Treatment of MPD/DID

HYPNOTHERAPY OF MULTIPLE PERSONALITY DISORDER
By
Ralph B. Allison, MD
Prepared for the
15th World Congress of Eclectic Hypnotherapy in Psychology, Psychiatry & Medicine
Manzanillo, Colima, Mexico
July 8-11, 2009

NOMENCLATURE
When I started my psychiatric practice in 1962, there was no code number for Multiple Personality Disorder (MPD) in the current DSM (Diagnostic & Statistical Manual of Mental Disorders of the American Psychiatric Association.) It was a subtype of Hysterical Personality Disorder. During my time in practice, a code number was assigned in the next DSM to Multiple Personality Disorder, and we clinicians seeing such patients were delighted to know they had a “real mental disorder” with its own official code number. When I left practice in 1995, there were certain “experts” in psychiatry and psychology (mostly university professors) who believed there was no such thing as MPD. They wanted to eliminate the label altogether. But the clinicians resisted this move. The two groups compromised by changing MPD to DID for Dissociative Identity Disorder in the latest DSM. I disagreed with that move, for both semantic and descriptive reasons, and refused to say all my former patients with MPD now had DID. In my own writings, I use MPD for a group of patients with the following characteristics:
1. The first alter-personality (a.k.a. alter) is created by a highly hypnotizable child who suffered life threatening abuse, usually at the hands of parents, before the age of six. (Highly hypnotizable means Grade V hypnotizable, in the top 4% of the population.)
2. The parents are polarized, one being “good” and the other “bad”, but they keep changing which one is which. So rescue is impossible while in the home.
3. If there are siblings, they are polarized, too. Only this one child is abused, and the other children are treated more humanely. They cannot rescue the abused child either. (“Equal opportunity abuse” is not typical of families with MPD patients.)
4. This results in an absent original birth personality replaced by numerous alters, often in the dozens.

I use DID for those patients with one alter, who have the following characteristics:
1. The first alter was formed from age six on, in a child in the top 50% of hypnotizability (Grades III to V)
2. The child suffered some kind of serious abuse, but it need not have been life threatening, only a type the child had no training in how to handle appropriately. Usually it was rape for girls and assault for boys.
3. Only one alter was created at the time of this assault. If another crisis occurred, another alter was created to deal with that new crisis.
4. The original birth personality is in charge except when the single alter comes out and takes over the body.

This paper is about those patients with MPD, as described above. The treatment of patients with DID is much simpler and will not be included herein.

INTRODUCTION
During the time I was in psychiatric practice in California, I was responsible for the treatment of a number of patients who showed me “other selves”. At that time, there was no published treatment plan which I could follow. I had to improvise and invent my own. During those years I worked in my private office, a public mental health clinic, a small psychiatric ward in a county or private general hospital, and finally, a prison.

At that time, no hospital wards specializing in the treatment of the dissociative disorders existed. These were created later and were located in cities where I did not live or practice. I understand that most, if not all, of them have now closed due to failure of insurance companies to pay the bills for long stays there.

My first such patient came to my private office in Santa Cruz in 1972. I moved to Davis to work in a county mental health clinic from 1978 to 1981. From 1981 to 1995, I worked in a state prison in San Luis Obispo, while maintaining a private office in Morro Bay from 1981 to 1986. I maintained contact with several of my MPD ex-patients over the next quarter century. So those of you reading this in 2009 and afterwards can consider this an historical document, presenting my way of practicing my trade with very difficult and perplexing patients, but usually to good results.

This was also the time when we “experts” really didn’t understand much of what we were dealing with, so I matured in my own understanding over time. In addition, in spite of three invalid malpractice threats in one year, I was not scared off from using hypnosis with these patients in therapy. I understand that now lawyers have scared many practitioners out of using hypnosis for any patients. But I used it with these dissociating patient most every time I saw them in my office. I have known of bad results when hypnosis was used by foolish, inept and unethical practitioners. That is to be expected when the skill of the practitioner is inadequate to the needs of the patient.

Also, I was a medical doctor first, then a psychiatrist, then a hypnotist. My friends told me that I thought like a surgeon. That is reflected in how I conducted myself with the patients with “broken minds”. My first question was, “Just what is wrong with the patient and why?” My next question was, “What can I do to bring all the parts together and have them work together like they are supposed to?”

Since I left practice in 1995, I have maintained a website of all my papers, www.dissociation.com. Many people have contacted me via that website, including people who feel being a “multiple” is superior to being a “singleton” like me. They have challenged my view that patients with MPD or DID should be encouraged to be psychologically integrated. They are satisfied to live a life as a dissociated/split person.

My answer to them has been that the ethics of my profession mandate that I offer integration as a goal to such patients with many “other selves”. It is the patient’s choice whether or not to work with me towards that goal. But I have also realized over time that some patients do not have the ability to integrate their various parts, usually because the life threatening trauma they suffered came so early in their young lives, between birth and six months of age. They have found it best to operate with a small committee of six or so alters who keep the body running. That meets their needs, and those I have followed have been as functional as anyone else in their environment.

THE TREATMENT PLAN
I. Making the Diagnosis
A. Dissociation versus Imagination
When I was in practice, the proper DSM label for most of my dissociated patients, who showed what I thought were alters, was Multiple Personality Disorder or MPD. At that time, none of us in the field understood the relationship between dissociation, the mental mechanism behind alters, and emotional imagination, which produces imaginary companions or playmates. Also, I only later realized we humans have two different kinds of imagination – emotional and inspirational. Emotional imagination is used to create temporary answers to present-day emotional needs, like loneliness, and has been used by a third of all children to make imaginary playmates. These psychic beings can be “seen” sitting in a vacant chair at the family dining table, inhabiting a favorite doll, or being inside the child’s body, allowing that child to pretend to be some heroic figure. In the latter case, the child may change behavior and appear to have an alter. What she really has is an Internalized Imaginary Companion or IIC which she created with her emotional imagination.

The other type of imagination, “inspirational imagination”, is what we humans use to create great works of art, inventions, new buildings, and all those other novelties that accompany our human progress. It is my opinion that imagination is the most powerful force the human mind has.

When it comes to the patients, however, we must realize that there is a range each of us is born with, regarding both dissociation and imagination. I believe dissociation is primarily used for self protection and defense against trauma and to allow us to heal from trauma. It is needed for survival.

In contrast, emotional imagination is used to try to solve some problem, whether it be loneliness or rage with a desire for revenge. The child using this talent for revenge is not endangered but is very angry at some adult for misbehavior towards someone else, such as a sibling. He will then use emotional imagination to create a hit-man to destroy the villain in his home. But since he is only four years old, this imaginary figure resides within him for several decades before coming out and brutally destroying an innocent victim. Those are the IIC whom I saw in court and prison.

