1. health and fitness
2. therapy

CJOT ® VOLUME 58 ® NO 5
SUSAN OKE • ELLIE KANIGSBERG
Occupational therapy in the
treatment of individuals with
multiple personality disorder
Multiple Personality Disorder (MPD) has been diagnosed with
KEY WORDS
ABSTRACT
Child abuse
increasing frequency in the last ten years. It is no longer considered rare. A result
Developmental therapy
of child abuse or trauma, MPD is a dissociative disorder which defends the child
Multiple personality
disorder
from the overwhelming experiences of abuse. In adulthood the client may present
Occupational therapy in
psychiatry
personality disorder. Occupational Therapy intervention has become more
with amnesia, auditory hallucinations, depression, eating disorders and borderline
common and has gained recognition by both clients and clinicians. Mosey's
developmental frame of reference serves as a basis for the treatment of Multiple
Personality Disorder by occupational therapists at the Royal Ottawa Hospital. This
treatment approach uses projective techniques and life skills teaching with alter
personalities to offer age appropriate learning experiences. A composite case
history is included to illustrate the range of goals and activities involved
RÉSUMÉ
Le diagnostic de troubles multiples de la personnalité est posé de
plus en plus fréquemment depuis une dizaine d'années. Il n'est plus considéré
comme un diagnostic rare. Résultant d'un traumatisme ou d'abus chez l'enfant,
cette condition est un trouble ciissociatif qui protège l'enfant contre les abus dont
il est victime. A l'âge adulte, le client peut présenter un tableau d'amnésie avec
hallucinations auditives, dépression, troubles de l'alimentation et troubles de
personnalité limite. L'intervention ergothérapique est devenue plus fréquente et
a réussi à être reconnue tant par les clients que par les cliniciens. Les ergothérapeutes
du Royal Ottawa Hospital s'inspirent du cadre de référence développemental de
Mosey qui sert de base au traitement de ce trouble de la personnalité multiple. Ce
Susan Oke, B.Sc.O.T. OT(C)
and Ellie Kanigsberg, B.O.T.,
OT(C) and are both Staff Occupational Therapists at the Royal
Ottawa Hospital, 1145 Carling
Avenue Ottawa, Ontario, K 1 Z
7K4
,
234 ® DÉCEMBRE 1991
traitement utilise les techniques de projection et l'enseignement des habiletés de
la vie courante en rapport avec cette atteinte de la personnalité pour offrir des
expériences d'apprentissage qui tiennent compte de l'âge. Une histoire de cas
exhaustive est présentée ici pour illustrer l'éventail des objectifs et des activités en
jeu.
CJOT • VOLUME 58 • NO 5
Multiple Personality Disorder (MPD) has been diagnosed with increasing frequency over the past .10
years. Once thought to be rare, about 200 cases were
reported in the world literature before 1980 (Bliss,
1980). Since then, over 5000 cases have been'diagnosed in No rt h America (Ross & Fraser, 1987). A recent
study in Winnipeg showed that 5% of inpatients in a
general psychiatry unit met the criteria for MPD (Ross,
Anderson, Fleisher & No rt on, 1990). As awareness of
this outcome of child abuse continues to grow, more
cases are likely to be diagnosed, therefore occupational
therapists have a responsibility to be aware of the
symptoms and treatment of this psychiatric disorder
(Baldwin, 1990).
DSM-III-R American Psychiatric Association, (1987)
defines Multiple Personality Disorder as:
a) the existence within the person of two or more
distinct personalities or personality states. Each
state has its own relatively enduring pattern of
perceiving, relating to and thinking about the
environment and one's self.
b) at least two of these personalities or personality
states take dominant control of the person's behaviour.
The purpose of this paper is to describe Multiple
Personality Disorder, its clinical manifestations and
occupational therapy assessment and intervention.
ETIOLOGY
MPD is a manifestation of child abuse. Studies have
shown that 97% of those diagnosed with MPD were
victims of severe childhood sexual or physical abuse.
