Continuum of Disease


Dynamics of Dissociation

The Personality System

Making the Diagnosis

Common Presentations of MPD



Nursing Implication

Cast Studies



Post Examination

Nursing Implications

            The confines of a hospital setting, with its rules and limits, can be quite threatening to MPD patients.  It can feel like a re-enactment of the childhood trauma, with the nursing staff that enforces the rules playing the role of abuser.  The patient will subconsciously assign trauma-related roles to staff and will react to them accordingly.

            Certain alter personalities in particular may have a difficult time in the hospital.  Child alters can be disruptive.  Limit settings can bring out the anger of a protector.  Alters may hide when they feel threatened, and the risk of elopement is high whether volitional or while in a fugue state.  An alter may even present as stable enough for discharge in an effort to escape from the demands of a hospital setting.

            Primary to the nursing role in working with MPD patients is creating an environment that is supportive accepting, and protective.  Establishing trust is imperative and is facilitated through consistency and honesty in dealing with the host and all alter personalities.  Alters are encouraged to come out in an environment which feels safe, accepting and empathetic.

Nursing responsibilities include:

  1. Provide a safe environment, protecting the patient from the self-destructive impulses which arise during therapy and from hostile alter personalities.

  2. Provide an environment of acceptance and support.

  3. Provide an environment for socialization.

  4. Support the patient in acceptance of the disorder.

  5. Provide consistency in treatment.

  6. Assist patients in learning new coping skills as they interact within the milieu.

It is important for nursing staff to continually observe and evaluate for potentially self-destructive or violent behavior and to intervene to keep the patient safe.  Getting the patient to contract for safety may need to be done each shift and with all alters.  Staff must insist upon assurance of safety and control from the patient and if the contract is not convincing or does not appear to be an agreement of the entire system, then suicide precautions should be implemented.

            Nurses have an important role in ongoing observation and evaluation.  Staff can observe what stressors bring out certain alters and what their functions seem to be.  This is a valuable adjunct to the psychotherapy session.  Where the therapist has only one hour to observe alter activities, nursing staff has the opportunity to observe around the clock.

As patients begin to break through amnestic barriers related to the childhood trauma they become more and more dysfunctional.  They may feel exhausted and hyper somnolent, or energized and hyperactive.  They can also become confused around identity.  Nursing staff can help patients to focus on concrete tasks of daily living and problem solving.  This helps the patient feel safe,, secure and contained at a time when everything seems out of control.

Nursing staff can help the patient become involved in activities such as art or writing projects which can be used to introduce the different alters to each other, and offer proof to the host of the existence of other personalities.  The artwork or writing can help define who the alter is and what his or her purpose is in the system.

When patients show signs of behaviors or somatic symptoms that might suggest the need for medication, nurses should remember that MPD patients respond better to psychotherapy than to medications for certain symptoms and behaviors.  (Kluft, 1991b)  For example, what may appear to be hallucinations or quasi-psychotic behavior may in fact be the inner noise of the system; or a severe headache may be due to the conflict of one particular alter.  The nurse can call out the alter or alters who are experiencing the problem, encourage them to talk about the conflict and therapy resolve the symptoms.

However, if medication does become necessary, it is wise to ask an adult alter, preferably the host, to come out and take the medication.  Staff should mentor the patient’s responses to medication, and particularly the different alters responses.

Because of the general chaos of the personality system, as well as the borderline characteristics demonstrated by many MPD patients, it is necessary to have a treatment plan that is clear to the entire treatment team.  This will provide consistency to the patient and cohesiveness among staff.

