATIVE PHENOMENA AND THE QUESTION OF RESPONSIBILITY' '

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SEYMOUR L. HALLECK'

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Unicersity of North Carolina School of Medicine.

Chapel Hill

Abstract: There are many controversies regarding the prevalence, causation, possible iatrogenicity, and treatment of multiple personality disorder. Those who view the disorder as much more prevalent than has previously been suspected believe it is caused by experiences of severe child abuse and have used rather unorthodox techniques to help the patient relate the experience of abuse to current problems of dissociation. Other clinicians believe the disorder is overdiagnosed and that it may be created or made worse by therapists who unwittingly reinforce symptoms of dissociation. Many of the controversies about these issues can be clarified by considering the manner in which clinicians attribute responsibility for undesirable conduct associated with the disorder. In dealing with multiple personality patients, clinicians regularly must decide whether their therapeutic approach will emphasize the patient's responsibility for undesirable conduct or will minimize it. Practical and theoretical arguments can be made for both approaches. There are important consequences to patients using either approach, and particularly harmful consequences with inconsistent approaches. Clinical experience and wisdom dictate that until we have more objective data about the results of various forms of treatment, the preferred method of treatment of multiple personality patients should continue to focus upon maximizing their responsibility for any type of undesirable conduct. Dissociative phenomena are not uncommonly associated with conduct that is harmful either to the patient or to others. Those who deal with such conduct must consider whether it is willful or voluntary and must determine whether the perpetrator should be held responsible (or blameworthy) for hidher actions. When undesirable conduct which is apparently related to a dissociative disorder involves a violation of criminal statutes, t h e criminal justice system must assess t h e extent to which the influence of that disorder diminishes an offender's culpability. The focus in the present paper, however, is on the clinical, not t h e legal setting. Here, t h e manner in which the clinician assesses t h e patient's responsibility for undesirable conduct will have a critical effect on t h e therapeutic outcome (Halleck, 1982, 1984, 1986). Current controversies as to the preferred method of treating dissociative disorders, particularly multiple personality disorder, are usually Manuscript submitted December 21, 1988; final revision received September 18, 1989. 'An earlier version of this paper was presented as the Presidential Banquet Address at the 39th Annual Sleeting of the Society for Clinical and Experimental Hypnosis. Asheville, North Carolina, November 1988. 'Reprint requests should be addressed to Seymour L. Halleck, 51 D.. Department of Psychiatry. Cniversity of North Carolina School of Medicine. Chapel Hill. NC 27599-7160.

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framed in terms of the prevalence of multiple personality disorder, whether it is a “real” disorder, and its possible iatrogenicity. The author will argue that those controversies have a moral and social, as well as a scientific dimension and that more useful insights into the phenomenon of multiple personality disorder can be obtained by pursuing the question, “How can the therapist best ascribe or not ascribe responsibility for conduct that appears to be temporarily separated from the full range of mental functions available to the patient’s integrated personality?”

SOCIALAND MORALASPECTS OF THE MULTIPLEPERSONALITY CONTROVERSY In the past decade, there has been a remarkable increase in the frequency with which the phenomenon of multiplicity is observed. There are also new ideas as to its etiology and treatment. A significant number of psychotherapists view these changes in diagnostic patterns and theories as a manifestation of scientific progress (Kluft, 1987). Others, however, are more skeptical as to the heuristic value of this trend and some view it as an unscientific fad (Victor, 1975). The extent of division on this issue is powerful. Communication between enthusiasts and doubters is limited. Believers are wary of the ignorance and conservatism of non-believing colleagues and will frequently attempt to shield their patients Gom contact with them. Doubters feel that the enthusiasts are misguided zealots at best self-deluded, at worst exploiting patients for their own narcissistic gain. Doubters tend to be older clinicians, usually over 45 with 15 or more years of clinical experience. Their concerns have been powerfully enunciated by two renowned students of dissociative phenomena, Thigpen and Cleckley (1984),who assert that the actual incidence of multiple personality disorder is low and that much of the expanded use of this diagnosis is related to social rather than scientific events. They argue that a small number of influential therapists have insensitively broadened the parameters of the concept by reinforcing dissociative tendencies in susceptible patients who seek the role of multiple personality patient in order to gain self-esteem, attention, or excuse from responsibility. Enthusiasts believe that there is more knowledge currently available about multiple personality disorder and specifically much more knowledge about the pernicious effects of child abuse. They point out that since more women have entered the mental health professions, there has been a greater willingness to believe in the reality of patients’ histories of victimization (Putnam,1986). By invoking victimization or unusual stress as a cause of illness, the enthusiasts come close to making a moral statement regarding the issue of responsibility. Explanations based on victimization seem to relegate blame for symptomatology away from the patient and towards external

