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MPD and DID are Two Different Post-Traumatic Disorders

Ralph B. Allison, M.D., Calif. Men's Colony State Prison, San
Luis Obispo, CA 

c 1995 Ralph Allison

ABSTRACT

	With the advent of DSM-IV, Multiple Personality Disorder (MPD)
was renamed Dissociative Identity Disorder (DID). This assumes
that there is only one condition to be named. Clinical
experience reveals that there are at least two dissociative
disorders commonly seen in practice, and it is proposed that
both of these labels can be used, but for different subgroups of
the dissociative patient population. The key item of
differentiation is the age when the patient first suffered
sufficient trauma to dissociate. If the first dissociation was
before the age of seven, a condition that should be called MPD
will be created. If the first dissociation occurred after the
seventh birthday, a condition that should be called DID will be
created. Each of these post-traumatic disorders is
differentiated from the other by at least 15 factors, including
the presence or absence of the Inner Self Helper, and the
effective treatment plan.

INTRODUCTION

	During the debate of the Committee on the Dissociative
Disorders for the creation of DSM-IV, the condition then known
as Multiple Personality Disorder (MPD) was renamed Dissociative
Identity Disorder (DID). I was not a part of that debate, but I
understand from those who were that there were two polarized
groups composing the committee. One group were the therapists of
multiples, and the other group characterized themselves as
experts on hypnosis. The experts on hypnosis favored DID and won
this battle. The experts on therapy felt beaten in this battle,
as their "favorite disease" was abolished, as the name had great
symbolism for both them and their patients.

	In this paper, I would like to attempt to restore a sense of
balance between these two forces. In my opinion, no one can be a
true expert on the treatment of multiplicity without being an
expert in the use of hypnotic techniques in treatment of
dissociators. Since dissociators are usually highly hypnotizable
individuals, an education in the proper, ethical use of hypnotic
methods is essential knowledge for these therapists.

	Therefore, as a result of seeing many multiples in many
settings, and from using hypnotic techniques in therapy ever
since I was first trained by Jay Haley during my residency at
Stanford, I have come to the conclusion that both diagnostic
labels can be used, because they can properly apply to two
subgroups of patients I will call multiples. When first
outlining the differences that can be identified between these
two groups, I found 15 points on which they differed. Nowhere in
medicine is it logical to consider two patient groups to be
suffering from such disparate conditions to have the same
diagnosis. Therefore, in the interest of "fine tuning" our
diagnostic, and therefore our treatment, criteria, I suggest
that MPD be applied one subgroup of multiples and DID to another
equally important, but quite different, group of patients.

ETIOLOGY

	MPD should be reserved for those dissociators who suffer their
first major psycho-sexual- physical assault before their seventh
birthday. DID should be reserved for those who suffer the first
assault to which they respond by a defensive dissociative
process after their seventh birthday. 

	Child development specialists have long considered that it
takes an average of seven years for any child to develop the
personality that will be theirs for life. The personality of a
child less than seven is too fragile to absorb life threatening
trauma without reacting in some fashion. Obviously not all
children react to early trauma by dissociating, but those who do
develop psychological entities which are different than those
created at an older age.

	Obviously, I am not pointing to the seventh birthday as a magic
moment when all is solid, and the moment before all was liquid.
The trauma to the younger child usually has occurred first at a
much younger age, since it most likely will have occurred in the
parental home setting. Therefore it is not uncommon to find
severe abuse by parental figures from infancy on. 

	However, if the patient came from a reasonably healthy family
and then went out into the cruel world around him/her, that
usually happened after the age of seven. Then the abuse most
likely was caused by some member of the extended family or
someone in the community. When the first abuse that caused
dissociation happened at the age of eight because of a rape by a
cousin, then the results are far different than if the rape was
committed by the father or stepfather at the age of three.

