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"Multiplicity and Victimization: What part of 'No!' don't you understand? Vs.
What part of you doesn't understand 'No!'?"

By: Patricia D. McClendon, MSSW

Date: April 7, 1994

TABLE of CONTENTS

dot-blue.gif (312 bytes) ABSTRACT
dot-blue.gif (312 bytes) INTRODUCTION
dot-blue.gif (312 bytes) PERCEPTION IS EVERYTHING?
dot-blue.gif (312 bytes) FEMINIST ANALYSIS OF MULTIPLE PERSONALITY
dot-blue.gif (312 bytes) WHERE ARE THE MEN WITH DISSOCIATIVE DISORDERS/MPD?
dot-blue.gif (312 bytes) GENDER, DISSOCIATION, AND POWER DIFFERENTIALS
dot-blue.gif (312 bytes) THERAPY THAT ADDRESSES PEOPLE'S MULTIPLICITY
dot-blue.gif (312 bytes) BLENDING PERSPECTIVES
dot-blue.gif (312 bytes) SOCIALIZATION
dot-blue.gif (312 bytes) A CLOSER LOOK
dot-blue.gif (312 bytes) TREATMENT RECOMMENDATIONS
dot-blue.gif (312 bytes) FURTHER READING RECOMMENDED
dot-blue.gif (312 bytes) CONCLUSION
dot-blue.gif (312 bytes) SUMMARY
dot-blue.gif (312 bytes) ACKNOWLEDGEMENT
dot-blue.gif (312 bytes) REFERENCES
dot-blue.gif (312 bytes) ADDITIONAL NOTES
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ABSTRACT

Although ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) is essential in the treatment of dissociative disorders and multiple personality disorder, it is seldom used with the general client population. Since all people have multiplicity (Beahrs, 1982), I believe that ego-state therapy is underutilized; it can be used to address people's multiplicity or different levels of consciousness. Ego-state therapy is equivalent to doing family/group therapy within the individual. State-dependent learning and memory are involved who we are in a given context; we are a microcosm of our environment (Rivera, 1989). In cases of victimization, dissociative disorders and multiple personality disorder are overlooked in the rush to punish the victimizer and empower the victim. Drug and/or alcohol abuse is frequently involved in cases of victimization. Many victims and victimizers are chemically dependent and are medicating the pain of their own victimization that they experienced as children. Drugs and alcohol need to be recognized as chemical dissociators (Beahrs, 1982; Braun, 1986; and Ross, 1989). The cycle of victimization cannot be broken unless the victimizer's and the victim's multiplicity are therapeutically acknowledged and confronted. Ross' (1989) general trauma model is the beginning of a paradigm shift away from viewing psychiatric symptoms as psychopathological and biomedical: to, viewing them as natural outcomes of trauma.

Note: Several people have told me that this abstract does not do justice to the article, and that they were glad that that read on.

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INTRODUCTION

In this article, I have synthesized several contemporary ideas that are impacting the thinking of many therapists and how they treat people's multiplicity and people with dissociative disorders (DDs) and multiple personality disorder (MPD). These ideas include the following: (1) All of us operate at multiple levels of consciousness, which we acquire through socialization and we are microcosms of our families and our society (Rivera, 1989). Perhaps the most important difference between a "normal" multiple and a person with DD/MPD is that a "normal" multiple has a consistent sense of self, an "I" that calls all the shots. A person with true DD/MPD does not have a consistent sense of self. The context, at the moment, becomes the defining factor of who the person is and how she or he responds. Many DDs/MPDs manage to live relatively normal lives and are very high functioning individuals. "The essential feature of dissociative disorder is a disturbance or alteration in normally integrative functions of identity, memory, or consciousness" (Spiegel, 1993, p.6). The ability to dissociate and encapsulate trauma is very adaptive initially; but, when the survivor is older and in a safe environment, the extreme use of dissociation becomes contextually inappropriate. (2) Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) is a powerfully effective treatment method with many client populations, not just people with DDs/MPD. (3) Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) is equivalent to doing family/group therapy within the individual. The power differentials that exist in the family and in society also exist within us all (some of which are based on gender) (Rivera, 1989). Cognitive distortions and narcissistic entitlement issues (Hill, 1993) need to be addressed at this level (the family within each individual) before we can hope to deal with violence in families and in society. (4) State-dependent learning (SDL) is involved in determining who we are in a given context (although this is the case much more so with DDs/MPDs). (5) The wealth of information about social work with groups can be applied to the family within us all - the group dynamics are similar and the group work can serve as a form of internal "consciousness raising" or integration (Rivera, 1989). When a social worker works with an individual, she or he is actually working with a group: The person's family of origin and all significant people in the person's life, for they represent part of the person. So, if you are thinking group work is not important and not your forté, you need to think again, if you really want to be an effective social worker. (6) To address the question "What part of `no' don't you understand?" is to ask the real question "What part of you doesn't understand `no'"? (Unknown source). (7) Our multiplicity needs to be recognized, honored, and when necessary, therapeutically confronted.


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PERCEPTION IS EVERYTHING?

