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Psychological Society of South Africa. All rights reserved.

ISSN 0081-2463

South African Journal of Psychology, 42(2), 2012, pp. 146-155

Hypnosis in the treatment of Dissociative Identity Disorder and Allied States: an overview and case study
Richard P. Kluft 111 Presidential Boulevard, Suite 238, Bala Cynwyd, PA 19004, USA rpkluftmd@gmail.com Hypnosis played a prominent role in the first successful treatment of the condition now known as dissociative identity disorder (DID) by Antoine Despine in the 1830s, and continues to be employed in its treatment in the twenty-first century. Despite its venerable history as a therapeutic modality for this condition, controversy has often compromised the acceptance of hypnosis by the healing professions. In this article, it will be argued that given the nature of hypnosis and that hypnotizability, a genetically mediated capacity, is high in dissociative disorder populations, it is inevitable that hypnosis will play a role in the treatment of DID patients, whether this is acknowledged or not. Thereafter, the roles hypnotically facilitated techniques might play will be reviewed, and the application of several of these techniques in the treatment of a DID patient will be illustrated. Keywords: dissociation; dissociative disorders; dissociative identity disorder; dissociative disorder not otherwise specified; hypnosis; hypnotherapeutic interventions

Close associations exist between hypnosis and complex chronic dissociative disorders such as Dissociative Identity Disorder (DID) and allied forms of Dissociative Disorder Not Otherwise Specified (DDNOS). Generally, the hypnotizability of those with chronic refractory posttraumatic states is elevated (Spiegel, Hunt, & Dondershine, 1988; Stutman & Bliss, 1985). DID has higher hypnotizability than any other mental disorder (Frischholz, Lipman, Braun, & Sachs, 1992). Hypnotic phenomena are central aspects of these conditions (Bliss, 1986; Braun, 1983; Spiegel & Maldonado, 1998). Hypnosis was used in the first successful treatment of DID/DDNOS and has been associated with most successful treatments to date (Allison, 1974; Bowers et al., 1971; Despine, 1840; Ellenberger, 1970; Janet, 1973; Kluft, 1982; 1984; 1986; 1988; 1989; 1993; 1994; Phillips & Frederick, 1995). Hypnotizability is a genetically-determined series of talents (Raz, Fan, & Posner, 2006), inherent in the patient. Even if heterohypnosis (hypnosis subsequent to induction by another person) is not employed, hypnotic phenomena associated with autohypnosis and spontaneous trance are ubiquitous and inevitable (Bliss, 1986; Kluft, 1982; 1991; 1994; 1999). The history of DID and the controversies that surround it are important considerations, but beyond the scope of this article. Hypnosis in the Treatment of DID/DDNOS Almost any classic hypnotic technique may find a place in the treatment of DID/DDNOS, and ego state approaches (Watkins & Watkins, 1997) are an inevitable concomitant of many useful methods. Despite the diversity and strength of available methods, the urgency and immediacy of the pain of these patients may constrict the therapists options dramatically. Every choice and consideration must respect the realities of the therapeutic encounter. The usefulness of relaxation and imagery methods of induction and intervention may be compromised by unfavourable risk/benefit ratios (Kluft, 2012). Many traumatized individuals struggling to keep control, and who may be hypervigilant, feel threatened by relaxation approaches. Many have been told to relax by abusers trying to calm or quiet them, and experience relaxation as the prelude to violation. Further, not only may imagery techniques that are usually assumed to be benign trigger connections to traumatic scenarios (Gruzelier, 2000; Kluft, 2012; Orne, 1967), but due to amnesia, inquiry with accessible personalities may seem to indicate a particular scenario is safe, only to find that in practice, it proves upsetting to other groups of alters.