	In the case of the younger set of victims of assault, they need
to defend themselves from further abuse by these primary
caretakers. Since they cannot have Basic Trust in their parental
caretakers, they must ensure their physical survival by mental
means. Those who are older when assaulted already have developed
Basic Trust in their core family members, and they then have a
need to protect themselves from others outside the core family.
They feel too immature or untrained to defend themselves with
physical means, so they resort to making defenders of their
bodies within their minds.

	Therefore, MPD should be used for those who suffer the first
major assault which causes a dissociative response before the
seventh birthday. DID should be used for those who experience
dissociation following the first major assault after the seventh
birthday. MPD multiples will have been abused in the parental
home. DID multiples will have been abused either in the home,
school, or community. MPD multiples need to dissociate to ensure
their physical survival after assault by a primary caretaker.
DID multiples dissociate to defend themselves from further
assault by those who are endangering their present welfare. They
do not know how to do it with coping methods which must be
learned from more experienced persons.

CLINICAL PRESENTATION OF SYMPTOMS

	In the younger group, which I call MPD multiples, the first
entity to dissociate from the Birth Personality (BP) is the
Inner Self Helper (ISH). The "Mind" that is left I shall call
the Original Personality (OP). The ISH is then the creator of
all subsequent alter-personalities, no matter what type. The ISH
creates them to assure the physical survival of the child, who
is known to the ISH as his/her "charge." Prior to this first
dissociation, that which becomes the ISH has been the "charge's"
source of inspiration, the "still small voice within" which I
prefer to call the Essence of the patient. The ISH role is only
a temporary "job assignment" for the Essence, which desires to
return to an original state of unity within the multiple's mind.

	Within the DID multiple's mind, (with the BP intact), the first
assault will create a defensive alter-personality. The mind is
mature and strong enough not to need the Essence to dissociate
and take on the role of ISH. Therefore, no ISH exists, and the
only dissociative entities are alter-personalities which have
been developed in response to the particular type of abuse that
the person suffered. If it is sexual abuse, i.e. a rape, then
the alter-personality will be sexualized and may become a
prostitute, using aggressive sexual behavior to control and
degrade men. If no more assaults occur, there may be no more
alter-personalities created. This would then result in someone
with only a Dual Personality, one "normal" and one socially
deviant.

	In the case of the MPD multiple, the second dissociated entity
to form would be a False-Front alter-personality. This must be
created by the ISH to replace the (OP) which has been deemed by
the ISH to be too inadequate to stay in social control of the
body. This first False-Front is designed and manufactured by the
ISH to present an image to the abusive parent which will assure
its survival. It may be made completely compliant, cooperative
without crying, and able to absorb abuse without responding
angrily. This will be the child the abusive parent can continue
to abuse without any adverse reactions being created.

	In the case of the DID multiple, the next alter-personality
developed will be unique to the next traumatic situation. If
there are no more traumas suffered, there will be no more
alter-personalities created. If the first trauma was a rape,
with a prostitute being created. If the second is a physical
assault by boys, then the second one might be a tough masculine
protective alter-personality.

	The OP of the MPD multiple will disappear from any social
control of the body with the creation, by the ISH, of the first
False-Front alter-personality. The OP will be hidden in a deep
recess of the mind, where it will be kept safe from further
assault. It will also be kept protected from any social training
by live human beings, until it reappears in the safety of an
ethical therapist's office. Then the OP must start growing
again, taking up where s/he left off. Thus, the patient who
comes in for therapy as an adult is not the OP. It is the latest
of a long series of False-Front alter-personalities. It is the
one designed by the ISH to deliver the body for therapy, and
take the body out the door at the end of the session.
Unfortunately for the naive therapist, no False-Front
alter-personality can grow and mature with verbal therapy. They
are programmed to be what they are, which is usually a whimpy,
depressed, suicide-prone whiner.

	The BP of the DID multiple will be in charge of the body at all
times, except when certain emotions trigger off the appearance
an alter-personality. Therefore, s/he who comes in for therapy
can grow and learn with verbal therapy. The BP can make
constructive changes if provided with the proper tools and
incentives. 

