family treatmen in dissociative disorders. benjamin. 1992

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f..\.\lILY T R n I ~ T

\

D1SS0WTIYE

DISORDERS

L ~ n n

R

Benjamin.

'lAo 'I.Ed.

Roben Brnjarnin.

'I.D.

R. Benjamin, ~ l A . , :\I.£d., is a marr iage an d family

rapist in private practice in Dresher, Pennsylvania.

Bel'tiamin, t-.'I.D.

is

a psychiatrist

and family

therapist

o SCl CS as Associate Medical Director o f Northwestern

utcofPs)'cbiauyin Fort Washington, Pennsylvania (sub

Philadelphia) and

is

a consultalll

10

its Dissociative

ers Program.

r

reprints

write

Robert

Benjamin, M.D., Northweslern

ofPS}'chiatry, 450 Bel..hlehem Pike, Fort Washington,

ylvania 19034.

amily trmlmrot inttromlimu, in ronlradistindion tofami/y Ihn-

1 an important concomitant to individual thoap in t

oj multipk Jxrsonality disorrl MPD). Such

intmxn-

IunN 1M fJotrotial to usto , tnlstworlh)' rtlationships

i n t il

mily and, thus, to p r o m o t ~ h ~ a l i n g

oj

individual patirot

nd

otherJamily

ml T1lbnl.

This arlick disl'WSd

s o m ~

o J t h ~

Jossi.

modalitid

oj

trratmrot, includingparalkltherapy with a parl·

l T, marrio17lherapy, child therapy,

parmtwg

cOl/liMling, group

rapy with MPD mothers, a7ldgroup thtraflJ with Imrlllf rJor par-

ts

oj

individuals with MPD also txf)lores s o m ~

oj

the p h i i ~

icolllnderpillnillf5SoJthest approaches with parlicu.lar~ T I I p h a -

ethical concepts derived from Contextual Famii)' Therapy.

li\'ely littJe has been wriuen about the useoffamily treat

\\ith families in which one or more members hasa dis

disorder

(Beal, 1978; Oa\is Osherson, 1977; Fagan

;\Idiahon,

1984; Sachs, 1985; KJuft, 1985; KJuft, Braun,

Sachs. 1984; Frischholz,

Woods, 1988: Panos, Panos,

lred, 1990; \\illiams, 1991).

It

seems ironic La us that a

approach

has been

underutilized

since this dis

is

precisely a bo ut t he failure of a healthy family pro-

ss. In dissociative families, either the family is directly th e

ofabuse through incest. alcoholism, brutalil)'in chil

which results

in

the direct traumatization

of

chil

orthe

familyis neglectful. inauentive, or overwhelmed

th e effects

ofextemal

trauma (e.g., war, natural disasters,

r physical or sexual abuse by non-famil)' members).

Dissociation is a defense mechanism which is charac

rized by a splitting

of f

of

troubling

memories, sensations,

or

thoughts

with an accOInpan)ing disowning

of

these disavowcd mental structures. Braun (1984) has con

ceplllalized

dissociation on a

continuum

which extends from

t he norma l loss of awareness in

daydreaming

through

incrcasing losses of memory, reality, or identity such as in

Multiple Personalil) ' Disorder (MI'D). According to th e

Diagnostic

and

Statistical Manual

orMental

Disorders

DSM-

IIl-H.),

MI'D is

characterized by tJle existence in a person of

twO

or

more

distinct personalities, lost

pcriodsoftime,

inter·

nal voices, an d a mechanism for switching from on e per

sonality state lO

another.

REV'IE\VOF

THE

F MILY LITER TURE

1

MP

KJufl (1984a: 1984b) has fonnulated a four-factor the

ol ) t o e xp la in t he etiology of the

disorder

which begins in

earl)' childhood. The first factor is the indhidual s biologi

calcap..cil) for dissociation.TIlesecond factor includes trau

matic events or life

experiences

which oven\'helm a child·s

non-dissociath·e defenses. In

addition

to sexual abuse,

extreme physical abuse, abandonment, neglect an d ps)'·

chological abuse, Kluft (1984a) has

catalogued

a list

of

trau·

mas such as th e loss or

death

of significant others, willlCSS-

in g a

murder,

an accidcnt or th c carnage of war, receiving

scriousdeath threats, beingdislocated culturally, beingcaught

between embattled parents in a divorcesituation, being treat

ed

as

if th e

child is

the oppositc gender,

and

excessive obser

vation of the primal scene. Th e third factor has to do with

two concurrent processes: the environmcntal shaping influ

ences on a child (such as t he mode li ng

done

by a parent

who may ha\·e

MPD

or

another

psychiatric disorder)