B. The Clinical Picture
These patients commonly have been through numerous institutions and various therapists with no constructive changes being made in their basic psychopathology. The foundation for the diagnosis is an accurate history. Common complaints are periods of amnesia, auditory hallucinations, fast mood swings, suicide attempts, severe headaches, difficulties in impulse control, and stormy marriages. Many are ashamed to tell of periods of amnesia and may forget they forgot. Some will attribute it to drinking bouts, but, when pressed, will admit to lapses of memory during times of sobriety, usually after getting angry.

Most will not volunteer a history of auditory hallucinations since they know that would brand them as "crazy", and they fear being locked up. Therefore, a very casual type of questioning about hallucinations is needed. Voices may be hostile or helpful or both, alternately. The hostile one may tell the patient very derogatory things and urge suicide or homicide. A helpful voice will reassure and guide the patient in a constructive direction. A helpful voice must receive the therapist's special notice, and the patient must be encouraged to do what the helper inside advises.

A history of mood swings from suicidal depression to happily bar hopping can be misinterpreted as a manic depressive (bipolar) pattern. However, 48 hours is the minimum time for a true bipolar illness to cycle, and a multiple can switch every few minutes, as each personality emerges. The patient may be quite conscious of the shifts from glad to sad or may black out while getting angry and wake up feeling hung over and depressed from drinking heavily.

The main feature to note is the patient's feeling of lack of control over the shifts. In contrast to a bipolar whose shifts occur without an outside stimulus, there is usually a situation which triggers the change in a multiple even though the multiple has repressed memory of this event. By using hypnosis, the therapist can often easily learn what event triggered the switch.

As a result of the depressive periods, suicide attempts occur in situations where desire for death seems absent. It is easy for the therapist to brush off these attempts as attention getting devices, which they are, but these patients are, at times, really suicidal if their vital emotional supports have been removed. They may show self mutilative acts, such as slashing their forearms with a knife, which is really not suicidal. This may be an angry persecutor alter punishing the false front alter for being such a weakling. The period of cutting is blocked out by amnesia, a very good clue. Several of my patients were easily diagnosed when they arrived at the emergency room with slashed arms and amnesia for the incident. They were eager to find out why they did that and willingly underwent hypnotic interviews in which they clearly described the alters who were responsible for the slashing. This problem had to be resolved before they could leave the hospital, and they then began effective therapy for the first time in their lives.

A number of patients suffered from severe "migraine" headaches and were hospitalized repeatedly for neurological evaluations and treatment. One patient had an elevated spinal fluid pressure, so was diagnosed as having pseudotumor cerebri. It was later determined that the headaches were caused by the angry persecutor alter using this way of punishing the weak false front alter, a common cause of severe headaches in these patients.

When parents of these patients are questioned, they report difficulties since birth with impulse control. These patients, as children, have struck out at siblings, become unreasonably jealous, exhibit temper tantrums and destroy property, all for what seemed to be minor irritations. At school, they trigger fights, then cry at being rejected by schoolmates.

They seem to have an unlimited capacity for hatred, yet relatives outside of the nuclear family may be extremely loving and protective of them. They gain friends easily with their charm, but lose them with escapades that make friends desert for self-protection.

The marital histories are usually full of failure and conflict, in the case of women. Many of the men were too unstable to enter into marriage, with two exceptions, and one of those marriages lasted only three months. The women ran away from miserable homes as teenagers and married the first men who asked them. With their low self esteem, they preferred men who were equally disreputable, so marriage to ex-convicts, sexual perverts, habitually unfaithful men, sadists, religious fanatics and fatherly types who needed child brides seemed to be the order of the day.

Relatives or close friends may tell the therapist about sharp changes of personality, even to the degree of claiming to have another name. Some relatives will refer to the movie "The Three Faces of Eve" as the source of comparison and be quite correct. However, the therapist must be careful that this description is not being applied to social role playing and must insist that the diagnosis only be made officially when the switching has been seen in person.

The basic criteria for making the diagnosis of MPD is the clinical presence of two or more alters alternating control of one physical body. Only when a therapist has seen a shift of personality can he make this diagnosis with assurance. If the patient is seen in a highly volatile state in an emergency situation, the switching may be easily observed as the facial expression, voice and posture all change spontaneously, often in the middle of a sentence. If the patient is in a calm state, a hypnotic induction for any reason may allow an alter to come out, even if not requested. This alter will often claim to have her own name, a very specific purpose to perform for the false front alter, knowledge of activities during amnesic spells, and knowledge of the incident which brought it into existence originally. If the patient has not been exposed to other multiples, such as on a small hospital ward, these alters can be taken as genuine and not play acting. However, if the patient has seen another active multiple switch personalities, great caution must be taken in assuming that these mental creations are anything more than an attempt to get as much attention as the multiple patient she observed. This situation requires continued observation and consultation with careful comparison to patients known to have genuine MPD. If the patient is currently being charged with a crime, it would be almost impossible to be certain that the phenomena is genuine, since the patient might very well be willing to fake such behavior to be declared not guilty by reason of insanity.

Some patients were referred by local physicians or psychologists who used hypnosis for weight control, smoking and sexual problems. Another patient manifested alters after her boyfriend hypnotized her for fun at home. Other patients, whose alters were in balance for years, became worse, bringing them to treatment. I consider hypnosis the method by which one can open the Pandora's box in which the alters already reside. I do not believe that such hypnotic procedures create the alters any more than the radiologist creates a lung cancer when he takes the first x-rays of the chest. But in the type of hypnotic approach used to get information about unconscious processes, or to implant corrective ideas, there is no stimulus to push a patient to make a new personality. Besides, that is not the way alters are created. It is much more complex than just responding to a non-specific hypnotic induction. The alters have existed for years, and hypnosis loosens the controls the patient has on them, except at times of extreme stress. These are the same alters who have been coming out for years to cause the problems the patient came complaining of in the first place. Also, a newly formed alter takes time to grow and develop. It cannot come out with any intelligence within seconds of its creation by the patient. It must mature and grow inside the mind for days or weeks before it is able to act as an independent entity.

Most patients have come to treatment for depression and suicide attempts, and they had no idea that multiplicity was involved. These can take months to diagnose properly because there is no logical reason early in treatment to use hypnosis, and the patient, being a good actress, puts on a pleasant face in the office, while living a chaotic life outside. Finally, the patient becomes trusting enough to report amnesic spells in which she does weird things, or she tells the therapist she is sure there is another one inside doing the dirty work. Then she is willing to cooperate in a hypnotic interview in which the alter emerges and exposes the secret to the therapist.

When the suspicion of MPD exists, an excellent physical test is to touch a forefinger to the patient's forehead between the eyebrows. In multiples, a change comes about in their mood and emotional control. Either the patient calms down from an excited state, or, if calm, may react violently with shrieks and visual imagery. The patients are very aware of this sensitive spot on their forehead and avoid wearing bangs which could touch it. If a hostile alter is out, the fastest way to bring a helper alter into control is to touch that spot and call for the other alter to regain control.