	Whereas the DID multiple will have few alter-personalities, the
MPD multiple must create a large number over the years of
"growing up." After the first False-Front alter-personality has
been created by the ISH, if the abuse continues, anger-energy
builds up inside the child. Since the False-Front has been
specifically created not to process anger, it has to go
somewhere. The ISH then has to create a Persecutor
alter-personality to hold and express the anger. This one will
inevitably come out and attack a sibling, for example, which
will create the need for a counter-balancing alter-personality.
The ISH then has to create a Rescuer alter-personality. As the
child grows in chronological age, each False-Front
alter-personality becomes obsolete and must be replaced by
another one which is designed to cope with the new
responsibilities of the next year(s) of life.

	In addition to these inevitable alter-personalities, the
specific bad home life may make necessary some disabled
alter-personalities, such as deaf ones who cannot hear the
parental arguing. There may also be those who identify with
important persons in the neighborhood or school, and these will
be modeled on significant characteristics of these other
children. The MPD multiple can make up to 60 legitimate
alter-personalities of all types. Beyond that, one should doubt
the reality of the other "creatures" seen as being true
alter-personalities since the ISH will likely have run out of
personality characteristics to use in new alter-personalities.

THERAPY ISSUES

	Since only a live patient can benefit from psychotherapy,
suicide prevention is a must for these patients. The DID
multiple will rarely attempt suicide, since the BP is usually
functioning well in a number of social arenas, such as home and
work. These patients will make their suicide attempts when the
alter-personality has put them in jail, or another such
embarrassing situation. It is when they feel helpless and
hopeless, not knowing why they are in such predicaments, that
they make their suicide attempts. It is at that point, of
course, that they are also most amenable to entering into
meaningful therapy.

	The MPD multiple, on the other hand, will have a history of
numerous suicidal attempts, often under bizarre conditions, and
frequent rescues from death. This is because the False-Front
alter-personalities have run out of programs to use solve normal
problems, and they view suicide as the only way out. The ISH has
to rescue them, so s/he calls for help, and the body ends up in
the hospital ER again, followed by a 72 hour hold on the
psychiatric ward. There the Rescuer alter-personality convinces
the psychiatric resident that the suicide attempt was just a
misunderstanding with her boyfriend, and it will not happen
again. Unless the MPD multiple is in serious therapy with an
ethical therapist who uses this incident to do effective
therapy, the patient will be discharged, only to return a month
later with a similar story.

	The therapy plan for the DID multiple must be individualized,
depending on the nature of the few alter-personalities. The
basis principle is that the BP must learn adult coping methods
to deal with the problem that each alter-personality was
designed to solve. Unfortunately, the methods used by the
alter-personalities are usually ineffective over the long haul,
and training in assertiveness, and other such complex socially
responsible behavior is required. What is needed is for the BP
to become able to cope with similar problems in the proper
fashion for the society in which the person is living. That will
cause the alter-personality to become obsolete. When that
happens, it might disintegrate of its own accord, since, without
a purpose, it cannot exist.

	However, for the MPD multiple, a more complex and structured
therapy plan is needed. The basic steps were outlined in 1980 in
Minds In Many Pieces as follows:
	1.	Recognition of the existence of the alter-personalities.
	2.	Intellectual acceptance of this condition.
	3.	Coordination of alter-personalities.
	4.	Emotional acceptance of multiplicity.
	5.	Neutralization of persecutors.
	6.	Psychological integration.
	7.	Post-fusion experiences.
	8.	Spiritual integration.

	Whereas in the DID multiple, there is no ISH to work with the
therapist, in the MPD multiple, the ISH is an essential
co-therapist who is always waiting inside to be invited to
participate in reconstructive therapy. Therapy must be guided by
the therapist and ISH, not by the patient. S/he will be running
away from the pain of effective therapy and will be creating
numerous crises to divert the therapist from dealing with her
intrapsychic issues. A clear plan of action must be followed by
the therapist, who can be guided by the ISH, who knows which
issues and alter-personalities need to be addressed in what
order. The ISH can also give the therapist feedback so that
mistakes can be quickly corrected.

