SPECIAL TREATMENT

TECHNIQUES TO ACCESS

THE INNER PERSONALITY

SYSTEM OF MULTIPLE

PERSONALITY DISORDER

PATIENTS

George A, Fraser, M.D.

George A. Fraser, M.D., is Director of the Anxiety and PhobicDisorders Clinic at the Royal Ottawa Hospital in Ottawa,Ontario.

For reprints write George A. Fraser, M.D., Director, Anxietyand Phobic Disorders Clinic, Royal Ottawa Hospital, 1145Carling Avenue, Ottawa, Ontario, Canada Kl Z 71(4.

ABSTRACT

In dealing with the inner personality states in dissociative state dis-orders, it is necessary to be able to effectively establish a communi-cation bridge between these states and the therapist. For the new ther-apist this may present a completely foreign concept in therapeuticdialogue. The idea of speaking for the first time with alter person-ality states may cause some apprehension. But the expectation thatthe therapist must be able to access the inner personalities may pre-sent a major problem that requires guidance for colleagues. Beginningwith a few examples of accessing techniques in past centuries, cur-rent accessing methods used by most therapists are then discussed.These include formal hypnosis, self-hypnosis, guided imagery, andchemical inductions of trance states such as those induced by theuse of sodium amytal. These accessing methods are overviewed withan example of a technique used by the author to illustrate the pro-cess of accessing inner personality states.

While researching this paper, I was impressed by themany approaches and techniques that have been writtenabout how to access and deal with the inner personality sys-tem of multiple personality disorder (MPD) . I found it some-what overwhelming as I pondered over which approach Imight choose were Ito be entering this field of work today.I would wonder if there was one which was the best, and ifso, how I would find it.

For those who may find themselves in this situation, letme share a principle I learned in quite a different field. Whenposted to West Germany in the mid-1970s with the CanadianForces, I was soon introduced to the many fine wines whichwere available. There were so many excellent ones that Ireally did not know how I should go about learning how tofind out which were the best wines. I asked a new Germanfriend who owned a wine cellar, "How do I determine whatis a great German wine?" He paused, and wisely answered,"The one that you like." And that is the principle I suggestyou apply in choosing between the many fine and variedtechniques written and taught about accessing the inner per-sonality system. Find the one that works best for you, that

you like, and that is the one for you. But have some othermethods in reserve - for no one approach will work for allyour patients/clients all the time.

I will be discussing some of these accessing techniquesand ending with an outline of the one I like and use mostoften. Although I will concentrate for the most part on cur-rent techniques, I did review the ways earlier "therapists"utilized dissociative maneuvers in people whose difficultiesresembled those we see in current day MPD. I will brieflymention three cases recorded prior to this century.

Before doing so, I will make it clear that I do heed theadvice given by Henri Ellenberger (1970). I believe all MPDtherapists should have in their libraries his excellent book,The Discovery of the Unconscious. He notes, "One should becautious in the study of old case histories, which have notalways been recorded with the same care as one would wishfor today" (p. 134). In any event, these three cases probablywere what today we might call MPD.

Ellenberger reports a case the German magnetizerEberhardt Gmelin treated in 1789 at the time of the FrenchRevolution. By the way, this was a good time for the Frencharistocracy, among others, to head off (so to speak) to Germanyin order to escape the guillotine! These new immigrants withtheir fancy ways and manners intrigued many Germans -especially a 20-year-old woman. She apparently developedan "exchanged personality" and was treated by Gmelin. Thisnew French personality spoke fluent French, possessed theFrench mannerisms, and spoke German with a French accent.When back to her normal state, she had amnesia for theactivities of her new French state. Ellenberger writes that"with a motion of his hand, Gmelin was easily able to makeher shift from one personality to another" (p. 127) . Gmelin'shand waving manoeuvre maywell be the first medical record-ing of an accessing technique for multiple personality dis-order. (From my point of view, there is much about this casethat we really do not know. I just do not believe that any"new " personality can emerge possessing the skill to speakan entirely new language without any previous learning. Isuspect she must have had previous dissociations involvingexposure to the French language.)