The remaining 3% were victims of neglect and other
deprivations (Curtis, 1988; Putnam, Guroff, Silbermen,
Barban & Post, 1986; Ross & Fraser, 1987). Abuse
alone, however, is not sufficient to cause MPD. The
child must have the ability to dissociate or split off the
normal flow of consciousness, identity or motor behaviour. It has been shown that clients with MPD are
in the top 10% of the population in hypnotizability, an
indicator of dissociative ability. To deal with trauma,
the child may dissociate and place the memory,
emotion and pain of an abusive situation behind
amnesic barriers. Repeated abuse reinforces the dissociative process, eventually forming a separate memory
bank which develops a sense of individual identity, or
alternate personality (Curtis, 1988; Ross & Fraser,
1987). Additional abuse may lead to new dissociative
splits and eventually to more alternate personalities.
The birth personality may be amnesic to the abuse and
to the existence of the alternate personalities. Thus, the
cause of MPD is repeated child abuse in a dissociationprone child, coupled with lack of corrective nurturing
usually due to threats against disclosure by the abuser.
CLINICAL PRESENTATION
Amnesia or "losing time" is a common presenting
problem. Blank spells or amnesic periods may last
minutes, hours or days. A client may remember having
breakfast, and then find herself in a bar with a strange
man at night, with no memory of getting there or of the
time between. Similarly, there may be complete or
patchy amnesia for childhood events. During these
amnesic periods, alter personalities have control of the
body.
Other experiences which many clients share involve
finding and losing possessions. Clothing may appear in
the closet, or items may be found in unusual places.
One client; in preparing for school the next day, would
leave her school bag by the door only to find that on
frequent occasions it would not be there in the
morning but rather in the shower or under the bed.
Years later, a child alter confessed to hiding it for fun.
Switches in personality frequently cause headaches,
which are a common complaint for these clients. When
there is a switch there may be sudden changes in
mood, body posture and voice; these in fact are not
mood changes, as they seem, but personality changes.
In addition, handedness and penmanship may change.
Personalities maybe of either sex and any age. In some
cases, alters may even be of another nationality (Kluft,
1985):
A'study by Putnam et al. (1986), found that clients
with MPD had averaged 6.8 years in the psychiatric
system before being correctly diagnosed ; In reported
literature, there are between four and nine times as
many females as males diagnosed with MPD. The
incidence of MPD among males may be higher than
this as it has been suggested that they experience
trouble with the law and end up in the criminal justice
system, undiagnosed (Kluft, 1984).
Many clients with MPD hear voices and consequently
are diagnosed as having schizophrenia. Generally for
the client with MPD these critical or hostile voices seem
to originate within or just outside the head while the
schizophrenic client usually hears voices from outside.
Like those with schizophrenia, individuals with MPD
may have experiences of thought withdrawal and
feelings of being controlled by an outside force (Kluft,
1987). These experiences are the result of alter personalities speaking amongst themselves and influencing
behaviour. It is common for these clients, when they
are seen in the mental health system, to be given a
number of different diagnoses before an accurate
diagnosis of MPD is made. In addition to schizophrenia, these may include affective disorders, anxiety
disorders, eating disorders, personality disorders, organic mental disorders, psychosexual disorders and
substance abuse. Although these conditions may be
'
DECEMBER 1991 • 235'
C10T ® VOLUME 58 ® NO 5
concurrent with MPD, they prove to be treatment
resistant until the underlying MPD diagnosis is made
(Coons, 1984; Ross & Fraser, 1987).
Horevitz and Braun (1984) suggest that up to 70%
of people with MPD meet the criteria for Borderline
Personality Disorder. Self injury is commonly seen and
may be the result of one personality trying to harm or
kill another. This may occur as punishment for divulging
long held secrets or for behaviours considered unacceptable. Kluft (1984) recommends including MPD in
every differential diagnosis and to suspect it when
other treatments fail, when there is a relapse for no
apparent reason, when many diagnoses have been
offered and when symptoms fluctuate. This is especially true if there is a history or suspected history of
abuse.
TREATMENT
The treatment for MPD involves contacting all the
personalities using hypnosis or guided imagery and
contracting for a therapeutic alliance. Alters must agree
to co-operate with each other and not injure the body
which, they must now learn, they share. Work is done
with each personality to determine its function within
the system, and each must share the memories of the
abuse they suffered. Once these memories are shared,
the need for separateness is reduced and an integration
of all the personalities can take place. No personalities
are eliminated or sent away, all are aspects of the total
person.