an d

th e

intrapsychic developmental subslr.ues (sllch as imaginary

companions, introjections, an d internalizations) that the child

experiences

aL

any gi\·en time t ha t pre di spos e t o th e dC\'el·

opment

of

alter personalities. TIle

fourth

fac tor has to

do

WitJl parenting. \\llen a child·s caregh·ers either d o n ot pro

\ide

barriers that protect a child from traumatic experiences

(neglect)

or

do no t prmide th e

child

\\ith restorative

expe.

riences

nurturing,

soothing, processing)

after

traumatic

C'o·ents, th e child adapts to th e situation bygoing inside him

self to find comfort and protection.

KJuft. Braun,

Sachs (1984) have

elaborated on

th e

characteristicsofparents in families in which children dC\'el

op MPD.

They

say a sense ofsadoma.sochism may be appar-

e nt , a nd t he p ar en ts may have low self-esteem.

On e

parent

may be grandiose while

th e other

is deflated

or

there may

be a fluctuation of

that

dynamic. Th e

parents

may not be

a bl e t o e mpat hi ze ,

an d

they may

misunderstand the

devel·

OI lSOClHlO\. \01. \.

\ I.l.

[)rnwbrr



opmcnl.al

needs of children. Other

characteristics

that

they

may possess are: impulsivity

or

aggrcssivencss, overvalue of

control,

and

an ability to

nurture the

child

that

limited

to

when the child is serving their needs. While social interac

tions

tend

not

to be

meaningful, some function well in cir

cumscribed roles

such

as

the

milil.ary or religious settings.

One

or

both

rna}

haye a

diagnosable

mental

illness

often

with dissociative or borderline qualities. These parents are

oftcn

users

of drugs or

alcohol

and

engage

the

children in

the

use

of

these substances

to

m'lke

them amnestic to thc

abuses.

The authors go on to

dcscribe thrce types

of

mari

I'll stylcs: a pseudo-normal

\ e n e e r ~

a conflicted relation

ship,

or

a relat ionship in which OIlC

panncr

is apparentl}'

overadequatc while

the other is

apparently

underade

quale.The Jhmilysystemas awhole C<lll be described asunpn.

dictablc, closedwith impermeable bmllldaries, having uncon

vendonal roles for family members, and an air

of

secrecy

and

obedience.

Braun (1985) has pointed OU that MPD is transgcncr

alional in

nature,

and

Kluft (1984b)

and

Coons

(1985)

notc

thatlhc children ofMPD mothers arc at risk for a

\ ~ d i e t y

of

psychiatric disordcrs. Kluft (1987) observes

that the

m.yor

ily of idcntified patients with MPD arc \\'olllen in the child

bearing and

childrearing age range. Kluft goes

on to

cate

gorizemotherswhohavc

J\{PO as

abusivc (mothcrswho inflicted

harm),

compromised/impaired

(mothers whose symptoms

got in

thc way of parenting,

who did Ilot behavc in

the

best

interests

of the

child),

competent

(mothers who acted in

the beSt interest

of the child), and

cxceptional

(mothers

who perfonned the

mothering

function in

one

personality

or

in a co-conscious fashion

or

who avoided swilching in

front

of

the child).

The

results

of

his study suggested Illat

61.3

of

the

mothers

fell in

the

range

of

abusi\'e

or

com

promised/impaired.

PHILOSOPHY AND METHODS OF

FAMILYTREATMENT

Exonerati g the Extended Family

The

ll'aditional trcatment

of MPD

has

bcen

individual

therapy although a number

of

clinicians have

begun

to sce

other

family mcmbers as an adjunct

to

individual therapy

(Beal, 1978: Davis Osherson, 1977;

Fabran

McMahon,

1984; Sachs, 1985; Kluft, 1985; Sachs, Frishholz,

Woods,

1988; Putnam, 1989;James, 1989: I'anos, I'anos, Allred,

1990; Williams, 1991).