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events, particularly the evil acts of others. Commonly, patients who learn that their symptoms are related to victimization feel less responsible for their undesirable behavior. The gravth of victimology theory appears to have two powerful sociological determinants. First, it emerges at a period in the evolution of psychiatric thinking which has been characterized by diminished commitment to classical psychoanalytic theory. Because victimology provides a plausible psychodynamic view of psychopathology, it has a special appeal to humanistic clinicians who are concerned with psychosocial determinants of illness but who cannot commit themselves to the tenets of psychoanalysis. Second, victimology theory justifies long-term psychotherapy. This is important in an era of cost-restraint, when younger therapists must find justifications for incorporating long-term therapy experience into their training. Working with the victimized patient is currently one of the last opportunities available to trainees for treating patients using primarily psychotherapeutic rather than pharmacological or behavioral interventions. There may be other social phenomena that account for the new interest in multiplicity. The influence of the school of therapy known as “transactional analysis” during the 1970s has made it somewhat easier for patients and therapists to accept the idea of multiple ego or personality states existing in the same individual. Transactional analysis relies heavily on the description of ego or personality states of parent, child, and adult which are conceptualized as existing in the patient at the same time (Berne, 1964). In the last two decades, many patients and many therapists became accustomed to accepting such a pluralistic view of personality. Finally, there has been a significant change in the social parameters which influence diagnosis, manifested in particular by a new willingness to accept the accuracy of the patient’s communications. This can lead to an increased incidence of diagnosis of conditions such as multiple personality disorder where the criteria of diagnosis are largely determined by the patient’s own reporting of behavioral and experiential phenomena. In the past. psychotherapists were trained to be skeptical of the accuracy of patients’ disclosures. Until the 1980s. diagnosis was a more leisurely process and was frequently a prelude to long-term treatment. The clinician believed that if enough time was spent with the patient, more meaningful information would eventually be obtained, and until consistent, meaningful material was obtained, the patient’s earlier communications were seen as possibly metaphoric as well as factual. In the current climate of briefer and “checklist” evaluation, more reliance is placed on the truthfulness of patient’s communications. This trend is fostered by the emergence of classification systems, DSM-Ill and DSM-Ill-R (American Psychiatric Association, 1980, 1983, which, in order to gain reliability, encourage the evaluator to focus upon and accept the patient’s communica-

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tion rather than make inferences as to what the patient has experienced or is experiencing (Burke, 1987). Conceivably, the clinician trained in the modern era may be too willing to accept the patient’s statements as to his/ her lack of awareness of mental processes or past victimization. The readiness with which clinicians are now encouraged to accept the accuracy of self-reported symptoms of patients leads those who are skeptical of the prevalence of the phenomenon of multiple personality disorder to view its increase as a function of the gullibility of younger clinicians. The enthusiasts have a very powerful response to this assertion. They insist that multiple personality patients do not flaunt their symptomatology, but actually try to hide it from mental health professionals (Braun, 1986). This claim buttresses their arguments that these patients are likely to be misdiagnosed by the ordinary practitioner and that only those therapists who are sufficiently skilled and persistent enough can detect the diagnosis. If the clinician needs special skills to detect the phenomenon, then those who minimize it are simply being misled. The assertion that multiple personality patients try to hide their disorder also makes it easier for proponents to dismiss the claims of skeptics who argue that the phenomenon of multiplicity disappears when therapists demand early fusion and hold patients responsible for fusion. Enthusiasts claim that these patients are merely covering up the continuing existence of their disorder. Whether multiple personality disorder patients confabulate their multiple personalities, try to hide them, or pretend to hide them while making certain that the observer knows about them is unclear. It is clear, however, that our views of this disorder are powerfully influenced by our intuitions as to the truthfulness of patients. A second group of arguments about the phenomenon of multiple personality disorder are centered around the question of whether it is a distinguishable mental disorder (Int. J . d i n . exp. Hypnosis, 32(2), 1984). Some of the controversy is sparked by the hct that many patients diagnosed as multiple personality disorder, as many as 70% according to some studies, can also be diagnosed as borderline personality disorders (Horevitz & Braun, 1984). Other observers note that some of these patients may more properly be diagnosed as having schizophrenia or temporal lobe disorders (Frankel & Orne, 1989). Enthusiasts, on the other hand view multiple personality disorder as a distinct entity, characterized by o b s e p b l e physiologml differences in various ego states and by at least some biological predisposition. These assertions support a general societal view that people who have “real” disorders, especially disorders that are associated with biological changes, are not fully responsible for some aspects of their behavior. Whether or not multiple personality disorder is viewed as a distinct entity, it is important to acknowledge that psychiatric diagnosis has little relationship to the

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question of responsibility. Even when it can be demonstrated or inferred that biological changes are associated with a given diagnosis, this still provides no guidance to the clinician who is trying to assess the patient’s responsibility for conduct associated with that diagnosis. Modern research in the neurosciences suggests that many behavioral patterns which are ordinarily viewed as willful or voluntary may be associated with biological phenomena (Kandel & Schwartz, 1985). A third major area of debate is the extent to which multiple personality disorder is iatrogenic, or, in this situation, created by the interaction of the patient and therapist. It is possible that the increased prevalence of this disorder represents a phenomenological reality which, nevertheless, has been artificially created. Those who believe this is happening argue that multiple personality patients are highly hypnotizable and suggestible. They also note that the disorder can be simulated and that a certain number of these patients seem to use the diagnosis to claim non-responsibility for the conduct of their various personalities (Kluft, 1987).Furthermore, many of these patients are easily classified as borderline personality disorders, individuals who have a disturbed sense of identity, and who are remarkably adept at molding themselves into whatever diagnostic categories are currently popular among mental health professionals. These patients have a powerful wish for the sustained attention of helping persons and are more likely to receive it if they are diagnosed as multiple personality disorders. Even if doctors are not creating more multiple personality disorder patients, it is likely that their new belief in the prevalence of the disorder leads to its more frequent diagnosis. There is ample evidence that the additudinal set or the expectations of the evaluator influence diagnostic trends (D. Spiegel & H. Spiegel, 1987). The availability of an effective treatment or a respectable theory of causation also exerts an especially powerful influence. At the turn of the century, Tourette’s Syndrome was clearly described. Yet, for almost 70 years, the diagnosis was almost’never made. It was only with the development of a treatment for the disorder and evidence for biological causation that doctors began to appropriately and more frequently make the diagnosis (Sacks, 1985). Does our belief that we now know the etiology of multiple personality disorder and can treat it, increase the frequency of its diagnosis? The answer is probably yes. Running through the dialogue as to the actual prevalence or possible iatrogenicity of multiple personality disorder is a concern with the issue of responsibility: How much control does the multiple personality disorder patient have over M e r symptoms and to what extent and in what manner should hdshe be held responsible for them? One useful way to think about this issue is to consider the arguments for emphasizing or de-emphasizing attribution of responsibility. It will then be possible to examine the manner in which various therapeutic approaches can either clarify or confuse the manner in which responsibility is ascribed.