C. Psychological Testing
When I was in practice, I had available computer interpreted Minnesota Multiphasic Personality Inventories (MMPI) and California Psychological Inventories (CPI). The CPI uses many question from the MMPI. I found the CPI the most useful, as several alters could take it individually. When the hysteria score was over 55 and the preferred diagnosis was hysterical personality disorder (dissociating type), I usually had a bona fide multiple patient.

Since then a test called the SCID-D (Structured Clinical Interview for Dissociative Disorders) has been developed. It is considered by some to be the “Gold Standard” for diagnosing MPD/DID. But in my use of it, I found that to be an overblown evaluation. When a therapist uses it with a new patient, he will be asking that patient many intrusive questions which he would not usually ask so soon. But if the examiner acts as if , “I’m just reading this because the test instructions tell me to,” much important information can be gathered which will be later useful in therapy. But it is hard to grade, and I would not rely on it as the only diagnostic tool.

D. Types of Alter-Personalities
1. The False Front Alter:
When a highly hypnotizable child, younger than age six, suffers a life threatening trauma, her original birth personality may dissociate from the other part of her mind, her Essence. The Essence then creates a false front alter to run the body in this dangerous environment. This is the alter others consider the social person, the one whom everyone knows as “her”. Some therapists call it the “host personality”. It is designed to placate the abusing parent and cope with repeated abuse. It is age appropriate and can mature a few months or years. When it becomes obsolete, it goes “on the shelf” and the Essence then makes a new, older false front alter. Often the false front alter made during the late teens comes in for therapy after she has married a sociopathic husband. She is weak, good, and kind, but suicidally depressed. She carries the body for therapy into the office, where the other alters show themselves.

2. The Angry Persecutor Alter:
This alter was created, again by the Essence, to contain and manage the anger at her abusers. This is the one which causes social and legal problems. She may talk nasty to and about the therapist, but I never felt afraid of these angry alters. I knew they were angry at some specific other people, such as parents and mates, but not me. I was the “Good Guy” in their lives, someone safe to be around. When they gave up their anger-energy in therapy, they became helper alters.

3. The Helper Alter:
For each angry persecutor alter, the Essence creates a helper alter to clean up the messes the angry persecutor alter makes. They are the natural allies of the therapist and can be instructed how best to handle the inevitable crises the angry persecutor alters have. For example, they are the ones the therapist should instruct as to how to find the suicide prevention services in their community.

One high level helper alter may act as a spokesperson for the ISH, described below. Oftentimes, early in therapy, the ISH does not yet trust the therapist and so sends messages on how to proceed in therapy through this “ISH helper alter.” It is commonly mistaken for the ISH, but can be distinguished by its ability to emote, while the ISH cannot.

4. The Handicapped Alter:
There may be an alter which has a physical handicap, such as deafness. In one case the false front alter became so tired of hearing her parents argue all the time, she decided to become deaf. She, via her Essence, created a deaf alter (hysterical deafness) who took over her social role. During that time, she was sent to a school for the hearing impaired, where she was taught American Sign Language. After nine months of deafness, she decided she had punished her parents enough and her hearing false front alter came back in charge. But that experience led the patient to eventually become a translator for the deaf at work.

5. Imaginary Companions or Playmates:
Above I have mentioned how Internalized Imaginary Companions (IIC) can be easily confused with alters. IIC are not made by the Essence for survival purposes and may act out in various serious ways. But sometimes an IIC will be created first by the original birth personality, and then alters are made later by the Essence. One of those IIC can perform the duties of a helper alter. Since “another self” is already on hand, the Essence need not make a helper alter in this particular situation. That need has already been met by that IIC.

E. The Inner Self Helper (ISH)
Somewhere in therapy, hopefully early, an important entity, which I have christened the Inner Self Helper, may make itself known. I eventually decided that the ISH is a work identity label for the Essence (see I.D.1 above). Normally it is integrated with the personality/ego part of the mind, but can dissociate from it in Grade V hypnotizable persons. This can occur under hypnosis and when the child’s life is threatened by abuse, before the age of six. It is the military equivalent of Disaster Control Officer. It is quite different from the persecutor or helper alters, whose characteristics are in Table I. The characteristics of this entity are listed in Table II.

I met my first such an entity in 1973. Since then, such entities have been manifested in all of the seriously ill multiples who have gone on to integration. This entity will not accept the label of an alter, and it has the power to create alters. I abbreviate the full name to ISH, which means "similar to, or alike." This is appropriate, since it is similar to the original birth personality in many ways. It has knowledge and strength but is incapable of showing hatred or fear. But it is a reflection, in a higher plane, of the original birth personality’s characteristics. It is bright if the patient is bright, and not so bright if the patient is dull. It is shy or assertive, depending on the nature of the original birth personality.

Its value to the therapist is tremendous, as it has awareness of all that is wrong inside the mind of the patient and can work with the therapist to make corrections. There are certain things the therapist must do, certain things the patient must do, and certain things the ISH must do. None can abdicate and expect the others to do its work. The ISH must let the doctor handle medicines and physical problems, since the ISH's role is primarily mental. Psychotherapy for the alters is done by both the ISH and the therapist. The patient has the duty to decide to become one and to make appropriate social decisions as well as to battle angry persecutor alters.

The most concise self-definition given by an ISH 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 which I do not need. But she will have my reasoning 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 is a shell. Now my function is overseer of the dump. I am kept busy sorting out the different messes created and the problems created between the alternate personalities."

The relationship between the therapist and the ISH is unique since the ISH is all intellect and a delight to converse with for an intellectual therapist. It is also aware of the therapist's feelings and failings and has no capacity for transference feelings. The ISH and the therapist are usually talking about a third party, the patient. They share ideas back and forth, with no coercion on either side. There is no human-to-human relationship with which to compare this partnership. It is so unique a relationship, it has to be experienced to be believed.

The therapist quickly comes to realize that the therapist, too, has an Essence/ISH, which is in constant communication with the patient's ISH. Why else did the therapist change tactics and do certain acts in the therapy session which worked out so perfectly? In successful people, it is well integrated with the personality. In the multiple, it is disconnected, as are many other parts.