Often, I am reminded of the analogy of the elephant being perceived as everything but an elephant due to all the different perceivers having different perceptual filters and rather narrow focuses - to the point of tunnel vision. When you blindfold the perceivers and allow them to touch the elephant and then ask them to describe what they perceive, they all have different perceptions. One feels the trunk and says that the elephant is a trunk. Another feels the tail and says that the elephant is a tail, and so on.

Everyone is staking out theories, often in direct opposition to other theories on the surface, that exclude each other; yet, conceivably everyone is really talking about the same thing. Perhaps the gestalt is a little bit of all and a unifying theory is possible with an open mind and that requires that we take off our blindfolds and stand back in order to take in the big picture.

At the V.O.I.C.E.S. (Victims Of Incest Can Emerge Survivors) 9th Annual Conference on July 21, 1991 in Lincolnwood, Illinois, Roberta Sachs, Ph.D., used the analogy of the elephant to explain why clinicians overlook dissociative disorders and multiple personality disorder. In her workshop on the "Diagnosis and Treatment of Dissociative Disorders and Multiple Personality - Part I & II", she said that dissociative disorders and multiple personality disorder represent the entirety of the elephant, while the trunk represents an eating disorder, the tail represents chemical dependency, the ear represents borderline personality disorder (or a mixture of personality disorders), the feet represent "mood swings" and so on. So clinicians need to stand back and take in the whole picture in order to see dissociative disorders and provide appropriate treatment for the client.

Colin Ross suggests that effective interventions can "arise from looking at the world through dissociative-colored glasses" (Ross, 1989, p.173). I think this approach holds the key to finding effective interventions for victimization on a personal level; as well as, a societal level. Ross (1989) has developed a general trauma model in which psychiatric symptoms can be viewed as traumatic and atraumatic (organicity or chemical imbalance). Most of the symptoms of a person with a chronic trauma disorder are viewed as dissociative in nature. Ross believes that "borderlines don't have either personality disorders or psychoses: They have chronic trauma disorder" (Ross, 1989, p.149). "Splitting is held to be the foundation of borderline personality, and dissociation the basis of MPD. This means that the distinction between the two disorders is real only if the distinction between splitting and dissociation is real, which it isn't" (Ross, 1989, p.151). Both, splitting and dissociation, are normal responses to abnormal situations (chronic trauma). I believe the unifying theory will be this general trauma model; and, dissociation, not repression, will be the defense mechanism responsible for most of the symptoms that clients present.

Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) is a powerfully effective treatment method with many client populations, not just people with DDs/MPD.

The Watkins (1979b) even define their "ego state therapy" modality as the use of group and family therapy techniques to deal with the "family of Self" comprising a single human individual. Gently extending this principle to cover almost the whole of psychotherapy, Watkins says (1979), "With any patient I assume that in a sense there are at least two `personalities'. One wants to get well or he would not be here in my office. The other does not want to get well or he would already be well." The wrong kind of reassurance to the first of these two personalities could make an enemy of the second, sabotaging treatment. Perhaps this is the primary etiology of resistance. If so, much resistance may be unnecessary (Beahrs, 1982, p.116).

Ego-state therapy utilizes an eclectic approach in helping the client solve internal diplomacy problems.


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FEMINIST ANALYSIS OF MULTIPLE PERSONALITY

Who are we? Margo Rivera in an article entitled "Linking the Psychological and the Social: Feminism, Poststructuralism, and Multiple Personality" speaks to this question.

Poststructuralist philosophy points to the similarities between individuals who elaborate multiple personality as an outcome of child abuse and others who, although they do not use the radical dissociative defenses individuals with multiple personality do, also construct their identities in a field of power relations, both personal and political, in multiple and contradictory ways. This perspective can aid us in seeing multiple personality more clearly and consistently, not as a strange and exotic phenomenon, a clinical oddity, but one of the many manifestations of alternative forms of consciousness that are on a continuum of the personal human responses both to our immediate, intimate environment that effects (sic) our growth and development and also to the wider social and historical context which has a no less powerful, although often less obvious, impact on determining who we become as persons.

Integrating psychological understandings of multiple personality with social and political ones is helpful in a number of ways, philosophically, clinically, and practically. That maxim of feminist praxis, the personal is political, can be an effective principle in therapy of individuals with multiple personality (Rivera, 1989, p.29).

Rivera views women as victims more so than men, since many identified people with multiple personalities are women.


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WHERE ARE THE MEN WITH DISSOCIATIVE DISORDERS/MPD?

Many men (and women) in prison have dissociative disorders or a multiple personality disorder that are not recognized due to many clinicians' unfamiliarity with dissociative disorders, as well as the legal dilemmas this recognition would present society: Are they to be held accountable for their crime or be released once psychotherapy has been successful?

We know that the prisons are loaded with persons who could otherwise be treated and who are not. We are beginning to appreciate that many sex offenders have themselves been victimized. While this does not diminish that their behavior is reprehensible and offensive, we are going to keep cranking out abusers and offenders until we begin to work with these populations and their dissociative disorders, which are born of their own childhood traumatization. Most so-called treatment programs for offenders don't recognize dissociative disorders (Calof, 1993, p.67).