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THE CASE FOR klINIMIZiNG ATTRIBUTION OF RJZSPONSIBILITY

The following propositions are of value in conceptualizing the manner in which clinicians assess responsibility. First, if responsibility is viewed as capacity or lack of capacity to choose one form of conduct over another (given some control of the issue of opportunity), it can be assessed in terms of those mental capacities involved in weighing risks, benefits, and alternatives (Halleck, 1988).Those who have greater capacity for perceiving, understanding, accurately assessing and weighing risks, benefits, and alternatives are more properly held accountable for their conduct. Second, since individuals vary in their capacities, choice exists on a continuum (Halleck, 1988). Some choices are easy for some individuals and much harder for others. In assessing responsibility in the clinical setting, we need not invoke the harsh, “all-or-none” morality required by the criminal justice system. We can acknowledge that many of our patients, particularly those with severe mental disorders, can make socially acceptable choices only at the expense of a certain amount of pain and suffering. This does not, however, mean that they are without choice. It merely means that their choices are hard ones. Third, we tend to view behavior that is highly susceptible to environmental influence as being under the control of the will (Halleck, 1988). If a patient demonstrates noxious behavior only in a permissive, but not in a restrictive environment, we generally assume on an empirical as well as on an intuitive basis that the individual has the capacity to control that behavior in either environment (although we may acknowledge that it is a harder choice for h i d h e r to do so in a more permissive environment). The strongest argument for excusing the undesirable conduct of the multiple personality disorder patient is that such conduct occurs at a time when the patient does not have the full resources of hidher integrated personality available to him/her. If a patient in one personality state commits an antisocial act, but is amnestic to the guilty feelings of hidher primary personality’s conscience or is amnestic to the likely aversive response of hisher family, friends, and society. hdshe is, at that moment, severely handicapped in hidher capacity to evaluate the risks and benefits of that act. It can be argued that part of the patient is literally not present and that the part that is present has diminished capacity to regulate hid her conduct. If this view is accepted, it would appear to be u& to hold the primary personality or any of the other personahies fully responsible for acts which occur when the total person is not present. Note, that this view of responsibility is supported by philosophies or techniques that deal with the differing personalities as separate or autonomous states, including any approach to the patient which even temporarily de-emphasizes the extent to which the various personalities are part of a unified whole. If a pluralistic view of personality is literally accepted, and if the multiple personality disorder patient is treated as a

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collection of relatively autonomous personality states, there is a strong rationale for excusing the undesirable conduct of any particular state. The problem with this view is that to the extent that we accept the separateness or autonomy of differing personalities, we cease to describe a morally or legally recognizable person. We are then dealing with a collection of partial persons who have no collective capacity for responsibility. We would also be dealing with a potentially dangerous entity, which (or who) has limited capacity to control undesirable conduct. Such a view of the multiple personality patient would justify society’s taking coercive action to control himher since it assumes hdshe would not be responsive to the aversive sanctions that control the rest of us. It is also a view that strips the multiple personality disorder patient of dignity and, as I shall note later, may make his/her treatment more difficult. Still another problem with viewing various personalities as autonomous is that such an approach raises serious questions as to whether the multiple personality patient can even be viewed as having one of the major moral and legal attributes of personhood the ability to choose. Can a patient who has several personalities, one or more of which do not want treatment, legally or morally make the choice of consenting to treatment? If we show too much respect for the idea of autonomous personalities, the answer is probably no. Such a person or collection of persons is incompetent to consent to any treatment. There is another more mystical view of the phenomenon of multiple personality disorder which if accepted simplifies the question of responsibility. Kluft (1987)has noted that patients who were at one time considered to be “possessed” were probably true multiple personalities. If a new or secondary personality actually represents a takeover of the patient’s body by some external agent, there can be no question as to the patient’s responsibility for conduct created by that agent. The patient is simply not responsible. In the modern era, most clinicians, of course, do not believe that states of possession are common or even exist. Yet, the dramatic nature of multiple personality disorder is such that it sometimes seems that the patient is taken over by an entity that is not himherself. The clinician who subliminally accepts a possession model and forgets or ignores the fact that the patient can only be “taken over” by him or herself is prone to exaggerating the patient’s lack of control of behavior. Here, any tendency to diminish attribution of responsibility represents an error in the clinician’s thinking. From a theoretical standpoint, the case for diminishing attribution of responsibility fbr the undesirable conduct of multiple personality disorder patients is weak. It can be made only at the expense of compromising our traditional moral and legal views of personhood or by invoking nonscientific explanations. At the same time, however, the case for non-

