Multiple Personalities: Some Psychoanalytic Listening Perspectives

Lawrence E. Hedges*

ABSTRACT: The history of multiple personality is reviewed.  Major research findings are presented and discussed along with the most important treatment recommendations that have been made by leading experts in the field.  A radically different approach to understanding and working with multiples is presented, one derived from contemporary psychoanalysis, object relations, and self psychology.  The Listening Perspective approach is introduced and the four major watersheds of psychotherapeutic listening discussed and applied to the problem of multiples.  The central thesis is that "multiple personalities" express the emergence and creative elaboration in the psychotherapy setting of the earliest affect-ego states, and that they may be considered unintegrated "ego nuclei."
  

The History and Themes of Multiple Personality

Throughout recorded time and across all cultures, altered states of consciousness have claimed a special place in human existence — a place often shrouded in mystery; mysticism and religious zeal.  At times altered states have been exalted to heights of cultural wisdom and prestige as in prophets, oracles, seers and religious glossolalia.  At other times altered states have been associated with evil, witchcraft, devil worship and madness.  In the twentieth century hypnosis, drugs, and meditation have been among the more common ways of producing and perhaps of benefiting from the effects of altered states.  Such techniques have largely replaced ritual incantations and other rhythmical and social forms of ecstasy production and enjoyment known for centuries.

The recent emergence of a large group of persons said to have "multiple personalities" is an altered state phenomena deserving special study.  One psychiatric observer (Schafer, 1984) estimates a rapidly increasing incidence of persons experiencing multiple personalities, numbering more than 50 per million in Southern California which makes multiple personalities hardly rare.

As an observer who is neither an enthusiast of mysticism nor a skilled practitioner of hypnosis, I would like to examine a few aspects of altered states as they appear repeatedly in the psychotherapeutic consulting room.  I will begin with a historical survey of how altered states have been considered in the past several decades in American psychiatric nomenclature.  I will review some of the salient themes appearing in recent research and clinical lore having to do with multiple personalities.  I will then explain the context out of which my own interest in "multiple personalities" has grown and summarize my own listening perspective approach which promises a fresh vantage point from which to consider some altered state phenomena.
  

Brief Historical Survey and Research Questions

The first Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-I, 1952) reflected the general view that "Dissociative Neuroses" are relatively rare, if not somewhat esoteric forms of psychological disorder.  Fugues, amnesias, sleep-walking, sleep talking, multiple personality; and other altered state phenomena were thought to be among the manifestations of persons who employed dissociation as a repressive defense.  The general notion was that a few persons, well enough developed to merit the general diagnosis of neurotic, employed dissociative mechanisms in the service of fending off unwanted or unacceptable ideas and impulses.  Dissociation was formulated as a "vertical" splitting of the personality; that is, a temporal or contextual separation or walling off of one or several aspects or constellations of personality from other aspects.  Vertical splitting was thought to contrast with the more widespread concept of repressive "horizontal" splitting, that is, a separation of so-called conscious from unconscious personality manifestations or constellations.

It was thought that The Three Faces of Eve (Thigpen & Cleckley, 1957) and similar rare cases could be understood as basically neurotic phenomena in a personality prone to repressive vertical splitting.  Since more or less intact ego structure was assumed to be present in neurosis, the expectation was that such splits would be restricted in number to one or possibly another.  That is, the assumption of good ego development in neurosis would be considered contradicted if extensive vertical splitting occurred so that a character diagnosis more in the direction of psychosis would be in order if many splits were in evidence.  For example, the later reported and widely publicized case of Sybil (Schreiber, 1973) could hardly be considered an instance of repressive neurosis.

The fate of the "dissociative neuroses" of the 1950s appears to have paralleled in American psychiatric history the fate of all the neuroses — a radically diminished reported incidence over time.   Since the dissociative pictures were already the rarest, they were the first to go.  In DSM II (1968) dissociation was collapsed as a category into a subspecies of the broader class of "hysterical neurosis."  Whether the number of diagnosed neuroses have diminished in proportion to the character disorders, narcissistic constellations, and borderline states because of cultural changes, conceptual advances, refinements in diagnosis, alterations in therapeutic practices, or fluctuations in psychiatric fads is still up for debate.

Elsewhere I have detailed the powerful arguments for continuing to consider certain styles and levels of personality organization as Oedipal-neurotic even if contemporary understanding of pre-Oedipal development modifies the way neurotic constellations are considered (Hedges, 1983b).  A spatial metaphor for considering dissociation as repressive activity was involved in conceptualizing the "span" of the ego.  The reasoning was that certain (potentially traumatic) impulses, ideas, and experiences which belonged to conscious awareness could not be contained" or "integrated into" the existing ego span (Cameron, 1963).  But because these selected psychological contents or experiences were so powerful they could not be relegated easily to unconsciousness, they were thought to become "dissociated" with their manifestations appearing only in altered states of consciousness.

This way of thinking about dissociated experiences has a certain clinical appeal.  For example, I recently consulted on the psychotherapy of a bright, lovely, shy, and markedly "feminine" little girl aged seven-and-one-half whose presenting complaint was nightly sleepwalking and sleep talking.  The child was also requiring special education procedures for problems in learning.  By day, this sweet, extremely pleasant, delicate little girl charmed everyone.  At night she stalked angrily to her mother's bedside to scream obscenities, accusations, and dreadful names.  It seemed no mystery that such feelings and words could not be easily integrated into her kind and gentle waking personality.  The approach taken by her play therapist was to verbalize even the most subtle nuance of negative affect which conceivably could be a part of the various play situations the child created.  The results, as anticipated, were that the shy; quiet little girl gradually became more certain of herself and assertive in her general approach to life.  Verbalization of her disagreeable affects first appeared in the mouths of little boy dolls before fathers, mothers and little girls were able to express such intense, aggressive feelings, or forbidden thoughts.  Needless to say, her learning problems cleared as she was able to be more aggressive in her approach to learning materials and in her challenge to her mother and her (woman) teacher.  She was extremely bright and quite bored with the simple tasks she had been presented to learn at home and at school.  Soon her reading and mathematics soared above her classmates and her parent, teacher, and peer relationships became drastically improved.

Similar dissociations are by no means uncommon in clinical practice and a wide variety of expressive techniques have been employed by therapists of all persuasions with similar favorable results.  The general formulation would be that expressions of assertiveness and negative affect had become unacceptable to this little girl, perhaps because of her associations to the meanings of masculinity or her wish not to be a "nuisance" like her little brother.  These expressions might be thought of as having become repressed through dissociation into her nocturnal activities.  An expressive, interpretive technique shed light on her impulses and inhibitions, thereby unraveling (analyzing) the need to repress her assertiveness with its accompanying consequences for learning activities and important relationships in school.  This sort of clinical formulation is common enough in practice and regularly yields sufficient enough clinical gain that there is seldom cause to question it.

Formulations of neurotic dissociation styled after DSM-I and DSM-II specified the criterion of amnesia for all or parts of the split off material, confirming the basic assumption that the dissociation mechanism was successful as a neurotic defense in preventing (at least temporally or partially) certain ideas from crystallizing in full consciousness.  A large conceptual shift occurred in DSM-III (American Psychiatric Association, 1980) which portrayed neuroses in general as a vanishing species and relegated advanced level repressive activities to relative unimportance in psychiatry.  The shift was partly based on the diminishing reported statistical incidence of neurosis, but many observers felt it was also based upon various political biases within the psychiatric community which have placed increasing emphasis on neurophysiological formulations in deference to psychological or psychoanalytic formulations.

DSM-III-styled thinking virtually obliterated the notion of dissociation as a neurotic level activity with the omission of amnesia as a necessary diagnostic criterion.  "Multiple Personality Disorder" received its own classification under "Dissociative Disorders" in DSM-III. Braun and Braun (1979) have provided a brief diagnostic description which incorporates the shift in psychiatric conceptualization:

... [O]ne human being demonstrating two or more personalities with identifiable distinctive and consequently ongoing characteristics each of which has a relatively separate memory of its life history ... [T]here must also be a demonstration of the transfer of executive control of the body from one personality to another (switching).  However, the total individual is never out of touch with reality.  The host personality (the one who has executive control of the body the greatest percentage of the time during a time) often experiences periods of amnesia, time loss or blackouts.  Other personalities may or may not experience this.

Does this shift in diagnostic thinking mean that dissociation cannot be nor perhaps ever was a form of repressive activity and that multiple personality involves more primitive splitting processes which are predominantly preneurotic?  And, how are we to consider the radical increases in reported incidence in recent years?  In what ways have the repeated showings of Sybil and other altered state adventures on network television and widely publicized court defenses affected the emergence of altered states in the therapeutic situation?  And do multiple personalities represent (as some observers suggest) an iatrogenic effect of a therapeutic technique (such as hypnosis) which tends to encourage or at least permit the therapeutic experiencing of altered states?

DSM-IV (American Psychiatric Association, 1994) continues to remind us that diagnoses used in psychiatry are not constant and unchanging scientific findings, but rather are the product of a myriad of forces operating within the socio-politic-economic purview of psychiatry.  Multiple Personality has now disappeared completely as an official diagnosis.  We now see a series of "Dissociative Disorders" which are characterized by "a disruption in the usually integrated functions of consciousness, memory, identity, or perception" (p. 477).  Amnesias, fugues, identity, and depersonalization disorders are all formulated to be the product of dissociation.  The essential feature of Dissociative Identity Disorder is "the presence of two or more distinct identities or personality states (criteria A) that recur and takes control of behavior (criteria B).  There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (criteria C).  The disturbance is not due to the direct physiological effects of a substance or a general medical condition (criteria D).  In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play" (p. 484).

Further, "Each personality state may be experienced as if it has a distinct personality history, self-image, and identity, including a separate name.  Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed ...  Individuals with the disorder experience frequent gaps in memory for personal history, both remote and recent ...  The number of identities reported ranges from 2 to more than 100. Half of reported cases include individuals with 10 or fewer identities" (p. 484).

The DSM-IV also indicates that Dissociative Identity Disorder may be a "culture specific syndrome" in the United States.  It is diagnosed three to nine times more frequently in adult females than in adult males with females averaging 15 or more personalities and males averaging approximately 8.  The diagnostic manual indicates that the presence of a true identity disorder must be "distinguished from 'Malingering' in situations in which there may be financial or forensic gain and from 'Factitious Disorder' in which there may be a pattern of help-seeking behavior" (p.487).  Obviously psychiatric thinking about the nature of multiple personality continues to evolve, especially with the escalation of reported incidence in the United States.
  