I was able to find a much earlier report of another access-ing strategy, this one from non-medical literature. This sec-ond case concerns an agitated and mentally disturbed adultmale who had broken free of his restraints and fled to livein the hillside tombs in an area of what is now the MiddleEast. By day and night he could be heard screaming. Heused stones for self-mutilation, gashing his arms. One day

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he spotted a preacher he had heard of and ran up to him,in this agitated state, to pay his respects. The preacher quick-ly recognized a problem which he believed to be a possessionstate. He immediately, in an authoritative voice, ordered thatthe malevolent spirit leave the man 's body. This appears tohave caused a spontaneous dissociative switch. The preach-erwas very perceptive, recognized a state change, and demand-ed the name of this new ego state. This state identified itselfby name and admitted that many others were lurking insidewith him. These ego states or alter personalities apparentlyfeared their personal elimination and pleaded that the preach-er should let them leave the man 's body and enter the bod-ies of a large herd of nearby animals. This apparently wasagreed upon and this preacher, using what today is termed"guided imagery," successfully suggested that the ego statesenter the bodies of the animals. The records indicate thatwithin no time this wild man had returned to his usual saneways and was wearing his normal clothing.

By now you may have likely guessed that the preacherwas Jesus Christ, and the unfortunate man was named Legion,who claimed to have "hundreds" with him. This overall strat-egy, of course, would have been called an exorcism. This "casereport " is described in The Gospel According to Mark (Ch.5: 1-16).

As one looks at the essence of this Biblical reference,there indeed are some aspects of what we use in current daytherapies of MPD. In today's terms, one can see elements oftherapeutic strategies attributed to Christ, including directconfrontation, identification of the alter by name, and guid-ed imagery. Like Gmelin 's accessing technique, this one byChrist would not go over well at all in today's politically cor-rect society!

I will touch on only one more early accessing technique.I think I would be remiss, here in Europe, if I did not men-tion the very important contribution to the field of dissoci-ation by France's Pierre Janet. His work is of considerablehistoric importance. An entire conference could be devot-ed to his research and therapy in the area of multiple per-sonality and dissociation.

Ellenberger (1970) notes that Janet demonstrated theimportant role of name-taking or name-giving. In Janet'swords, "Once baptized, the unconscious personality is moreclear and definite, it shows its psychological traits more clear-ly" (Janet, quoted in Ellenberger, 1970, p. 139). It is inter-esting to note the similarity of this statement by Janet withthe technique Christ used with Legion. Besides using alteridentification as an accessing facilitator, Janet would accessalters by a magnetizing technique called "automatic writing. "

He used this "indirect accessing" in such cases as his famous"Leonie." In effect, automatic writing consists of an alter per-sonality/ego state using the writing hand of the primary per-sonality to communicate without taking full executive con-trol. This technique is still used at times in present day therapies.It has severalvariations, including "automatic drawing." Morerecently, some patients have reported doing their own "auto-matic personal computer writing" (communicating on avideodisplay terminal) !

The common pattern in these early cases and others of

the latter part of the 19th Century and first half of this cen-tury was that the inner personality system could be discov-ered by various hypnotic manoeuvres. It would thus seemonly natural to use hypnosis as part of the treatment strate-gy when the new awareness of MPD began in North Americaaround the 1970s. But this time around the use of hypnosisin MPD was greeted with skepticism in some quarters.

The argument that hypnosis could causeMPD challengedthe use of this modality. Richard Horevitz (1983) states, "Thedoubts about the validity of multiple personality stem fromits association from hypnosis" (p. 139). This concern aboutthe risks of using hypnosis in MPD has been echoed by manyauthors, including a recent article by H. Merskey in the British

Journal ofPsychiatry entitled 'The Manufacture of Personalities:The Production of Multiple Personality Disorder" (1992).