	The methods of treating the DID multiple can be multiple,
including hypnotic visualizations as needed, assertiveness
training, job training and supportive psychotherapy. However, in
the case of the MPD multiple, those methods are inadequate. A
major goal is for the therapist to bring forth the OP, who is
the patient who needs to be rehabilitated. That requires
extensive use of many hypnotic techniques, and the regular use
of age-regression sessions. Each Persecutor alter-personality
needs to be evaluated and understood, which can only be done
effectively in the context of hypnotic age-regression sessions.
In those sessions, the assault/conflict situation which preceded
the creation of that particular alter-personality must be
identified. Then the misunderstandings the child developed and
the emotional reactions s/he had are explored and resolved. To
do that effectively takes four basic steps as follows:
	1.	Abreaction
	2.	Reframing
	3.	Acceptance
	4.	Discharge

	How to do this is described in the manual for the course on
Working With the Inner Self Helper (ISH) During and After
Therapy, given at this meeting. These steps must be followed,
without fail, in dealing with each Persecutor alter-personality.
This will bring about the Neutralization of each Persecutor, and
thereby the obsolescence of the associated Rescuer
alter-personalities. This must be done for all Persecutor
alter-personalities before the ISH will deem it safe for her to
bring out the OP, who then must assimilate all of these parts
into herself. That is what constitutes Psychological
Integration. The final Spiritual Integration of the OP and the
ISH will occur sometime after formal psychotherapy has been
completed. That requires that the integrated OP be exposed to
many real life situations, so that s/he can learn how to cope
with them in a socially constructive fashion. When the ISH
considers his/her "charge" to have passed these "tests of the
School of Hard Knocks," s/he will then blend in with the OP,
accomplishing the final goal of Spiritual Integration into the
Birth Personality.

THERAPY WHILE INCARCERATED

	Since I have worked part of my career in jails and prisons, and
have seen a number of alleged multiples faced with serious
criminal charges, I have been able to arrive at some tentative
conclusions about the wisdom and reasonableness of treating
either kind of case while the person is incarcerated. This
includes the forensic psychiatric hospital as well as a prison
where rehabilitation services are added to the custodial
operations.

	Before I discuss that issue, I must make one caveat regarding
the finding of either of these diagnoses, MPD or DID, in the
severely criminal subgroup of our society. I am excluding from
consideration here the issue of malingering, and will assume
that the clinical picture shown by the defendant in jail or the
inmate in prison is not fabricated for the purpose of a defense.

	In the case of the MPD multiple, once the Essence has taken on
the role of ISH, it is committed to the welfare of its charge,
and it is operating under the highest ethical standards. It
cannot condone the killing of its charge by anyone. It also will
not allow its charge to fatally harm anyone else. It cannot
prohibit an angry alter-personality from striking out in
self-defense against an attacker. But, once its charge's
physical safety is assure, the ISH can block all physical action
that would lead to the death of the attacker. 

	These patients, therefore, would not be likely to murder
someone, especially a stranger who was not attacking them at the
time. So, in those cases where the subject of forensic
evaluation is an alleged MPD multiple, with early child abuse
history before the age of seven, it is not likely that this
person would commit "cold-blooded" murder. I have not even seen
any who are guilty of killing in self-defense, since the ISH has
ways of getting away from the scene of harm once personal safety
is secured. The ISH will not allow revenge to take place, if
that will cause death of someone else. They just will not be
allowed to do that by those entities supervising them.

	In the case of the DID multiple, the alter-personality is made
for self-defense by the non-dissociated Essence, not for planned
offense against others. It may play a role in street gangs, but
to plan an execution of anyone else would be quite against its
reason for existence. Survival is the reason for its existence,
and killing "in cold blood" is not a tool for survival.