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responsibility might be strengthened by considering certain practical clinical issues. The most important of these is the actual perceptions patients have of their responsibility for symptoms. It is very difficult to hold patients responsible for conduct which they feel helpless to control. Multiple personality patients generally have no sense that they are capable of creating or terminating the dissociative phenonema they experience. They do not perceive themselves as having the power to will their personalities to integrate. Nor do they feel in control of the appearance or the conduct of their alter personalities. Whether or not their view of their capacities is correct, the clinician who is unwilling to empathize with their experience of disability will have little therapeutic influence on their conduct. No sensitive clinician would ever tell a multiple personality patient: “Stop behaving this way and get your act together.” There is little likelihood that the patient would respond to or cooperate with this approach. Rather, the clinician must begin treatment by communicating acceptance of the patient’s perception of loss of control. While such communication does not precisely f i r m the patient’s perceptions of loss of control, it may easily be taken as firmation by the patient. Thus, in the early phases of treatment of multiple personality disorder, a certain degree of communication which minimizes attribution of responsibility may be inevitable. It is also true that most patients whose disorders are characterized by undesirable conduct (including many patients diagnosed as having multiple personality disorder as well as others diagnosed as having impulse disorders, sexual disorders, or substance abuse disorders) welcome explanations of their conduct which tend to excuse it. Moreover, they often feel considerable relief that such an excuse (which reinforces their perception of loss of control) is forthcoming (Snyder, Higgins, & Stuckey, 1983). It is usually comforting to attribute one’s suffering or shortcomings to something beyond one’s control, such as a biological lesion or the oppressive actions of others (Strong, 1978). Multiple personality disorder patients appear to gain considerable relief when they learn that their symptoms are caused by the abusive practices they were exposed to as children (Kluft, 1986). Such an explanation minimizes their sense of responsibility or self-blame for some of their past and recent conduct. Because patients experience themselves as lacking control of their symptoms, and because they may be comforted by explanations which reinforce such perceptions, there appears to be a practical argument for clinicians using techniques which minimize attribution of responsibility. This is an extremely complex issue, however, which involves many variables. Timing, for example, is important; how long should the patient be viewed as non-responsible for the sake of gaining rapport? So are the precise dimensions of the clinician’s explanatory communications; it is one thing to remind the patient that he or she was incapable of avoiding

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the experiences of child abuse but this does not necessarily mean that the patient’s experience of abuse rendered him or her incapable of controlling subsequent dissociative acts. In using practical considerations to decide how vigorously to communicate messages which diminish attribution of responsibility, clinicians must also consider the negative consequences of such communication. In the next section the author will argue that these are likely to be formidable.

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THE CASE FOR hfAXIM1ZWG AITUBUTIONOF hSPONSIBlLITY

A critical issue in dealing with the multiple personality disorder patient is the extent to which the treater emphasizes some unifying thread between the personalities - some common purpose in their emergence which serves the needs of the total organism. Emphasis on such a unlfying thread strengthens the case for viewing the patient as a whole person who will like all other persons be assumed to be accountable for all aspects of hidher behavior. The case for ascribing responsibility to the total patient is also strengthened when the clinician infers that the patient has influence over the appearance of the various personalities. Such influence is much more likely to exist if the emergence of the various personality states is dependent on environmental events. As noted earlier, conduct that is highly responsive to environmental events is potentially controllable. External reinforcements and punishments can be internalized so that control is possible, even when environmental contingencies that favor control are no longer present (Schunk, & Carbonari, 1984). The arguments for environmental control of multiplicity are powerful. First of all, the very fact that fusion of personalities is possible without biological intervention, suggests that the patient possesses latent capacity to control dissociative phenomena. It is also true as Kluft (1986), has noted, that the manifestations of multiple personality are transitory. In a given patient, the phenomenon of multiplicity may disappear for long periods of time and.then suddenly appear again. The reappearance of various personality disorders is generally related to environmental events and will usually serve specific organismic needs. Some patients diagnosed as having multiple personality disorder are also aware of the differing personalities they deal with and are capable of creating switches at their own volition. And certainly in the process of psychotherapy, these patients learn to create switches and to present different personalities at the request of their therapists. It would be difficult to imagine a psychotherapy of a multiple personality disorder, which had as one of its goals fusion of the personalities, which did not assume that the patient had the capacity, under proper environmental circumstances, to create that fusion. If the patient has this capacity and does not use it, simply because the environment favors multiplicity, the

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argument for holding himher responsible for the undesirable behavior of any of the personaiity states is strengthened. (The patient may have a hard choice, but he/she still has a choice.) Finally, even the argument that these patients are adept at hiding their multiplicity from insensitive clinicians suggests that they can for at least brief p e r i d s of time control the emergence of alter personalities. The argument for holding multiple personality disorder patients responsible for undesirable conduct can also be phrased in terms of the question of unconscious motivation. If the different personalities are unaware of one another, the acts of any of the personalities, and particularly those of the secondary ones, can be viewed as expressing unconscious motivations of the total person. In almost all such patients who reach treatment, one of the personalities is demonsbating undesirable behavior. Is the total patient then responsible for unconscious wishes expressed through the behavior of a secondary personality? The manner in which we go about answering this question will depend upon our general views with regard to the issue of the patient’s responsibility for any type of unconscious motivation. The traditional psychoanalytic approach to this question is clear. Freud (19%/1961) at one time stated: obviously, one must hold oneself responsible for the evil impulses of one$ dreams. What else is one to do with them? Unless the content of the dream [rightly understood] is inspired by alien spirits, it is a part of my own being. If I seek to class$ the impulses that are present in me according to social standards into good and bad, I must assume responsibility for both sorts? And if in defense, I say that what is unknown, unconscious, and repressed in me is not my “ego” then I shall not be basing my position upon psychoanalysis [p. 1311.