However, Kluft (1982) and Braun (1984) have addressedthese concerns about the use of hypnotherapeutic techniquesin the treatment of multiple personality. Kluft carefullyreviewed the critical literature and concluded, "There is nofirm evidence that hypnosis in and of itself creates or wors-ens multiple personality. Evidence has been presented toshow that carefully applied hypnotic procedures may serveuseful roles in its diagnosis and treatment" (p. 238). Kluft(1982) , however, does concede that, "Phenomena analogousto and bearing dramatic but superficial resemblance to MPDcan be elicited experimentally or in a clinical situation if onetries to do so or makes clinical errors " (p. 232). For thosewho wish more information about hypnosis and MPD, EugeneBliss (1986) discusses extensively this topic in his book, MultiplePersonality, AlliedDisorders, and Hypnosis. In addition, an entireissue of the journal DISSOCIATION was devoted to the ques-tion of iatrogenesis in MPD (Kluft, 1989a).

Within the field, there is consensus that the prudent useof hypnosis is a valid accessing and therapeutic tool to aug-ment the core treatment of MPD patients which, of course,is the psychotherapy. Thus, it is very useful for MPD thera-pists to have a grounding in hypnosis and hypnotherapeu-tic principles. Such a grounding, for instance, alerts thera-pists to the fact that recall under hypnosis may not alwaysbe accurate, and poor questioning techniques can influencea patient's apparent memory recall.

However, hypnosis induced by the therapist is not theonly means available to contact personalities. Multiple per-sonality patients are generally highly hypnotizable(Loewenstein, 1991) and some may learn to communicateacross their system through what would be termed sponta-neous self-hypnosis. The personalities may emerge without anyaccessing strategies on the part of the therapist and mayinteractwith the therapist on their own initiative. Flashbacksof memories, for example, is probably a form of spontaneousself-hypnosis in which amnestic barriers are suddenly andunexpectedly penetrated. Thus, such patients accessinginner personalities and memories via self-hypnosis couldengage in therapy without using any formal procedure.

Half-way between the two modalities of formal hypno-sis and self-hypnosis would be one often referred to as guid-ed imagery. In the case of guided imagery, since MPD patientsare readily hypnotizable and prone to spontaneous tranc-

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ing, a therapist, without using any formal hypnosis, couldprovide imagery and/or suggestions adapted from such areasas gestalt therapy, meditation, and formal hypnosis. Usingthese, the patient could be guided into self-hypnotic statesand be taught to access the inner personality system. Manytherapists untrained i n formal hypnosis use guided imagery.

In attempting to provide an outline for accessing strate-gies to alter personality states, it should be understood thatthere is no agreement about whether a hypnotic state is thesame as a dissociated state. There also have been contro-versies as to whether hypnosis is a special state or a trait.These controversies continue to be the subject of ongoingscholarly debate (Lynn & Rhue, 1991; Horevitz, 1992; Bliss,1986). Though the factors involved in dissociative state dis-orders are complex, nonetheless, one that does seem pre-sent in all is that there does appear to be a change in statesimilar to the trance state observed in deep hypnotic respon-ders. So in spite of the differences between a state of hyp-nosis and dissociation, the trance states present in both sharemany similarities. A similar trance state may also be inducedby sodium amytal (Ross, 1989).

I believe there are basically four overall methods to accessinner states: self-hypnosis, formal hypnosis, guided imagery,and trance-inducing drugs (i.e., sodium amytal). However,two other situations have led to accessing trance states. Inthe histories given by dissociative state disorder patients, theyappear to have formed such states due to fear related to psy-chic trauma or pain. Fear or trauma, then, could also be con-sidered an accessing method, though hardly one appropri-ate to therapy. Some patients using meditation have reportedentering trance states. In summary then, trance states canbe accessed in at least six ways:

1) Formal hypnosis,

2) Guided imagery,

3) Self-hypnosis,

4) Meditation techniques,

5) Drugs (i.e., sodium amytal), and

6) Fear, pain.

While often one method is favored by a particular ther-apist (most often, formal hypnosis or guided imagery), it ispossible that two or even all of these basic approaches couldbe used during the course of therapy.