The

aulllOrs

of

this article see the

family as a resource for rebuilding trustworthiness in rela

tionships (Boszormenyi-Nagy& Ulrich, 1981).

The

individ

uals who

enter

treaUDCnt for ]\fI D ha\'e been S}'Stematically

and

consistently robbed

of

their ability

to

trust themselves

and others. Although some

practitioners

have included the

extended

family

of MPD patients

in treatment (Beal, 1978;

Kluft. Braun,

Sachs. 1984;

Putnam.

1989),

our

experience

has been

that the extended

family has been so excessivel}'

abusive

to the MPD

client

that contact

has

often had

to

be

terminated to

insurc

the

safety

of

the client.

Ncvertheless, the issues

around

relationships

to

extend

cd family members are main themcs in

thc

treatment of

MI D

c1icllts. Boszormenyi-Nagy

Krasner (1986) belicve

Illat clinical improvemelll oftcn coincideswith a parcnt-elicnt's

ability

to exonerale- or apprcciate

in a

mature

fashion the

limil.ationsofherown parents. (Although

the

pronoun she

is

used for simplicity,

ou r

explanation is

cquall)' applicable

tomalesand females.) hshould

be

noted thatm

the

Contextual

Approach

to

famil)·therapy,

there

isa slrongdistinction

madc

between

· f o r g i \ · e n e s s ~ a n d

-cxollcr<ttiOlI-: -...exoneration typ

ic-<tlly

rcsults from an adult rcassessment

of the

failing par

cnt s own past

childhood

victimization.

t

replaces a framc

work

of

blame with mal lire

appreciation of

a given person s

(or situation's) past options, eJI'ortsand limits (Boszonnenyi

Nagy

Krasner, p. 416).

Consequently. in utilil.ing this concept. it should be

clearly understood

that

wc

are

not advocating

that

a client

who

is

a victim

of

abuse utlconditionally

pardon or <.:xcuse

abusive

or

neglectful parents.

butl ather that

the clicntcomc

to a mature understanding

of the parents

actions

as

a prod

uct

of

the parents own traumatiz<ltions in a trallsgetlcrd

tional

chain

of

disturbcd parenting,

This

idea becomes

par

ticularlykcybecauseas therapy unfolds,a clientwho

prescnts

as

.1

\1ctim may ultimatcly come to rcveal

that she

herself

\ \ ~ d S

a

perpetrator of

abuse

of

her own children. Indeed, this

isa

rather

common scenario. Onl}'when

the

clienl can \'iew

he r )l< 1rents

as

\ ~ C l i m s of

Irdnsgencrational

abuse docs she

have the rcsources

10

sec

herself

in a fair light: as a

\ -

tim/perpetrator of

an inlergenerationallegacyofchild

abuM:.

At

that

point,

the

client is

much

freer to begin

to learn to

parent in

healthier\ a) S

willlOut being paralyzed

br

Ihe

cm<>

tional baggage from

the

relationship between

Ihedient and

he r

parents.

The Distinction etween Family Therapy

n

Family

Treat lnd

BeCllUse

thc

dcvelopmcnt of MPO happens within

the

contcxt

of an

abusive and/or neglectful

famil)

we believe

that family

intervcmions

arc an integml

part of

the

treat

IlIclllofthe disordcr. Like Sgroi (1982)

and

Fricdrich (1990),

we

diflerentiatc family therapy from family-ccntered treat

ment stratcgies. \Vhile family-ecntercd

trcatment

is all

umbrclla

that

covers many family interventions, family ther

apy is one

of the

possible intervcntions under that umbrel

la.

Our

main treatment goal

is

to

stop

thc cycle

of

trans

gCllcmtional abuse and/or dysfunctional parenting and to

encourage

healthier ahemath·es.

Qur

emphasis

is on Ihe

family as a whole entity and particularly on

the

parenting

within the famil)'. Boszormenyi·Nagi

Ulrich (1981) point

ou t

that the potential for trust in future generations isdecply

rooted in parental accountability. Because

of the

transgen

erational nature

of the

illness. we see

the

responsibilil}' to

posterity

to

be as

imponatll

as the responsibility

10

the indi

vidual MI O client.