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GENDER, DISSOCIATION, AND POWER DIFFERENTIALS

Women are socialized to take their anger out on themselves - witness the incidence of eating disorders, depression problems, violence that women experience, and similar problems. Men are socialized to act on their anger and do so regularly. I will discuss both more later in this article. The point that I am trying to make is that we are all victims of our socialization. It is pointless to look for blame: besides, we do not know which came first - the chicken or the egg (Still, people must be held accountable for their behavior). People are more open to therapeutic intervention when they feel the family therapist is more interested in helping them to become healthier individuals, than in "finger pointing."

The power differentials that exist in society and the family also exist within us all. A person with multiple personalities is a microcosm in which much can be learned and applied to the rest of us (Rivera, 1989). Dissociation is a normal defense mechanism that we all use. The problem for people with dissociative disorders and multiple personalities is that they have built barriers in between their personalities. The more trauma and greater the severity of the trauma, the greater the number of personalities formed and/or the thicker the dissociative barriers between the "parts" or personalities become. Dissociation can be conceptualized as lying on a continuum from normal to pathological (Braun, 1988). The degree of multiplicity experienced by individuals also lies on a continuum: some of us have experienced small traumas, while others have experienced horrendous traumas. The degree of dysfunction is determined by the amount and quality of the internal communication and the degree in which the different personalities or "parts" of themselves cooperate (Kluft, 1988). Good communication and cooperation are necessary for families or families within to be healthy. "Normal" multiples ("normal" people) have an "executive personality" or "part" of them that evaluates the family within's different wants, needs, views, and then determines what consistent course of action needs to be taken. A person with true multiple personalities doesn't have a consistent executive personality because given a particular context, one personality may have more power than another personality in different context. This power differential is dependent upon the context: the situation, the players involved, and so on. This is true in a family (or any group). If family therapy is useful for families, then why not use it to help people with true multiple personalities and, most importantly, why not use it to help "normal" multiples with their families within?


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THERAPY THAT ADDRESSES PEOPLE'S MULTIPLICITY

Using ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) or internal group therapy (Caul, 1984) or voice dialoguing (Stone & Winkelman, 1989) or internal family systems model (Schwartz, 1992) or "parts party" (Satir, 1991) can help people to deal with their families within no matter where they lie on the continuum of multiplicity. In particular, instead of looking for blame, get on with treating victims and victimizers using ego-state therapy (a form of family/group therapy) to help their families within come to some peace. Perhaps the goal of therapy with the family within is the same for therapy with families: unification and preservation of the family. To unite and preserve the family, a family therapist can tell you that working with only one member of a family is not as effective as if you can get the whole family into treatment. Why do we treat only the presenting person in individual therapy: Why not treat the family within, starting, as some therapists suggest with the most malleable member of the family (for families), or as I am suggesting, starting with the most malleable member of the family within (for individuals)? Victimizers may need to be removed from the home to prevent more abuse from occurring. Victimizers and victims must have a "consciousness-raising" or integration (Rivera, 1989) within their family within before they can be safe, because like abusive families, victimizers and victims have persecutors in their family within (internalized persecutors or misguided protectors).

The treatment outcome that David Caul hoped for when working with people with multiple personalities would be applicable to all of us: "It seems to me (David Caul) that after treatment, you want a functional unit, be it a corporation, a partnership, or a one-owner business" (Kluft, 1987, p.370).

Personalities within us all are formed from identification, internalization, and introjection of important people (good or bad) in our lives in given contexts. Who we are at any given time depends on the context and the power differentials within our family within. (Recall: state-dependent learning, SDL). Kluft (1988, p.57) in reference to complex MPD (greater than twenty-six personality states or alters) suggests that: "If one understands the process of alter formation as one of defensive reduplication and/or reconfiguration rather than division, the problem of wondering how the mind becomes divided into such complexity ceases to be relevant. The alters become different patterns of whole and/or partial copying and/or reconfiguring, which, when activated, may be more or less similar to one another, and inevitably will have a lot in common." I believe this still the case for all people, but barriers between "personalities" or "parts" for people with dissociative disorders are thicker and less permeable. We all have multiplicity and are socialized to take on many different roles and probably assume many different ego-states in a chameleon fashion to accomplish all that is required of us.

Why isn't the treatment (psychotherapy and/or psychoeducation) of victims and victimizers more successful than it is? I think it is because we are doing treatment with people who aren't in the room with the clients and us. It may be that we need to do the psychotherapy and/or psychoeducation with the internalized father or mother or someone else that the clients have internalized (or introjected or identified with) when they were 5-years- old. The clients need to examine these internalized parts of themselves and redefine those aspects of themselves from a more mature (cognitive, developmental, emotional and moral) perspective: The client must be able to say, this situation is happening now, not when I was 5-years-old and I can choose a response that is contextually appropriate, not a response of internalized or introjected person of my childhood. Our perceptual filters changed over time and with experience. A 5-year-old's perception of dad or mom may be fairly accurate or skewed depending on the context and the child's developmental level. What is important is that victims and victimizers receive therapy for their family within so that they can redefine who they are in the present safe context: They are more mature now. This therapy is necessary before they can ever hope to change their reaction to situations that are throwbacks to their childhood when they were powerless to define who they were. The "consciousness- raising" or integration (Rivera, 1989) within their family within will be the "consciousness- raising" of future generations.