	Therefore, in those cases where what appear to be hostile
alter-personalities who have allegedly killed a stranger "in
cold blood," I recommend that neither MPD nor DID be used as an
diagnosis. These individuals have more likely created revengeful
"imaginary playmates" from their imaginations, and this process
can occur before or after age seven with equal ease. In the
cases I have evaluated, these Imaginary Malignant Playmates
(IMPs) have been made by the defendant when he knew of violent
harm being done to members of his family, members he should have
but could not protect. In his distress at being unable to
protect them, he sought a means of revenge against this abuser
of a helpless family member. He made up this IMP out of his
personal imagination, to use as a tool of revenge, not
self-protection. The reason we see him in court is that he has
used this IMP as a tool of destruction against some stranger in
the community, usually doing unto them what the original villain
did unto the beloved relatives he could not protect at the time.

	This type of individual I cannot and will not include in the
MPD or DID categories. He is, more properly, Whoever Has an
Imaginary Malignant Playmate (WHIMP). I called these the Maybe
Multiples in Courts and Corrections in 1987, but WHIMP seems
accurately descriptive. They are too cowardly to face the
attacker of childhood themselves, so they make a hitman in the
form of an IMP, and let it do the dirty deeds they dare not do.
They are very confusing since they are only seen in the forensic
setting, where the expert witness are wondering first whether
they are real or the products of malingering. We need to be very
careful not to confuse these WHIMPs with their IMPs with the
other two types of multiples already described.

	But, on the issue of whether or not to recommend treatment in
an incarceration setting for the DID or MPD multiples, my
opinion is mixed. The MPD multiples would be too fragile to
survive the demands of any prison, no matter how progressive,
without further disintegration. Also, with the bureaucratic
organization of the treatment staff, is would be highly unlikely
that a single competent, ethical therapist in an institution
would be able to allot the time and continuity of care to such a
person. It would seem impossible to treat an MPD multiple in a
prison or jail setting. 

	I would also find it difficult to envision how any forensic
psychiatric hospital could do any better, since it must operate
under very strict rules at all times. Any therapist and ISH of
an MPD multiple will be constantly denied the means to meet the
special needs of the therapy which will inevitably occur. They
are best treated on an out-patient basis in a community setting,
where the full array of opportunities exist. Only there can the
community resources be used effectively when needed in the total
therapy plan.

	On the other hand, it is reasonable to expect to be able to
treat the DID multiple in either a prison or forensic hospital
setting. These places operate on a social learning, behavioral
modification model, and that is just what most of these patients
need. They need to learn how to behave in a socially
constructive and appropriate way, instead of splitting off
another "self" to do what they don't know how to do. They need
the social, education, and communication skills that such
institutions provide to all their clients. The therapist
provides the role of coordinator, referrer, and stimulator of
the use of these institutional services. These functions can be
well managed by most of the treatment staff members of any well
run such institution.

CONCLUSIONS

	The dissociative defense mechanisms which some abused
individuals utilize for their own personal protection create a
different clinical picture depending on the age of the
individual being abused. Therefore, it seems reasonable to
separate these patients into at least two groups. The term MPD
should be used for those severely abused before the age of
seven, as they develop a different and much more complex set of
clinical symptoms than do the patients abused at a later age.
The Original Personality is not operating socially and therefore
cannot have an Identity Disorder. In truth, the ISH has created
Multiple Personalities.

	The term DID can be reasonably applied to those who first use
the dissociative defense mechanism after their seventh birthday.
They then develop alter-personalities of a different type
because they have different needs to fulfill. The Birth
Personality then does indeed have an Identity Disorder.

	Neither one of these labels should be applied to criminal
defendants who have clearly killed "in cold blood" in a fashion
similar to the way someone else attacked their relatives, but
not themselves. These persons are not likely to have created
alter-personalities of the same type as those created by the two
groups described here.

	Recognizing the existence of these subgroups is essential if we
are to provide adequate, ethical and responsible management and
therapy to any of them. Much of the confusion in the past decade
has resulted from mixing these two groups, MPD and DID, into one
pool and then applying the same diagnostic and therapeutic
principles to all of them. This is not reasonable in any field
of medical practice, and it is no more reasonable in the
practice of treatment of those patients of ours who suffer from
dissociative disorders.