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In my work, I use neither relaxation nor imagery for induction or deepening. I will use imagery in therapeutic techniques after discussing the particular imagery with my patient, asking all alters to share any concerns or misgivings. Specific techniques In a series of articles (Kluft, 1982; 1983; 1988; 1989; 1990; 1994) I reviewed over 20 types of intervention with specific usefulness in working with DID/DDNOS. Space precludes their discussion in depth. Fine (in press) has authored a thoughtful review. Here I will indicate their functions, emphasizing that the therapists verbalizations must be individualized for each patient. 1. Accessing alters. These are suggestions asking that a part come forward to talk to the therapist. They may involve asking the alter currently in control to step back, or even to go elsewhere in the mind or to sleep to allow this. This facilitates exploration, and also stabilization, because upset alters that need to be worked with can be asked to step back or sleep between sessions, and then to come forward to work, after which they can be asked to step back, etc., and the alter that generally function can be asked to return and resume control. 2. Alter substitutions. These interventions replace the alter in executive control with an alter more suitable and safe; e.g. if a child alter is in control at the end of a session. 3. Reconfigurations. Reconfiguration uses combinations of the prior two techniques to rearrange the inner world and/or the outer world complement of alters to achieve better functioning or to achieve a particular therapeutic objective. 4. Ideometer Communication. This venerable technique is often useful to work with alters unable or not permitted to take executive control, or to circumvent a prohibition against talking. Alters may try to block one anothers responses, so be sure both hands and feet are completely visible because undesignated fingers or even a foot may respond. 5. Provision of sanctuary. Safe place techniques are familiar. With this patient population there are two caveats: first, be prepared for different groups of alters to insist on different types of safe place; second, be sure to instruct several helpful alters about how to initiate this for overwhelmed or terrified parts, because it is not unusual for a helpful part to become unavailable after it experiences itself to be exhausted. 6. Bypassing/attenuating intense affects. These involve metaphors and images that indicate unsettling materials or affects can be sequestered, including images such as rheostats and dials that offer tools to permute and reduce discomfort. 7. Slow-leak techniques. These techniques suggest that what material is likely to escape containment will be released at a rate and in a manner that will not disrupt function, transforming the risk of helplessness into an experience of control and mastery. 8. Curtailing abreactions. These techniques suggest that whatever needs to come through for the patient to end the session in a stabilized state, will come through at a rate suggested by the therapist over a period of time specified and counted down by the therapist. (It is invaluable for ending sessions on time!). 9. Fractionated abreactions. These techniques, discussed in detail below, process trauma using the paradigms of systematic desensitization (Wolpe, 1973) and thought-stopping (Beck, 1979) as opposed to standard abreactive procedures. 10. Gathering historical data. Any use of hypnosis for the exploration of memory should proceed with appropriate cautions. In view of the controversy that often surrounds such efforts, it is useful to document both indications and prehypnotic knowledge of the area to be explored, to review issues relevant to informed consent, and to avoid suggestive inquiries (Brown, 1995; Brown, Hammond, & Scheflin, 1997). McConkey (1992) demonstrated that actually inducing hypnosis does not contribute to memory artifacts, and that hypnotizability and the nature of the inquiries made are the crucial factors.

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11. Time sense alteration. It may be useful to either speed up or slow down the experience of time to review a scenario rapidly without getting into the bulk of the feelings, or to restrict how much information is let through per unit time. It may be helpful to pseudo-orient the subject in time to take a person beyond a date on which some adverse reaction is anticipated or for other therapeutic purposes. 12. Distancing maneuvers. These efforts reduce the impact of reviewing a scenario in order to minimize the possibility the patient will become overwhelmed. Instead of reliving a scenario from the perspective of a participant, the patient is encouraged to envision it on a screen, perhaps with the use of VCR-like controls to stop and start, speed and slow the images. 13. Facilitating integration. These efforts encourage alters to interact in the inner world and to be co-present for neutral and positive experiences in the here and now. They diminish the barriers between and among the alters. 14. Temporary blendings. Two alters are invited to blend to address a particular issue, and to reverse this process thereafter. This is part of a specialized strategy (Fine, 1991; 1993) and may have adverse consequences if applied outside of that specific paradigm of treatment. 15. Integration rituals. Combinations of suggestions and imagery are offered that encourage parts to join with one another. These should communicate messages of joining and coming together, and avoid messages of departure, death, or going away. They should be individualized, and approved by the patient before they are put to use. Illustrative examples are given below. 16. Recheck protocols. These are efforts made with verbal or ideomotor inquiries to inquire whether alters not currently working actively in the therapy are in difficulty or planning disruptive activities. I also check to see if alters represented as integrated remain separate. 17. Symptom relief/substitution. These efforts suggest the relief of symptoms that have lost their dynamic valence. They also explore and process the determinants of, and alters involved in, symptoms, the dynamics of which are active and powerful, and mollifies problematic symptoms by replacing them with less destructive alternatives. 18. Teaching autohypnosis. Here we face a paradox. Every time a DID/DDNOS patient initiates many of these techniques or a therapist uses them without performing an induction, autohypnosis is involved, but usually the patient is unaware that this is the case. Some DID/DDNOS patients who are taught formal self-hypnosis methods will have alters that use these skills to oppose the therapy or to battle one another 19. Suppressive measures. In the past quasi-exorcistic procedures to drive out alters deemed undesirable were advocated by some (Allison, 1974). Subsequent explorations (Bowman, 1989) had demonstrated that these measures are usually counterproductive. They are mentioned for historical reasons and for their usefulness in rare situations in which an emergency requires a radical authoritarian intervention. I have used them twice in 40 years. 20. Trance ratification. These interventions are useful to demonstrate that hypnosis can do something and may serve as the launching pad for therapeutic interventions (see above). Perhaps they are most important in socializing the patient to a positive set toward hypnosis and an anticipation of success when it is applied. It is devilishly difficult to introduce hypnosis to terrified and traumatized individuals whose life experiences have taught them to anticipate harm in the middle of a crisis. It is more therapeutic to create an atmosphere and expectation that indicates that when hypnosis is to be used, pain relief is not too far away and it is time to be receptive to help. I have found glove anesthesia most useful in traumatized populations. 21. Relapse prevention. Brief suggestions for my completely integrated patients may be crafted for use if and when they feel their togetherness is at risk. These interventions are all most effective when individualized and used in combinations. Using integration as an example, a mature female patients alters might integrate with an image of the alters ready to join holding hands and letting all of their feelings, knowledge, and strengths flow into one