I wish the idea of doing family therapy with the victims' and the victimizers' families within were as easy as family therapy with the whole families. Family therapy is no easy task because of denial, repression, and dissociation. Doing family therapy with victims and victimizers is complex because, like the people with true multiple personalities, victims and victimizers use denial, repression, and dissociation as defense mechanisms to varying extents to cope with the hand dealt them in childhood; and that, continues to be dealt to them through the socialization process (thus reinforcing earlier training, making it difficult to change perceptions and behaviors). In fact, many victims and victimizers probably have dissociative disorders (DDs) or multiple personality disorder (MPD). To quote Judith Herman:

Denial, repression, and dissociation operate on a social as well as an individual level. The knowledge of horrible events periodically intrudes into public consciousness, but is rarely retained for long. To speak publicly about one's knowledge of atrocities is to invite the stigma that attaches to victims. Those who attempt to describe atrocities that they have witnessed also risk their credibility (Herman, 1990, p.290).


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BLENDING PERSPECTIVES

I think the gestalt of human experience can include analysis of the many facets of our social ills and interventions that structuralists, family systems therapists, clinicians, and others can all buy into and then contribute ideas and strategies that are effective in improving the human experience. Structuralists, you ask? "The structural approach asks the practitioner to consider first the structural surround before placing the problem(s) within the person of the individual(s). If there is no pressure stemming from outside the person, then the focus can shift to a more internal realm" (Wood & Middleman, 1989, p.13). What better place to look for the environment than within each person's family within? We are our environments.

Conceivably the wealth of information about social work with groups can be applied to the family within us all, but especially with the families within of victims and victimizers; external juxtaposed to internal: group scanning, fostering group cohesion, and thinking group are required for external (and internal) group "consciousness-raising" (Middleman & Wood, 1990). The difference would be that individuals need to be empowered to become their own group worker, in a sense, and to share the family within's process with a social worker who teaches individuals the skills for working with social work groups (or their family within). This "consciousness-raising" would be an integration of the family within.

Linda J. Hill, L.C.S.W., B.C.D., Louisville, Kentucky, tells the clinicians that she supervises to "think multiplicity, multiplicity, multiplicity. 'Parts work' can be used with most people who come to treatment, not just people with MPD (multiple personality disorder)." I believe people do not consciously want to be victims or victimizers, if they feel like they have a conscious choice. "The problem is that few of these people view themselves as having choices (Lay, 1993). Hill (1993) believes that there are people who may not have the capacity to make choices due to organicity or a chemical imbalance, but for the most part, people are dysfunctional because of their life experiences. Again, I suspect that many victims and victimizers have dissociative disorders (including multiple personality disorder) that are not being diagnosed and treated. Hill (1993) finds that labels are not always helpful, but if the label gets people the correct treatment to end their suffering and the suffering that they may inflict on others, then use it. In a humorous way, when clients who are also therapists deny their multiplicity (i.e., "Part? I don't have any parts."), she asks them if they would prefer being labeled borderline personality disorder, instead. Most therapists consider "borderlines" difficult and often untreatable, whereas "multiples" have a better prognosis. This usually stops the argument.

I believe that when victimizers claim partial or full amnesia for their violent behavior, many people believe that they are lying and close their minds to the possibility that victimizers are describing a dissociative episode. Moreover, when victimizers claim inability to control their behavior, many people miss what is called "passive influence" common to dissociative disorders (Kluft, 1991; Loewenstein, 1991; and Putnam, 1989) or an outright switch to another personality of an antisocial presentation (Lay, 1993) and, therefore, in both cases eliminate appropriate diagnosis and treatment for the victimizers.

Jean Franklin (1988, p.31) describes how "alters" or "parts" of a person can influence each other in an excellent article entitled "Diagnosis of Covert and Subtle Forms of Multiple Personality Disorder":

The personalities and personality states of patients with covert and subtle forms of MPD usually influence each other rather than emerging overtly. They may influence each other by talking to or transferring thoughts and feelings to one another or by imposing themselves on, dominating or suppressing each other.

These influences take the form of co-presence, co-consciousness and passive influence, which often overlap. In co-presence, an alter influences the behavior or affective state of another without assuming control (Kluft, 1984). In co-consciousness (Prince, 1906), an alter is aware of the feelings, actions and thoughts of another. In passive influence, patients feel that impulses, acts and affects are imposed on them, that their body is influenced by some force, that thoughts are withdrawn from their mind, or that their mind is influenced by thoughts they ascribe to others (Kluft, 1985b, 1987a).