Within the system of personalities, many agree that
there also exists an observing personality, generally
referred to as the inner self helper, central-ISH or
center (Adams, 1989; Allison, 1974; Fraser, 1987; Fraser
& Curtis, 1984). Using guided imagery, this special ego
state can usually be contacted. With its understanding
of the system and access to all the memories, this inner
self-helper can be a valuable asset to the treatment
process.
Prognosis for the treatment of MPD is very good but
therapy can be long and arduous (Kluft, 1988). One
study has shown that approximately 80% of integrated
clients with MPD are without symptoms of dissociation
after two years (Kluft,1984). Issues of trust, denial, guilt
and self-esteem are interwoven with dissociative defences and must be dealt with. The concurrent diagnosis of Borderline Personality Disorder in many
individuals with MPD indicates the complexity of
therapy with these abuse victims.
236 ® DÉCEMBRE 1991
ROLE OF OCCUPATIONAL
THERAPY
Assessment
As occupational therapists, we are concerned with the
individual's ability to function independently in the
areas of self-care, productivity and leisure. With a client
with MPD, it must be remembered that the individual
is not any one of the alters, but a conglomerate of all
aspects of each alter. This is called the "personality
system".
Assessment must be done on how the system
functions, as well as how each individual alter functions. We assess the ability of the personality system to
function within the chosen external environment, and
we assess the degree of intra-psychic well-being.
To further evaluate the system, alters are assessed
using a developmental frame of reference which states
that development is sequential and that behaviour is
primarily influenced by the extent to which the individual has mastered and integrated the previous stages
(Tiffany, 1983; Mosey, 1986). A developmental frame
of reference has been adopted because alter personalities represent earlier developmental levels where
trauma disrupted the mastery and integration of adaptive skills. Although the personality system continued
to develop, splinter skills exist in many areas for all
alters where the developmental tasks were not adequately learned. Splinter skills are fragile or nonintegrated skills which may fail when the individual is
under stress.
Observational assessments, then, are done of each
alter when they reveal themselves to the therapist. In
addition to establishing the alter's perceived age, sex
and name, the therapist will informally assess the
alter's developmental level according to Mosey's six
adaptive skills. Although some alters display mature
skills in some areas, the presence of alters who display
deficits indicates that the apparent skills are splinter
skills. Briefly, these skills and the common deficits
found in multiple personality disorder will be described:
Sensory integration s
is the ability to receive,
select, combine and coordinate sensory information
for functional use. Although alters perform according
to their perceived age, deficits in this area are not
generally seen.
Cognitive skill is the ability to perceive, represent and
organize sensory information for the purpose of thinking
and problem solving. Deficits are common and profound for many alters. A typical difficulty is the inability
to differentiate between thought and action (magical
thinking), a task usually complete by 5 years of age.
C10T • VOLUME 58 • NO 5
Dyadic interaction skill is the ability to engage in a
variety of primary groups. Those with MPD have
difficulty in entering into a trusting relationship which
indicates disruption of this skill starting in infancy.
Group interaction skill is the ability to engage in a
variety of primary groups. This is another problematic
area and deficits among alters indicate that the ability
to participate in a project group (a 2-4 year old skill) is
inadequate.
Self identity skill is the ability to perceive the self as
a relatively autonomous, holistic and acceptable person who has permanence and continuity over time.
The profound failure of this skill has its roots in infancy
and is manifested by the fragmentation of the personality system.
Sexual identity sIdll is the ability to perceive one's
sexual nature as good and to participate in a relatively
long term sexual relationship that is oriented to the
mutual satisfaction of sexual needs. Again, failure to
master developmental tasks in this area is profound
and is evident in alters of all ages (Mosey, 1986).
Assessments are done by observation over time. Formalized or standardized assessments have limited use
because of the personality fragmentation (Fike, 1990b).
The therapist must- constantly assess the risk for
suicidal and self-harming behaviours (Fike, 1990a).
Suicide prevention techniques including contracting
are used when necessary. The therapist continually
assesses the level of healing, and the integration of
memories, affect and behaviour. Because integration
of alters is the goal of therapy, the therapist must assess
the degree of integration readiness.
OCCUPATIONAL THERAPY
INTERVENTION
Skills which are taught and practiced in therapy to
alters at their own developmental level will be integrated into the whole when fusion takes place. It
makes sense to teach alters skills as part of the
therapeutic process because the immature skills which
they demonstrate are much more difficult to access and
change once fusion has occurred. Based on assessment and the authors experience with clients with
MPD, the following goals for Occupational Therapy
intervention have been developed:
1. To develop a trusting relationship. This is the most
basic and integral component of therapy.