TABLE I
Characteristics of an Alter
1. Has identifiable date of creation
2. Was created as a result of specific life threatening trauma
3. Was created to serve a specific emotional and survival purpose
4. Has potential range of positive and negative emotions
5. Has potential for positive and negative motivations
6. May be interested in establishing separate identity from the original birth personality
7. Is capable of making other “psychic entities” (IIC)
8. Has a sense of being male or female

TABLE II
Characteristics of an Inner Self Helper (ISH)
1. Has no date of origin; has always been present since patient's birth
2. Can only agape love; is incapable of hatred or any other human emotion
3. Has awareness of and belief in The Creator
4. Is aware that The Creator put it in charge of teaching this person how to live properly
5. Has the power to clean up the mess, with help from the therapist
6. Has more powerful supervisors above itself
7. Knows all past history of patient and can accurately predict short term future (three days maximum)
8. Has no sense of personal sexual identity but uses gender designation for therapist’s comfort
9. Talks in short, concise sentences; prefers to answer questions and give enigmatic instructions
10. Is aware of patient's prior lifetimes

II. Psychopathology
Before we can deal with ideas about treatment, we must concern ourselves with why this ailment exists in the patient at all. There is no generally accepted etiologic reason propounded by psychological theorists. My constant probing for answers has led me to hypothesize that these patients were born this way, not necessarily split of mind, but with a readiness to split with the slightest emotional trauma (a dissociative tendency). The psychological foundation is an innate defective unconscious mechanism for integrating daily experience into knowledge. They cannot be conditioned by experiences. They keep making the same mistakes over and over again. Therefore, they do not act socially responsible since they do not correct their errors. This leads to recrimination on the part of others and further emotional trauma, leading to the eventual creation of alters. This same feature of inability to lean from experience has been shown to exist in professional criminals and may be why the disorder is so seldom diagnosed in men. They probably become criminals earlier and easier in our society than do women and are then absorbed into the penal system. The women are tolerated longer at home and considered mentally ill while the men are called antisocial.

Another etiologic factor which has been strongly indicated by ISH's is that the original birth personality has never taken a stand for being good or bad and is still sitting on the moral fence, playing both sides. Staying in this state of moral limbo perpetuates the existence of alters, who represent one side or the other of this moral dilemma.

Those of us doing therapy may find it hard to identify with a person in a moral limbo state, since we made our choice for good before entering our professional education. But these patients have not done so and need to be guided to where they can make a conscious choice for good or bad, hopefully for the former. The choice must always be theirs, and they can choose to be fused bad, I believe. If that should happen, no one is safe around that person, and there is no longer any hope for a cure in the positive direction. I did deal briefly with the husband of one of my multiple patients, who may have gone in that direction. Their antisocial alters “fell in love” with each other, and they married one another. A few months later they separated, and he subsequently killed a woman and then a man. On Death Row he became psychotic, his death sentence was later reversed by decree of the Supreme Court, and he subsequent was moved to a regular prison, where he was involved in gun smuggling and other illegal acts. He is now serving two concurrent life terms in prison.

There is, of course, the total personality structure present in the person at birth, which is another important factor to understand. The most important facts leading to pathology are the emotional hypersensitivity, hypersuggestability, and psychic talents. The hypersensitivity may be so extreme they perceive auras, or energy fields, around people. In a room of strangers, they may feel literally burned by anger or other negatives feelings of these persons. They soak up these feelings like sponges and may become suicidal after exposure to depressed people. This factor must be appreciated and is countered by "Building the Eggshell", which is described below.

All multiples are hypersuggestible and therefore excellent hypnotic subjects. But that is where the therapist is walking on a narrow ledge. The therapist may inadvertently suggest a symptom the patient doesn't need. Hopefully, the suggestions are positive ones regarding improved coping methods. With this suggestibility used effectively, the therapist should comment that the patient can do many positive acts she didn't think she could do. When the patient acts on these suggestions, she is surprised at the results, and this builds self confidence, which is sorely needed.

While multiples are hypersuggestible, at the same time they very stubbornly stay the way they are and refuse to accept any suggestions the therapist might give for improved social functioning. So they are a paradoxical combination of hypersuggestability and stubbornness.

Most of the multiples have been involved in some type of psychic or parapsychological activity, and it is important for the therapist to be aware of the theories behind these phenomena. Readings in standard texts in parapsychology will help the therapist understand such activities as extrasensory perception, poltergeist, out-of-body experiences, precognition, psychic attack, psychometry and energy sapping. Again, it is essential that the therapist understand the ethical and unethical ways in which these various talents may be used. Involvement in such religions as Satanism and black witchcraft is to be soundly denounced, but the motives must be explored, so that alternate ways of meeting the patient’s needs can be found.

The characteristics which are useful for healthy improvement are creativity, good imagination, excellent memory and diversified interests and activities. Many are excellent artists, using various mediums. Poetry is a very common way of expressing their thoughts. Their imagination can be used creatively in the hypnotic process. But the therapist has to keep in mind the problems these patients have separating their fantasies from reality and the tendency to make reality out of imagination.

In spite of many amnesic spells, multiples have excellent memory for isolated details. Never can therapists get away by claiming they didn't say something last week. The patient can remember interactions in complete detail. Patients who have been accused of lying in childhood will start memorizing everything that they are aware of, so they can defend themselves from further accusations. They never forget an insult and latch onto the memory of the hurt until the therapist hears about it and persuades them to stop the one-sided feud.

The family structure in which the early pathology is played out is listed in Table III. I do not blame parents for raising their children to be multiples, because of the defects in the child I have already listed. But these patients are raised in polarized families where multiplicity is encouraged, and irresponsible behavior is supported by example. Seldom is there an alternative parental figure who can help the child understand and cope with what she is going through. Therefore, the child may seek inside for a playmate made of emotional imagination, and start creating “other selves” that way. Later they usually marry an emotionally unstable spouse, and the home problems are perpetuated. The spouse becomes the caretaker. But when the patient is psychologically integrated, the spouse starts showing psychopathology, and a divorce is soon sought by the ex-patient.

Therefore, the pattern seems to be this. The personality of the patient arrives in this lifetime incapable of learning by experience and undecided about being good or bad. The nervous system has an exquisite sensitivity to emotional energies of others. The family is pathological, with polarity being encouraged. The acting out forces the patient into therapy, into a corner where she can no longer get by being irresponsible and undecided by letting alters live out her life for her.

TABLE III
Common Factors in Childhood of the Multiple Personality Patient
1. The child is unwanted at birth.
2. There is intense polarity between mother and father.
3. One parent, especially the favored one, may disappear before the child is six years old.
4. Sibling rivalry is encouraged, and the child is not helped to deal with it.
5. The child is taught to be ashamed of her family tree.
6. The first sexual experience for girls is extremely traumatic.
7. Home life as an adolescent is so miserable the girls run away to get married, and the boys join the military.
8. The girls marry sexual deviates who carry on the pathological traditions of their parents.

III. The Therapy Plan
In my experience, therapy consists of nine intertwining stages. The order in which these processes occur varies in each patient, but, with the help of the ISH, the therapist will be able to take each step as needed.