As a therapist, one must become familiar with at leastone of the above approaches to gain access to the system ofinner ego states and be able to lead these states to a resolu-tion of their conflicts and ultimately to an acceptable formof integration. In addition to knowing these basics, it cer-tainly is an advantage to have knowledge of a wide range ofhypnotherapy-based manoeuvres (which may not need tobe applied through formal hypnosis). These can be used inaddition to accessing and may be of great aid in diminish-

ing crisis situations or in ameliorating distressful symptomsduring the process of therapy.

This situation of using various strategies is addressed byKluft (1989b) who states, "The majority of the extant liter-ature on the use of hypnosis for the treatmentofMPD address-es the processes of the accessing of alters, arranging recon-ciliations among the alters, and facilitating integration" (p.90). He shows how more specialized hypnotherapeutic-basedprocedures can also be used, in the interest of stabilizingthe MPD patient, such as "alter substitution , provision of sanc-tuary, distancing manoeuvres, bypassing time... and rear-ranging the configuration of alters by bartering..." (p. 90).Others might add traditional hypnotic techniques such asthe affect bridge, automatic writing, and ideomotor signalling.

Accessing alters is not invariably a benign procedure forit can open a Pandora's box of previously dissociated trau-mas. Therapists should remain within their level of compe-tence and should not go beyond the scope of their field ofexpertise. When in doubt, one should ask for a consultationwith a colleague or seek supervision.

Before using accessing techniques, you also should havea diagnostic case history. You should be familiar with theways in which inner personalities develop, present them-selves, and can directly and indirectly influence the symp-tomatology as well as the therapy. You should understandsuch concepts as the delusion of individual separateness, thealter personalities' initial fear of being eliminated in thera-py, and the management of abreactions, to name just a few.With this basic knowledge you are now ready to access yourpatients' inner world.

There are two excellent books in the MPD field whichnot only cover these basics, but also contain alternate access-ing techniques. I recommend you refer both to Putnam'sDiagnosis and Treatment of Multiple Personality Disorder (1989)andRoss's Multiple Personality Disorder:Diagnosis, ClinicalFeatures,and Treatment (1989).

Many other therapists and speakers at this conferencehave developed excellent strategies of accessing alters.Constraints of time and space do not allow me to discuss themany techniques now available. The conference organizingcommittee requested that I outline a strategy for accessingthe inner system which I have been developing. Although Iam most comfortable with this approach, I am prepared toemploy various other hypnosis-based strategies if they arerequired.

In the early 1980s, I was developing a group of tech-niques combining gestalt therapy with hypnosis. It was aCanadian colleague, Dr. John Curtis, who encouraged meto write a paper formatting these strategies. In the begin-ning I borrowed from many disciplines of psychotherapyand hypnosis and adapted these for my use with MPDpatients. Other strategies I improvised or invented as need-ed. These strategies together form a "package" which I callTheDissociative Table Technique. Details of this technique havebeen published in DISSOCIATION (Fraser, 1991).

As other therapists in my area have found this DissociativeTable Technique useful, there has been an unexpected advan-tage. When such patients are seen in consultation or looked

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FIGURE 1Modalities of accessing ego states/alter personalitites

SELF-HYPNOSIS

GUIDED IMAGERY

FORMAL HYPNOSIS

MEDITATION

DRUGS

FEAR, PAIN

INNER PERSONALITYSYSTEM

after when their usual therapist is not available, if that ther-apist has been using the Dissociative Table Technique, I amalready aware of the accessing techniques and imagery thatthe patient is using. Therefore, our having a standard access-ing technique for the ego states is quite beneficial for patientand therapist when the patient has to be covered or trans-ferred to another therapist.