2. To teach life skills in deficit areas. This is done
according to the needs of each alter or group of
alters.
3. To increase internal cooperation. These clients
have survived by being separate and must learn to
respect other parts of themselves.
4.
5.
6.
7.
To facilitate memory retrieval. Remembering the
abuse is a necessary pa rt of healing.
To aid in the identification and expression of
repressed emotion. Emotions were split off from
consciousness and must be reintegrated.
To increase self-esteem. Clients with MPD share
with all abuse survivors poor self-esteem, feelings
of inadequacy, guilt and shame (Bass& Davis,
1988) which must be addressed in therapy.
To correct cognitive distortions. Thinking patterns
which helped the abused child make sense of their
experience are no longer needed and must be
challenged and corrected.
Therapy sessions and the therapist must remain flexible at all times to accommodate the needs of these
fragmented clients. The client is encouraged to use
internal negotiation to determine who gets time for
therapy; The therapist is aware many alters may be "watching"
what occurs' in the treatment session and may later
request time for themselves. A nine year old boy alter,
David, who was not known to the occupational
therapist, presented during a session with another alter
named, Ann. David announced that he was only
watching to protect Ann incase she was in danger. In
fact with help, he was able to admit that he had been
watching for weeks and now wanted time for himself.
The problem solving used to determine who has time
during a treatment session is an important reinforcement for the ongoing cooperation that is taught to the
alters concerning sharing of time in everyday life.
MODALITIES OF THERAPY
Occupational therapists across No rth America are
increasingly being 'involved in the treatment of individuals with multiple personalities.' Fike surveyed
occupational therapists from across the U.S.A. and
categorized intervention techniques being used. These
are developmental techniques with child alter personalities, leisure and recreational activities, projective
and self-exploratory techniques, activities of daily
living training, and role management (Fike, 1990b).
The authors are using the following modalities in their
interventions.
Play. Toys are displayed in the treatment room to
appeal to child alters. Play is the work of childhood and
it is in play activities that children learn about the
world, about relationships. It is in the arena of play that
they can test reality and practice life skills. Play used in
therapy is usually non-directive and allows the child
alter the opportunity to express and deal with past
experiences.
DECEMBER 1991 • 237
CJOT ® VOLUME 58 ® NO 5
Guided
err is used in a number of ways. Each
client has his/her own internal world where alters live,
participate in activities, and avoid reality. Using guided
imagery we can pair or group alters to look after one
another. An adult alter might be taught how to comfort
and nurture a young alter. Alters who believe they are
dirty or naked can be internally cleaned up and
dressed. It is preferable for alters to do this for
themselves, next best is to have other alters help. We
might ask, "who can comfort Sally and help her get
cleaned up". Guided imagery can also be used in a
traditional manner for stress reduction.
life skiffs teachhig in deficit areas is an integral
component of occupational therapy intervention. Many
alters were present only during abusive episodes, and
subseqeuntly did not have any exposure to normal
developmental experiences. Cognitive distortions are
a common problem (Fine, 1988). For example, one
eight year old personality broke a pencil and expected,
as in the past, to have to "pay" for it by being abused.
She was confused and puzzled when in therapy she
was told "accidents happen" and punishment is not a
consequence.
Learning ways to appropriately express and deal
with emotions is another difficult life skill for many.
Some alters have so many strong emotions that they are
afraid to enter therapy, although they may be watching
from the background. These alters must be assured that
feelings are natural and acceptable and they need to be
taught how to appropriately deal with their emotions.
An angry alter of a 38-year-old woman presented
herself first to the occupational therapist after 1 1/2
years of therapy, saying "Everyone hates me, I've
caused so much trouble, they don't want me". This
alter's anger towards men had been expressed by
promiscuous behaviour over the years. With recognition and reassurance that her feelings were justified,
she was able to join the therapy as an active pa rt icipant.
Projective techniques are important tools for clients with MPD (Frye, 1990). Painting, sand play,
drawing, clay and play therapy allow alters to communicate non-verbally. While these media are used
extensively for many alters, they become especially
impo rt ant for the withdrawn, deaf and non-verbal
personalities. Many alters have been threatened by the
abuser "not to tell" about the abuse, therefore "showing"
through art or play seems safer at first (Higdon, 1990).