Furthermore, Philip M. Coons, M.D., has been investigating dissociative disorders not otherwise specified (DDNOS) and believes that intermittent explosive disorder (also called "berserker/blind rage syndrome" by A. Simon) deserves further study as a DDNOS entity (Coons, 1992 and Ross, 1989). Intuitively, I believe that most or all intermittent explosive disordered behaviors are dissociative in nature. Just saying, "No!" to people with dissociative disorders is not going to stop their violent behaviors. And just saying, "Don't go back to that abusive environment" is going to stop victims from returning to their victimizer. (The victims probably have a vulnerable child personality that will continue to go back to the victimizer for parenting and/or abuse (the victim may have an internal persecutor that insists that they (other "parts") go back to take their punishment). A child personality usually fears abandonment and will endure the abuse ("It doesn't hurt, much.") because of a need to attach to someone.)

By using an eclectic approach (including Ego-state therapy or "parts work"), the saying "What part of `no' don't you understand?" becomes "What part of you doesn't understand `no'"? (Unknown source). Clinicians must be prepared to therapeutically engage children in adult bodies because it is usually a child part that doesn't understand "no." What is this eclectic approach? It is whatever works. Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) or internal group therapy (Caul, 1984) or voice dialoguing (Stone & Winkelman, 1989) or the internal family systems model (Schwartz, 1992) or "Parts Party" (Satir, 1991); identifying and correcting cognitive distortions of the family within; structural solutions (i.e., removing victimizers from the home, individual/couples/group therapy for victims and victimizers, jobs to help families function in society, alcohol & drug rehabilitation, and more). Using hypnosis, therapeutic metaphors, positive reframing, and paradoxical permission (the Change Model of the Palo Alto group), will be necessary to gain access to the family within due to denial, repression and dissociation. Hill (1993) believes in confronting narcissistic entitlement issues directly and repeatedly: She believes that the client must have personal integrity which means "personal integrity in regards to the self, as well as to others. The parts of self need to learn to negotiate in a way that is fair and reasonable. It's not fair for one part to beat up on another part and behave like a bully. It's not fair anywhere in our social life together as human beings. People are not entitled to injure themselves; because, it hurts not only them, but everybody else around them in some way. A person has to have enough personal integrity to be able to stick with psychotherapy because if he or she wants constant stroking and won't allow anyone to criticize his or her destructive behaviors then psychotherapy is not therapeutic nor particularly helpful."

Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993), regardless of the clients' diagnostic labels, is an effective intervention to use when working with most clients who have narcissistic entitlement issues, i.e., clients who feel entitled to abuse other "parts" of themselves or others because they were abused as children. Ego-state therapy is also effective with most clients who have difficulty with personal integrity, i.e., not taking responsibility for their behavior by projecting the blame onto other "parts" of themselves or others. Some of the questions to ask are: What "part" feels entitled and why? What cognitive distortions does this "part" have? What "part" thinks it isn't responsible for its behavior and why? The client's destructive behavior(s) must be confronted before the cycle of internal and external victimization can be broken.

Hill (1993) believes that therapists working with dissociative clients are assisted by knowledge of borderline theory since many multiples have a borderline component within their personality structure. To be effective, therapeutic boundaries must be maintained. When the therapist doesn't understand this, the borderline parts will escalate. Narcissistic behavior (i.e., expecting special treatment and expecting not to be held accountable for their actions) must be confronted when it happens and crises need to be evaluated in an objective manner. The borderline parts will do everything possible to distort the therapist's objectivity.


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SOCIALIZATION

Society is sick and in denial about how harmful child abuse is to children and society, however, assigning blame is counterproductive and divisive. It is time to point the finger at ourselves and work on ourselves to become empowered by our "consciousness-raising" within, for we are the seeds of the future: We must break our own denial. We can change only ourselves; but collectively we can change our society and the way we socialize our children. We must look at our collective and individual defense mechanisms of denial, repression, and dissociation, for they have run amuck. "If nothing changes, nothing changes" (Larsen, 1987, p.25).

The patriarchal power structure is still a legitimate target of intervention, but so are individuals: We have been co-opted by our socialization. The purpose of socialization is to maintain the status quo and to make sure that change, when it does occur, occurs very slowly. We are unwittingly going along with much of the socialization that makes victims and victimizers and thus reinforce the very behaviors we say repulse us. Perhaps the "finger pointing" is the root of all evil: denial, repression, and dissociation. Assigning blame lets the rest of us off the hook and we expect the victimizers to change while our environment and we remain the same. Now, that is crazy making! Change is fine for someone else, but not for us. It is like sending alcoholics just out of treatment back to their drinking buddies and expecting them to stay sober - it usually doesn't happen. Alcohol and drugs are chemical dissociators; that is, they facilitate "switching" into different "parts" for people with dissociative disorders or MPD (Barkins et al., 1986; Beahrs, 1982; and Ross, 1989). "Alcohol may be more of a facilitator than a cause of the underlying `personality' that gets `let out.' Alcohol intoxication is one of two methods par excellence for letting out a persecutory alter-personality. The other is hypnosis, which is therapeutic in providing more rather than less control. It is likely that in many alcoholics the substance abuse is secondary to a primary dissociative disorder" (Beahrs, 1982, p.94). The executive personality is displaced by the alcoholic part (sometimes before the actually drinking begins) that is based on state-dependent learning: That personality is probably a child or adolescent cognitively, developmentally, emotionally, and morally. (There could be more than one alcoholic personality, therefore more than one child or adolescent personality.)