K1uft

(1985) and others (Sachs. 1985:

Goodwin. 1989)

recommend

routine asscssmelll

of

children

who ha\'c a parent with

MPO.

Our

treatment

philosophy is

aimed at dual goals: both

the

traditional

one of

providing

trcatmcntto thc

individual family

member \ \ ~ [ h MPD

in

an

effon

to move

the

person in

the

direction

ofintcgration

of

persollalities

and

also the additionalgoaloffacilitatinghealthy

relationships

ithin

the

family. \Ve provide a varielyofinter-

237

D l S S O C I A T I O ~ . 1 \. \0 t Dl « mbl r 992



- -

FA.,nLY

TREATME:\ T

ventiollS: supportive indi\idual

treaunent

for

the partner

(either with

another

therapist or with liS). assessment and

treaunent

i

necessary) ofindhidual children (either

ith

another

Lherapist or with us). marriage work, parent<hild

dyad work, sibling observation,

group support

for the

mother and group

suppOrt

for

the

MilD

partner

or

parent

of an

MP child. Famil}'

lhcrapy

in which

parents

and

child(ren) work togelhcr is another important modality.

Occasionally

the client

who

is

referred

to ou r

practice

is the child

of

an MPD parent.

Usually .he

MP D parent

is in

indi\;rlual lherapywith

another

clinician. In thate em,

one

of us may work with the child and

one

with the MPD par

em s

partner. We

will

do parenting counseling for

one

or

both

parents,

and we

will

imite

the

;\fPO

morner

the

moth

er s

group

and the

parmer

tothe partner sgroup, Additionall}'.

we will

use

pan

or

all

of

each

child s

session

to

work

on

the

relationship between parem and

child.

Parenting Issues

in

MPD

Our

experience in working 'lth MP parents suggests

thai the MPD parent has manyspecific issues that affeci par

enting:

• Inconsistencies in relating

the child because of

S\\'ltchingfrom personalityto personalitywith accom

panying loss ofmemory

• ModelingS\\'llchingbeha\'lorssllch ase}'croll orcO\'

ering the

eyes

• Confusion in

the head

from a multitude

of

\'oices

that makes it hard lO focus on thc needs of the child

• Competitivefcelings

tQ

'3rd thechild whohasmuch

more

familial

support

that the MPO parent did

as a

child

•

Child

alters who want

to

play in their alter statcs

, ,'l th a child

•

nleir

own

inadequate parental role models

• Problems in the marital relationship that interfere

with team parenting

• Persona l social problems that make it hard to deal

' lth teachers. neighbors,

or

parents

of the

child s

friends

• Feelings

of

guilt for

their

inadequacies

and

worry

about the effects of the inadequacies on the child

•

The adjustments on

recO\'ery when

the

parenting

cannot be delegated to

one or

several designated

parenting alters

• Emotional separations

(due

to dissociation) and phys

ical separations

(due

to hospitalizations) from

the

child

•

Other

complications as a result

of additional psy

chiatric disorders or consequences of the underly

ing MP (alcoholism, depression, anorexia/bulim

ia. phobias, suicidal tendencies, etc.)

As

a result

of

the

MPD

parent s

specific issues,

the

chil

dren

of MPD parents are

at

a risk for emotional/physical

abuse

or

neglect.

There is often confusion

in

the

commu

nication

from

the MPO parenL The child

may

be

parenti

(jed

and

o\'erly protective

of

the MPD parenL The child

may

feel responsible for the parent s illness particularly because

often the child s behaviors trigger memories for the parent

which may resuh in S\\'ltching and eithcr

hurting

or with

d -d.wing from thechild,TIle child may feel abandoned because

of

frequent

hospitalizations of the parent or emotional dis

lancing,

The

child may be afraid to (because of

the unpre

dictability of

the

parent)

or

told

no t

to bring friends home

because

the parent cannot handle the

ext.-d stress.

T pes Therapeutic Interventions

Because we

dew

parenting

as a critical issue in thera

py, we have a

number

of ays of intelTening, We do indi

vidual

or

couples parenting counseling. We talk about par

eming

in the mothers

group

and the parmers

group.