The therapist can then use the uncovered material in
the review of memories which is necessary for eventual integration. Art also assists in the identification of
alters who have not yet made themselves known in
therapy. In one case, while an alter was painting, a
different voice inquired, "Can anyone paint what they
want?". With reassurance, the "new to therapy" alter
painted a picture portraying an incident of abuse.
Although he would not identify himself, he asked if he
238 ® DÉCEMBRE 1991
would be allowed to come again stating, "I've got lots
more pictures".
Groups exclusively run for child and adolescent
alters have become an impo rt ant component of occupational therapy treatment. These groups are co-led
by two therapists and accommodate a maximum of six
multiples. The groups present opportunities for young
alters to meet and interact with their peers who also
"live inside adult bodies". The alters share information,
provide mutual suppo rt and confidence in a way that
has enriched their experiences. In one play group, the
children appropriately argued the statement "You
aren't allowed to get dirty". One five-year-old alter
believed that to be dirty meant she was bad. With
reassurance that this was not true, she was able to join
in with the others who were smashing cupcakes in an
expression of anger regarding the parental abuse that
followed birthday parties. It has been the experience
of the authors that clients in the early stages of therapy
do not benefit from pa rt icipation in groups which are
not specific to MPD. Groups trigger a chaotic response
before adequate internal cooperation is established
(Frye, 1990).
CASE ILLUSTRATION OF
DEVELOPMENTAL THERAPY
Sharon is a 25-year-old single woman who reported at
age 14 that she was being abused by her father.
Sharon's accusations were vague and inconsistent
(now known to be due to her dissociation), and
although she was removed from the home, her father
was not charged. She lived with foster parents but
continued to see her parents regularly until she was 23.
Sharon's first hospitalization occurred when she
was 16. It was noticed that she had episodes of unusual
hyperventilation. Shortly after discharge, she attempted
suicide and required readmission. There were over 20
psychiatric admissions in the following six years with
suicide attempts by drug overdose, slashing of the
wrists, hanging and jumping in front of cars. Diagnosis
made over these periods of hospitalizations include
sleep disorder, major affective disorder, hysterical
dissociative episode, borderline personality disorder,
schizophrenia, bipolar affective disorder and impulse
disorder. At the age of 21, Sharon was diagnosed with
MPD. With the onset of treatment, alters were identified and over time Sharon's psychiatric condition
stabilized. She was discharged and has been treated as
an outpatient for the past 3 1/2 years.
A retrospective review of Sharon's chart clearly
shows behaviours which can now be understood in
terms of Sharon's alter personalities. For example, the
atypical hyperventilation was caused by an alter who
was afraid of suffocating because of memories of father
holding a pillow over her face during rape.
CJOT • VOLUME 58 • NO 5
Initially, Sharon herself had amnesia for all her alter
personalities. Denial of the diagnosis was strong and
time was needed to help her understand MPD. Sharon
has now been able to accept her alters as parts of
herself who coped for her during years of abuse. She
has learned to nurture her child pa rt s, to listen to all
alters for their information, and has become sensitive
to their emotions. With this growing co-consciousness,
dissociation as a response to stress is used infrequently.
Sharon had 18 personalities, seven of which were
involved in occupational therapy: Peter, a five-year-old
alter, used play to show and work through abuse
suffered. He was able to establish trust quite easily thus
allowing the others who watched to learn about trust.
Peter had started fires in the past. His desire to burn
down his parent's house as revenge for the abuse he
suffered remained. He was taught about fire and fire
safety and why this behaviour was not acceptable. He
was reassured that expressing this anger was both
necessary and safe in play. therapy.
Jane, aged 8, had co-consciousness with Sharon.
She was therefore to accompany her to an upcoming
gynecological appointment. Much time was spent in
occupational therapy prior to the appointment in
preparing Jane for the examination. Although these
sessions were directed at Jane, it was evident that
Sharon was just as anxious to learn about the procedures. A teddy bear, as a model, was used to explain
what would occur during the appointment. Procedures
such as the breast exam and pap smear were demonstrated using this model.` This not only significantly
reduced the anxiety they felt, but also opened the door
for further frank discussions concerning sexuality.
Debbie, age 16, was in the throes of adolescence.