There are women who are also victimizers of men, children, and other women. Women have not been socialized to be violent to the extent that men have been. Sticks and stones will hurt you, but so will words. Many of us can remember hurtful things that our mothers (and fathers) have said to us. I guess what is important is to look for the gestalt and not lose one's perspective by looking too closely, for too long, at a portion of the picture. We are all in this boat together: the women are bailing water and the men are rowing a sinking ship and the children are the real victims...and their generation's victimizers.

Family "cut-offs" (little or no contact at all between disengaged family members) are seen as problems by some family therapists (who strive for family unity); and, solutions by some structuralists (who may view the family as the problem, not the individual). There is room for compromise on this one, depending on the situation/context. For example, removing a victimizer from the family until it is therapeutic to allow him/her to return to his/her family could be one such compromise.


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A CLOSER LOOK

Now, I reluctantly approach this next topic, because it requires the reader to be familiar with the defense mechanisms of dissociation, identification, internalization, introjection and state-dependent learning (SDL) (Braun, 1988), and the lexicon of dissociative disorders (i.e., introjects, internalized persecutors, "switching," "triggers," and others). A truly remorseful victimizer (who may initially present as an antisocial victimizer without remorse (Lay, 1993)) is victimized by his/her abusive behavior, and a victim can have an internal persecutor asking for the victimization. A victim may consciously, but usually unconsciously, push the victimizer's "buttons." The victimizer is unable to control his/her response because it was state-dependently learned, and the "button" or "trigger" is automatic. This causes a "switch" to occur and the power differential within to be shifted to an immature (cognitively, developmentally, emotionally, and morally) personality state, introjected (or internalized or identified with) from an abusive childhood experience. Some victimizers have chosen a structural solution for themselves: They avoid stressful situations/contexts and people who "push their buttons." Some victimizers have this solution chosen for them, i.e., they are sent to prison for injuring or murdering their spouses (or others). Intimate relationships can be full of "triggers" for the victimizers and dangerous for themselves, as well as their partners (the victims). In order to be able to control his/her abusive behavior, the executive personality must be strengthened. Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) is a way to accomplish this. Sending a victimizer to behavior modification therapy has only fleeting results - they last only until the next switch when presented with a context in which a victimizing "part" appears on the scene. It's like the treatment failure of an alcoholic multiple who can't get the alcoholic "part(s)" to go to AA (Alcoholics Anonymous) or treatment: the bewildered host personality is held responsible for all the personalities' behaviors (as it must be!), yet the host feels powerless to do anything about it and feels victimized by the experience (as it is, indeed) (Unknown source). Victimizers are victimized by their family within and we are all victimized by our socialization. The bewildered host personality has been forced into the passenger's seat and must watch in horror and dismay as the victimizing personality drives down a one-way street in the wrong direction (Unknown source).

I do not believe people want to be abused, if they felt they had a choice not to be abused. The victim, also, can be put into situations in which the host or some other "part" experiences the abuse and the internalized persecutor (or a misguided protector) does not feel it: It is not her or him that is being abused - it is a "part" who is perceived weak or bad that needs to be punished to learn her/his lesson. We could say that the victim has been co-opted by her/his socialization and by her/his family within. The victim's host personality also watches in astonishment at her/his predicament and wonders why she/he stays around to be abused. If only she/he realized that a "part" of her/him is working against her/him in an abusive or a misguided way. Hill (1993) believes that victims are afraid to tell the authorities about their abuse, not only because of the fear of the victimizers' reprisals, but for fear of the reprisals of their internalized persecutor(s) and/or misguided protector(s). There is a lot to this and requires some reading about dissociative disorders (Beahrs, 1982; Bliss, 1986; Braun, 1988; Bryant et al., 1992; Kluft, 1985; Loewenstein, 1991; Putnam, 1989; and Ross, 1989, and others). Without reading this material, you might read what I have written as victim blaming: It is not. I don't know who to blame, the chicken or the egg, so, I am not assigning blame: It is useless. Prevention needs to focus on how we socialize our children and on much earlier detection of abuse. Clinicians must learn how to recognize and provide appropriate treatment for people with dissociative disorders and multiple personality disorder.


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TREATMENT RECOMMENDATIONS

1. Remove victimizers from the home and require individual and group therapy that addresses their multiplicity issues.

2. Victims, also, should be required individual and group therapy that addresses their multiplicity issues and must be protected from further abuse, even if it means hospitalization or confinement from the abuser or to prevent them from seeking out other situations/victimizers that cause them harm.

3. Children must be protected and receive the same therapy recommended for their parents. If possible the children should be left in their homes, because foster placement traumatizes them and makes them more likely to use denial, repression, and dissociation as defense against this trauma. Maybe group homes are not such bad solutions as long as they are run by "healthy role models": It might be better than a series of foster homes or constant removal from their homes and repeated return to their homes. Conceivably the children could be "reparented" in a healthy context. I believe it's time to overhaul the foster care and adoption systems.