We

send individuals to outsideparentingeducation groups, Also,

e provide chi ld therapy which focuses both

on the

indio

\'ldual child and healing

traumas

as well as

on

relationships

between

the

child and

both

parents and

the

child

and

sib

lings, In both

the mothers group and the partners group,

we credil parents for everything they

are doing including

attending the group,

Specifically, we

encourage parcnts to

set limitsand care for thcmseh'es so they arc not g h ~ n g more

than they can

handle

either emotionally or in physical wa S

10 other

familymembers, SuchQ\'ergidngmay result in emo

tional exhaustion, guih for failing to adequately

meet

the

needs ofothers. or

anger that

the needsofothers

seem like

insatiable

demands,

We try

10 build

hope and trust in

the

family

through

giving

the MPO parcntencouragemenl about

his/her

power to change

and break the

cycle

of

abuse,

For young childrcn,

we pro\'lde pia}'

therapy LO

help

them 'ork through their feelings, (Fagan Mc.\bhon,1984;

Gucmey,1983;Griff,1983:Terr,1984:Jarnes.1989;Gil,I99I)

e conduct some sessions or parts of sessions with

one

or

both parents

presentin order

to model how to listen, accept

feelings, and set limits, In situations

in

which the parent fits

Kluft's (1987)

competent or -exceptional

description,

the

parent may function as a co-therapist \\'lth occasional

cues

from

the

therapist. Children

are helped

to feel safe in

a stable therapeUlic situation in

order to build

trust in

the

olltside world and ultimately lO build self-trust, Strategies

are

aimed

at leaching appropriate boundaries, the idea of

fairness,

and

what constitutes

appropriate touch

(in cases

in

which

there

has been sexual molestation).

.\[anyplay therapistsand clinicianswhowork \\'lth MPD

children concur that unless

the

traumatized child can re

cnact

and

process

the

traumatic Cl'ent(s), healing cannOt

occur (Fagan

McMahon. 1984;James, 1989; Terr, 1983;

KllIft, 1991; Gil, 1991). Consequently,we usea trauma-based

DISSOClUIO\,

rol \ .

: \0. Dectmbrr

l m



model (Gil, 1991) in which. after an

appropriate sequcnce

of

explor-dtory

and

non-directi\'e sessionshave

been provided

(with

opporllmities

to allow the ch ild to test limits), play

materials are set ou t that prO\;de a context for a child to re

enact the trauma.

Materials

that arc

I)articularly useful

are

ar t

media,sandtray,

puppcts,

dolls

and

figures, bopbags,

and

rubber animals

and

insects. Hypnosis has becn usedby

some

clinicians in

the treatment

of traumatized

children

(Friedrich,

1990; Kluft, 1991; Rhuc

Lynn, 199 I). Where

appropriate,

we use hypnosis with the

parents'

permission to

enhance

mastery,

promote relaxation, and

assess

for MPD. The

major

it} of h)1motic inter.'entions

tend

to be naturd.listic induc

tions

through the

use

ofmetaphorical

stories. FinaUy,

where

needed,

we call in outside agencies such as child protective

services or we maintain a relationship with The child's leach

er, guidance counselor,

or pediatrician.

Marital Issues

n

Couples Treatme t

A

Ilumber of

clinicians have felt

that

marital inter.'ell

tiollsenhance

the

treatmentofMPDdients

(Sachs, Frischholz

Woods, 1988;

Putnam,

1989; Panos, Panos,

Allred,

1990;

\Villiams, 1991).Two specifically caution thatsllchwork

needs

to focus

on

~ h e r c n d now issues (Sachs, Frishholz Woods,

19S8;

Putnam,

1989). Sachs, Frischholz and Woods (1988)

see marriage work as focusing on the

education ohhe

part

ne r

about

MPD dealing

1th

the disruptions of the home

ostasis

of

tile marital system,

sharing

thoughts and

feelings,

and preventing the sabotage of the primary trealmentofthe

MPD client. Panos, Panos,

and

Allred (1990) expand the

issues

of marriage

work

to include education, understand

ing seepage or what thc}' see as the pervasion of the feel

ings

of one

alter

into another

alter,

handling

conflicting

demands, responding to child

alters,

the

sexual relation

ship, adjusting to integration. and having

patience

with the

therapeuticprocess. \\rdliams (1991) alsofocllscson the themes

ofmarital treatment: education, limitsetting,contracts, map

ping

of

the

MPD client's internal system, knowledge of the

trauma

history, play

and

intimacy,

The needs of the

partners

and children, partner's

issues,

and the emotional impact on

tJle marriage.