In outline, the dissociative table strategies center aroundan extension of the gestalt two-chair technique. In effect,the patient is guided by imagery (or, if wished, by formalhypnosis) to visualize a safe place in which "no one gets hurt."Generally, I encourage visualization of a room with an ovaltable (some patients prefer to avoid rooms or tables). Next,the patient is asked to visualize himself or herself sitting inone of the chairs around the table. Being highly hypnotiz-able, the MPD patient can readily enter a trance state whencooperating with the imagery suggested by the therapist.The patient is in a trance state visualizing himself or herselfat a table, thus being in my office and in that safe room withthe table at the same time. Next, alters in the system areinvited into this room and asked to take a seat. Special careis taken to avoid iatrogensis. I do not suggest personalitiesare present but do set up an imagery template based on thehistory given by the patient. This history must indicate pre-vious experiences suggesting the presence of dissociated egostates. My task is to access previously-formed ego states, notto produce new ego states. The unique aspect about thisvisualization imagery is that the inner personalities show upat the table, not necessarily with the physical appearancethat the presenting personality might have expected, butwith the image each ego state has of itself. Thus, for the first

time the system has made a gigantic conceptual advance inachieving inner awareness.

With the group around the table, and able to see thosewho were willing to come to the table, they are able to com-municate with each other very much like the technique devisedby David Caul (1984) called Internal Group Therapy. I want-ed some way to be able to have input into who was going tospeak, rather than let themdecide who would speak and whowould not. Interestingly, the solution to this problem camefrom the book describing David Caul's therapywith his famouspatient, Billy Milligan (Keyes, 1981). Billy's alters related tothe outside world by taking turns standing in the light of astage spotlight maintained in their inner world. The personunder the spotlight was the one who related to the outsideworld. I adapted this by having a spotlight (or a microphone)above the group or conference table and whoever wantedto speak could ask for the light (or microphone) , or the lightcould be placed on someone who would find himself or her-self "on the spot" and thus able to speak to me.

Another very important advantage of this technique ofhaving the group able to now visually and verbally interactwith each other as well as the therapist, is that the person-alities now are able to know everything that is happening intherapy. No longer need the patient ask what happened whenthe therapistwas talking to another personality state. I remindthem that everyone at the table is able and expected to lis-ten to all conversations; therefore there is not longer theneed for the patient to have amnestic episodes during thetherapy unless there is an agreed upon need for a tempo-rary amnesia. Previously, an amnestic period could have ledto some concerns by the patient in regards to what might

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have happened in the office during that amnestic period.In this era of increased litigation against therapists, it is use-ful to have a therapeutic technique in which alter person-alities can be dealt with without any loss of awareness by thepresenting personality. i remind them that in using this tech-nique they have the ability to know all that goes on in thetherapy.

Because of the difficulty in going through vigorous abre-actions in a busy clinic setting, I experimented with havingthem visualize the traumatic memories on a movie or T.V.screen within this board or conference room. These trau-matic scenes could be shown on the screen. Their pace andextent could be controlled by the use of a remote controldevice to stop, slow, speed up, or reverse them. At the sametime, the other alters are reviewing the same scene, thussharing that memory and emotion. While this techniquecould encourage a cognitive awareness without too muchfeeling (which may initially be useful for some traumaticmemories) , steps are taken to ensure that the emotions areeventually paired up with the rest of the aspects of memo-ry. The rationale for this approach is explained in Braun's(1988) description of his BASK model.

As memories are recovered and worked through, I havefound it useful, though not essential, for personalities to per-ceive that they have "grown " along with the therapy so thatat the time of preparation for fusion/integration, those whoremain separate are at least all of the same sex and age asthe host body. This is achieved through the image of a smallstage by the side of the table. The personality, when ready,can enter onto the stage to either advance in age (age pro-gression) or change to the actual biologically-assigned sexvia guided imagery, described elsewhere (Fraser, 1991) . Thisstrategy was developed because patients repeatedly told methat they felt uncomfortable joining as a child ego state withthe adult state without having had some perception of inter-mediate stages of growth. While not necessary, I frequentlyuse this strategy in preparation for fusion/integration.