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another so they, having shared all, have become the same, followed by the falling away of boundaries between/among them and their blending and settling gently into a new unity. But an eight-year-old boys two remaining separate alters might be sent on an elaborate Star Trek mission of exploration on a fascinating unknown planet. In the course of their adventures, they learn of a cave of wisdom. Arriving there, they look into a telepathic mirror. Seeing only one image, they realize that they are one and the same boy. Transmitting this information to their space ships commander, they request to be beamed up as their true self, and the transporter beam in fact returns them to their ship as one strong boy. When matters of identity are in play, the more congenial the intervention to the ideals and objectives of the patient as a person, the more likely the success. The effort to individualize is considerable, but pays for itself many times over. I gave a full hour of science fiction adventure to the 8-year-old boy described above before actually suggesting integration. Now a 40 year-old married father of two sons of his own, he remains integrated and well on 32-year follow-up. CASE STUDY Gwen (a pseudonym) is a successful professional woman who has given informed consent for the use of her material in this publication. Background Gwen is a successful lawyer who survived over 20 years of well-documented incest and exploitation in prostitution and pornography. She presented disabled, suffering myriad unsettling symptoms she endured without comprehending their meanings or origins. They proved connected with traumatic scenarios. Gwen was raped and suffered a blunt head injury while at law school. Subsequently traumatic nightmares, probably flashbacks of horrible mistreatment, began to surface. After graduation she worked with her lover, a former mentor who became a nationally prominent politician. He came to fear their affair would be discovered, and fired her abruptly. She sought treatment for her despair. Treatment Relocating, Gwen was referred to me. Her efforts to find and hold employment failed because she seemed to lack all legal knowledge. As we explored her memory problems, Dissociative Identity Disorder was diagnosed. Treatment proceeded under difficult circumstances. Gwen was nearly destitute. But she was beautiful, always being approached and offered money for sex. The personalities that attended law school had withdrawn from participation in life when Gwen was rejected by her lover. We could not mobilize them and access their knowledge and strength. Gwen rapidly lost well-paying jobs that capitalized on her looks. Her peers were jealous of the attention she received, and her employers thought she might be a prostitute. Despite formidable obstacles, Gwen was ferociously motivated. She now is integrated and quite successful. Hypnotic techniques were employed to facilitate her basic psychodynamic psychotherapy. Here I can only illustrate a few of these methods. Stabilization and preparation for trauma work Initially Gwen was so symptomatic and so many alters were active that Gwens attempts to function, or even to discuss an emotionally laden issue, were often profoundly disrupted. She suffered recurrent migraines. We had to settle down her system, to clear the decks. It also was clear that Gwen knew nothing about hypnosis. I chose not to undermine her apparent belief that induction was a powerful process able to exert a degree of control. I started hypnotic work by inviting all parts of the mind to participate in learning glove anaesthesia. The invitation given and trance induced, Gwen was taught to achieve glove anaesthesia, transfer the anaesthesia by touching