In our

experience, marriage

ork

has tJle

potential to

be very helpful in the overall

treatment

plan. TIle timing of

marriage

work

isdifferent

for individual couples. Sometimes

the marriage

work

needs to

pave

the way

for

the

individual

work in

order

for the MPD client to feel that

he/she

has a

safe haven

togo

back

toduringthe

process

of

therapy. Other

times,

the

individual work

preceeds the marriage

work

and

shores

up

each

of the

partners before

they feci

confident

enough to

work

on the

relationship.

Sometimes

we

do

the

marriage work as a co-therapy team and other times one of

us sees the

couple

as

an

individual therapisl. The focus

of

the

work

is on the

marital

relationship and

promoting

a

sensc of

appreciation and empathy

of

each partner

for the

other.

While

the MPD panner has

usually

been

se\'erely trau

matized, the non·MPD paruler has his/her own Story (which

is regarded

as equally legitimate)

to

tell. Family

of

origin

issues

and their

effects

on the relationship. current

marital

issues such as tbe

impact

of the

MPD

on the family, sexuali

ty trust, feelings,

and co-parenting

all

come

up in marital

sessions. The

therapy hour

provides a safe place

where the

MPD client can feel comfortable ~ s w i l c h i n g

in

a

controlled

way and

in the

reassuring presence of

the therapisl.

This

process allows

an introduction of the spouse

to

the alters

in

a constructive manner

rather than

in the usual

chance

intcr

action during tbe throes

of

an emotional storm

or a mar i

L l

misunderstanding.Theymaymeetalterswho

do not

view

themselvcs as

married,

child alters, and angry alters.

This

setting

provides

an

opportunity

for

education

about

useful

communication

skills

such

as

how to

listen

and how to

dis

agree

respectfully. i.e., fair f i g h t i n g ~ . Appreciating family

loyalties

and

how

each

indi\1dual

can

give

to and

receive

from the other in fair ways helps to bui ld a sense of rruSt·

worthiness in the rclationship. B o s z o r m e n y i - N a ~ , Y Spark,

J

984) Asscssingwhat

the strengthsof the

family

arc and

what

resources are available

to

thc family (e.g., help from

extend

ed

family

of the non-abused partner,

da.ycare

help,

etc.)

and

dealing

\\1th tJle practical issues

of

everyday living find

their

place in marital sessions.

Groups

for

MPD Mot/It n Parhlers/Parenls

Adjunctive modalities

arc the

t\\'0 types of

groups that

we

run: one for motherswho

ha\'e

MPD and one for parents

ofor parmersof a person witJl MPD. BotJl

groups meet

once

each momh.

t has

long hcen

known

that groups

have the

potential

to prov ide

healing experiences for

individuals

(Yalom, 1975). Homogeneous

groups

for individuals with

MPD

have

been

discussed in

the literature (Coons

Bradlcy,

1985; Caul, Sachs, Braun, 1985; Putnam, 1989). n MPD

mothers'group,

however, issomewhat distinctive from those

described.

The

group

is

composed

of

mothers

from

our

own

practice as ell as

referred mothers

who we have

screened

and accepted from other

practices.

This group therapy is

for

toIPD clients

who are

responsible

for the rearing of

chil

dren

ranging

in age from newborns to young adults.

t

pro

vides for

them

a safe cont.ext in which they

can share

with

otherwomen the

difficulties

of

parenting

with a dissociative

disorder. Additionally, as Yalom (1975) notes, it gives them

COITccti -c

emotional experiences

via

a

group

imeractionwhich

pro\1des aconstructive contraSt to the family oforigin

group

settings from which they

came.

The

group is

struCturedwith

a

number ofground

rules

including

a

request that mother

ing alters stay

prescntfor

the group. The group provides an

arena

for

both education about parenting and support

for

difficult issues

that

MPD

mothers

face.