Finally, the time arrives for a fusion/integration or acoming together of the personalities. This is accomplishedby a very simple ceremony. I merely have them join handsin a circle, and I count to five (or whatever) for them as theywalk towards one another to blend into a co-conscious unity.If ritual abuse has been an issue, by this stage of therapy theuse of a circle usually does not present a problem.

The Table Technique actually is not only a series of access-ing strategies, but is a setting (including table, screen, stage,etc.) which offers a consistent milieu where much of thetherapy can be done.

All this sounds rather straightforward and simple. It isnot simple! The accessing outline I presented is only thestage setting for a course of prolonged and often emotion-ally stressing psychotherapy - stressful to patient and ther-apist, to families and friends.

In essence, the dissociative table technique allows thetherapist to encounter a patient with a multi-levelled egostate disintegration, and gradually, through hypnosis or guid-ed imagery, to lead the patient to a sense of unity ofself/selves obtained through the harmony and the integra-

tion of the ego states. This technique is only one of the manywhich are now available to therapists who wish to gain accessto the inner personality system as they prepare to help vic-tims/survivors of childhood abuse who dissociated their trau-matic experiences.

Though many good accessing models are available, thenovice therapist will discover that they all revolve aroundone of the four methods mentioned - formal hypnosis, vari-ations of self-hypnosis, guided imagery, and chemical induc-tion of trance states such as with sodium amytal or (in itsnon-therapeutic setting) alcohol. Like a good wine, youraccessing techniques will improve with time! ■

REFERENCES

Bliss, E.L. (1986). Multiple personality, allied disorders, and hypnosis.New York: Oxford University Press.

Braun, B.G. (1984). Hypnosis creates multiple personality: Mythor reality? InternationalJournal of Clinical and Experimental Hypnosis,32, 191-197.

Braun, B.G. (1988). The BASK (behavior, affect, sensation, knowl-edge) model of dissociation. DISSOCIATION, 1(1) , 4-23.

Caul, D. (1984) . Group and videotape techniques for multiple per-sonality disorder. Psychiatric Annals, 14, 43-50.

Ellenberger, H. (1970). The discovery of the unconscious. New York:Basic Books_

Fraser, G.A. (1991). The dissociative table technique. A strategyfor working with ego states in dissociative disorders and ego-statetherapy. DISSOCIATION, 4(4), 205-213.

Horevitz, R. (1983). Hypnosis for multiple personality disorder: Aframework for beginning. American journal of Clinical Hypnosis, 26,138-145.

Horevitz, R. (1992). Hypnosis and Multiple Personality Disorder:Connections and Controversies. American Psychological Association(Centennial Presidential Address). Washington, DC.

Keyes, D. (1981). The minds of Billy Milligan. New York: RandomHouse.

Kluft, R.P. (1982). Varieties of hypnotic interventions in the treat-ment of multiple personality. American Journal of Clinical Hypnosis,24, 230-240.

Kluft, R.P. (1989a). Editorial: Thoughts on the issue of iatrogene-sis. DISSOCIATION, 2 (2) .

Kluft, R.P. (1989h). Playing for time: Temporizing techniques inthe treatment of multiple personality disorder. American Journal ofClinical Hypnosis, 32, 90-98.

Loewenstein, R.J. (1991) . An office mental status examination forcomplex chronic dissociative symptoms and multiple personality.Psychiatric Clinics of North America, 14, 567-604.

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Lynn, Si., & Rhue, J.W. (Eds.) (1991) . Theories of hypnosis: Currentmodels and perspectives. New York: Guilford Press.

Merskey, H. (1992). The manufacture of personalities. The pro-duction ofmultiple personality disorder. British Journal ofPsychiatry,160, 327-340.

New American Bible (1971). The new testament. The gospel accordingto Mark, Ch. 5: 1-16. Chicago, IL: The Catholic Press.

Putnam, F.W. {1989). Diagnosis and treatment of multiple personalitydisorder. New York: The Guilford Press.

Ross, C.A. (1989). Multiple personality disorder: Diagnosis, clinical fea-tures, and treatment. New York/Toronto: John Wiley & Sons.

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