A. Recognition of Alters
As in any disease, until the patient is aware of what disease she has, she cannot effectively work with the therapist. There is massive resistance in most patients against accepting the label of MPD, since denial and repression are their favorite defense mechanisms. But when the therapist has adequate proof of amnesic spells in which alters make themselves known, this must be presented to the patient. Various physical methods of proof may be needed. A photographic picture may be taken when an alter is out. A tape recording of conversation between therapist and alters may be made. Asking the patient to talk out loud, in trance, with an alter, creating an inner dialogue, may be very useful. When the patient is able to do automatic writing, this proof may be convincing, since the therapist did nothing to put those words on paper. If family members or neighbors will confirm the therapist's suspicion and tell the patient, that may begin to dissolve her denial. But, in the early stages of therapy, there is only going to be a tentative agreement that it may be so, but not whole-hearted acceptance. That only comes later.

1. Special Techniques #1 – Building the Eggshell
There are two imagery techniques which I have found useful for most multiples. The first is "Building the Eggshell." Since these are hypersensitive people, I show them how to develop protection against psychic harm by building an imaginary eggshell around themselves. The patient rests quietly in an easy chair while I go through the following spiel:

"Rest quietly, relax and close your eyes. Now think of a beam of pure light coming down from the sun into the top of your head. Have it radiate from the very center of your being outward into your air space. As it does, have it push out all that is unworthy in you, all that is evil, harmful or unwanted. Let this energy fill your entire air space so that in no way can you be outside it. Let it expand and become stronger and more brilliant so that it goes as far above your head as you can reach, as far to your side as you can reach, as far behind you as you can reach, and as far below you as you can reach. Then, as a tomato with a soft pulp needs a skin to hold it together, start thickening the outer surface of this energy field. Because of the shape of the human body, it will be shaped like an eggshell. Thicken this eggshell as thick as you think you need for protection.

“If things are calm and peaceful, you may need it to be only one or two inches thick. If you anticipate being around difficult people, you may need it two or three feet thick. Now if you remember your biology class in school, you know that every cell in your body has around it a semi-permeable membrane. (Vary this part depending on the education of the patient.) This membrane is designed in such a way that food will pass through it into the cell, but poisonous substances are kept out. Also, all the elements manufactured inside the cell that are needed for the function of the cell are kept in, but all waste products are passed out. In this way, a perfect relationship is maintained between this cell and all other cells. Exactly the same type of membrane is needed around your body to allow it to be in balance with the bodies of others.

"The first thing you need to do is to cover the outside of the eggshell with many tiny mirrors. These mirrors are designed to reflect back to their makers all the negative thoughts that may be sent your way by anyone, all thoughts of malice, hatred, jealousy, etc. The mirrors are 100% reflective, so you need add no energy to the system; just let the negative thoughts rebound like ping pong balls off a paddle. In this way the negative thoughts will not enter your body of thoughts and interfere with the quality of your thinking. However, all positive thoughts, such as admiration, love, or affection will come right through to improve you, help you, teach you and otherwise benefit you. That is the first step.

"The next step is to coat the outside of your eggshell with a non-stick surface, like the Teflon used in frying pans. This non-stick coating is to be designed to deflect all negative emotions others may dump on you. These negative emotions of hatred, guilt, self pity, etc., are just their mental garbage which you don't need. With the Teflon coating, you can have it just slither down into the garbage disposal system the Good Lord provides for such trash. However, all the positive emotions such as love, affection, praise and appreciation will come right through to warm you and strengthen you. These feelings will also stimulate you to express the same emotions towards others. Now, that is what is needed for the outside.

"On the inside, you need to do the same as that which works for each cell in your body. The first thing is to get rid of the junk in your mental household. You will notice down by your feet a one-way-out trap door. Pick up that silver shovel and start shoveling out through that door all the mental trash you have – preconceived notions, outdated ideas, fears, anxieties resentments, etc. These may have been useful at one time but they are now junk; so get them out of there.

"At the same time, you keep all the valuable things in your mental house – the lessons you have learned, the experiences you value, the talents you have, your favorite memories. Polish them, keep them clean and beautiful.

"Every morning before you get out of bed, repeat this process so you keep your eggshell in good repair. It can't last long without repairing. Let the light in through the top of your head, repair the cracks in the shell, replace any broken mirrors, fix any scratches in the Teflon, and shovel out the trash that has accumulated since yesterday. Then you will be ready for the rest of the day. When you feel you have finished, you can open your eyes."

This is usually very much appreciated, enables the patient to cope better and use fewer tranquilizers.

2. Special Technique #2 – The Bottle Routine
"The Bottle Routine" was invented to cope with the over-accumulation of negative energy one patient had. She was so full of unmanageable hatred and fear, no tranquilizer could calm her down. This method, which presupposes that one can transfer human feelings into a physical object, worked in her case and was useful in emergencies until the underlying problem could be resolved. The spiel goes as follows:

"Close your eyes and think of your body as a giant battery with positive and negative emotions flowing around in it. Like any battery, it has two terminals, an 'out' terminal, which is your left hand, and an ‘in’ terminal, which is the top of your head. (Place your right hand on top of the patient's head and push down slightly.) We all easily pass outward to others the positive emotions such as love and affection since this is permissible in our society. However, we are not encouraged to pass out the negative emotions, so they store up in our body and cause us harm. But they can be moved out, and I will show you how. It doesn't matter how long they have been there; they don't change with time. Even those from early childhood can be removed. Now just concentrate on moving the anger-energy out of your left foot. (At this point I touch the left shoe with my left hand and move my hand to the areas I am taking about, avoiding touching the erotogenic areas.) Move the anger-energy out of your toes, sole, heel and ankle, moving it up through your calf into your buttocks. Move it out of your pelvis and buttocks. Move the anger through your abdomen and out of your back, up through your heart, lungs and chest into your shoulder. Then move it down your left arm to your elbow, through your forearm, wrist and store it temporarily in your left hand."

By then I will have moved my left hand to the back of the patient's left hand. Then I repeat the same statements for the right side, starting with the toes on up to the shoulders, continuing from the right shoulder to the left shoulder and down the left arm to the hand. Then I place a bottle or another disposable object in the left hand and say, "Now start pushing all the stored up anger into the bottle."

If the patient is cooperative and starts squeezing hard, I know the imagery is going well. Then I touch the right hand and say, "Now start moving the anger-energy out of your right hand, through the wrist, to the forearm, past the elbow, into the upper arm, into the shoulder. Then move it over to the other shoulder, down the arm to the wrist, to the hand and pour it all out. Now the greatest amount is stored in your head. I want you to take through the top of your head all the energy which is the opposite of hatred, which is love. Imagine a beam of pure white love energy coming down from above to act as a counter force to drive the anger out." (Here I keep my right hand on top of the patient's head and cup my left hand above the left ear as if I am pushing something downwards.)

“Push the anger energy out of your skull, hair, brain, ears, eyes, nose, cheeks, chin, into your neck, down into your shoulder, down your arm, past your elbow and wrist, into your hand. Now continue to push all the anger out. Once you have the flow channels started, they will continue to work."