Salient Themes from Clinical Research and Lore

Psychiatric Annals devoted its January, 1984 issue to a series of updated reports from prominent researchers and clinicians in this area.  Donald Schafer in June, 1984 has reported on his impressions from a long-term multiple personality study group which he heads.  Since that time a mushrooming literature suggests a marked increase in the frequency of multiple personality diagnosis.  Most authors in one way or another attribute this increased frequency to increased sensitivity on the part of members of the therapeutic community.  The effects of media information on the clinical population seem to be, "it is okay to be a multiple, there are others like me."  But some observers question even if multiple personalities exist or if the idea represents some sort of ruse people use to get off the hook for things they do.  Legal implications regarding personal responsibility for activities sometimes cloud clinical issues.

The vast majority of reported cases are women (9 out of 10 or at least 4 out of 5).  The chief etiological hypothesis is exposure to overwhelming experiences in early childhood, usually of a violent, intrusive sexual nature.  The supposed early traumas are often reported as some form of incest perpetrated by an older male, though mothers or other women are frequently named as co- or passive collaborators.  More recently multiples have claimed memories of satanic ritual abuse or abductions by space aliens.  Frequent homosexual themes are said to appear in male multiple personalities and are presumed etiologically related to the maleness of the molester.  No other significant etiological hypotheses tend to be cited in the literature though direct trauma or abuse often cannot be confirmed and corroborating evidence of satanic cults and alien abduction is lacking.  The possibility continues to arise that, since the therapist expects to hear of early abuse, the person produces it — certainly a possibility that has been noted often enough in other kinds of therapeutic research.  In the earlier literature persons with multiple personalities are generally spoken of as being exceptionally intelligent with IQ's often estimated to exceed 130, though that factor is not emphasized so much recently.  High intelligence has sometimes been postulated as a key factor which kept the person from becoming seriously psychotic (Schafer, 1984).

The central dynamic universally cited is that at the moment of severe stress part of the personality defensively splits off.  Altered states are said to emerge for the "purpose" of avoiding traumatic (sexual or violent) overstimulation.  The effect of the split in terms of pervasiveness is said to range on a continuum from most of the person's conscious life to only occasional dissociations under conditions of severe stress in an otherwise intact personality.  Schafer (1984) states, "a personality comes into existence when the personality already in existence can no longer tolerate the world.  That new personality may then be brought back in parallel emotional situations."

Researchers are not altogether clear on the nature of subsequent additional splits — whether later traumas which are different in character tend to produce altered personality states compatible with the type or source of the new trauma or whether splitting simply becomes adopted as a style with later splits representing attempts to cope with other aspects of one's personality.  In using the concept "defense" as a cause for splitting, researchers neglect to differentiate between "defense" meaning fending off real intrusions, and "defense" as used in the more traditional sense meaning fending off unconscious wish/fear contents or psychic conflicts of various types.  The diagnostic and therapeutic approach most often described is based upon the assumption that there was, in fact, traumatic abuse and that therapeutic benefit comes through encouraging repeated abreactions related to the supposed traumas.  Since traumatic etiology and cathartic therapy approaches have repeatedly been found to be oversimplified in other areas of psychological research, they certainly must be questioned as the best explanatory hypotheses or treatment approach in multiple personality as well.

Much to their credit, hypnotherapists appear to have recognized the highly hypnotizable nature of this clinical population early on.  This is no doubt partly because hypnotists are trained to be sensitive and responsive to alternating states of consciousness.  Perhaps they also tend by virtue of training to be more comfortable, or at least less upset, than the average therapist when strange or contradictory mental states begin emerging in psychotherapy.  Perhaps hypnotherapists have less of a need to observe monistic, consistent personality functioning than other groups of psychotherapists.  Responsible hypnotherapists are sensitive to the limits of hypnosis as a technique and are judicious in its application in psychotherapy.  Braun (1984) states:

I withhold the use of hypnosis until I have exhausted other means.  One consideration is to avoid difficulties and criticism (including artifacts).  A more substantial reason is that since these patients have been abused, I do not want to do something abruptly or early on that might be perceived as another assault.  Spending extra time in observation and building rapport is generally worthwhile (p.35).

There also seems to be a general awareness in the hypnotherapy community that, especially with the multiple personality population, the hypnotic trance experience itself can be used as a way of evading social or unconscious issues.  Conversely, Braun (1984) notes that "heterohypnosis may facilitate rapport via its association with autohypnosis which has rescued them so many times before from overwhelming circumstances" (p.36).  There is limited recognition in the literature that hypnosis itself might replicate whatever early trauma the person might have experienced in the past.  That is, the hypnotist may be unwittingly repeating the intrusion.

The assumption of an abusive etiology in early childhood suggests to many therapists a definite therapeutic direction — remembering and abreacting to the early trauma(s).  In using this approach, therapists stress the importance of establishing rapport and trust.  They also consider it important to establish various indirect ways of obtaining data about the alter personalities since the main or host personality cannot be expected to be consistent and reliable.

Kluft (1984a,b) has elaborated a number of ways of inquiring indirectly about the alternate personalities.  He suggests asking questions about problems with memory, overwhelming experiences in the past, or being as a child called a liar or blamed for things the person couldn't remember doing.  Questions can be asked about inner voices, imaginary companions, and autohypnotic experiences.  Since Kluft believes most multiples had school problems, questions can address this; for example, did the rest of the class seem to have been taught something that the person had missed?  Has the person ever found something in his or her possession which cannot be accounted for, such as personal articles, art work or handwriting?  The therapist might inquire about perplexing incidents in relationships such as people behaving as if the relationship had been affected by factors they couldn't understand or explain.  Perhaps people they don't know appear to know them on occasion and even to greet them by another name.  Are there experiences of passive influence, such as thoughts being put into the person's head, or being withheld from consciousness, or sudden impositions of thoughts, or feelings or acts?  Kluft suggests that the person maintain a journal in which the person writes for 30 minutes a day whatever thoughts seem to be present.  Other personalities may announce themselves in the journal.

Most earlier authors report an interval of perhaps a year or more as not unusual before a confirmed diagnosis of multiple personality is established.  Putnam, Post and Guroff (1983) reported a median of 6.8 years from time of initial therapeutic contact to diagnosis.  That time has been shortened drastically in more recent years.  Most of these people apparently do believe that something is wrong but they frequently cannot say quite what (Schafer, 1984).  Once a diagnosis is made and/or the alter personalities begin to appear in the therapeutic setting, therapists typically attempt to gather as much information as possible on the attributes and habits of the alters and eventually to establish names, ages, life histories and times of emergence of each personality.  Keeping careful notes and even a family tree of the various personalities has been suggested since the therapist can easily become confused.  This material is then used by different therapists in various styles of working.

Perhaps they inform the main personality of information provided by alters or encourage conversations among the various personalities.  To the extent that the trauma theory is correct, the importance of remembering, restoring and abreacting in some way to the traumatic scene is assumed to be central to the course of therapy.  Interestingly, both patients and therapists often question the actuality of traumatic events reported or relived through in the therapeutic setting (with or without hypnosis).

In addition to the "main," "host," or "birth" personality, a variety of "alter" personalities may be constellated.  Sometimes these have names or telling nicknames and may have even been thought to have participated in an inner dialogue for years.  They may have begun as imaginary companions.  Some alter personalities emerge only slowly as therapy proceeds.  They may take on designations such as "the bitch," "the rapist, the competent one, momma's little angel," "the anesthetic personality," "the memory trace personality," and so forth.  There may be an opposite sex personality and perhaps even one or more homosexual or otherwise perverse personalities.

Allison (1974) has suggested a name, "internal self-helper" (ISH), to designate the core of the personality that desires to be healthy.  Schafer (1984) has commented that "the killer" personality often possesses considerable strength that the therapist can ally with.  Suicidal and homicidally prone personalities often exhibit no understanding that all of the other personalities in the same body will be punished or die if the offending personality murders, suicides, or is killed.

Therapists working with multiple personalities have become accustomed to entering a subjective world in which sometimes characters "switch" rapidly, each in turn giving its special messages to the therapist.  A therapist has more than once been used as a "switchboard" for intercommunication of the various characters until the time they can comfortably "talk to each other."

Most cases reported in the past have had relatively few personalities.  For example, Taylor and Martin (1944) reported that 48 of the 76 cases they reviewed had only two personalities while 12 had three and only one had more than eight.  Among modern cases "Sybil" had 16, "Eve" had 22 and "Billy Milligan" had 24.  Kluft (1979) reported in one study a modal range of 8 to 13 personalities in a series of 70.  In a later study (1982) he reported 55.7 percent had between 2 and 10 personalities while 44.2 percent reported 11 or more.  The historical change in the number of personalities suggests either an emergent phenomenon or increased clinical sensitivity.

A certain tone often found in reports of multiple personalities may demonstrate how difficult it is even for therapists and researchers to completely free themselves from the amazing, awesome, other worldly, unreal, or near mystical qualities frequently associated with altered states of consciousness.  For example, otherwise bright and objective researchers tend to report with a tone of awe or amazement (as if to challenge the reader's disbelief) that evoked EEG potentials, Rorschach protocols, or EKG tracings are markedly different when different personalities dominate.  That cardiac arrhythmia or petit mal seizures can be prevented by the person's recognizing the physiological or prodromal signs and "switching" personalities may be presented in the literature as "evidence" for the existence of multiple personalities.  Perhaps this tone derives its justification from the numerous attacks which have been made on practitioners involved in this area of work or some of the challenges posed in courts of law.  The existence and influence of altered states apparently is still puzzling, troublesome, or even unbelievable to many.

Diagnostically, reports indicate that it is not unusual for multiples to have been previously diagnosed as hysteric or phobic or to have received any one of a variety of major (psychotic or character disorder) psychiatric diagnoses.  A wide range of somatic or psychosomatic disorders frequently accompanies the multiple personality picture.  Psychotropic drugs are considered at times to benefit one personality but simultaneously they run the risk of putting other personalities out of commission so that drugs have tended to be used conservatively.  Hospitalization tends to be advisable when a controlled environment for the expression of rage may be required or other disruptive psychotic manifestations occur.

Kluft (1984b) proposes a multidimensional treatment approach in which he sees the therapist's empathic capacities as often being greatly taxed. In speaking of hospital treatment he has a series of suggestions to make to therapists:

1. A private room should be provided so that the person will have a refuge for diminishing crisis situations.
  
2. The personalities should be met "as they are," calling the person by whatever name he or she desires at the moment and treating all alters with respect.
  
