Biomedical subjects
Publications and source records attributed to R P Kluft.
This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.
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Dissociative Identity Disorder (DID) is identified and studied with increasing frequency. However, the controversy that often surrounds DID can make it difficult to approach its treatment in a circumspect manner. This paper will provide an overview of DID treatment as it is practiced by those experienced and skilled in the treatment of this group of patients. The treatment of DID resembles the treatment of other traumatized populations in that it is stage-oriented, beginning with supportive and strengthening work. Various stances toward the treatment of DID are reviewed, and specific issues that arise in the psychotherapy of DID are addressed, such as pragmatic arrangements, informed consent, work with alters, and the use of specific techniques, such as hypnosis. The employment of therapeutic modalities and ancillary therapies is discussed. The heterogeneity of DID patients is reviewed, and the characteristics of three general groups of DID patients, high, intermediate, and low in both function and prognosis, are explored. Considerations in the matching of DID patients to either exploratory or supportive treatments are discussed, and observations are made about both trauma work and the supportive psychotherapy of DID.
OBJECTIVE: The author uses clinical experience informed by research findings to suggest approaches to the treatment of the traumatic memories of patients with dissociative identity disorder. METHOD: Recent findings in the treatment of patients with this disorder and current considerations with regard to memories of childhood trauma are used to develop recommended approaches. RESULTS: Treatment of traumatic memories appears crucial in the recovery of patients with dissociative identity disorder, even though the reported memories may not be historically accurate. Criteria are available for determining whether a patient with the disorder is able to undertake such efforts, and methods such as fractionated abreaction have been developed to make the process less unsettling. CONCLUSIONS: Despite the difficulties posed by the vulnerability of patients with dissociative identity disorder to decompensation when working with traumatic material and the vicissitudes of autobiographical memory, modern therapeutic approaches allow the processing of such patients' traumatic material in a manner that reduces the likelihood of disruptive events and the misuse of recovered material.
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Although the exploitation and abuse of patients is forbidden by every code of medical ethics, physicians are in a power position vis-a-vis their patients, and this power may be misused. The spectrum of abusive physician behaviors includes doctors functioning as agents of control, exploiting physicianly perogatives, acting out personal problems in the medical setting, allowing subversion of their judgment, deliberately delivering suboptimal care, dehumanizing care, and sexually exploiting patients. Guidelines for the treatment of patients with such prior experiences are offered.
Many symptoms suffered by dissociative disorder patients are unresponsive or incompletely responsive to medications. This poses a unique challenge to the staff of specialized dissociative disorder units, in which many such patients who require hospital care suffer serious distress that may not respond predictably to the pharmacological interventions that are available. However, the majority of their symptoms are dissociative in nature, and dissociative disorder patients generally are quite hypnotizable. Anticipating the need for nonpsychopharmacological interventions that we could use in the absence of the treating psychiatrist, we taught the unit's nursing and social work staff to rely on the inherent trance-proneness of these patients to utilize hypnotic techniques without the formal induction of hypnosis. Their implementation facilitated crisis resolution, led to a greater sense of safety on the part of the patients, enhanced the staff's sense of mastery, and minimized the need for emergency sedation and restraints.
The dissociative disorders are characterized by difficulties in the integration of memory and/or identity. Typically this is manifested by amnesia and either the development of alternate identities or an estrangement from one's own identity. Spontaneous and self-generated dissociative states and phenomena sharing much in common with those that can be induced with hypnosis are thought to play a major role in their development, symptomatology, and perpetuation. Medical heterohypnosis offers a powerful tool to reestablish a functional continuity of memory and identity in many such cases. The application of hypnotic interventions in the treatment of such conditions will be discussed, explored, and illustrated with clinical vignettes.
It is hoped that this discussion of MPD will discourage stereotypic thinking about this condition and encourage the inclusion of MPD in virtually all differential diagnoses. The major thrust of what has been learned about the natural history of MPD is that most patients with this condition spend most of their lives not manifesting their MPD in classic manner. The typical presentation of MPD is the tip of a rather large iceberg. Covert and other nonclassic presentations are much more characteristic. An appreciation of this will help the clinician approach the diagnosis of MPD with a heightened sensitivity to the possibility of encountering it within his or her practice.