Some

OftJl0se issues

include:

• Guilt

for no t being nonnal

• How

to care

for themselves

• Lack of trust in the outside world

•

Children

as triggers

for memories

• How

to

focus on individual

therapy

while having to

manage the

practicalities

of parenting

239

DJ -somno\. \o l

\.

\ Dtttllbtr 1m



FAMILY TREATME..\ T

• Feeling like

they

are living a

Mlic

or the illusion of a

-nonnal-life

• Social s truggles

• How

to

handle

lheir

feelings

around

their

own

pasl

abuse or

neglect

of their children

• Sexual issues

• Parenting issues

• Competition with

the MPD

mate s lhcrapist

• How to balance work \,ith home life

•

Ilow to explain MPD to their children • Loss of expectations of whal life was supposed to be

like

•

How to

deal

with

the relationship

with lheir partners

• How

to

set boundaries in their Ih es

• How to

deal

wilh TeeO\ cry

The

group formal for

parmers

and/or parentsofMJ>D

dients is

alsoa unique

model.

Agroup

setting

for

these

i n d i ~

\iduals gi,-es mem a social mil ieu to talk aoom issues that

they feel they cannOt

bring

up in

ordinal)

social

encoun

ters.

Hearing

other

people

talk

about their problems

\\ ilh

an MPD

partner

or child gives

them opportunities

to

both

give

and receive

around issues

that are

VCI)

cenlral

LO their

lives. bi le

thegoalsareeducatioll and

support. the empha

sis in

the

group

is

on whal

is

going on for lhe group mem

be r

at any given

lime

rather

than

on the

MP

client.

The

grOllP

is

made up of clients from

ou r

own practices as well

as screened clients from olher practices.

TIlemes lhal

com

monly

come

lip are:

• How

to

care for themselves

• Guilt

over

no t

noticing

that

a

child

was

being abused

or

neglected

• Feeling like the) arc

not doing

enough for the ;\IPD

parmer

• Upset o\ er false star ts for

lhe

MPD client in

therapy

• Grief

and

confusion over

lhe

diagnosis

• Coming to terms with

the

disability

oflheir

partner

or

child

• How

10

deal

with

anger

toward

the

perpetrators

of

lhe

partner/child,

toward

lhe

partner, tow ard them

selves

• How to relate to others

• How to

set

boundaries

for

lhemseh·es in lhe relation

ship

• How to deal with the practicalities

of

everyday living

• How much to trust lhe partner

or the

child

• Marital issues

240

• A sense

of

unfairness

A Case Example

the us o Family Treahnellt Modalities

Mrs. 0

<lS a woman in he r thirties who callle initially

for

treatment of

postpartum depression. After nine months

of

the

rap} , it became apparelH lhal

she

suffered from

~ I I D

She

realized that her

son

had been involved in

inuafamil

ial

incest

ith her parents and herself. He was assessed in

play therapy

for

MPD.

She attended

his sessions and occa

sionally

alternated

with

her husband. On

several occasions

the

whole family,

including the

year

old

baby, attended a

family session.

Mr

0

and

Mrs. 0 came for marital work.

Mr

o joined

the

parents /parlllers g roup

and

realized lhat he

needed indi\idual work around hisown neglectful familyof

origin. He continued in both group and individual thera

py_ ~ o r s 0 joined

the

mothers group as well as attending

indh·idual sessions lwice weekly. Mrs. 0 also

attended an

ancillary parentingeducation group.

Their child continued

in

pia)

therapy.

CONCLUSION

We

b e l i ~ e that

the

therapistwho creatsindividuals\\ ith

a dissociative disorder needs to be well grounded in indi

\idual U eaunent so that the use of famil) Centcred inter

\ entionscan

beappropriatelydirected

and effective. H o w ~ - e r

in our view, often the individual

intervention

is not suffi

cient. Unless lhere

is a

family treatment

approach

as well,

the MP

client may not derive maximal benefit from the

therapeutic process.

or

~ · e n if

the

indi\idual makes an ade

quate

recovery, lhe famil), rna) still

be

grossl), impaired or

not sunive as a uni t. We see

the

family approach as critical

for utilizing

the resources

that already exist within lhe fam

ily to

rebuild

the tnlstworth} relationships and to prmide a

safe

context

for

healing

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