3. The therapist should not assume the responsibility for promptly being able to recognize each alter as it emerges nor try to play dumb.
  
4. Likely crises should be discussed with the staff in advance.  They should be encouraged to phone the therapist rather than pressing extreme measures without consultation.
  
5.

The ward rules should be personally explained by the therapist instructing all alters to listen.  When amnesia or inner wars lead to infractions, the rules should be reexplained to the offending alter in firm but nonpunitive terms.
  

6. The therapist should consider excusing multiples from verbal group therapy (at least at first) since confusions often result for the patient and for other group members.  Participation in art, music and occupational therapy groups should be encouraged.
  
7. The staff should be warned that disagreements often arise in planning for and working with a multiple personality.  The staff should be prepared to work through their disagreements gradually.
  
8. Issues of greatest priority should be focused on with the multiple rather than permitting minor mishaps to take center stage.  Side issues frequently preoccupy the multiple patient.
  
9. The therapist should make clear that no other person should be expected to relate to the various personalities in the same manner as the therapist.1

Group therapy is often reported to be useful for increasing the time of therapeutic contact (though not necessarily with the same therapist) as well as letting the person know that there are others with similar difficulties.  Caul (1984) has developed an interesting ''internal group therapy'' technique to be used judiciously.  Joint patient and therapist videotape viewings of sessions in which the alter personalities have appeared can provide a valuable form of feedback to the patient if done in a collaborative and non-threatening manner.

The age of confirmed diagnosis of multiple personality disorder tends to be between 18 and 30, with children seldom receiving this diagnosis.  Early reports of treatment were characterized by extensive involvement with the therapist over a protracted period of time.  Now it is generally believed (after Beahrs, 1982) that the therapeutic relationship can be maintained on as little as an hour or two a week, perhaps with additional group time.  Countertransference is often viewed as a potential danger since this population can be extremely demanding of time and energy if reliable boundaries are not set and maintained.  Schafer (1984) sees five to seven years of several times a week psychotherapy as not unusual therapeutic contact for functional integration to occur with multiple personalities.

In attempting to make a differential diagnosis, most authors agree that multiple personalities are not overtly psychotic in the traditional sense of presenting delusions and hallucinations or their affects being radically out of control.  Like schizophrenics, multiple personalities report "head voices" but the nature and content of these voices tends to be quite different (Schafer, 1984).  Schizophrenic auditory hallucinations tend to feature voices which are not always identifiable or are perhaps identified as mother or vaguely as a man or a woman who is castigating them harshly or telling them to do something.  In contrast, the head voices of multiple personalities are more likely to have whole conversations with one another, often carrying on complex discussions and disagreements between the characters who frequently have names and assume various roles.

Schafer (1984) emphasizes distinguishing the true multiple from the "pseudo" multiple.  The pseudo generally has a life history of social isolation through puberty, often having one or several imaginary companions which at that time are thought to become "introjected as internal characters."  In contrast to the true multiple, when the therapist "calls out" one of the personalities, the pseudo may close his or her eyes and go through a variety of "getting into character" rituals or fantasies.  The true multiple simply opens his or her eyes and "switches."  At that moment he or she is the other personality.  Schafer speculates that the pseudos are likely to show little real differences on EEG evoked potential or on psychological tests when in different characters whereas pronounced differences are reported in true multiples.  Sociopaths in trouble with the law may indeed attempt to appear multiple but Schafer maintains these can be easily unmasked through common diagnostic procedures.  On the other hand, most psychiatrists agree that occasionally multiples can and do have run-ins with the law when in alter personalities and since this is a psychiatric difficulty they do have a legal right to an opportunity for therapy.

Discussion of psychotherapy with multiple personalities centers around the notion of establishing trust so that traumatic situations which produced the original splitting can be remembered and abreacted to.  The process is spoken of as making possible gradual "fusion" or "amalgamation" of personalities which finally permits a resolution of the conflict" and ''integration of the personalities.''  Some quasi-religious techniques are based upon mystical or ritual exorcisms, but any apparent positive effects of these techniques are not fully explainable at this time.  Schafer (1984) makes it clear that each personality must be valued and respected if it is to be fully understood and finally traced to its origins, abreacted, and integrated.

Beahrs' (1982) approach in Unity and Multiplicity stresses that complete unity is not always necessary if all of the personalities remaining are fully aware of all of the others.  His therapeutic aim is not so much for unity as for a person who doesn't need to split defensively, for a person who has developed new ways of handling stressful situations.  Schafer (1984) holds that every important trauma must eventually be worked through.  All reports in the literature portray successful treatment of multiple personalities as a long and arduous task, requiring continuous therapist availability.  Availability is especially important during the working through phases of the psychotherapy since various personalities tend to emerge spontaneously, giving rise to confusions of all sorts.

Wilbur (1984) formulates that:

(T)he ultimate goal is to fuse the alternates with one another and the original personality ...  Fusion begins with the coming together of alternates who are close to one another and deal with the same or similar conflicts and affects. ...  As the affects are abreacted and the conflicts resolved, fusion often takes place automatically.  Fusion, of course, can be encouraged or facilitated by suggestion, but in my experience fusions which occur through suggestions will come apart more readily than those that take place spontaneously. ...  Final resolution is the result of the total integration of all personalities into the birth personality (pp. 28-31).

Marmer (1980) has published a quite interesting and detailed case study of a multiple personality treated with fairly standard psychoanalytic technique.  His discussion revolves around Freud's concept of "split in the ego" and the use of self as a transitional object.  In time his patient came to use her analyst in a transitional way which made personality integration possible.

One can see from this brief review of the salient themes in the multiple personality literature that many questions remain unanswered and many paradoxes remain unresolved.  It is my purpose to present a way of considering multiple personalities which is compatible with but basically different from the approaches discussed so far.  But before going to the specifics of theory and technique I must outline briefly the listening perspective approach which I have spelled out in detail in Listening Perspectives in Psychotherapy (1983b).
  

The Listening Perspective Approach

The psychotherapeutic enterprise has been considered in a variety of ways over the past century.  Central to any discussion of the nature of personal psychological dilemmas is the language and conceptual system in which the issues are framed.  Ekstein (1984) has noted that implicit in each of the languages of psychotherapy and psychoanalysis is always a working technique.  That is, we formulate issues in terms which reveal the way we work in the clinical setting.  Far from being objective or neutral, theories of psychotherapy and psychoanalysis are laden with various assumptions, values, and implied technical approaches.  For example, Kohut (1984) has pointed out the hidden moralities in the Freudian and KIeinian criteria for cure (i.e., adult genital heterosexuality and post-ambivalent object relations).  Kohut further acknowledges a strong value system implicit in his own "self-psychology" approach (i.e., mature self to selfobject resonance.)

Post-Einsteinian science no longer assumes that there are observer-free, value-free, context-free, theory-free facts, but rather that we have defined a series of specified approaches for noting and interacting with the realities of the universe.  In translating these notions to psychoanalysis, I have borrowed from the work of the philosophers Gilbert Ryle (1949), Ludwig Wittgenstein (1953), Jean Paul Sartre (1956) and J. Michael Russell (1978a, 1978b, 1980) to demonstrate how four distinct "Listening Perspectives" have evolved in psychoanalytic and psychotherapeutic thought over the last 100 years.2

In considering four vantage points for listening to people who consult a therapist, I have chosen a line of consideration known as "self and object representations" (following Jacobson, 1954, 1964; SandIer & Rosenblatt, 1962).  This approach considers the expanding psychoanalytic narrative in terms of how at any given moment in time the person experiences sensations or "representations" of self (ego, I) as distinguishable or indistinguishable from various sensations or "representations" of others.  The criterion for making such inferences is not the verbal content or linguistic form of the narration (such as using "I," you, or "they"); but rather, the manner or mode of relatedness actually being lived at the moment.  A very brief statement of each Listening Perspective should clarify my general approach.

1. The Listening Perspective of the Constant Self and the Constant Other is a way of listening when the speaker appears to be making a clear and reliable distinction between his or her needs, motivations and activities and those of others.  Other people are considered and related to as separate (parallel, contrasting, or conflicting) centers of initiative.  The activities and motivations of other people may be experienced as gratifying to, harmonious with or frightening and dangerous to the needs and activities of a reliable unitary, consistent, and constantly experienced sense of self It is within this listening context that "normal/neurotic" modes of relating which persist from the Oedipal period of development have been defined.  The specific ways in which an Oedipal child (aged 4 to 7) experiences loved ones tends to persist so that various expectations based on those separate but intimate relationships tend to be transferred to new people in subsequent life experiences.  Until the last two decades all psychotherapies have been characterized by an implicit assumption of experienced separateness and constancies between selves and others.
  
2.

The Listening Perspective of the Selfother is a way of listening when the speaker's mode of address or activities indicates that the other person is thought of as separate but in fact is being related to or used as a part of or augmentation of a fragile or nascent sense of self.  Heinz Kohut (1971, 1977) has specified an era prior to the Oedipal (i.e., Mahler's "rapprochement," 1968) in which the growing child's sense of self relies upon various mirroring, twinning, and inspirational experiences in connection with important others (so-called selfothers or "selfobjects").  Kohut has shown the ways in which these grandiose, twinned and idealized aspects of self are transferred to others and has developed therapeutic techniques for analyzing what he has called "narcissistic" or "selfobject" transferences.
  

3. The Listening Perspective of the Symbiotic or Merger Object is a way of listening to a speaker who may appear (linguistically or cognitively) to be distinguishing between self and other but who, in fact, fuses, entangles, or confuses the distinction in any of a variety of ways.  Metaphorically, the merger experience is thought to date from the eras between 4 and 24 months of life that Mahler (1968) has called "symbiosis" and "separating."  A young child is thought to engage in mutual cueing with important others which establishes permanent modes of relating to other people.  What mothers call "the terrible twos" marks the (separating) opposition a child develops to relinquish the established symbiotic bonds.  Individuation to the later selfother era is facilitated by parental acceptance and containment of the separation-individuation activity.  To the extent certain entrenched modes of fusing with, entangling with, or opposing the relatedness demands of early others are retained, the ongoing personality displays what have been called "borderline features."  For listening purposes the concept of "scenario" defines the interpersonal relatedness dimension or interaction which persists from the symbiotic or separating era and which tends to be replicated in subsequent relationships, especially the therapeutic one.  That young toddlers internalize both active and passive roles of the scenario means that skills in "interpreting the counter-transference" (Hedges, 1992) are important.
  
4.