If one substitutes the term “personality state” for the term “dream,” and assumes that both are manifestations of unconscious processes, the Freudian position as to the responsibility of the multiple personality patient is unequivocal. Furthermore, Freudian therapy goes even further in holding patients to a negligent, as well as to an intentional, standard of responsibility. The patient in psychoanalysis is repeatedly reminded that he/she is responsible for what he/she forgets, and is even held responsible for slips of the tongue. Other schools of therapy are no less rigorous in trying to develop strict standards of responsibility. Whether one is dealing with clientcentered, existential, cognitive, or social psychological approaches, all schools of therapy are based on the idea that people will behave better and show psychological improvement if they are told they are responsible for their conduct and are held maximally responsible (Halleck,1967). The practical arguments for maximizing patient responsibility are also powerful. In another paper, the author (Halleck, 1988)has argued that it is entirely consistent and practical to maximize demands for patients to

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be responsible while holding to a deterministic view of behavior. This is because once the patient enters treatment, a new dimension is added to the deterministic equation. Treatment creates an environment for the patient which expands the patient’s capacity to experiment with new behaviors. But behavioral change in this new environment is dependent upon a process in which the clinician provides a clear message that the patient has the capacity to improve. Patients are unlikely to utilize those capacities they actually possess, if they do not receive messages that they have the capacity to utilize them. Thus, communications which maximize the patient’s sense of responsibility are a critical vector in behavioral change. How does the clinician balance the clinical imperative of maximizing responsibility with the realization that patients do not perceive themselves as having choice and may be comforted by explanations that support these perceptions? In most therapeutic encounters, the balancing process is not too difficult. The emphasis is on helping the patient make maximum use of hidher capacities. Demands for responsibility are a consistent aspect of the therapeutic approach, and they are muted only when it is feared that they call for capacities the patient does not have. The issue of the patient’s own perception of lack of choice is usually dealt with by acknowledging it and by reassuring the patient that choices will expand as treatment progresses. In effect, the clinician tries to empathize with the patient’s perception of helplessness without accepting these perceptions as an excuse for undesirable behavior (a very difficult task but one of which most sensitive clinicians are capable). The observation that multiple personality patients appear to at least temporarily feel better when they grasp on to explanations of non-responsibility raises more troubling clinical questions. Clinicians may have ethical concerns with symptom relief promulgated by the acceptance of half-truths (just as they are concerned about the paranoid patient who obtains comfort by completely accepting untrue belief systems and becoming delusional). but if the patient is really helped by explanations of non-responsibility, such concerns may not be very important. The major problem here is that not very much is known about the persistence of symptom relief based on external attribution of blame. nor is much known about how acceptance of such attribution influences the patient’s subsequent adjustment. Here the clinician can obtain guidance only by relying on clinical experience and wisdom, which generally teach us that patients do not do well in life unless they assume responsibility for some of their past and most of their present actions. It would seem that multiple personality disorder patients (just like any other group of patients) would benefit most from completely candid explanations of how past experience influences their present conduct. Thus, these patients might learn in therapy that they have been exposed

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to a highly oppressive experience in childhood which has severely compromised their current capacities. Their past helplessness in dealing with such experience and unrealistic guilt about it might also be emphasized. At the same time, however, these patients must retain awareness of how, as adults, they have had some control over past behavior and how they continue to have a considerable range of choice as to how they will conduct themselves in the future. Providing such communication to the patient requires that the therapist be both skillful and willing to deal with complexity. Again, this is not too much to expect from a sensitive clinician.

THERELATIONSHIPOF '~CHNIQUETO RESPONSIBILITY All of the conventional ways of thinking about responsibility seem to be brought into question by the phenomenon of multiple personality disorder. The apparent fragility and dramatic presentation of these patients have generated a number of approaches to treatment which vary in the extent to which they direct the therapist to accept and relate to the various personalities. These differing techniques provide different messages to patients as to responsibility for undesirable conduct and these messages have behavioral consequences. Consider the many possible approaches that can be taken when personality B tells the therapist that he/she has just committed an antisocial act and seeks to justify or excuse it on the basis of hidher current needs. Does the therapist question these justifications or excuses? Does the therapist ask personality B if he/she feels guilt, or does he/she secretly wonder where the guilt has gone? Does the therapist point out to B how he/she could have behaved differently? Does the therapist urge personality B to tell the primary personality A about what heishe has done? Or does the therapist then incur the obligation to tell personality A about the event? If the therapist does tell personality A that B has committed an antisocial act, how does the therapist convey A's responsibility for that act? Does the therapist ask A about guilt? Does the therapist try to make A feel accountable? Or does the therapist simply ignore the question of responsibility and allow B to talk about hidher antisociality and A to gradually discover that such behavior is actually going on? If the therapist does, how forceful will he/she be in helping A learn about B? A second and related issue is the manner in which the patient is held responsible for fusing hidher personalities. Most therapists ultimately ask the patient to take some responsibility for fusion, but they differ widely in how they go about this. Therapists differ in how quickly they seek to have the various personalities become aware of one another and communicate with one another. They differ in the length of time they will allow a personality state to express itself without reminding that personality of its relationship to the total organism.