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her anaesthetized hand to other parts of her body, and to send the anaesthesia through the blood stream to wherever it was needed, for physical or emotional distress. Gwen learned to stop her migraine pain and to interdict incipient panic attacks. As Gwen achieved some degree of self-efficacy, I communicated with alters encapsulating traumatic experiences and with those based on her abusers. Some traumatized parts chose to be asleep between sessions and during work not related to their experiences. Younger parts preferred to be in an imaginary safe place, a play-room equipped with all manner of toys and suitable friends. It proved challenging to contain male alters identified with abusers. I reached them by repetitively demonstrating the ties between them and the victim alters that they tried to see as separate from them, and by demonstrating that every time they inflicted hurt or humiliation I would focus treatment on them. Ultimately they responded to imagery that took them to a rural area where deer were plentiful and a nearby lake was full of largemouth bass (a favoured American game fish). I supplied them with superlative armaments, including 50 caliber sniper rifles, and automatic weapons. I provided them with an infinite supply of their preferred food and drink. I believed I could begin to effect a change in them by playing on their love for beer. I refused to provide their favourite beer unless they also accepted a small amount of imported beer. I reasoned that if they accepted imported beer, I might develop that into the acceptance of other foreign notions. Over a period of 18 months, I checked in with them monthly while Gwens other alters and I established a solid foundation for our work together. On my second check, I was told that they liked the foreign beer, but had run out of it. I discoursed for about 10 minutes about great beers I had enjoyed, and gave them their choice of a second imported beer as well. By the time they were ready to work in treatment they had widened their tastes to about 10 international beers and the foods of many nations. They had become socialized to the idea that new things might be interesting rather than threatening. This illustrates how I work to individualize interventions and capitalize upon whatever therapeutic opportunities present themselves. Initial efforts to contain alters based on Gwens mother, a psychopath and compulsive nymphomaniac, were dismal failures. It was essential to contain the mother parts outrageous plans and behaviours. I worried that Gwen might endanger herself, poisoning her reputation within the local professional community, and generating enough humiliation that Gwen might withhold crucial information from me, undermining our work together. I used a previously unpublished technique I call origins work, involving a modified form of age regression. Inducing and deepening trance, I invited whichever personality based on mother that was proving problematic to go back to shortly before it became separate, and move forward in time. The objective was not to discover historical material. The goal was to expose parts that were identifications with an aggressor to their origins in the attempt to evade the subjective experience of those helpless, terrified, and painful moments during which they were betrayed and mistreated, finally escaping by identifying with the mother . After several such awakenings the mother parts asked to be left safe and asleep until it was their turn to work on the traumata that led to their creation. Sexualized enactments became largely a thing of the past, with only rare unfortunate episodes. Exploring Gwens history We began. I neither knew nor could anticipate how much documentation of Gwens mistreatment would ultimately be available. Here I cite only one example. When cleaning out a storage bin after her mothers death she found a cache of hundreds of pornographic photographs and movies in which she had participated. But I did not know about this massive documentation until late in treatment. Historical material later confirmed had emerged as we explored symptomatic behaviours. I would simply ask to speak to what alter was associated with (or behind) some distressing symptom, was ready to talk, or could