4. Children should receive concurrent therapy with the non-offending adult, if the parent is capable to parent.

5. Couples' therapy when deemed appropriate (i.e., after six months of separation, if ever.)

6. Family therapy when it is deemed appropriate, if ever.

7. Journaling can be used as a means of increasing and improving communication with the victim's and the victimizer's families within, as well as children who are old enough to journal. This is a special kind of journaling requiring the different members of the family within to write to each other in a dialogue format. Having the person write with her/his left hand may facilitate this. Adams (1993) covers some of this in her book.

This combination of individual (family within), couples, family, and group therapy is necessary in order to stop the transmission of dissociative disorders to the next generation. Lynn and Robert Benjamin, in their article "Intervention With Children In Dissociative Families: A Family Treatment Model," state, "It is our belief that treatment of the child- parent subsystem of a dissociative family has the most potential to interrupt a transgenerational chain of dysfunctional family patterns" (Benjamin & Benjamin, 1993, p.54). In a previous article, "An Overview of Family Treatment In Dissociative Disorders", the Benjamins state: "It seems ironic to us that a family-based approach has been underutilized since this disorder is precisely about the failure of a healthy family process" (Benjamin & Benjamin, 1992, pp.236). We need to treat the whole family, not just the "identified patient."


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FURTHER READING RECOMMENDED

I would like to suggest that clinicians who are interested in multiplicity and dissociative disorders read the original manuscripts of John and Helen Watkins (Ego-state therapy), John Beahrs, Margo Rivera, Frank Putnam, Richard Kluft, Colin Ross, and the Benjamins. John Beahrs' book on this subject has some illustrative analogies and addresses the question of whether our identity is unified or multileveled. Be sure to read about the executive role in consciousness and the conductor-orchestra analogy, pp.6-9, and how it is a model of communication and cooperation for our multiplicity, pp.69-73 (Beahrs, 1982). Margo Rivera's offers a feminist analysis of multiple personality disorder and does an excellent job of linking it with the socialization process that we all experience (Rivera, 1989).


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CONCLUSION

Social constructionists, probably, would agree that since we have constructed selves, therapy that addresses our multiplicity would be appropriate. Systems theory can be applied to victimization without blaming the victim, and I think, interestingly enough without blaming the victimizer because circular (cybernetic) causality can't answer the question of which came first - the chicken or the egg. Socialization is learned sequentially and through constant feedback, so causality is both linear and circular: we are continuously constructing and reconstructing ourselves. Intervention needs to be done on a societal and personal level simultaneously, and at the interface continuously. The patriarchal tenets must be challenged in favor of an egalitarian society. Our multiplicity needs to be recognized, honored, and when necessary, therapeutically confronted.


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SUMMARY

All of us operate at multiple levels of consciousness (Beahrs, 1982) and are microcosms of our families and our society (Rivera, 1989). Ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) can effectively address our state-dependent learned multiplicity, which is determined by the existing power differentials and the contextual environment. Ego-state therapy is a form of family/group therapy for our family within. Couples, family, and group therapy are also needed. Drugs and alcohol are chemical dissociators and need to be recognized as such.

There is already a stream of consciousness by many therapists towards a paradigm shift away from psychopathology (based on repression) to a general trauma model (based on dissociation) where most of client's symptoms will be viewed as dissociative in nature (Ross, 1989).


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ACKNOWLEDGEMENT

The author is grateful to: Linda J. Hill, LCSW, BCD (Louisville, KY), for her suggestions and help in clarifying ideas put forth in this article; Kathy Lay, ACSW, LCSW , for reading earlier drafts of this article and making specific suggestions; and Bob Youngblood, English teacher at Floyd Central H.S., Floyds Knob, Indiana, for his editing of an earlier draft of this article; and numerous others who have read drafts of this paper and shared their views with me.


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REFERENCES

Adams, Kathleen. (1993). The Way of the Journal: A Journal Therapy Workbook for Healing. Lutherville, MD: Sidran Press.

Barkin, Robert, and Braun, Bennett G., and Kluft, Richard P. (1986). "The Dilemma of Drug Therapy for Multiple Personality Disorder". In Bennett G. Braun (Ed.), Treatment of Multiple Personality Disorder. (pp.109-132). Washington, DC: American Psychiatric Press.

Beahrs, J.O. (1982). Unity and Multiplicity: Multilevel Consciousness of Self in Hypnosis, Psychiatric Disorder and Mental Health. New York, NY: Brunner/Mazel.

Benjamin, Lynn R. and Benjamin, Robert. (1992). "An Overview Of Family Treatment In Dissociative Disorders", DISSOCIATION, V(4), 236-241.

Benjamin, Lynn R. and Benjamin, Robert. (1993). "Intervention With Children In Dissociative Families: A Family Treatment Model", DISSOCIATION, VI(1), 54-65.

Bliss, E.L. (1986). Multiple Personality, Allied Disorders and Hypnosis. New York, NY: Oxford University Press.

Braun, Bennett G. (1988). "The BASK (Behavior, Affect, Sensation, Knowledge) Model of Dissociation", DISSOCIATION, I(1), 4-19.

Braun, Bennett G. (1988). "The BASK (Behavior, Affect, Sensation, Knowledge) Model of Dissociation: Part II - Treatment", DISSOCIATION, I(2), 16-23.