I watch to see the degree of tension in the squeezing left hand and encourage the patient to keep pushing out all the anger possible until the hand relaxes and the grip loosens. I don't put a time limit on this but tell the patient to take as long as is needed to do the job, and then I will take the anger-energy away for good.

Whether or not something really goes into the bottle, who can tell? But when I have handed such a bottle to another multiple who was not present and had no idea what happened, she always showed terror of the object and insisted I throw it away. There are times when the patient should not cast out negative feelings, but must accept and integrate them. If so, the patient will refuse to do this procedure and must be allowed to do it her own way. The preferred disposal method is to place the bottle in two plastic bags and toss it into the trash can. It is important that the therapist act as if this bottle is a toxic item and takes the danger of exposure to it seriously.

B. Intellectual Acceptance of Having Multiple Personalities
After the evidence accumulates, and the patient (the current false front alter) has reason to believe her therapist and friends, she will stop denying that alters exist inside her head. She will start talking about the alters as real people who co-exist inside her head and will have an intellectual curiosity about why they came about and what they are all about. However, the therapist must not be lulled into a feeling of complacency that the patient really believes all this stuff about other personalities. She is still playing a game with the therapist and going along with the theory but does not believe it "in her gut." Doubts that are expressed by relatives, teachers, friends or others will be readily accepted by the patient to deny what the therapist is telling her. The therapist can expect to be accused by unhappy relatives of having brainwashed the patient into believing a fairy story. The therapist may be accused by the pathogenic relatives of making the patient sicker, since "she was fine until he put all this nonsense into her head about these other personalities." This, of course, ignores the fact that the patient had been acting weirdly since infancy and was practically forced into the therapist's office by these same people because of her odd behavior.

But that is the time to get started on substantial psychological problem solving. The most effective way I have found to do this therapy is with hypnotic age regression or revivification. Since all multiple patients are highly hypnotizable, they can age regress if they are willing to try.

The first step is to have the patient enter a light trance and ask the all knowing part of her mind to lift one finger when an age is mentioned when a major event occurred which feeds energy to the angry alter that needs to be dealt with first. The patient always has a "biggest baddie," and that is the one to tackle first. I count from zero to the patient's current age and make a note of when the finger lifts. If there is time, I will follow with the first age regression/ revivification session. If the finger first raised at number five, I will then tell the patient that, as I count downwards, I want her to become the age I count to. When I reach five, I will ask to talk to the patient as she was at the age of five. I keep repeating this, suggesting that when her eyes open, the patient will be age five, feeling just like she did at that age, and that she will be willing to talk over the important problems she faced at that age. If the process is not interfered with by an alter, I am talking with a five year old child when the patient awakens. This is age revivification, something only Grade V hypnotizable persons can to – BE the child at an earlier age.

Then I enter into a therapeutic discussion in the same way a child therapist would. The child brings up the problems of a new baby sibling, or a move to a new home, whatever was the issue at that age. There is seldom any difficulty with the child understanding my presence or questioning why she suddenly dropped into my office. If need be, I will explain that her parents were aware she had problems and had asked me to talk them over with her, just as one would in regular child therapy. The goal of the session is to help the child come to a resolution of her emotional conflict. It might be getting over hatred of the sibling, or receiving reassurance that she will make friends in the new town. Whatever it is, when the resolution is reached, the child often closes her eyes and returns to a trance state spontaneously. If she doesn't, she may ask to leave, and I tell her she can leave the same way she came, by closing her eyes and going back inside her head. When the trance state is again apparent, I tell her to start counting up to the present age.

After a session or two, I learn how fast the patient works out problems. Some are very resistant to changing their attitudes and require an hour per problem. Others are more flexible and can work through three or four problems per hour. By starting at the early ages and working chronologically, the child-patient and I develop a rapport, and the themes are repeated. I can refer to an earlier session for material to help in a later problem, if need be.

Since I have previously listed the ages to be covered, I cross off each age as we cover it and its associated problems. When I get to the end of the list, I presume that I have resolved all the problems that have fed negative energy, such as anger or fear, into that particular alter. Theoretically, that alter should be ripe for neutralization. I view it as a tree with several roots. Each problem is a root, and if we can pull up each root which ties this alter into the patient's unconscious mind, then, when all roots are pulled up, the tree can be toppled with a breeze. On rare occasions, the alter is such a weak fragment it just evaporates an we resolve the final problem. (In such cases, it most likely was an IIC, not an alter.) But the long standing "baddies" have to be approached through a ritual. Each patient has her own effective ritual.

It often requires the therapist's presence to "catalyze" the interaction between the ISH, which has the power to neutralize the angry alter, the current false front alter, who must make the decision to give up the angry alter, and the angry alter itself, which may fight to stay the way it is. While a benign helper alter can be brought into the group, a hostile destructive alter will usually have to be neutralized in some fashion, depending on the ISH's instructions.

If the ISH does not advise a specific mechanism, I use the approach described for "The Bottle Routine". After checking with the ISH to be sure the patient has met all the conditions to neutralize the alter, I put a bottle in the patient's hand, ask her to close her eyes and go up to the level of the ISH. Then I ask the patient to join with the ISH, to become one with its power and to bring the ISH down to cast out the negative energy of the angry alter. Than I put my hand on top of her head and move my cupped hand down her head, neck, shoulder and arm out to the bottle, all the time telling the patient that I am helping by pushing out the negative energy from each part of the body I touch into the bottle. The patient, when cooperative, goes through quite a contortion as if really pushing something down her arm and out her fingers. Some patients need no object and just extend their fingers. One "spoke in tongues" to do it. Some silently sat and prayed, showing no outward movement, but said they consigned the alter to God to do with as He wills. The patient may have a vivid visual experience of powerful helpers dealing a deadly blow to an enemy inside her head. Whatever works should be used. No one can say what really happens. The goal is to drain the negative alter of energy. The alter can be recharged if the patient backslides and repeats the kind of poor problem solving which brought it about in the first place. Then the therapist has to tackle the psychotherapy problem again until permanent changes are effected.

While some negative alters will totally disappear with this approach, others will remain, but without their negative attitudes. These are the ones who are still needed by the patient for some useful purpose, such as providing information for further therapy sessions. So that these "shells" of alters will not reabsorb the anger and hate that still resides in the patient, I find it essential to have them fill up their "emotional vacuum" with positive energy. To do this, I put my hand on the patient's head and ask her to pull in from the universe all of the healing, agape love energy available for the asking, to have it fill all the space that was just vacated by the anger-energy. When that alter then returns to normal awareness, she is glowing with happiness and love for all mankind. She then becomes a helper for the rest of her tour and can aid in therapy as long as she is needed. When she is no longer needed, she comes out to say farewell and goes away to "someplace yellow."