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It seems likely that extreme positions taken with regard to the question

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of fusion could have negative effects on treatment outcome. Too much emphasis on the unity of the organism can be viewed as a demand to force the patient to acknowledge unconscious experiences he/she has gone to great lengths to disavow. Such an approach carries the risk of making the patient extremely anxious or, more likely, driving h i d h e r away. On the other hand, ignoring the issue of responsibility in the early phases of treatment and failing to remind the patient of the need for fusion also carries risks. If the total patient or various personalities are not held accountable for antisocial conduct, it is likely that such conduct will escalate. If it does, the patient will experience more difficulty with the social environment and the primary personality will experience more guilt. (Differing techniques also have bearing on the questions of diagnosis and iatrogenicity. To the extent that efforts at fusion are delayed and viewed as beyond the patient’s present capacities, the patient’s multiplicity is reinforced. ) It is not easy to determine exactly how therapists who treat multiple personality disorder actually deal with the issue of responsibility. The technical approaches to treatment of multiple personality disorder which have been most explicitly described by Braun (1986)reflect a great deal of inconsistency with regard to the issues of responsibility and competency. Braun (1986)advocates contracting with the “whole personality system” to hold each of the personalities fully responsible for his or her conduct (which seems grossly unfair) and at the same time insists that each personality must be dealt with as a separate entity. He also tries to contract with “the whole personality system” to agree not to harm him or herself or anyone else, either “accidentally or on purpose at any time.” It is unclear which role edch personality takes in such contracting, or how any being can contract to prevent accidents. Braun (1986)may be deliberately using a paradoxical form of communication with these patients, but it is difficult to conceptualize how it is helpful. The method of Braun (1!386), endorsed by Kluft (1986) and others, seems an inconsistent approach in which the patient is informed of hid her responsibility, but in which various alter personalities (who could not logically be held fully responsible) are treated as separate persons. Conceivably, a skilled therapist, such as Braun or Kluft, can manage such paradoxical communication, particularly if it is presented in a manner which implies that the patient is capable of fusion and if the therapist views hislher work with various alter personalities as merely a technique for allowing the therapist to empathize with the patient’s difficulties in obtaining fusion. It is also likely, hodever, that unskilled therapists are unaware of the paradoxes involved in this approach and, by working intensively with the various personality states, may actually reinforce the symptoms of the disorder.

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In my experience, younger therapists who follow the methods of Braun (1986) and Kluft (1986) have a tendency to quickly forget that aspect of the therapeutic approach which demands that the patient be responsible fbr undesirable conduct. Too often they either ignore the issue of responsibility or they focus simply on explaining that conduct to the patient as determined by past victimization. In either case, they imply to the patient that the conduct is excusable and in so doing, they reinforce it. Not surprisingly, these patients have a difficult course of therapy and fiequently engage in self-destructive or assaultive conduct. Nor do they improve with the frequency reported by senior therapists such as Braun or Kluft. There are also practical consequences to treating volatile and dramatic behavior with unorthodox or experimental methods. Even in the best of hands, the current treatment of patients with multiple personality disorder is not always successful, and a significant number of these patients become highly disturbed in the course of treatment (Wilbur, 1986). Where treatment is both r i s k y and unorthodox, it is only a matter of time until patients who believe they have been harmed or not helped by treatment will begin to sue their therapists. This has happened with troubling frequency in the treatment of borderline patients who share many of the volatile characteristics of the multiple personality disorder patient. One useful way to diminish the risks of malpractice, while adhering to the ethics of our professions, is to be scrupulous and exhaustive in providing informed consent. When treatment with a multiple personality patient is likely to make that patient worse, even for a brief period of time, the therapist is obligated to inform the patient of that risk before therapy begins. (I will avoid the difficult question of how many of the personality states the therapist must so inform.) If the patient cannot competently consent to such treatment (and this is no small issue), the patient should not be treated with a technique that might make himher worse. Providing a potentially harmful treatment to a patient without that patient’s consent is not only legally actionable, but it is also contrary to professional ethics. In conclusion, the patient diagnosed as having multiple personality disorder is best viewed as having many hard choices. Hdshe will have difficultybeing fully aware of various personalities, regulating which personality might assume governance at any given time, and controlling undesirable conduct which meets basic organismic needs. Such difficulties, however, should not preclude the patient from being treated in a manner which is based on a logical and consistent approach to the question of responsibility. Generalizing from the treatment of other patients (including borderline personalities), such treatment would emphasize the patient’s capacity to behave in a socially acceptable manner &om the first day of treatment, while recognizing that it is extremely diacult for him/

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her to do so. The approach should be one in which the emphasis is on maximizing the patient’s responsibility for undesirable conduct and one in which such conduct is never tacitly excused. By avoiding reinforcement of undesirable behavioral aspects of the dissociativeprocess, this approach would diminish iatrogenicity. It would also allow for the expression of empathy and for a search for explanations of symptomatology which enlighten without excusing.