The following are guidelines for hospital treatment of MPD patients:

  1. Make it clear to the patient that the staff is not expected to recognize each alter.  Alters must identify themselves to staff and it is appropriate for staff to ask the patient the name of the alter who is out.  Nurses are not expected to change their own behavior according to the alter they are speaking to.  This may anger or frustrate the patient, who wants each alter to be regarded as special and recognized as a separate entity.  However, they must understand that to outsiders, many alters in the system look the same and that in society people will not change their behavior to respond as the system switches.  Also, nurses should not assume that because they are known to the host or certain other alters, that the entire personality system knows them.  Meeting each personality is like meeting a new person.  Introductions need to be made, trust established, and the milieu regimen explained.
  2. Treat all alters with equal respect and address the patient as he or she wishes to be addressed.  In this general functioning of the unit the patient should be referred to by the legal name.  However, in a more in-depth one-on-one conversation, the patient may be called by the name of the particular presenting alter.  Complete abandon of social conformity is regressive and strict adherence to the use of the patient’s legal name only serves to set up a power struggle as the alter attempts to demonstrate his or her separateness and specialness.  (Kluft, 1991b).

  3. Staff crises are to be expected.  The therapist should be available for supervision and problem solving.

  4. Explain hospital rules and ask all alters to listen and comply.  If problems of compliance occur, respond with firm yet caring limits.  Punitive measures are to be avoided.  Too much limit setting and too much intimacy should be avoided.  A professional, caring attitude is appropriate.  Let patients know that they are expected to attend activities in alters who are appropriate for the occasion, who can participate and conform to the limits of the situation.  A child alter who comes out during group therapy and wants to pay would be invited to leave the group and play in her room.  T is not a necessary part of treatment for alters to appear at random and be allowed to disrupt or control the milieu by their erratic behaviors.

  5. Encourage non-verbal groups, such as art, music, or movement.

  6. Maintain cooperative therapeutic goals among staff.  A consistent approach and attitude are extremely important.

  7. Help the patient to stay focused on the goals of treatment rather than become distracted by problems in the milieu.

  8. Clarify the various roles of staff members to the patient so that he or she does not become confused or perceive a staff member as uncaring for not working with them as someone else did.  For example, the psychotherapist will work with each alter in depth, and may not wish for nursing staff to do the same.  Explain to the patient the role of nursing so he or she will not have the same expectations of nursing staff as of the psychotherapist.

Techniques for Managing Dissociative Crisis
(Parsons, 1989)

            Switching, in and of itself, is not an indication of decompensation or crisis.  An alter is generally out for a reason and nursing staff can reassure the patient of this.  Staff need not be alarmed by switching behavior.  Rapid switching might be a sign of a great internal struggle and the therapist should be notified in such cases.

It is generally not the role of nursing staff to uncover alters or work in-depth with them on issues.  When possible, it is appropriate to encourage the patient to delay such work until he or she meets with the primary therapist.

            Nevertheless, there are times when nursing staff are confronted with the memory work, and must take measures to assure successful management of such crises.  The first attempt should be to contract with the alter who has the memory to wait for the therapist.  Imagery, such as putting the memory in a box and leaving it on a shelf until the next meeting with the therapist is sometimes easily accomplished due to the patient’s high degree of suggestibility.

            If the patient is unable to delay the emergence of the memory, the nurse can help with the abreaction.  The nurse should remain calm and insure patient safety by removing the patient to an area designated for such work (e.g. usually an unfurnished room with pillows and carpeting where the patient can have privacy; often called a quiet room or safe room).  Notify her staff in case assistance is needed as the patient abreacts.  The nurse calls on the alters who need to be present to do this work, while others are asked to go far away.  Any physical contact, such as holding the hand or touching a shoulder, should only be done with the patient’s approval.  As the memory unfolds, the nurse asks the patient to talk.  If the patient is unable to talk, ask if it is alright to interpret, and suggest the patient indicate a correct interpretation by the use of hand signals (e.g. index finger for yes, thumb for no).

            At the completion of the memory, the nurse summarizes the experience as valid and painful, and that the child was not responsible for the experience; it was the sick and dysfunctional adults who were responsible.  The child is not to blame and is not bad.  It is then reinforced to the patient that the experience took place in the past and although it was terrible, it cannot harm him or her today.  Encourage the alter to go to a safe place and recall the host.

            If it appears the patient’s behavior is threatening to become self-destructive or other-destructive, the nurse must act quickly to control the situation.  The out of control alter can be counted down by the nurse into a safe place.  The nurse counts out loud 5-4-3-2-1.  The system is then asked to call up an alter who can handle the present situation and keep everyone in the system safe.  The nurse counts out loud 1-2-3-4-5.