MPD patients are not rare. They frequently need hospital treatment. This brief and necessarily incomplete communication has attempted to share what is generally known and accepted with regard to their inpatient care. Such knowledge, however, even though it represents the current state of the art, is, like all state-of-the art knowledge, preliminary with regard to what remains to be discovered and developed. It is anticipated that within the next decade the increasing recognition of such patients will result in their becoming commonplace within most psychiatric hospital settings, drawing the attention of more and more hospitals and psychiatrists alike to the study of their care. At that point, the concentrated attention and endeavors of large numbers of skilled mental health professionals and administrators will, in all likelihood, bring fresh insights and offer new approaches that will enrich and perhaps supplant the observations and advices offered in this contribution.
The treatment of multiple personality disorder (MPD) is often a prolonged and grueling enterprise, which imposes taxing demands upon the therapist and the patient alike. It becomes quite important to pace the therapy, lest the already beleaguered patient become both acutely and chronically overwhelmed. The majority of the extant literature on the use of hypnosis for the treatment of MPD addresses the processes of accessing the alters, abreacting traumata, arranging reconciliations among the alters, and facilitating integration. This communication discusses the necessity of titrating the amount of discomfort the patient must endure against the patient's resources and capacity to achieve mastery and self-efficacy. Several hypnotherapeutic techniques for offering respite and temporary asylum are explained and illustrated: alter substitution, the provision of sanctuary, distancing maneuvers, bypassing time, bypassing affect and/or memory, attenuating affect and/or memory retrieval, and rearranging the configuration of the alters by bartering or "shuffling the deck."
Patients who have experienced sexual exploitation by a previous therapist constitute an increasingly recognized clinical population. Although some of these patients were transiently overwhelmed or mildly disturbed when exploited, the majority were severely symptomatic and the victims of incest or other previous abuse. Many demonstrate a constellation of four factors that predisposes them to revictimization or the sitting duck syndrome: severe symptoms, idiosyncratic dynamics, atypical socialization that discourages self-care, and cognitive difficulties. The experience of such exploitation is not benign, although the sequelae vary considerably. The treatment of such patients is facilitated by arranging the therapy in a way that maximizes safety and clear communication. The importance of hearing the patient' own reconstructions, pacing the treatment to the patient's tolerance, and respecting the patient's agenda cannot be overemphasized. A cluster of issues that appear central to the treatment of such patients includes addressing their helplessness, their ambivalence about the exploitive therapist, their difficulties with trust, their guilt, their depression and pressures toward self-harm, their confusion over sexuality, their post-traumatic and dissociative features, their severe symptoms and the diagnostic confusion this involves, and the countertransference pressures upon the therapist.
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The treatment issues encountered in the unified multiple personality disorder (MPD) patient have received little attention in the literature to date. This study reviews the therapy records of 91 such patients and identifies seven recurrent areas of concern: (1) coping with the psychophysiologic changes associated with unification, (2) coping with the psychologic changes associated with unification, (3) working through, (4) abandoning autohypnotic evasions, (5) modifying adaptive and coping mechanisms, (6) interpersonal adjustments, (7) and major life changes. Some therapeutic approaches are indicated.
Recent studies show that nearly all individuals who develop multiple personality disorder (MPD) were abused as children. The majority of identified MPD patients are women in the age range associated with child-rearing responsibilities. A review of the parenting patterns of 75 mothers with MPD yielded findings suggesting that 38.7% were competent or exceptional mothers, 16% were grossly abusive to the extent of injuring, molesting, or placing their children at risk, and 45.3% were compromised or impaired as parents. The compromised/impaired mothers were a mixed group, including psychologically abusive individuals and those whose symptoms interfered with parenting despite their best efforts. Clinical illustrations are offered.
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