REFERENCES AMERICAN PSYCHIATRIC &SOCIATION. Diclgnoatic andstatistical manual of

mental disorders (DSM-Ill). (3rd ed.) Washington, D.C.: American Psychiatric Association. 1980. A.ME~CAN psucnumc &SOCIATION. Lhagnosticand statistical munual of mental disorders (DSM-III-A). (Rev. 3rd ed.) Washington, D.C.: American PsychiatricAssociation. 1987. BRAWN, 8. G. Issues in the psychotherapy of multiple personality disorder. In B. G. Braun (Ed.), Treafment of multiple personality disorder. Washington. D.C.: American Psychiatric Associati~n,1986. Pp. 1-28. BERNE, E. Games pcoplc pfay. New York: Grove, 1964. BURKE, J. D. Diagnostic assessment. In A. E. Skodol h R...I Spitzer (Eds.). An annotated bibliography of DSM-Ill. Washington, D.C.: American Psychiatric Association, 19117. FRANKEL, F. H..& OWE. M. T. Treatment of anxiety and panic disorders: Sbategies of relaxation, self-control. and fear-mastery. In American Psychiatric Association, Task Force on Anritty Disorders. Washington, D.C.: American Psychiatric Association. 1989. Pp. 2052-2064. FREUD,S. Moral responsibility for the content of dreams. (Vol. 19.) In J. Strachey (Ed. & Trans.),The standard edition of the complete pcychological works of Sigmund Freud. London: Hogarth, 1961. Pp. 131-134. (Orig. Publ., 1925.) HALL~CI, S. L. Psychiatry and the dilcmmaJ of crime. New York: Harper, 1967. HALLECK.S. L. The concept of responsibility in psychotherapy. Amer.]. Psychother., 1982, 36,2923(M.

HALUCK,S. L The assessment of responsibility in criminal law and psychiatric practice. h ment. Hlth: lnt. Perapect.. 1W. 1, 193-220. HALUCK.S. L. Responsibility and excuse in medicine and law: A utilitarian perspective. Low contemp. Probl., 1986.49.127-146. HALLECY, S.L.Which patients are responsible for their own illnesses?Amcr.]. Psychother., 1988.42.338353. Holrevfiz, R. P., h BRAWN. B. C.Are multiple personalities borderline? Psychid. Clin. North Amcr.. la.7.60-88. X”ATIONAL JOURNALOF CLINICAL AND EXPEIUMENTAL HYPrwsis. Special Monograph Issue on Multiple PenonaIity, 1984,32(2). KAMIEL, E. R., & S-ARIZ. J. H.Principhofneuralscience. New York: ElsevierlNorth

H o h d . 1985. K L U ~R . F’. Personality unificntion in multiple personality disorder: A follow-up study. In B. C. B n u n (Ed.), Trerrtmd of rnultrpb p.rsonality disorder. Washington, D.C.: American Psychtric huodatioa,1986. Pp. 29-60. KLUPT, R P. Multiple personality disorder: An update. Hatp. comm. Psych.. 1987.38, m 3 . -M(, F. W. The trafment of multiple personality: State of the art. In B. G. Braun (Ed.), Treatment of #y dirordcr. Washington, D.C.: American Psychiatric Association, 1986. Pp. 175-198.

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SACKS,0. The man who mistook his wifefor a hut. London: Duckworth, 1985. SCHUNK,D. H.. & CARBONARI, J. P. Self efficacy models in behavioral health. In J. D. Matuazzo. S. M. Weis, J. A. Herd, N. E. Miller, & S. M. We& (Eds.), Behuoioral health: A handbook of health enhancement and duease preomtiOn. New York: Wiley. 1984.Pp.230-248. SNYDER, C. R., HIGGINS.R. R., & S w c ~ nR.. J. Excuses: Masquerades in search of grace. New York: Wiley, 1983. SPIEGEL,D., & SPIEGEL,H. Forensic uses of hypnosis. In I. 8. Weiner & A. K. Hess (Eds.), Handbook offoremic psychology. New York: Wiley. 1987. Pp. 490511. STRONG,S. L. Social-psychologicalapproach to psychotherapy research. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapyand behaowr change: An empirical analysis. (2nd ed.) New York: Wiley, 1978. Pp. 101-135. ? ~ I G P E N , C. H., & CLECILEY,H. M. On the incidence of multiple personality disorder: A brief communication. I n : . ] . d i n . exp. Hypnosis,1984.32,63-136. VICTOR,G. Sybil: Grand hysteria or folie a dew? Amez.1. Psychiot.. 1975, 132.202203. WILBUR,C. B. Psychoanalysis and multiple personality disorder. In 8 . G . Braun (Ed.), rnatment of multiple personality disorder. Washington, D.C.: American Psychiatric Association, 1986. Pp. 133-142. Dissderende Phinomene und die Frage der Verantwortlichkeit Seymour L. Hdleck Abstrakt: Er bcstehen viele Kontroversen in h u g auf PrPvdenz, Ursache, m@icher iatrogener Entstehung und Behandlung der multiplen Persanlichkeitsstcirung.Diejenigen, die dieses Leiden ds mehr verbreitet ansehen, ds zuvor vermutet wurde. glauben, QB a durch Erlebnissc von schwerer KindesmiBhandlung ausgelcbt wurde und bbm ziemlich unorthodoxe Techniken a n g d t , um dem Patienten zu hclfen, das Erlebnt der Mi& handhmg auf gcgenwartige Probleme der Dissuziation zu beziehen. Andere Kliniker glauben, da6 d i m Leiden Bberdiagartiziert worden ist und dd sein Entehm durch Therapcuten gesehaffen oder v e d e c h t e r t wurde, die umriumtlich die Diuozi.tionssymptome verstPrh haben. Viele d a Konhwersen iiber d i e Meinungsverschicdenheiten k6nnen dadurch geldkt werden, indem man die Art in Betmcht zieht, mit der Kliniker es der Vmmhwrtlichkeit fir ungemnlleJ Betragen zuschnibm, dar mit diesem Leiden a s d e r t ist. Im Verkehr mit Patienten mit multipler Per%nii&eit miissm Kliniker r e g e l d i g entscbeiden, ob ihr therapeutirches Verf.hrca die Vemhvordichkeit des Patienten fiir ein ungemiilkr Betmgen vmtarken oder verringem wird. RpLtirchc und theoretirche Argumente k6-n fiir beide BehuxnunyveiKa aufgebracht werden. Es bestehen wichtige Konxqueazen fir die P a t h t e n , die sieh h e r der beiden Beh a d n n y w e h e n unterziehen, md besoadem s&digemle Konsequemen d u d inkonsirtente B e h d u n g s w e h . Klinirche Erfphrung und Weisheit diktimn, dd die bevormgte Behandlungswcisc ftir Patienten mit multipler Perdohhkeit weiterhin auf das Maximienn ihrer Veranhwortlichkeit fiir jeden Typ des ung&n Betragens fokussiert sein sollte bis zu der &it, wenn wir mehr objektive Einzelheiten iibcr die Resultate der venchiedenen Behandlungformen haben werden.