Discussions focused around dating and making choices
about sexual involvement. Cognitive distortions such
as, "If anybody is nice to you, you have to `pay' for it",
led Debbie to believe she was obligated to have sexual
relations with her dates. Role play was used to practice
the assertive skills of saying "No Birth control, AIDS,
sex education and homosexuality issues were all dealt
with.
Rachel, 10 years old, holds much of the anger in the
system. In occupational therapy she felt she needed
permission to yell, to paint as an expression of anger
and to c ry . She used drawings to help retrieve memories
she had long repressed. As her generalized anger
started to focus, she began to understand and voice her
feelings toward her mother who was emotionally
unavailable to her.
Seven-year-old Jennifer had many cognitive distortions about how a "good little girl" behaved. She was
always clean and polite, feminine and happy. Books
and dolls triggered her expression of false beliefs. For
example, when given a pre-teen doll wearing a bathing
suit, Jennifer said "You can't wear a bathing suit
without making trouble with men". Therapy for Jennifer has allowed her to change her perceptions.
Margaret, age 12, was plagued with many of the
eating disorders that are commonly associated with
MPD. Much of the abuse that Margaret suffered for
Sharon involved food and took place in the kitchen.
For example, after eating peanut butter without permission, Margaret was forced to lick a mixture of
peanut butter and mustard from her father's penis. One
goal of therapy was to reframe eating experiences into
normal social circumstances. Making peanut butter
cookies became very therapeutic and subsequently
many cognitive distortions about eating were corrected. Margaret had never eaten french fries, the
thought of this made her ill. This was explained when
a particularly difficult memory surfaced which involved
abuse with boiling hot french fries. Eating french fries
with the therapist allowed her to begin to deal with her
anger, hurt and pain.
Gigi a street smart 18-year-old, exhibited borderline
personality traits. She used manipulation and maintained shallow relationships to protect herself from
rejection. Her belief was, "If you hurt someone first,
they can't hurt you". She did not come forward to join
therapy until almost two years after it began because
of her fear of being rejected by the therapists. In
occupational therapy she was listened to and felt
validated as a person for the very first time. She learned
about normal relationships, communication skills and
sexuality. She began to explore new activities, such as
indoor gardening, and she learned to express anger at
herself for past behaviours without inflicting self-harm.
Although only seven of Sharon's 18 alters have been
involved in occupational therapy, others have watched.
This has always been encouraged.' Sharon is well on
her way to integration. However, even after the alters
come together, work remains to be done. Issues such
as self-esteem, building relationships, dealing with
sexuality, expressing emotions and sexuality must be
explored. Occupational performances such as vocational planning and leisure pursuits will also be addressed. As therapy nears completion, the work will
focus on the integration of the more complete person
into their chosen environment.
SUMMARY
Treatment of MPD is a long and complex process.
There is a real potential for over-involvement by the
novice therapist as this diagnosis is fascinating and
these clients are very needy. Mixed feelings will be
elicited for both the therapist and the client. These
feelings must be carefully monitored and clear and
consistent boundaries must be maintained (Chu, 1088).
DECEMBER 1991 • 239
CJOT ® VOLUME 58 ® NO 5
Frequent team meetings and time for processing are
essential for successful therapeutic outcome.
The treatment of MPD is still in its early years and
no differential treatment outcome studies have been
completed. The occupational therapy treatment described, which focuses on the dissociated personalities, has been very well received by the clients. Many
feel it has been the pivotal experience of their therapy.
A 41-year-old client states, "I was so ashamed of my
children pa rt s. I never wanted to admit they were there.
In occupational therapy I was finally able to face them,
let them deal with their issues and accept them as pa rt
ofmysel.UntiIbcavoedwhupatinl
therapy, my treatment had stalled." (Client, personal
communication, June 1990) This woman has now
integrated her personalities and is in her final stages of
therapy.
Occupational therapy using a developmental frame
of reference is a valuable approach to the complex
issues of MPD. Although research concerning treatment outcome needs to be completed, the authors feel
confident that occupational therapy plays an invaluable role in the treatment process.
REFERENCES
Adams, M.A. (1989). Internal self helpers of persons with
Multiple Personality Disorder. Dissociation, 2, 138-143.
Allison, R.B. (1974). A new treatment approach for multiple
personalities. American Journal of Clinical Hypnosis, 17
(1), 15-32.