The Listening Perspective of the Part-Self and Part-Other is a way of listening to a person whose basic modes of living and relating are of a "personality in organization."  My work on "The Organizing Personality" (Hedges, 1983a, 1983b, 1994b, and in press and Hedges & Hulgus, 1991) assumes that infants organize basic sensorimotor and cognitive-affective systems in accordance with the way they experience various types of consistency or inconsistency in relationships with early others.  Exposure to and assimilation of a consistent patterning of care giving leads toward a highly stylized, idiosyncratic symbiotic mutual cueing process with others.  However, if for any reason (genetic, physiological, or environmental), the infant cannot experience and learn a consistent address for reliably available others, various incomplete or faulty organizational patterns are established which create a wide variety of limitations in cognitive controls and/or affective regulation.  The early limitations of personality functioning may produce later psychotic indicators or simply give rise to a loosely or idiosyncratically organized individual.

The "organizing personality" is thought to be in continuous search for connections with people but is generally not able reliably or consistently to sustain connections once they have been established.  The patterns or styles of relatedness of the personality caught in continuous organizing activities are in some sense so unchanneled, unformed, or unreliable that even connections which may become established have no secure permanence.

The work of Franz Kafka illustrates the unending, confusing, and generally unrewarding or frustrating search which organizing personalities conduct in pursuit of organized modes of establishing and maintaining reliable connections with the environment.  Jerzy Kosinski's hero in Being There (1970) provides another such example of a character in search of identity and personhood who is only able to obtain limited, confusing, changing or ungratifying relationships.  I have developed the concept of "mimical self" to capture the qualities of highly sophisticated mimicry or imitation of others which characterizes personalities suspended in various forms of perpetual organizing activity.  A "mimical self" would be a formation which precedes developmentally Winnicott's "false self" (1952) which arises out of conforming to environmental demands in deference to more authentic demands of the infant's nature.
  

The Listening Perspective Approach with Multiple Personalities

As mentioned earlier, the vast majority of persons in the group now being defined as "multiple personality" are not readily classifiable as "neurotic" (i.e., suitable for The Listening Perspective of Self and Other Constancy).  This is because of the multitude of ego splits and the general failure of repression.  The multiples now emerging in clinical practice seldom address the therapist "narcissistically" either, so The Listening Perspective of the Selfobject is also largely inapplicable.

In merger or "borderline" states (The Listening Perspective of the Symbiotic or Merger Object), as puzzling as many of the symbiotic and separating scenarios can be to the clinician, the expected feature stemming from early mutual cueing experiences is a reliable mode for experiencing and engaging others.  It may require the therapist several years to find ways of emotionally interacting with (joining, replicating and ultimately standing against) the highly idiosyncratic but stylized relatedness modes.  Understood in this way, "bad self" experiences might be split off from "good self" experiences and experiences of "bad" others might be split off from experiences of "good" others (Kernberg, 1975, 1976).  But a host of identifiable alter selves with various affective potentials would not be expected in the good-bad split.  That is, borderline features are essentially definable as vestigial or retained modes of interaction based on extensive early symbiotic and separating mutual cueing experiences featuring more or less consistent but alternating affects.  As strange as many varieties of parent-child bonding may appear to an outside observer, in time the modes can be shown to be entrenched, reliable, and once understood, to make a certain special kind of sense within a given parent-child rearing context.

Ultimately in the therapeutic (analytic) study of borderline level personality features, the clinician begins to discern a "method in the madness."  Certain relational demands and expectations which early on seemed puzzling, self-destructive, chaotic, fragmented, abusive, and so forth, slowly begin to form a pattern which is comprehensible in light of the developing creative narrative and narrational transference interaction reflecting the parental personalities and early life experiences.  Analysis of the "replicated transference, in contrast to "analysis of the transference neurosis, or the selfother transferences" (at higher developmental levels), gives rise to a series of individuating boundary issues between the personality needs, activities, or "personal space" of the person and the therapist's activities, understandings and "personal space."

These interactional modes and conceptual tools used with "borderlines" are likely to be minimally helpful in responding to the variety of (presymbiotic) organizational aspects presented by multiple personalities.  The "split off selves" portrayed by the multiple are born in isolation and disaffection rather than in interaction.

Although multiples are not treatable in the same fashion as borderlines, almost all of these "lower level" personality features are indistinguishable from one another upon initial clinical presentation.  Typically, the personality styles presented to the clinician represent the person's favorable and unfavorable capacities for adjusting to important demands of the world.  Winnicott (1952) has described the "false self" capacities which a person mobilizes to conform to early parental and later environmental demands.  As an avenue for interacting the false self maneuvers arise in response to symbiotic or borderline developmental demands.

My central thesis is that "multiple personalities" represent the emergence and creative elaboration in the psychotherapeutic or psychoanalytic setting of a variety of earliest affect-ego states, and that they may be considered unintegrated "ego nuclei" (Glover, 1932) or early centers of organizing experiencing.  "False self," "mimical self" or social self" adaptations may take many forms so that the person's life adjustment may be highly effective.  The person may be basically well coordinated, intelligent, pleasant, capable, and quite likable.  The overall style and effectiveness of the social self may or may not have permitted awareness of different types of ego, self, or altered states which emerge at various times for various purposes.

If we grant that in some sense all people have multiple selves or various frames of mind, moods, or affect-ego states, it is not difficult to understand how under some circumstances the usual, expected, or hoped for integrating effect in personality formation might not be completely achieved.  Kohut's (1979) notion is that a unitary cohesive self develops because from the first day the mother addresses her child as if the child had a self.  The many affect-ego states of the first months of life are thought to come under the conditioning influence of what Mahler (1968) has called the symbiosis (4 to 24 months).  Gradually in later individuation (Mahler's "rapprochement"), emerging individual self states may become admired, confirmed, and inspired under the influence of selfothers, thus bringing all of the early affect-ego states into what Kohut calls the cohesive self.  The constant self and constant others of the Oedipal period inherit this development.  But the experience of multiple selves harks back to the earliest organizing affect-ego centers or ego nuclei before they have been brought into reliable unification through symbiotic bonding.

On the basis of recent clinical experience with narcissistic, borderline and organizing states, we can now surmise that several difficulties might arise in the self consolidation process.  These possibilities stand as clinical hypotheses regarding how we might view the experience of multiple selves in different individuals:

1.

Integration of various self states may be limited due to faulty, inadequate, or insufficient age-appropriate consolidating experiences.  Symbiotic bonding experience has been partial or incomplete so that affect-ego states are included.
  

2.

Self consolidation may be warped or deformed through systematic conditioning experiences.  The demands of bonding or later selfother experiences may continue to exclude or warp affect-ego states as they develop.
  

3. The process of evolving a cohesive self may at any developmental era be disrupted by overstimulating experiences which interrupt or destroy the effectiveness or cohesion of tentative ego or self experiences causing a functional regression to previous unintegrated levels of affect-ego states.
  
4. Problems in the self consolidation sequence may frequently undergo later repetitions or replications fostered by persons in the child's environment and/or invited by the child (usually inadvertently) as a part of a chaotic or ineffective search for connections with people.  These later encounters are often so intense that they produce regression and fragmentation to earlier unintegrated states.

Current literature on multiple personalities places etiological emphasis on actual traumatic disruptions (number 3 above) which were perpetrated by intrusive and/or abusive older persons in the child's environment.  But similar effects can be achieved in at least these three other ways.  Access to multiple early affect-ego states can be retained if later opportunities are insufficient to coalesce early merged symbiotic selves and a subsequent personal cohesive self.  Certain types of symbiotic molding can promote a socialized or false self which fails to integrate many early affect-ego nuclei.  When the social self is traumatized or has an opportunity to relax (as in psychotherapy), the more basic states or personality constellations may become accessible.

The replication possibility (number 4 above) is difficult to explain succinctly.  In wandering, searching, organizing states or certain established symbiotic ways of connecting with others, a person may reach out to persons in the environment in ways that invite, induce, or seduce others to invade, abuse, or molest them.  This is not to say, as we might in an individual with more advanced symbiotic, narcissistic or neurotic structures, that the person "sets himself up" for abuse or that a clear motivating repetition compulsion is engaged.  Rather, lacking certain nuances of self-consolidation or social skill which ordinarily develop through satisfactory relations with people, the personality in organization moves about the world almost as a ready or available target ("sitting duck") for those whose need is to intrude or abuse.  We have seen this kind of phenomena with brain defective and retarded children who are frequently abused and molested because they seek human contact and yet don't know how to prevent being taken advantage of.

In a given instance some "repetition compulsion" or motivated phenomenon might or might not be detectable.  But I suspect that most of the time these people as children, and often in many circumstances of adolescence and adulthood, simply miss (receptively and/or expressively) subtle social cues and fail to understand fully the implications of how abusive others approach them.  And in their approach to others they may fail to understand what they are (inadvertently) making themselves available for.  This point is important since many clinicians think of the repetition compulsion as a way of "holding the person responsible" for social consequences of their activities.  Or conversely, in "not blaming" the person who has received abuse, clinicians may miss an opportunity to understand what personality needs and features may have contributed to the person's "availability" as a target for various forms of abuse.

I wish to stress the importance of considering multiple etiological possibilities because a therapist committed to the position that a person with multiple personalities was invariably molested may become enmeshed in a serious and naive listening error.  For the therapist to believe that each personality was necessarily created by another traumatic intrusion or that all early traumas must invariably be tracked down and catharted may also lead to grave listening errors.  The content, memories, and affects produced in organizing states cannot be trusted in the same way that we tend to trust similar events and activities emanating from more integrated states.  We have now studied enough about "screen memories" (Freud, 1914), "telescoped memories" (Kohut, 1971), and the workings of "projective identification" (Klein, 1952) to know that anyone can produce memories and affects (with or without hypnosis) which are not veridical but which contain significant emotional or phenomenological truths.  A therapist would do well to keep to the task of encouraging the subtle growth of the therapeutic relationship and its analysis and to suspend judgment (permanently) on such matters.3

My impression is that for every molest or abuse scene that can be narrated in psychotherapy or psychoanalysis, many more emotional experiences of a like genre have occurred which will not and probably cannot be narrated but are contained in moods, self management styles, and longings for transformation (Bollas, 1984, 1982, 1978).  These statements bring us face to face with some of the many problems of therapeutic technique.  I oppose considering the appearance of any memory, affect or affect-ego state per se as "evidence" of anything.