During this part of therapy, the patient must be advised of the wisdom and judgment of the ISH and urged to submit in every way to the ISH's directions. This is a difficult instruction for most patients to accept, being rebellious as they are and seeing the ISH as a harsh parent. But experience usually teaches them the reasonableness of this advice. But it must be repeated over and over again. The patient must develop a sense of being a disciple of the ISH, who is the guru, as well as a feeling that the ISH is a higher part of her mind. Frequently, the patient will become jealous of the attention the ISH receives from the therapist. Then resentment develops, followed by refusal to follow the instructions of the ISH. Remember, the ISH is with the patient 24 hours a day, 7 days a week. It gives guidance all that time in a calm, deliberate fashion. The patient has the option of ignoring the orders at her peril, but she can do so. Only on the request of the therapist, or in a life and death emergency, will the ISH take over the control of the body, but never to do something the main personality should but won't do. The ISH allows mistakes to happen, but not to the point of serious physical or mental harm.

C.. Coordination of Alters
During the entire course of therapy, the patient and therapist both must work to coordinate the efforts of the positive alters. They often have been working in parallel, not knowing what the others are up to, or even that others exist. Often, an alter will be out to do its duty and have no awareness that it is only one of many. When I first meet such an alter and inform it that there is a whole family of alters in the head this one must know and work with, it frequently tells me this is nonsense, since multiple personality just don't exist. To correct such doubt, I just ask the ISH to speak to that alter, and the booming voice in the head is usually quite persuasive that I know what I am talking about.

When a negative alter is encountered, a positive side must be sought. If there is any way to move an angry alter into a protective role, it should be done. Conversion to the cause is much preferred to excommunication. Each alter started for a purpose, and if that purpose still must be served, the alter must be kept. Only when the current false front alter has learned how to handle that issue by herself, can the other alter cease to function. Helpers will fade when they are no longer needed. No ritual is needed for them, as they just lose energy and no longer function, blending their talents, attributes and memories with the original birth personality when it comes back to the body.

An ambivalent alter may want to help but is made up of both negative and positive aspects. If it wants to shed the negative aspects of itself and become a full fledged helper, then "The Bottle Routine" is used with that alter.

Since suicidal and murderous impulses are contained in the negative alters, a clear understanding of the proper rescue methods must be developed by all entities involved. The ISH must know how to contact the therapist during off hours, and the spouse must be taught how to bring the ISH into control if a angry alter gets out. The hospital emergency room and inpatient psychiatric ward staff must know how to cope with suicide attempts and reach the therapist quickly.

There must be one alter whose duties includes suicide prevention. The therapist must keep contact with that one to assess suicidal risk and determine how much external control is needed. Since the current false front alter may be quite an actress, the therapist can seldom get a true idea of the suicidal potential from her. The rescuer will be the informant needed to evaluate and report such risk.

In case of violent behavior, a simple and essential technique to teach nurses, spouses and close friends is the “Touch on the Forehead”, described in "The Clinical Picture". Firm touching of that spot will usually bring out whatever helper personality is called. The one exception is when the patient goes into a "transitional trance," a coma in which no personality is in charge. Then no response is noted to any outside stimuli, and calling loudly and waiting is about all one can do. Eventually someone will take charge of the body.

D. Emotional Acceptance of Being Multiple
During most of the treatment, the false front alter who is the “identified patient” may still doubt the existence of the other alters, the accuracy of the diagnosis and the sanity of the therapist for reporting such ridiculous observations. But at some point, an event occurs which cannot be ignored, forgotten or denied. It may be the first time the voice of the angry alter is heard. It may be when filthy hitchhikers are found in the car, and the patient knows that she would never have picked up those awful people. Whatever it is, the patient becomes aware of the negativity within herself and cannot avoid facing it any longer. Then and there, emotional acceptance of being multiple occurs, and the patient enters the next phase in the therapy program. Now the patient becomes the director of the treatment activities, since the ISH is now able to feed information directly to her on how to improve, and the information is acted on without delay or question.

This is when the therapist must back off on pursuing any preconceived notions of what therapy should be, for the patient know what needs to be done. The drive to get well is now strong and over-shadows all the neurotic drives that have previously pushed the patient into such chaotic life patterns. Major changes are demanded by the patient if the old patterns interfere with getting well. This may include separating from the spouse, or at least being willing to, if the spouse's psychopathology and need to keep the patient sick becomes apparent.

Now may arise the crucial question – Who is really the patient? Who is the original personality? The therapist must look for the underlying original birth personality, since only that one can get well. Usually the original birth personality did not enter therapy and is discovered during therapy. The ISH knows it is under there somewhere and will advise the therapist in due time when it is safe for that one to come out. A careful history of the starting ages of the personalities is most helpful in preparing the therapist for this aspect. When the first negative alter has been created before the age of six, the original birth personality went underground, and a false front alter was formed to take over. Unfortunately, the new alter is usually weak, neurotic, depressed and limited in emotional scope and eventually ends up in a therapist's office. I have heard of this retreat of the original birth personality as early as birth, right on the delivery table. Others have been out of consciousness since 6 to 50 months of age.

There are many different ways in which this original birth personality may first manifest itself. It may be the only one present, if all alter-personalities have just disappeared. In that case, the therapist may suddenly have a three-year-old patient, with a family to raise and a job to do. Fortunately, it is only emotional growth that is missing, not intellectual or physical. It is of utmost importance to control with whom the patient is in contact at that point. If this transformation occurs at home, the spouse must take time off to be there, acting as a good friend, since the patient knows no three- or four-year-old can be married and have little offspring running around. The hospital may be the place for her, and the nurses become family figures who help the patient become oriented.

I explain to the patient that she has had a "sleeping sickness" and is a modern version of Rip Van Winkle. They marvel at their big bodies, but I explain that the body continued to grow while they were asleep and their emotional growth will soon catch up.

In other situations, the child-like original birth personality will only come out when the therapist is present, to work out problems that occurred in past times. Then the therapist must go through "age progression" therapy. As the child personality grows, she becomes upset about those events that were traumatic, such as rape, parental desertion, physical attack, or death of a close friend. These episodes must be faced, accepted, and dealt with. The therapist must perform the role of crisis counselor, providing guidance and understanding as if the rape has just been completed, for example. Forgiveness towards self and enemies must be taught, to eliminate the intense anger which developed in her at that time.

Substitute parents may have to be provided, if the real parents were so brutal the patient will not accept them as parents now. The selection of proper persons for the new parental roles is a delicate procedure. Never should the therapist volunteer. The therapist is needed as a therapist, and therapist and parent roles cannot be easily mixed. Usually there is a good friend available who has already assumed that role for the patient and is willing to be the new parent for the growing child personality. The most important fact that this person needs to know is that the assignment is for life. A new father figure doesn't have to be around the patient at all, after integration, but he must never deny his fatherhood role. This new parent must be willing, during the growing period, to deal with the grown adult patient as if she were a little child, bringing dolls, toys and cuddly blankets to the hospital if indicated. Again, the ISH gives explicit directions as to what to bring at what time to support the growth process. Primarily, the “parent” is there to provide the love and attention that every child needs, and that is what gives the patient the strength to face the problems she had avoided for years.