American Psychiatric Association. (1987). Diagnostic and
statistical manual of mental disorders. (Third Edition
Revised). Washington, D.C.: Author.
Baldwin, L.C. (1990) Child abuse as an antecedent of multiple
personality disorder. American Journal of Occupational
Therapy, 44, 978-983.
Bass, E., & Davis, L., (1988). The courage to heal: A guide for
women survivors of child sexual abuse. New York: Harper
and Row.
Bliss, E.L. (1980). Multiple personalities: A report of 14 cases
with implications for schizophrenia and hysteria. Archives
of General Psychiatry, 37, 1388-1397.
Chu, J. (1988). Ten traps for therapists in the treatment of
trauma survivors. Dissociation, 1 (4), 24-32.
Coons, P.M. (1984). The differential diagnosis of multiple
personality. A comprehensive review. Psychiatric Clinics
of North America, 7, 51-65.
Curtis, J.C. (1988). Exposing multiple personality disorder. The
Canadian Journal of Diagnosis, 5 (2), 85-95.
Fike, M.L. (1990a). Clinical manifestations in persons with
multiple personality disorder. American Journal of
Occupational Therapy, 44, 984-990.
Fike, L. (1990b). Considerations and techniques in the treatment
of persons with multiple personality disorder. American
Journal of Occupational Therapy, 44, 999-1007.
Fine, C. (1988). Thoughts on the cognitive perceptual substates
of multiple personality disorder. Dissociation 1 (4), 5-9.
240 • DÉCEMBRE 1991
Fraser, G.A. (1987). The central-ISH The ultimate self helper.
Paper presented at the meeting of The International
Society for the study of multiple personality disorder and
dissociative states, Chicago. IL.
Fraser, G.A. & Curtis, J.C. (1984). [A subpersonality theory of
multiple personality]. Unpublished Data.
Frye, B. (1990). Art and multiple personality disorder: an
expressive framework for occupational therapy. American
Journal of Occupational Therapy, 44, 1013-1022.
Higdon, J.F. (1990). Expressive therapy in conjunction with
psychotherapy in the treatment of persons with multiple
personality disorder. American Journal of Occupational
Therapy, 44, 991-993.
Horevitz, R.P. & Braun, B.G. (1984). Are multiple personalities
borderline? Psychiatric Clinics of North America, 7(1), 6987.
Kluft, R.P. (1984). Aspects of the treatment of multiple personality disorder. Psychiatric Annals, 14 (1), 51 55.
Kluft, R.P. (1985). Making the diagnosis of multiple personality
disorder (MPD). Directions in Psychiatry 5, (23), 1-10.
Kluft, R.P. (1987). First rank symptoms as a diagnostic clue to
multiple personality disorder. American Journal of
Psychiatry, 144, 293-298.
Kluft, R.P. (1988). The post-unification treatment of multiple
personality disorder. American Journal of Psychotherapy,
42, 212-228.
Mosey, A.C. (1968). Recaptulation of ontogenesis: A theory of
practice of occupational therapy. American Journal of
Occupational Therapy, 22, 426-432.
Mosey, A.C. (1986). Psychosocial component of occupational
therapy. New York: Raven Press.
Putnam, F.W., Guroff, J.J., Silbermen, E.K., Barban, L., & Post,
R.M. (1986). The clinical phenomonology of multiple
personality disorder: Review of 100 recent cases. Journal
of Clinical Psychiatry, 47, 285-293.
Ross, C. & Fraser, G. (1987). Recognizing multiple personality
disorder. Annals of the Royal College of Physicians and
Surgeons of Canada, 20, 357-360.
Ross, C., Anderson, G., Fleisher, W., & Norton, G. (1990).
-
Dissociative Symptoms and disorders among psychiatric
inpatients. Paper presented at the meeting of the International Society for the study of multiple personality and
dissociative states, Chicago, IL.
Tiffany, E.G. (1983). Developmental Approaches. In H. Hopkins
& H. Smith (Ed.), Willard and Spackman's Occupational
Therapy (6th ed.), (p. 101-105). Philadelphia: Lippincott.
ACKNOWLEDGEMENT
The authors wish to thank George Fraser, M.D. for his
continued support and encouragement, and Freda
Godby, B.Sc.O.T. for her editorial assistance.