Therapeutic narrations stem from an ageless human tradition of myth making, storytelling, and cultural legends (Schafer, 1976; Spence, 1982).  As such, the narrative truth of psychotherapy must be considered profoundly allegorical.  Truth contained in narrations and allegories need not be confused with historical truths nor need its truth value in any way be discounted.  But a naive listener believing the simple story at face value is in a poor position to consider the broader picture or to know how to call for an effective creative elaboration of various key elements of the narration.  A naive therapeutic approach is bound to slow things down.  An exclusive insistence on ascertaining and catharting to the effects of events remembered or perceived to be real runs the risk of failing to broaden the catharsis to include all similar events and then to move the concerns on to the plane of transference and countertransference.  That is, the therapeutic value of straightforward historical truth pales by comparison to the rich possibilities of narrative truths which reach into all recesses of the mind and leave no emotional effect untouched.

Surely here someone will say, "but it is often so important for some of these people to be believed since many times they have tried to tell their stories and have been discounted."  I say, "believe them for sure; but don't for one minute assume that the narration and its accompanying affect anywhere near tells the entire story — becoming too literal or too concrete means one only gets exposed to the tip of the iceberg.  Psychoanalytic empathy means keeping many possibilities of meanings simultaneously before us."  By analogy, as therapists we must be able to take a conversion paralysis seriously, but an eventual therapeutic effect depends upon our also taking the person seriously in many other ways as well.  In couples work we hear two versions of reality but seldom feel a need to side with one or the other as more true.  So what can be our therapeutic approach to the multiple personality?
  

Psychotherapy and Psychoanalysis with Multiple Personalities

Ekstein (1984) maintains that the psychotherapeutic and psychoanalytical languages we use always contain hidden technique.  I will begin by briefly surveying the treatment dimensions implicit in the Listening Perspective "approach" before specifying further treatment ideas related to multiple personalities.  The four Listening Perspectives follow a developmental format for reasons of logic, consistency, and coherence.  That is, one's listening interests might be specified in many different ways.  The implicit value system of the Listening Perspective approach is not developmental, but rather one which places a premium on noticing the nature of each uniquely interacting analytic couple.  It does not have a value system which holds "separation-individuation" as an ideal or which promotes "mature development," "self cohesion," "self and object constancy" or "unity in personality" as necessarily positive achievements.  While these may all be worthwhile goals, they are misleading in analysis and sidestep what is most important in our work — developing the capacity to listen in the most comprehensive and flexible ways possible to the person who has come to tell a story.

We can and often do define the development of human possibilities with an "unfolding" or "growth" metaphor which has a strong attraction because we know that living things grow and that complex functions expand in surprising ways.  To conceptualize psychoanalysis as a process to promote unfolding or growth is therefore tempting.  One unfortunate consequence of succumbing to the temptation of the growth metaphor is that we then view the therapist as some sort of a parent, teacher, guru, or gardener.  Again, not a bad set of models to put before ourselves, but surely by this point in time we are able to do better.

The Listening Perspective approach is organized around the chief task which faces the therapist or analyst — listening, not with our ears only, but with our entire being to what people have to tell us, to show us, to do to us, and have us do to them.  Arranging one's Listening Perspectives along a developmental axis emphasizes the wide range of human activity to be communicated and considered in psychoanalysis and the various ways in which communication can be achieved.  It further suggests that activities and engagements of most humans span the entire developmental continuum.  Some of our most delightful moments are clearly "infantile" and some of our greatest sufferings spring from the most "mature" parts of ourselves.  Further, conceptualizing psychoanalysis exclusively along either Oedipal-neurotic, self-psychological, or self and object representation lines necessarily limits which of the many features of an analytic hour we are likely to consider and narrows considerably what we believe our analytic function to be.4

I find that even the most efficaciously conceived theories and therapeutic guidelines are in some sense utterly useless when I sit trying to contemplate and to appreciate the person before me.  "Who is this person?  What does he or she want or expect from me and from our time together?  What on earth will we come to do with one another?  How will I manage to stay abreast of what is being shown to me?"  These are the questions with which I face each clinical hour — hopefully, as much as possible in the way Bion (1962) has suggested, "without memory or desire, without undue preoccupation with the past or the future."

A rich armamentarium of theories and techniques may indeed reduce my fear of the unknown, but I can't imagine how they will help me — except as they sharpen up my listening habits and open my mind to a wider range of listening possibilities each hour.  The Listening Perspective approach thus promotes a value of individualized listening but specifies four broad categories of types of human activities and interpersonal engagements which we may expect to experience or hear about during analytic hours. In not considering these categories as "developmental levels" but rather as four distinctly different but simultaneously useful perspectives, vantage points, or positions from which to hear what is told to me, I realize that I am always adrift, never certain, and always appealing to the person before me for help in understanding how it is or was for him or her.  I will now summarize a few of the implications which the Listening Perspective approach provides for the psychoanalytic hour:
  

1. The Constancy Perspective (For Neurotic Personality Organization)

In states of self and object constancy, verbalizations and gestures can be assumed to be symbolically integrated and expressive of often disparate or conflicting feelings or thoughts.  Because the constancy mode is predominantly an individuated way of reacting and interacting, both members in the analytic couple can generally rely on some degree of mutual restraint and rapport within a contractual atmosphere containing a certain degree of emotional distance or separateness (i.e., "the therapeutic frame").  All that Freud taught about wishes, conflicts, dreams, symbols, impulses, defenses, compromise formations, and so forth can be assumed to be operating as "neurotic" transference configurations.  What one experiences as "inner life" is basically, or will through analytic narrations ultimately be, connected to or accessible through verbalization and verbal-symbolic interpretations.  In constancy states a person seeks out and perpetuates complex cognitive-affective states and interactions.  These complexes can be expected to appear in therapy as "neurotic transferences" and eventually to be largely resolved through a creative narrational process involving verbal-symbolic interpretation, insight, and working through.
  

2. The Selfother Perspective (For Narcissistic Personality Organization)

Selfobject states are communicated partly by verbalization but usually are most evident in the orienting or approach of the person to the analyst.  Although the analyst is known to be separate, emotional affirmations, confirmations, and inspirations are actively sought from the "selfother" analyst.  Kohut (1971) has formulated these trends as having the purpose of completing or coalescing the sense of self.  Transference repetitions usually take the form of disappointments with the functioning of the analyst (so-called selfother failures) which result in various forms of stressed, tense, and/or disturbed behavior.  If the therapist can acknowledge the failure and correct his/her understanding with empathic words or gestures, the self gradually develops the capacity to maintain constancy and cohesiveness without such frequent, intense, or archaic selfobject supports.
  

3. The Merger Perspective (For Borderline Personality Organization)

Merged or borderline states take on as many forms as there are parent-child dyads in the world.  When the original mode or patterning of relatedness can be achieved in the therapeutic relationship, a sense of wholeness ensues, even if that pattern may seem grim, depriving, or somehow abusive to an outside observer.  Preverbal idiosyncratic patterns are always difficult to grasp.  Verbalizations by the client only rarely provide the therapist access to the "scenarios" which the person must actively replicate in the emotional interchange of therapy.  Countertransference responsiveness is often the "royal road" to understanding borderline scenarios (Hedges, 1983b, 1992).  Countertransference responses serve as informers providing rough approximations of the (passive or active) merged states being sought after and lived out.  Interpreting the Countertransference (Hedges, 1992) involves the therapist being able to speak the countertransference experience in such a way as to show a recognition of the infant side of the mother-child interaction.  Only after emotional "togetherness" is in some way achieved is the therapist's knowledge of the scenario or scenarios sufficient to be able to engage in activities which promote separating and individuating modes.  The false or socialized self constellation which may seem cooperative with the treatment must ultimately be confronted as not operating in the person's best expressive interests.
  

4. The Organizing Perspective (For Use with Various Psychotic States and the Personality in Organization)

Every infant's perceptual-motor and cognitive-affective systems organize around various available features in the immediate care giving environment.  The wide range of affective responses in the early months of life is subtle and may appear limited because the infant has so few ways of communicating.  The unobservant or untrained adult may only perceive pleasure-pain potentialities since these match the best available communication modes.

In therapy, quests for connection to the person of the therapist or for experiences with various part-aspects of the therapist or the early part-other milieu are bound to take many forms which may seem as puzzling to the therapist as the seemingly odd things which infants seem to request from their parents.  Affective states vacillate widely and rapidly.  The phenomenology of experience is unpredictable and psychic content often seems controlled by forces other than human volition.  Delight in and study of various sensorimotor and cognitive-affective experiences with available others predominates.  Many infants learn to flee from traumatic or overstimulating human contact in various ways (i.e. fight, flight, and/or freeze) or to organize their cognitive-affective systems in idiosyncratic ways which may change rapidly and vary widely (Tustin, 1981).  Such fluctuations may make it difficult for a therapist who is functioning in a more stable organized state to empathize.  Transference expresses the internalized modes of disconnecting used by the earliest (m)other.  Rupturing of interpersonal contact and continuity is the hallmark of personality functioning at the organizing level.  This is vividly manifest in the multiple "switching."

In a therapeutic milieu which permits the emergence of organizing states, largely freed of the burden of false self conformity but not the effects of mimicry, the "personalities" of the multiples have maximal opportunity for creative elaboration and expression.  The search for contact and the many (transferential) ruptures become the focus for study in this Listening Perspective.
  

Recommended Therapeutic Approaches to Multiple Personalities

Each experienced psychotherapist or psychoanalyst has developed an individual working style and has explicitly or implicitly adopted a set of theoretical constructs which provides a consistent backdrop and justification for that style.  What the analyst claims to be doing is invariably embodied in an impersonal theoretical framework and is not nearly so important as the personal availability and consistent listening attitude which is established and maintained during the analytic hour.  Actual working techniques are primarily a matter of personality and choice and the analytic work goes forward so long as persons in analysis sense that they are being heard and responded to according to their needs.

What has traditionally distinguished psychoanalysis from the other therapies has been close systematic attention to the developing "transference neurosis;" that is, the emergence in the analytic relationship of features which characterized the child's Oedipal relationships.  As psychoanalytic inquiry has broadened its scope to include pre-neurotic personality constellations, the distinguishing feature of an emerging "transference neurosis" per se is not expected in analytic work with pre-Oedipal states.

However, the history of the study of Oedipal "transference neurosis" provides a relevant context for contrasting the expected clinical effects now being spoken of as "selfobject transferences," "borderline replications," and "organizing connections."  Each of these four sets of relational phenomena can characterize certain developmental configurations and become available to analytical attention through each of the four Listening Perspectives.  Each set of experiences may be thought of as built upon or growing out of the successes and failures of previous "layering(s)" of experience.  Thus, when considering the listening context for "higher" organizational aspects, features from each of the "lower" constellations may well make an appearance at various points in the analysis.