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continue the topic that was generally under discussion. If I anticipated that the material would be problematic, I might suggest all other alters distract themselves or go to sleep during the inquiry. If nothing presented itself, which was rare, I might ask Gwen to close her eyes, slip into trance, and imagine a blank screen. I would suggest that as I counted from one to ten, an image or idea would develop that might help us move the treatment forward, or address some particular problem. Usually, nothing would appear, but when I repeated this technique and asked that something be shared that explained why the previous screen was blank, useful material usually became available. This might be understood to be a hypnoanalytic approach to defense analysis. Once an area was open, Gwens alters usually worked to discover and discuss whatever was involved. My most characteristic inquiry is Whatevers there I never used focused inquiries until a scenario had already emerged suggestion-free. I usually find little need for aggressive inquiry unless I suspect that the welfare of a child is at stake. Shame reduction usually opens the gates of memory quite nicely, but rarely can serve as the sole means of accessing the past. Shame reduction procedures Shame is capable of causing and perpetuating dissociation, and makes dissociation more difficult to resolve (Kluft, 2007). Shame reduction was crucial with Gwen, who rarely got through a day without being approached by several men, and had difficulty believing that this was not her fault. In one procedure, I would ask Gwen to envision a lovely woman whom she respected going through her day attracting unwanted attention without trying to do so. After several reiterations during which my commentary was minimal, Gwen broke out of trance and exclaimed, She isnt doing a damn thing, and still it happens! Soon she could envision herself in that womans place and realize that the same applied to her. I asked Gwen to envision a magical cleansing stream (see Kluft, 1994), drawing upon icons of cleansing and rebirth from many cultures. In individualizing this image for Gwen, I addressed her firm conviction that her orifices were irretrievably filthy and soiled. My initial presentation of this imagery was minimally successful. I progressed to very specific and intimate instructions about exposing these parts completely to the cleansing power of the stream. Gwen later told me that she could not believe how explicit I had been, but that she had augmented my images even further and now felt clean for the first time in her life. Techniques to bring sessions to safe closure and to stabilize As dissociative barriers began to fray we had to take more elaborate steps to stabilize Gwen at the end of the session. We still were not doing deliberate abreactive work, but almost all alters had entered the therapeutic alliance. Protecting the DID/DDNOS patient from destabilization, especially during trauma work, is essential. We had to set the stage for processing rather than just learning about traumatic material. When I asked Gwen for her suggestions, she told me she heard from somewhere inside herself that those parts whose issues were disruptive or potentially disruptive should be placed in bubbles between sessions. Bubbles seemed too fragile an image to me, and they proved to be unsuccessful. Not to be deterred, Gwen suggested they be made thicker. By the time Gwen integrated, the bubbles were 12 times thicker than when we started! We developed a protocol for stabilization between sessions. Those alter groups that had been assigned to bubbles would be sealed off in those bubbles as I counted from one to three. Then the bubbles were stored in a powerful vault, leak-proof and strong. Finally, those alters that needed to hide away in safe places would go there at the count of three, and those who needed to go to sleep would go to sleep at the count of three. Finally, a buffer, a barrier, a force-field would surround and protect the vault, the safe places, and those who were asleep, powerful enough to protect them from disruptive influences within the mind or from the external world. As I counted, the force-field would become more powerful and profound with each number. We started with a count of 10, but by integration I was counting up to 30 to give adequate reassurance.

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Fractionated abreactions for trauma work How to process the trauma? In the 1970s I developed an approach to abreaction based on the work of two of my mentors, Aaron T. Beck and Joseph Wolpe. I quickly came to see that traditional abreactive approaches often proved overwhelming to the ill, elderly, compromised, or avoidant patient. I used techniques from behaviour therapy (Wolpe, 1973) and cognitive therapy (Beck, 1979) primarily systematic desensitization and thought-stopping, plus hypnosis, to develop a technique that allowed these patients to process trauma more safely. I developed the technique of fractionated abreaction (Kluft, 1990) in the 1970s. A colleagues book containing my original article remained unpublished. Aspects have been described by my colleague Catherine Fine (1991; 1993) and many have described it without attribution. Consistent with systematic desensitization, traumatic material is presented in graded hierarchies. However, here graded hierarchies are created by subdividing the totality of the traumatic event. The dimensions appropriate for fractionation are: 1. Temporal sequences the time line of a traumatic event can be broken into portions of brief duration, beginning with exposures limited to a few seconds. 2. Percentage titrations using hypnotic methods, a patient can be taught to titrate the percentage of the discomfort, and begin with 5% or lower if necessary. 3. Input divisions using hypnotic methods, either the A (affective) or the S (sensation) of the BASK dimensions of a trauma (Braun, 1988a; 1988b) can be ablated for the duration of the procedure. 4. Alter participants using hypnotic methods, related alters are protected as the trauma work is done, reducing decompensation potential. This is because one alters experience may be followed by anothers beginning to process its trauma, one alters overflow of pain may have generated other alters, so that work with one mobilizes many, and, at times many alters are traumatized at once, and protector personalities may jump into the processing and create confusion and chaos in a misguided effort to be of help. Working with these dimensions makes it possible to titrate the intensity of the trauma to which the patient is exposed. Gwen and I would agree on what portion of an event we would begin to process, and at what degree of intensity. We would contract with the alter system to keep out of the way, but if there was widespread concern about working with a vulnerable part, a helper might be allowed to participate or remain nearby. This latter idea is not foolproof. Protectors and helpers may themselves be overwhelmed and lose their power to be of assistance either transiently or permanently. Arranging the details and teaching the elements As we worked out these details, I taught Gwen percentage titration using a rheostat metaphor. In hypnosis we often build successful suggestion upon successful suggestion, encouraging a yes set (Erickson, 1976) predisposing the patient to be favourably inclined toward what comes next. Therefore, most colleagues who try to teach the titration of pain with rheostat and dial and similar metaphors are upset by my tendency to start by beginning to teach my patients to increase their discomfort as a first step. Yet traumatologists know that profoundly traumatized people expect the negative and doubt the possibility of the positive. Depressed people demonstrate the cognitive triad of a negative view of self, others, and the future (Beck, 1979). A yes set is more easily achieved by working within the patients subjective realities. In such case, that means negative expectations. Gwen had suffered years of profound trauma and was still rather depressed and demoralized. I taught Gwen to imagine a traumatic scenario at a very painful level, and to simultaneously imagine a rheostat. She learned to turn the rheostat up to create more discomfort. This was easily achieved. Then she learned to dial it down to her baseline of extreme discomfort. After several exercises increasing and reducing pain, but never going below her baseline severe discomfort, she knew how to raise and lower her distress and could do so with facility. The symptom was captured. Next, she learned to take the pain up, down to baseline, then up somewhat less, and then to 2%