Bryant, Doris, and Kessler, Judy and Shirar, Lynda. (1992). The Family Inside - Working with the Multiple. New York, NY: W.W. Norton & Company.

Calof, David L. (1993). Multiple Personality and Dissociation - Understanding Incest, Abuse and MPD. Park Ridge, IL: Parkside Publishing.

Caul, David. (1984). "Group and Videotape Techniques for Multiple Personality Disorder", Psychiatric Annals, 14:1, 43, 47, 49-50.

Coons, Philip M. (1992). "Dissociative Disorder Not Otherwise Specified: A Clinical Investigation of 50 Cases With Suggestions For Typology And Treatment", DISSOCIATION, V(4), 187-195.

Franklin, Jean. (1988). "Diagnosis of Covert and Subtle Forms of Multiple Personality Disorder", DISSOCIATION, I(2), 27-33.

Herman, Judith. (1990). "Discussion". In Richard P. Kluft (Ed.), Incest - Related Syndromes of Adult Psychopathology. (pp.289-293). Washington, DC: American Psychiatric Press.

Hill, Linda J. (1993). Personal Communications. Louisville, Kentucky.

Kluft, R.P. (Ed.). (1985). Childhood Antecedents of Multiple Personality. Washington, DC: American Psychiatric Press .

Kluft, Richard P. (1987). "An Update On Multiple Personality Disorder", Hospital and Community Psychiatry, 38:4, 363-373.

Kluft, Richard P. (1988). "The Phenomenology and Treatment of Extremely Complex Multiple Personality Disorder", DISSOCIATION, I(4), 47-58.

Kluft, Richard P. (1991). "Clinical Presentations of Multiple Personality Disorder", The Psychiatric Clinics of North America: Multiple Personality Disorder, 14:3, 605-629.

Larsen, Earnie. (1987). Stage II Relationships: Love Beyond Addiction. San Francisco, CA: Harper & Row, Publishers.

Lay, Kathy. (1993). Personal Communications. Louisville, Kentucky.

Loewenstein, Richard J. (1991). "An Office Mental Status Examination for Complex Chronic Dissociative Symptoms and Multiple Personality Disorder", The Psychiatric Clinics of North America: Multiple Personality Disorder, 14:3, 567-601.

Middleman, Ruth R. and Wood, Gale Goldberg. (1990). Skills for Direct Practice in Social Work. New York, NY: Columbia University Press.

Putnam, Frank W.(1989). Diagnosis and Treatment of Multiple Personality Disorder. New York, NY: The Guilford Press.

Rivera, Margo. (1989). "Linking the Psychological and the Social: Feminism, Poststructuralism, and Multiple Personality", DISSOCIATION, II(1), 24-30.

Ross, Colin A. (1989). Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. New York, NY: John Wiley & Sons.

Sachs, Roberta G. (1991). "Diagnosis and Treatment of Dissociative Disorders and Multiple Personality - Part I & II", VOICES 9th Annual Conference, July 21, 1991, Lincolnwood, IL.

Satir, Virginia, and Banmen, John, and Gerber, Jane, and Gomori, Maria. (1991). "The Parts Party: Integrating Inner Resources". In The Satir Model - Family Therapy and Beyond. (pp.175-204). Palo Alto, CA: Science and Behavior Books, Inc.

Schwartz, Richard. (1992, 1992). "Rescuing the Exiles", The Family Therapy Networker, May/June 33-37 & 75.

Spiegel, David. (Ed.). (1993). Dissociative Disorders - A Clinical Review. Lutherville, MD: The Sidran Press.

Stone, Hal and Winkelman, Sidra. (1989). Embracing Our Selves: The Voice Dialogue Manual. San Rafael, CA: New World Library.

Watkins, John G. and Watkins, Helen H. (1988). "The Management of Malevolent Ego States In Multiple Personality Disorder", DISSOCIATION, I(1), 67-72.

Watkins, Helen H. (1993). "Ego-State Therapy: An Overview", American Journal of Clinical Hypnosis, 35:4, 232-240.

Wood, Gale Goldberg and Middleman, Ruth R. (1989). The Structural Approach to Direct Practice in Social Work. New York, NY: Columbia University Press.


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ADDITIONAL NOTES

Added note on August 17, 1995:

An excellent article that is a "must read" and goes along with/adds to much of what I have posted on my home page is:

"Reenactment and Trauma" by Mark F. Schwartz and Lori D. Galperin in EATING DISORDERS: A Journal of Treatment & Prevention, Vol 1, Nos. 3&4, Fall & Winter 1993 (Brunner/Mazel Publishers). Though I advocate clients being held responsible for their actions/behaviors, I agree with the authors of this article that: "The message of self-responsibility is an essential one, but taken to an extreme, it is revictimizing. It leaves individuals feeling they are failures or weak." (p.315)

Mark F. Schwartz, Sc.D., is the Director of Masters & Johnson and their Sexual Trauma, Sexual Compulsivity and Dissociative Disorder Programs & Lori D. Galperin, LCSW, is the Clinical Co-Director Masters & Johnson Sexual Trauma, Sexual Compulsivity and Dissociative Disorders Programs.


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