Conversely, when considering a listening context for "lower" level organizational aspects, one does not necessarily expect that aspect to be meaningfully integrated with or connected to other (similar or parallel) aspects or to be fully integrated with "higher order" organizational achievements.  According to this use of the developmental metaphor, we would expect at more differentiated levels to hear strivings for a more integrated, cohesive, monistic and separate sense of "I" while at less differentiated levels various disparate, unintegrated, confusional, partial or pluralistic "I's" will be more apparent.

During the last decade hypnotherapists and developmental psychoanalysts have been more prepared than ever to hear and experience these unintegrated and often contradictory aspects of early self development.  This preparedness has allowed the configurations found in multiple personality pictures to emerge with greater frequency and clarity.  This, however, does not imply iatrogenesis in the usual sense that the treatment causes the illness.  Rather, since Freud first opened his ears to hear the hidden features of hysteria, the history of our field has been one of learning how to create an empathic listening atmosphere which permits elusive aspects of personality to be interpersonally experienced, expressed and transformed.

Basic organizational aspects of personality are not readily accessible for therapeutic study via the usual verbal-symbolic, introspective techniques which characterize the analysis of neurotic and narcissistic configurations.  Nor are they available to interactive techniques or systematic countertransference studies commonly used in understanding the symbiotic and post-symbiotic relatedness seen in borderline personality organization.  The investigative mode for listening to aspects of personality arrested at the organizing level necessarily becomes that of "interception" (Hedges, 1983b).  Organizing Personalities must be met (intercepted, contacted) during moments of sensorimotor extension in order for the organizational impetus to be understood and for the impact of the inconstant contrasting configurations of the (part) other to be experienced and registered in the emerging personality formation along with various experiences of (part) selves.

The crucial implication of this is that therapeutic connection with early organizational aspects of personality usually will not be possible through extensive analysis of symbolic or body-symbolic representations (the so-called symptom constellation), since these manifestations are secondary or reactionary to faulty early object relations.  That is, psychotic phenomena represent abortive attempts at self stabilization or self nurturing and soothing which only seldom include representations favorable for realistic relatedness to others.  Grave therapeutic limitations have been repeatedly demonstrated through exclusive reliance on: (1) Extensive analysis of the symbolic content of the psychotic life, (2) therapeutic immersion in the subjective psychotic world, (3) systematic utilization of countertransference reactions to (the fragmenting/withdrawing aspects of) psychosis.

The infant, child or adult whose personality is arrested at or regressed to early organizing attempts is usually seen as living in a world of his own.  The nurturing, soothing, pacifying other must patiently wait until the infant or person is momentarily oriented for contact with the other.  The child Celeste reported by Ekstein (1979) played quietly every day in her therapist's room until at last representations began to emerge in the form of small Kleenex figures which begin to relate silently to one another until the magic day when one special Kleenex figure approached and came to rest on the therapist's shoe!  Had the therapist intruded on her play before she was ready to acknowledge his presence he would no doubt have been repeating the intrusive trauma of her infancy.  The therapist's work consists of creating an atmosphere in which sensorimotor extensions can be met or intercepted when they occur.

In Bollas' (1978) language, the task of the mother/other is to be available to assist in the transformation of various self states as they occur ...  Stimulating experiences produced by internal states as well as experiences produced by impinging external stimuli are intercepted with affective containment and pacification, thus "teaching" (almost by classical conditioning) the possibility of altered or transformed states.  Adequate interceptive pacification experience leads toward mutual cueing which characterized the "protective shield" (Khan, 1963) of the symbiotic envelope or canopy.  Subsequently overwhelming states are only experienced during the absence of the symbiotic partnering experience (Hedges, 1983a).

In taking this general approach to the early organizational aspects of personality formation I have specified several critical listening dimensions:
  

1. Reflexive Mental States

Freud (1900, Chapter VII) first described elemental mental processes as "reflexive."  While many writers speak of early mental states as unintegrated, segmented, disintegrated, or fragmented, such terms reveal an observer bias or describe confused or pluralistic states, but fail to describe fundamental organizing processes.  Images in earliest mental states, according to Freud, can be thought of as passing reflexively forward and backward along a reflex arc, whereas a later buildup of memory traces causes the arc to become unidirectional.  Freud's conceptual model prepares clinicians to listen for often confusing and fragmented reflexive sensorimotor and cognitive-affective experiences passing into and out of awareness with hallucinatory vividness.  Observation of reflexive mental processes is frequently obscured by regressive phenomena such as those seen in "psychotic" symptoms and in multiple personalities the rapid ''switching'' from personality to personality.
  

2. Nonhuman Imagery

Victor Tausk's (1919) classic paper on "The Influencing Machine" was the first of a long series of psychoanalytic formulations which have highlighted the dominance of nonhuman imagery in early personality organization.  Searles' (1960) focus on The Nonhuman Environment has clarified the kinds of relatedness which tend to characterize organizing processes.  His careful delineation of mechanical, impersonal, and supernatural forces which govern the nonhuman world prepares the analytic listener to observe and interpret the attempts to organize sensorimotor and cognitive-affective experience.  Searles' attention to the mystical, mythical, totemistic and animalistic sheds light on a wide range of possible interpretations of sensorimotor and cognitive-affective phenomena which are involved in any given person's effort to organize and relate to perceived dimensions of the world.  The mechanical or nonhuman features of organizing experiences are frequently found in multiple personalities, in a particular "robot" personality or can be seen to operate in the way that the personalities interact with one another or in which certain personalities interact with the world.  Content involving demons and devil worship, as well as mystical, otherworldly or past life experiences and vivid "memories" of uncontrollable beatifications and atrocities, as well as alien abductions all feature the nonhuman aspects which can be expected to constitute as "real" in organizing states.
  

3. The Centrality of Bodily Sensations

The early organizational strivings which form the core of what is to become known as the self begin with cognitive-affective sensations and sensorimotor operations.  Mahler (1968) and Tustin (1981), in their studies of disturbed children, have regularly observed preoccupations with and exaggerations of various sensory experiences.  Sensations or hypersensitivities often represent more than simply symptoms, but rather must be listened to in the context of developing potentialities for personality integration and functioning.  A preoccupation with body parts and sensations is clearly the essence of the organizing process.  Various forms of focus on the body range from somatic symptoms to sharply distinguished perceptual experiences in different "personality" states of multiples.  As with psychosomatic indicators, many features encountered in multiple personalities are usefully considered as somatic sensations or states which have not found psychic representations which can be integrated within the ongoing fabric of personality.
  

4. The Transformation of Primary Sensation and States

As a therapist first assumes a place in the life of the organizing personality, it will likely be in a transforming role.  Bollas' (1978) discussion of "the transformational object" contributes fundamentally to an understanding of the listening context of psychotherapy.  Earliest experiences of parenting involve the transformation of bodily functions and mental states.  Bollas points out that Freud (forgivably) failed to note the fact that the analytic situation itself constitutes an "acting out" of the early transformational experience.  A person arrested in an organizing state is presumed to have suffered deficits and/or traumas in the early transformational processes.  While the person may sometimes be quite ready to have the deficits (usually various dependency needs) responded to by the therapist, the traumatized areas pose more of a problem.  Early parental omissions and commissions missed their mark in some way, resulting in various affective and cognitive constructions which are not integrated within the entire personality structure.

An awareness that the transformational processes themselves may enhance or thwart the therapeutic connection with organizing personalities suggests a new kind of listening concern.  The therapist must be content to set aside verbal and even interactional approaches in deference to the more crucial role of promoting micro-transformations of various early developing self states through contact or interceptive pacification until the mutual cueing of the analytic couple can become an important factor.  Bollas (1982), following Winnicott, has subsequently developed his ideas to include a therapeutic regression to dependency; which includes attention to primary cognitive-affective and sensorimotor experiences in the presence of and with the aid of the analyst.
  

5. The Establishment of Mutual cueing

Sensitive noninterfering work with all varieties of organizing personalities may be expected to lead toward mutual cueing processes between basic personality dimensions of the therapist and elemental aspects of the organizing personality.  In the multiple personality, as the therapist responds to each different self and attempts to understand the various selves and, in turn, their relations to one another and to various experiences of others, a reliable communication system (largely nonverbal or paraverbal at first) will begin to evolve.  Searles (1979) has depicted psychoanalysis with this level of personality organization as consisting of the formation of a "therapeutic symbiosis" — a symbiosis de novo — followed by successive phases of individuation.  Both members of the analytic couple have the eventual task of individuating from the symbiotic union in such a way as to be able to honor the other's separateness and individuality.  Searles' notion of the therapeutic symbiosis can prepare the analytic listener for the gradual emergence of a mutual cueing process based upon the establishment of ways of handling needs which each has in the relationship.  Only after the holding (Modell, 1976) and containing (Bion, 1962, 1963) functions are smoothly in operation as a symbiotic relatedness pattern can the individuation process be expected to go forward in multiple personality work.  The functional integration of various aspects of self slowly proceeds as the therapist is consistent in addressing the person as a single unitary self.  I have suggested that various "personalities" be addressed in the spirit of always recognizing each as a part of the whole person.  None of us are ever so integrated as to be totally without multiple self states.
  

6. Fusion and Confusion of Identities

Elemental organizing processes usually do not include reliable differentiation of self or various selves and/or others.  Klein's (1952, 1975) discussion of infantile greed and envy may help to specify expected "positions" which the organizing person may assume vis a vis the therapist.  More importantly, her concept of "projective identification" points toward an expected blurring or indistinctness of early self-other relatedness which is bound to be a part of the listening situation with organizing personalities or with organizing states in persons primarily integrated at other levels.  While the essence of creativity is the projection into the parameters of the world a vision or belief which is then taken back into the self as reality, relatedness on the basis of projective identification is likely to have significant interpersonal effects which can eventually become the focus of careful clinical scrutiny.  Frances Tustin's work with autistic states (1981) formulates ways in which young children may wall off, encapsulate, or confuse their identities with mother.  She has developed fascinating treatment techniques for making contact with people in such states.
  

7. The Movement Toward Transitional Activities

Various objects and activities may become part and parcel of the processes of sensorimotor and cognitive-affective experiences and transformations in organizing states.  Relationships with inanimate (hard and soft) objects and part-aspects of the therapist and others may be understood as a beginning concrete means of manipulating or controlling various sensorimotor and/or cognitive-affective experiences.  Winnicott (1953) has written of the first "not-me" possession as a transitional object that simultaneously symbolizes mother in her absence while it remains under the child's manipulation and control.  Winnicott broadens "transitional" to include many other phenomena which have in common the quality of representing something uncontrollable in a controlled guise.  The worker with multiple personalities will quickly understand many representations, transactions, and personality features serve this transitional function.  Transitional use of a talisman, photos, tape recordings, gifts, and other less tangible phenomena can be expected to mark the transitional phase in therapy with organizing states.
  