La question de la responsabilitb & les phbnomhres diuocintifs Seymour L. w l c c k RCsumb: Il existe de multiples nnrtrovelres concernant la prbvdenct, les causes. la iatrogenese probable et le traitement des dbsordres de personnditb multiple. Ceux qui attribuent h ce desordre une prbvalence plus forte que ce qui btait soupqunne antbrieurement,

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eroient que cc phbmmbne appPrPitrnit chez des enfanb ayant Ct6 pavement .bus&. Les tenants de ntte b y p o t k c ont u W des techniques d'itervention peu orthodoxa en vue d'awner le patient 1 exprimer r@rience d'abus qui serait r e k au pmb&me dtsocLtif -el. D'autru cliniciens &rment que k phcwmtae cst r u r d m t i q u b . IL s u e r e n t qu'il pourrait Ctre cr& ou aggrav6 par des tkrapeutes qui renfomnt, sans k s a d , l a symptbmes diuodotifs. Plwieurs des controverses concernant le =jet, se dari6-t lorsque I'on d i s c comment ler diniciens attribuent In mpoaubifit6 des actes iadhirables associ& au probkmc. L m q u l hrv?illc avcc des p a b b 1 peMonalitC muhipk, Ie clinicien doit dCcfder rCylitrement si soo intervention maximisera ou minimisera la mponsabiitioa du patient face L ses conduit- indkirables. Des arguments tbtoriques et pratiques peuvent &re invoqds dam ks deru au. L'utifis&on de I'um ou rautre d a d e w approelm v d n e des cms6quenccs important- pour le patient, et les am&+ace m t particulilrement dfastcs si I'approcfie a t inconsistante. C:exptricnce clinique et U M ccrtaine sagnous dictent que. tant que nous ne pouMeroos pas plus de donnks objectives sur ks rhultats des &verses f o r m a de trPitemmt, Ie type de traitemeat L privil6gier pour l a patienb P pcrsonnalitt multiple den-ait mmtinuer #&re iub sur la nsponubditb du patient f a n 1 KJ coaduites ind6sirables quenes qu'ena soieot.

Fen6menos disochtivos y la cuestih de la responsabilidad

Seymour L Halleek

Resumen: La prevaiencia, cadidad, pmible introgenia y tratamiento del dtsordm de persodidad mliltiple ha provocada mliltipla controversias. Aquenos que v i s d i z p n el dcsordcn otorghndde UM mayor prevde!ncia dc lo que previamente se L b i a sxpechdo, crecm que a ca& por erperieociv infantiles de sever0 aburo, han utilizado W c a s no o r t o c k u para a y d a r ai paciente a rcbcionar I.experienci. del a b w con lor frccuentcs probicmas de d h c h c i h . Otms dinicos m c n q w a t e desorden a diagnosticado exageradamente y que puede scr credo o empeorado por terpputas que sin dame cuenta nfuerZM lor riatomas de d b c k k i o Much, de lu w o t r w m t s de este terns pueden x r dprificodv teniendo en cwnta la manera en la cupl los clinicm Ic atribuyen la mponrpbilidod de la conducta indcseable procisdp con a t e d e d e n . Crundo se trata con poricntes de perponnlidpd mdtipie, habitualmente loa &iau deben decidir si su enfoque teraptutiw enfarbvp o mhrimizPr6 la mponrnbilidpd del priemte por su d u c t ? indeseabk. D e a t o s e n f o q w ~se derivan A pvtieularmentc perjudicida si se u t i h n cnfoques incauistentes. La expcricncia c k y la cordura nas diceo que hnsta tanto no tengamas m& &tos objetivm accrca dc la d t a d o s de vuios t i p de tratamiento, el mbtodo & tratpmiento pref'erido para br ppcientes de persondidad mriltiple debicra continuar ponieado el foe0 en maxim& su mspomabilidad freote a uu conductas indcscables.

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Dissociative phenomena and the question of responsibility.

There are many controversies regarding the prevalence, causation, possible iatrogenicity, and treatment of multiple personality disorder. Those who vi...
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