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below baseline. Her reaction was immediate and enthusiastic. I let her practice to going down 510%. The next session she arrived eager to learn to use the technique to effect greater reductions. Over a period of sessions, Gwen learned to reduce her discomfort over 90% and to block out either physical or emotional discomfort completely while the other type of discomfort persisted to some extent. Putting the technique to work In a session, we would agree how much of an event we would cover and at what percentage we would work. (I never start with more than three minutes and 510%, and rarely with more than one alter.) I refused to rush what must have seemed like an endless process. However, after several sessions during which small increments of time and percentage distress were abreacted and discussed, Gwen became unafraid of processing trauma. Her sense of helplessness and her fear of being overwhelmed were conquered. Also, because the full scenario was not being played out, Gwens fears that I might be using her trauma as my private pornography or sadistically enjoying imposing retraumatization upon her were reduced. Gradually Gwen became counterphobic and aggressive toward her traumatic experiences, confident that she would survive processing them and become stronger as a result. The more trauma we processed, the stronger Gwen grew. She began to recover her legal knowledge and skills. Safe and secure in handing these attenuated abreactions and the slow and gradual approach to longer and more intense trauma, she spontaneously moved toward more classic abreactive work. Further, a great deal of generalization occurred. As we progressed, we usually found that new areas of trauma were processed with much less time and effort. What had initially taken months now could be managed in one or a few sessions, using the hypnotic techniques noted above to curtail and contain them when necessary. Gwens grit and determination made it possible to do this work without major disruption to her functioning or life circumstances. It took many years to deal with what Gwen had endured, to mitigate its consequences, and to help her develop a more powerful and healthy unified self, but her treatment brought about profound improvements and allowed her a satisfying quality of life. Most DID/DDNOS patients have neither experienced the amount of traumatization Gwen suffered, nor been gifted with her intelligence, courage, and ego strength. Nonetheless, many can benefit significantly from individualized programs of hypnotherapeutic interventions. Therapists with an ego-state and or Ericksonian orientation might approach the same problems with a somewhat different repertoire of techniques (Phillips & Frederick, 1995; Watkins & Watkins, 1997).