8. Disruptions in the Personality Functioning of the Therapist

Empathic contact with elemental organizing processes inevitably entails disruptions in the personality functions of a parent or therapist. Giovacchini's (1975, 1979a,b) penetrating focus on the disruptive effects which "primitive mental states" regularly have on the personal and professional integrity of the therapist points toward very special listening problems.  Giovacchini speaks of "the impact of the delusion" to refer to both the positive and negative effects which the person's experiences of reality have on the comfort and identity of the therapist.  His discussions of the problems involved in maintaining) losing, and regaining the analytic stance prepare the clinical listener for disruptions in his or her personality functioning when working with organizing and multiple personality states.  Giovacchini indicates that often interventions and maneuvers must be undertaken by the therapist so that the therapist can continue functioning as a therapist.  Anticipating disruptions in the therapist's personality functioning and being prepared to undertake tactics or maneuvers designed to maintain the therapeutic stance or to shore up the personality functioning of the therapist constitutes an important contribution to clinical listening with organizing and multiple personalities.

There are several kinds of countertransference to organizing states which can be expected by listeners working the organizing experience.

a. Denial of human potential.  The most common form of countertransference has seen organizing personalities as witches, evildoers, hopelessly psychotic, and in other ways not quite human.  In this attitude is a denial of human potential and a denial of the possibility of being able to stimulate desire in such a way as to reawaken it and to analyze blocks to human relating.  We hear: "I can't reach you, you are too sick.  You are untreatable so we will lock you up or give you drugs to sedate or pacify you."
  
b. Fear of primitive energy.  When an analytic listener invites the organizing experience into a transference relationship, he or she is asking that the full impact of primitive aggressive and sexual energies of the analytic speaker be directed squarely at the person of the listener.  Listeners fear the power of this experience because it can be quite disorienting and, if not carefully assessed and monitored, potentially dangerous.  But fear of basic human affectivity is irrational and we now have at our disposal many rational ways of inviting and managing the organizing level affects and energies.  The key technical consideration is not whether the person on the basis of a priori criteria is "treatable," but whether the listener has sufficient holding and supportive resource available on a practical basis to make the pursuit of treatment practical and safe for all concerned.
  
c. Encountering our own organizing experiences.  When we as listeners invest ourselves emotionally in reaching out again and again to an analytic speaker only to be repeatedly abandoned or refused, it stimulates our own most primitive experiences of reaching out to our own mothers during our organizing developmental period, hoping for a response and feeling traumatized when the desired response was not forthcoming.  Our own "psychotic mother" transference can reappear projected onto the analytic speaker as we attempt to provide systematic and sustained connection for people living organizing states.  How each of us as individual practitioners develop staying power is the crucial question.  Our own therapy is essential as is consultation with colleagues during trying phases of this work.  Attempting to work the organizing experience without adequate resource and backup support is like a single mother trying to manage a difficult or sick baby while holding down a job to support herself, caring for several other children, and trying to live some life of her own.  We need support to do this very taxing kind of work.
  
d. Empathy leading to breaks in contact.  After the preliminary phases are well under way — that is, after two have established basic working rhythms that are comfortable and safe, and after the listener has been able to discern and bring up for discussion the specific ways in which the speaker searches for contact and then cuts off contact — we notice the speaker begins excitedly to see in outside contacts as well as in the analytic hour how the breaking of contact is being regularly accomplished.  Speakers in analysis are often excited by the therapeutic process at this point because for the first time in their lives something is finally making sense about themselves.  They begin a valiant struggle to maintain contact nearly everywhere they go, especially with the listener.  Then, we notice a tendency on the part of the analytic listener to begin withdrawing into inattentiveness, preoccupation, or even drowsiness.  This type of countertransference activity, which generally occurs only well into the treatment process, represents the listener's empathy for the terror which contact provides for the speaker.  That is, the speaker for the first time feels he or she is hot on the trail of something that promises human satisfaction — sustained contact.  But in the person's enthusiasm to achieve as much contact as possible as fast as possible, it is the listener who senses the internalized danger and in some way is deliberately (consciously or unconsciously) slowing things down a bit.  This countertransference reaction can be spoken to the speaker so that two may gain a fuller appreciation of the joys and dangers of human contact.

Once again the developmental metaphor may help us to conceptualize the transforming and/or integrating functions which the psychotherapist or psychoanalyst serves for the multiple personality.  The basic task of the neonate appears to be that of organizing and integrating a wide variety of sensorimotor and cognitive-affective experiences in relation to (m)other.  The child who is empathically met (contacted, intercepted) in moments of sensorimotor or cognitive-affective extension is able to use people in the environment as the organizing, synthesizing principles and to move toward the development of the symbiosis with the (m)other.  A child whose extensions are not met in timely fashion or whose peaceful states are intruded upon carelessly will remain to some degree perpetually caught in a searching, organizing, unintegrated state.  Development of good intelligence and good social skills may constitute what I have called a "mimical self" or a later constellation of a "false self" or "social self" which is more or less successful in imitating or adapting to the demands of the world, but the person remains in certain important respects outside the pale of human relatedness.  A personality arrested at or regressed to organizing states may or may not show signs of attempts at secondary restitution (psychosis) either through exaggerated affects or nonconventional thinking.  Recent observations have suggested that there are many more persons functioning at the organizing level than has been previously recognized.  One variety of these heretofore invisible organizing features is recently appearing on the clinical scene as the multiple personality.5
  

Varieties of Transference and Resistance

There are four major categories of transference and resistance memories.  In neurotic personality organization, the subjective sense of a five-year-old child's instinctual driveness is remembered in transference along with intense fears (resistance) of experiencing sexual and aggressive impulses toward anyone so intimate as the analyst because such intensity was forbidden in the family, triangular structure.

In narcissistic personality organization a three-year-old's intense needs for admiration, confirmation, and inspiration in relation to his or her selfothers is central to transference memories.  Natural narcissistic needs are enshrouded in shame (resistance) regarding one's desire to be at the center of the universe.

In borderline personality organization transference remembering is rooted in the replication of a set of interpersonal emotional scenarios.  Resistance memories mitigate against living out the positively and negatively charged emotional interactions (scenarios) in the analytic relationship so that they can not achieve representation and will not be relinquished.

In personalities living out the earliest organizing processes, what is structured in transference memory is the continuous rupturing or breaking of each and every attempt to form organizing channels to the other.  Resistance takes the form of terror and physical pain whenever sustained contact with a significant other threatens.
  

Expressions of the Search for and the Rupture (Primary Repression) of Channels or Links to the Other

The earliest transference and resistance memories are those from the "organizing" period of relatedness development (Hedges, 1983).  In utero and in the earliest months of life, the fetus and neonate have the task of organizing channels to the maternal body and mind for nurturance, evacuation, soothing, comfort, and stimulation.  Infant research (Tronick & Cohn, 1988) suggests that only about 30% of the time are the efforts made by an infant and mother successful in establishing that "rhythm of safety" (Tustin, 1986) required for two to feel satisfactorily connected.

The many ways in which an infant fails in securing the needed contact from its (m)other become internalized as transference to the failing mother.  Because the biological being of the baby knows (just as every mammal knows) that if it cannot find the maternal body it will die, any serious impingement on the infant's sense of continuity of life, of "going on being" (Winnicott, 1965) will be experienced as traumatic.  An internalized terror response marks that failed possible channel of connection with a sign that forever reads, "never reach this way again."  Such traumatic organizing level transference memories are not only presymbolic, but preverbal and somatic.  Resistance to ever again reexperiencing such a traumatic, life threatening breakdown of linking possibilities is expressed in somatic terror and pain which mark "where mother once was."

Green (1986) speaks of "the dead mother" internalization as the earliest psychic structure (memory) laid down by the early sensual, pleasurable links to mother which are bound sooner or later to be subject to being experienced as maternal failure.  (Note that the real mother may be working hard to stay attuned to the organizing needs of the infant, but for any of a variety of reasons the pleasurable connection cannot be maintained.)  We are left forever searching for this internalized mother of pleasure who "died," trying in every way to revive her through searching the world for love and stimulation according to the pleasure mode we once experienced with her in a primordial and primeval Eden — the paradise we knew before we tasted of the fruit of the tree of knowledge of good and evil (splitting).  Of course the search fails because the paradise of life as pleasure is not to be found in the outside world but inside our own bodies.  But the human search for the dead mother of primordial pleasure, along with her failures and our incessant futile efforts to bring her back to life by finding her outside of ourselves, outside of our bodies, expresses the earliest transference and resistance memories we bring to the analytic relationship.

Winnicott (1965) points out that early impingements on the infant's sense of continuity with life forces the infant to react to environmental failure before the infant is fully prepared to begin reacting and thinking.  The result of premature impingement is the formation of a primary persecutory mode of thought which forms the foundation from which all subsequent thought processes of that person arise.  That is, traumatic impingement on the infantile (omnipotent) sense of "going on being," insures that the first memory which is destined to color all later memories is "the world persecutes me by intruding into my mental space and overstimulating (traumatizing) me.  I will forever be on guard for things coming at me which threaten to destroy my sense of being in control of what happens to me (my omnipotence)."

As a lasting imprint this earliest memory is psychotic because the world at large offers many kinds of impingement.  And searching the environment tirelessly for the kind of primary intrusion that once forced the infant to respond in a certain way not only creates perennial paranoid hazards where there may be (in reality) none, but causes the person to miss other realistic dangers that are not being scanned for because of this prior preoccupation of the sensorium.
  

The Freezing of Environmental Failure

Donald Winnicott, a British pediatrician trained as a psychoanalyst, is renowned for his understanding of early psychic development.  It is his view that there is a possible maturational or unfolding process for each child in which environmental provision is a necessary facilitator.  An environment with limited provision or unempathic intrusiveness may leave the child with a painful sense of personal failure:

One has to include in one's theory of the development of a human being the idea that it is normal and healthy for the individual to be able to defend the self against specific environmental failure by a freezing of the failure situation.  Along with this goes an unconscious assumption (which can become a conscious hope) that opportunity will occur at a later date for a renewed experience in which the failure situation will be able to be unfrozen and reexperienced with the individual in a regressed state, in an environment which is making adequate adaptation (1954, p.281).