E.. Neutralization of Persecutors
The way to deal with the roots of negative alters with age regression/ revivification therapy has been described earlier. The same procedures must be done with each negative alter unless the ISH informs the therapist of an easier or shorter way. To neutralize them requires the patient to overcome those two basic defects mentioned before, one psychological and one moral. The patient must now accept responsibility for everything she thinks, feels or does, no longer delegating responsibility to another personality. This should be done by the current false front alter, who copped out in the first place. It cannot be done by a helper alter. This may seem like a simple pattern for therapists who have always been accountable for their behavior, but it is a new type of commitment for the patient.

The other aspect that needs solution is the failure of the patient to pick which camp to join – the "White Hats" or the "Black Hats." This process may be described in any terminology, but it is important that the patient get off the moral fence and choose sides. Here, religion may be the way to go for the patient. The failures in this stage are either those who give lip service to some abstract religious idea, or who could accept none of those offered. Church attendance is not related to religious belief, and may be detrimental if the clergyman and congregation try to coerce the patient into a belief system and pattern of behavior contrary to what the ISH is advocating. But the patient must be supported in her quest for a compatible religious orientation.

The patient's clergyman may be well involved already and now is the time for him to work closely with the therapist. The clergyman can take a great deal of the burden off the therapist's shoulders, if the therapist will explain what is going on and accept the clergyman as a co-professional.

In one case, the integrated multiple lady had been raised in a Fundamentalist Christian family. After integration, she learned that her mother had been born a Jew. Since Jewishness is passed down through the mother, the patient now saw herself as Jewish. She then looked for a suitable synagogue in which to worship with fellow Jews. I talked this over with her ISH, who told me that the ISH cares not where her charge goes to church, as only the emotional personality cares about that. For this patient, the synagogue was the right place for her charge to worship now.

F. Psychological Fusion
When the original birth personality has been uncovered, when the ISH is always listened to by that personality, and when all the negative alters have been neutralized, it is time for integration of all the resident alters. This process may happen spontaneously and take no work on the part of the therapist. It may happen in an hour, after the last persecutor alter is neutralized, or it may take several weeks. There may be a partial integration first, of several similar alters before the final integration. The integration process may be quite discomforting for the patient. There may be poor memory, mental confusion, alterations in mood and temper control. It may be necessary for someone else to manage the cooking, shopping and housekeeping chores for a few days.

There are many styles in which this occurs, but the end result is always the same – one original birth personality, all alone, except for the ISH. This is another very important point in the life of the patient, when she is exquisitely vulnerable to bad advice or a poor emotional environment. Now is when the patient is most likely to leave the spouse or ask the spouse to leave. If combat then ensues between the two, a murderous or suicidal fragment may be formed. Immediate therapy must be instituted, often in a hospital. Within 24 hours, the ISH can shed the bad energies developed and heal the split between the fragment and the original birth personality. Other than such short lived fragments, no solid alter should be formed after psychological integration. If they are, the patient has not yet finished her task of neutralizing angry persecutor alters, and that process must now be repeated to completion. One description was that when the original birth personality is ready to take charge of the body again, the neutralized alters are “layered onto” that personality.

The patient now has one personality, which is always listening to her guru, the ISH. As soon as she has caught her breath, new problems face the patient, only these are not really new problems. They are duplicates of the old problems which the patient failed to deal with adequately in the past and resorted to dissociation to deal with. The patient must be advised that these apparent catastrophes are happening because of the patient's need to face exactly these problems now that she has better coping methods available. If these problems are faced and dealt with, then she will pass the test for promotion to the next grade in the "School of Hard Knocks."

It is amazing how the problems hit. The patient may be fired from her job, have her house burn down, face a death in the family, find she is again pregnant while unmarried, and so on. They are tempted with every old vice the negative alters indulged in, such as alcohol, marijuana, cocaine, LSD, heroin and all the rest. The therapist must remember that the patient now knows perfectly well what to do and can assume responsibility for taking appropriate action. The therapist assists and discusses options but must not take responsibility out of the patient's hands. Only if the patient becomes suicidal must the therapist actively intervene. This need to suddenly step back from a previous posture of active intervention may be a problem for some therapists, but those I have worked with have been glad to take a breather by this time.

I can talk very glibly about psychological integration coming about, but I really do not know what that phrase means. The process is a reality but, since I have never experienced it, I cannot describe it. The patients know what it is, they know they are "one", and they intend to stay that way. All sorts of subtle and not so subtle changes occur, all for the better. The patients are a delight to have around, they are considerate of others, they start taking care of their physical health for a change. They are more productive at work. Their personal cleanliness improves. They no longer get into sadomasochistic games with people. They become independent and no longer ask for hospitalization. It is really a lovely state of affairs, at least for a while.

G. Spiritual Integration
If, after several months, the patient has faced and coped with all the old problems which have been now presented in new dress, the "School of Hard Knocks" has a graduation ceremony called spiritual integration. This occurs imperceptibly, as it is the blending of the ISH with the original birth personality. As a result of the patient always listening to the ISH and following its advice, the two become as one, and thus occurs the same sort of integration the therapist has had in his mind all the time.

During this time, the patients are not likely to be in regular psychotherapy, but will be learning from the usual support and educational groups in the community. They go to work, attend school, join Alcoholics Anonymous, go to church, and otherwise learn how to cope from successfully coping people.

H. Post Integration Experiences
During this time, the patient continues to face problems, as do all of us, but is coping in a more effective way. Old legal problems may still have to be faced. Marriages may be broken and child custody battles may have to be fought. The therapist will have to shift into a new role. The patient may leave town to start a new life, keeping the therapist informed by mail. Some patients will be personal friends of the therapist thereafter. Others will drop out of sight, to lead the life appropriate to their basic character.

CONCLUSION
Whatever the result, neither the patient nor the therapist will ever be the same again. The patient has found what had never been expected – mental health, a phrase which had no meaning before it was a reality. And what did the therapist get out of it all, besides the fee? If my experience is any guide, we therapists had our eyes opened to the. unconscious mind in a way few people have. We saw both the heights of glory and the depths of degradation to which a human can reach. We saw the healing power which resides in our universe and in each individual in that universe. We, ourselves, became a small part of that healing force. In doing so, we found out a lot more about ourselves than we ever thought was there. Some of it scared us, and some of it worried us. Some we found we had to change. But most of it we found we could be proud of, just as we were proud of our patient, the integrated multiple personality.