DISCUSSION Judiciously and circumspectly applied heterohypnotic interventions have a positive and constructive role to play in the treatment of DID/DDNOS. While there is no guarantee that the therapists preparations, however assiduous, will result in a completely safe and protectively structured therapeutic approach, my clinical experience in the successful integration of over 180 DID patients indicates that the quality and efficacy of the treatment I can provide is profoundly improved by the use of hypnotherapeutic interventions. My work with those who refused to allow work with hypnosis was much more difficult and challenging. While most emphasis and controversy has surrounded the exploration and processing of traumatic memories, hopefully the emphases of this article highlight the contributions hypnosis can make to the safety and effectiveness of DID/DDNOS treatment. Maximizing safety is among the most important aspects of the treatment of DID/DDNOS. When crises, panics, and moments of terror and dyscontrol are numerous and severe, the patient may become too disrupted and frightened to pursue a definitive treatment, may lose his or her sense of safety within the treatment, experience escalating distrust in the therapeutic alliance, and mobilize a wide range of negative transferences, all of which

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impede the treatment and may lead to transient or fixed stalemates (Kluft, 1983). Elsewhere I proposed an approach (Kluft, 1991) that has been termed Klufts rule of thirds. I argued that spontaneous abreactions held the potential for disruption and tended to occur so late in the session that their management was problematic. Therefore, I advised that if a therapist and a patient plan to do abreactive work, they should begin this work by the end of the first third of the available time, use the second third to do the trauma work, and reserve the last third for processing and restabilization. Most of the techniques discussed above had powerful potential to contribute to safety. In essence they offer approaches to breaking the often horrific traumata endured by DID/DDNOS patients into manageable bits. What has been sufficiently traumatic to cause dissociation may have the potential to prove overwhelming when encountered anew. Hypnosis played a crucial role in the first successful psychotherapy of DID/DDNOS, and continues to be a valuable asset to the contemporary psychotherapist working with these conditions. Given the inevitability of encountering autohypnosis and spontaneous trance phenomena in work with this patient population, the therapist who treats DID/DDNOS will benefit from acquiring both a general knowledge of hypnosis and more specific expertise in the use of hypnosis in the treatment of the dissociative disorders. Readers interested in the brief discussions of the omitted topics noted above may request them from me at rpkluftmd@gmail.com. REFERENCES
Allison, R.B. (1974). A new treatment approach for multiple personalities. American Journal of Clinical Hypnosis, 17, 15-32. Beck, A.T. (1979). The cognitive therapy of depression. New York: Guilford. Bliss, E. (1986). Multiple personality, allied disorders and hypnosis. New York: Oxford University Press. Bowers, M.K., Brecher-Marer, S., Newton, B.W., Piotrowski, Z., Spyer, T.C., Taylor, W.S., & Watkins, J. (1971). Therapy of multiple personality. International Journal of Clinical and Experimental Hypnosis, 19, 57-65. Braun, B.G. (1983). Psychophysiological phenomena in multiple personality and hypnosis. American Journal of Clinical Hypnosis, 26, 124-137. Braun, B.G. (1988a). The BASK model of dissociation: Part I. Dissociation, 1(1), 4-23. Braun, B.G. (1988b). The BASK model of dissociation: Part II. Treatment. Dissociation, 1(2), 16-23. Brown, D. (1995). Pseudomemories, the standard of science, and the standard of care in trauma treatment. American Journal of Clinical Hypnosis, 31, 1-24. Brown, D., Hammond, D.C., & Scheflin, A. (1988). Memory, trauma treatment, and the law. New York: Norton. Despine, A. C. -H. (1840). De L'Emploi du magntisme animal et des eaux minerales dans le traitement des maladies nerveuses, suivi d'une observation trs curieuse de gurison de nvropathie [A study of the uses of animal magnetism in the treatment of disorders of the nervous system followed by a case of a highly unusual cure of neuropathy]. Paris: Germer Baillire. Ellenberger, H. (1970). The discovery of the unconscious. New York: Basic Books. Erickson, M.H., Rossi, E., & Rossi, S. (1976). Hypnotic realities: The induction of hypnosis and indirect forms of suggestion. New York: Irvington. Fine, C.G. (1988). The work of Antoine Despine: The first scientific report on the diagnosis and treatment of multiple personality disorder. American Journal of Clinical Hypnosis, 31, 33-39. Fine, C.G. (1991). Treatment stabilization and crisis prevention: Pacing the therapy of multiple personality disorder patients. Psychiatric Clinics of North America, 14, 661-675. Fine, C.G. (1993). A tactical integrationalist perspective on the treatment of multiple personality disorder. In R.P. Kluft, & C.G. Fine (Eds.), Clinical perspectives on multiple personality disorder (pp. 135-153). Washington, DC: American Psychiatric Press. Fine, C.G. (in press). Cognitive hypnotherapy of the dissociative disorders. American Journal of Clinical Hypnosis.

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