Winnicott's use of the metaphor "unfreezing of the failure situation" makes clear that he has a specific psychoanalytic situation in mind which fosters emotional regression to the dependent infantile state in an environment in which hopefully more understanding and empathic adaptation to the infantile need can be made the second time around.  Note that what he speaks of as frozen until it can later be reprocessed in some relationship, is a specific environmental failure.  There is no mention of forgetting and recall but rather that a failed situation is set aside (frozen) until a relationship comes along which permits a reliving of infantile dependency in which there is believed to be the possibility that the failure can be made good.  The purpose of Winnicott's formulation is to define a kind of memory which the psychoanalytic relationship calls forth so that an earlier failure of the environment can be worked on in the current relationship.

Winnicott's formulation does point toward how traumatically experienced environmental failures may be set aside until an analyst or therapist comes along with whom the person can relive the failure.  The popular notion of "recovery" being the recall of early memories, having them validated by others, and then confronting those "responsible" for the long ago failure misunderstands the psychotherapeutic process of reviving in the present the environmental failure situation so that it can be worked through in transference and resistance with the person of the analyst as therapist, not acted out in the person's contemporary world.  It would seem that therapists collude with the acting out so as to avoid the difficult and sometimes dangerous transference working through process.

Winnicott's formulation clearly points toward a treatment situation in which the split off internalized object relation has an opportunity to become manifest in the analytic relationship as transference and resistance to transference.  Psychoanalytic technique as practiced by analysts and psychoanalytically informed therapists is designed to bring early childhood experience into the here and now relationship so that transference and resistance memories have an opportunity to emerge.  Such recovered memories, like screen memories, are never to be taken at face value because the very way in which they are secured for analytic study necessarily imbues them with extensive primary process thinking (condensation, displacement, and symbolization).
  

The Fear of Breakdown

Donald Winnicott was the first pediatrician to become a psychoanalyst.  His understandings of the early mother child interaction have made a significant contribution to British psychoanalysis and his powerful influence is now rapidly spreading worldwide.  As a result of Dr. Margaret Little's (1990) publication of her own analysis with Winnicott, Psychotic Anxieties and Containment, we now realize that Winnicott was the first psychoanalyst to learn how to systematically foster a "regression to dependence" in which the most primitive of human psychotic anxieties could be subjected to analysis — even in people who are otherwise well developed.

In "Fear of Breakdown" Winnicott shows that when people in analysis speak of a fear of a psychotic break, a fear of dying, or a fear of emptiness, they are projecting into future time what has already happened in the infantile past.  One can only truly fear what one has experienced.  Terrifying and often disabling fears of breakdown, death, and emptiness are then distinct ways of remembering terrifying processes that actually happened in a person's infancy.  This nugget of an idea and all that has followed in its wake has changed the face of psychoanalytic thinking.  What is dreaded and seen as a potentially calamitous future event is the necessity of experiencing in the memory of the psychoanalytic transference the horrible, regressive, death threatening dependent breakdown of functioning that one, in fact, experienced in some form in infancy.  The fear of breakdown manifests itself in many forms as resistance to transferentially reexperiencing in the transference and resistance (remembering) the terror, helplessness, rage, and loss of control once known in infancy.  Therapists and clients both dread disorganizing breakdowns and there are many ways in resistance and counterresistance that two can collude to forestall the curative experience of remembering by reliving the breakdown experience with the therapist.  One way of colluding would be to focus on external perpetrators or long ago traumas to prevent having to live through breakdown recreations together.

When the environmental provision fails to support the infant's need to be in control of his or her world, a massive breakdown of psychic functioning occurs.  The break is one of loss of whatever ego functions the child has attained at the time.  Rudimentary or developing ego functions are not fully independent of the interpersonal situation in which they are being learned.  So when the environment fails at critical moments, the child experiences a loss of his or her own mind, a loss of any attained sense of control, and a loss of whatever rudimentary sense of self as agency may have been operating.  From the point of view of the infant, the loss of psychic control over his or her environment is equivalent to the loss of the necessary life support systems so that fear of death (as an instinctual given) is experienced as imminent.  The environment is empty, the environment that is not experienced as separate from the infant's rudimentary consciousness.  When the necessary environmental supports for ego skills and consciousness are lacking, the infant psyche collapses.

At the level of the infant's primary organizing attempts there is a functional equivalence between failure of environmental provision, a sense of emptiness, loss of control, loss of omnipotence, total painful psychic breakdown, and the terrifying prospect of death.  Memories of primordial breakdowns are embedded in somatic symptoms and terror.  This level of memory is guarded with intense physical pain attributable to the process of primary repression.  No one wants to go through the excruciating gross bodily pain and terror necessarily entailed in physically remembering the process of early psychic breakdown.

In more normal infantile frustration the disillusionment is managed by the environment through small and tolerable doses so that the terrifying fear of death and an empty world (and therefore empty self) may be averted and the breakdown of omnipotence will be gently helped along, rather than traumatically forced and abusively intruded into the child's body and mind.  Now it is possible to make sense of the strange and compelling nature of recovered memories.  Environmental failure in infancy has led to a breakdown of early psychic processes with accompanying terror and threat of death.  The breakdown experience is blocked by primary repression that says "never go there again."  The breakdown fear lives on as the somatic underpinning of all subsequent emotional relatedness life but cannot be recalled because: (a) no memory of the experience per se is recorded, only a nameless dread of dependence which can be violated, (b) the breakdown experience itself is guarded with intense pain, somatic terror, and physical symptoms of all types, (c) the trauma occurred before it was possible to record pictures, words, or stories so it cannot be recalled in ordinary ways.

The mythic themes of recovered memories allow for a creative narration to be built in psychotherapy which conveys the emotional essence of the infant's traumatic experience.  The demand to be believed represents in some way the violation of boundaries which can be registered and interpreted in the counter-transference.  The working through of the repeated ruptures of interpersonal contacts by flashbacks, sudden physical symptoms, bizarre thoughts, panic attacks, personality switches, and boundary violations can be accomplished through securing the organizing transference and resistance for analysis.6
  

Summary and Conclusions

The remarkable recent increase in the reported incidence of "Multiple Personality Disorders" has stimulated many questions regarding how to understand these altered state phenomena and what approaches might provide optimal therapeutic or analytic responsiveness.  Four developmentally derived Listening Perspectives are summarized which are thought to be ways of listening and responding to four major levels or styles of personality organization.  The expected listening features for neurotic, narcissistic, borderline, and organizing states are defined.  In principle, an individual's personality might be dominantly organized in one or another style or mode, but the multiple selves phenomena are thought to be derived from early cognitive-affective organizing states or affect-ego nuclei.  By implication, listening to multiple self states in terms of constancy, selfobjects, or scenarios is likely to detract from the therapeutic process.

Four complementary etiological hypotheses are considered: (1) limited early integration, (2) warped or deformed self-consolidation, (3) overstimulating disruptions, and (4) replicated intrusions.  Simultaneous consideration of all four possibilities is a safeguard against biased or naive clinical listening.  Considering the profoundly allegorical and narrational context of psychotherapy and psychoanalysis can prevent faulty listening which stems from an exclusive concretizing emphasis on abreaction of traumatic memories and affects.7

Optimal listening and responsiveness according to the Listening Perspective approach places an emphasis on the relatedness dimension.  That is, the mode of self and other relatedness being experienced and lived at any given moment will determine the therapist's choice of response.  Meeting, intercepting, or contacting various affective-cognitive states in moments of sensorimotor extension is taken as the optimal mode of therapeutic responsiveness for working with features of personality "in organization."  Eight expected dimensions have been defined to enrich the listening context in work with the organizing features found in multiple personalities.

The key to transformational analytic work with multiple personality formation is the analysis of the organizing or psychotic transference.  Organizing transference is a structure which spontaneously appears just as the person orienting for human contact begins to feel the threat of the engagement. "Something happens" (often silently, invisible to the therapist) so that the developing interpersonal contact is ruptured or not sustained.  Therapeutic technique is aimed at finding ways of interpreting the transference which motivates contact rupture.  The interpretation is a variant of, "Your past experience tells you it is not safe to stay connected to me, but that simply isn't true.  You can connect to me, take things from me, give things to me, and permit us both to enjoy the relationship."

The current emphasis in research and lore on an invariably traumatic or seductive etiology, and the importance of fostering a revival of memories with emotional abreactions have been challenged.  Broadening the therapeutic or analytic approach through the elaboration and utilization of Listening Perspectives is justified on epistemological, scientific, and clinical grounds.  Multiple personality cannot be effectively treated without a thorough understanding of how to work with the organizing transference and resistance.  Viewing the emergence of various affect-ego states as a creative way of expressively elaborating oneself in a psychotherapeutic setting goes a long way toward removing the magical, mystical, or pathological emphases which have proven confounding in past work with multiple personality formations.
  

Endnotes

1 A more recent psychoanalytically informed institutional treatment approach has been put forth by Ganaway (1991).  [Back]
2 In a later writing I have reviewed the scientific paradigms used by quantum physicists and chaos theorists which further point toward the importance of a "listening perspective" approach in psychotherapy and psychoanalysis (Hedges, 1992).  [Back]
3 I have considered in detail the problems involved in "Taking Recovered Memories Seriously" (Hedges, 1994).  [Back]
4 I have considered these issues extensively under the heading, The Paradigm Shift in Psychoanalysis (Hedges, 1992).  [Back]
5 Since this paper was first written, I have written in great detail about the nature of and treatment of the Organizing Experience (1994a, 1994b, 1994c).  [Back]
6 I have written two books which detail the problems with these kinds of transference and resistance memories and how to treat organizing issues whether they are pervasive in the whole personality or whether they form only pockets in the personality (as with most people).  The books are Working the Organizing Experience, (1994b), and In Search of the Lost Mother of Infancy, (1994c).  A four-hour videocassette presentation by Dr. Hulgus and myself, also titled "Working the Organizing Experience" is available now through my office.  [Back]
7 Recently, concern has moved to the danger of taking "recovered memories" too literally or concretely.  See Hedges (1993) "Taking Recovered Memories Seriously."  [Back]

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* Lawrence E. Hedges is a psychologist and psychoanalyst at 1439 East Chapman Avenue, Orange, CA 92666.  He is the founding director of the Newport Psychoanalytic Institute, the director of the Listening Perspectives Study Center, holds a faculty appointment at the University of California at Irvine, and is a training and supervising psychoanalyst at the California Graduate Institute.  This article originally appeared in Remembering, Reporting, and Working Through Childhood Trauma (Hardcover) (pp.85-138). Jason Aronson: Northvale, NJ.  [Back]

 

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