            These experiences can be unnerving, but after working with a patient consistently the nurse will find it easier to assess when a crisis may occur and how to prepare for it.  Staff will also gain an understanding of how a particular patient responds to crisis and to the above techniques.  It is often surprising to nursing staff how susceptible MPD patients are to suggestions and prompts.  In this, their behavior is much more easily handled than in many other psychiatric manifestations.


            It is important for staff to remember that the MPD patient looks at the world and all experiences from the position of the traumatized child.  Kluft suggests that more MPD patients are “borderline in appearance than in fact.”  (Kluft, 1991b)  Attention to limit-setting and establishment of boundaries is of primary concern to nursing staff with this group of patients who can be particularly manipulative and provocative.  Staff should be aware of the patient’s attempt to split staff, should try at all times to work together cohesively, and not allow the patient to manipulate favorite staff members.

            Even if the patient does not actively participate in the split, nursing staff can become split by their own different feelings and beliefs about this very controversial disorder.  Staff members will have vast differences in level of empathy and believability, and their ideas for treatment can be quite different.  It is important to have and maintain a treatment philosophy, goals and methods so that the patient experiences consistency among the staff.  Since these patients grew up with inconsistent and confusion messages from their families, it is imperative not to re-create a split and confusing picture for them in treatment.

            It is helpful to remember that current behavior is predicated on a past wherein the traumatized child’s ability to use his or her own wits to rise above a situation meant survival in a hostile environment.  MPD patients are constantly evaluating their environment  for the changes they are sure exist and working within their detailed framework of alter personalities to outsmart the situation.  Most MPD patients will interpre4t even the most gentle limits as punitive.  This is where nursing staff can help the patient learn new ways of dealing with the world.  Nurses can help the patent to understand the source of anxiety or panic, to see how it relates to past experiences, then to see the current situation as different and chose to respond differently to it.

            There are theoretical differences between the splitting behavior of the borderline patient and the MPD patient.  The borderline patient is testing staff investment and acting out unfinished business with mother.  For the MPD patient, however, the behavior can be related to the varying attitudes of different alter personalities, and an inability to separate here and no from then.  (Parsons, 1989)


            MPD patients can cause anxiety, frustration and anger in nursing staffs for a number of reasons.  MPD patients are often experienced as to overwhelming that it threatens the sense of competence of the staff.  The sense of helplessness that the staff may feel an create a negative response toward the patient,.  This especially happens if the staff has not be adequately educated or prepared in understanding MPD and how to work with such patients, and if the hospital has no particular policy or treatment modality for these patients.  Staff may become angry with the therapist whom they feel has left them to deal with the overwhelming behavior.  Hospital staffs are often split in their feelings about MPD.  Credibility is an issue.  Kluft feels that thought MD patients certainly do demonstrate the borderline quality of splitting a staff, staffs more often split themselves by their own differing feelings and opinions about the disorder.  Because of the MPD patient’s sensitivity to the feelings of others they will they will necessarily withdraw from staff they feel rejected by and gravitate to those they find accepting.  This will add to the polarized stance of staff members.  Kluft also suggests that, because nurses may feel unprepared to deal with the MPD diagnosis, they may resort to treating the MPD patient as if his or her psychopathology is one the nurse is more familiar with, such as psychosis or borderline personality disorder.  (Kluft, 1991b)

            Kluft suggests that it is not necessary for nurses to come to a collective agreement about their feelings of MPD, or that it is necessary to convert those who don’t believe.  What is necessary is for the clinician to establish goals of admission, clearly convey them to nursing staff, and expect that nursing staff will facilitate the achievement of these goals in a professional manner, despite their personal feelings,  In areas of safety, limit setting, getting along in the milieu, appropriate groups and activities, it is not necessary to get in conflict over the believability of MPD.

            The constant dealing with traumatic material from MPD patients makes a staff venerable to secondary posttraumatic stress disorder.  It is necessary for the staff to have support groups.  Supervision must be provided for staff, with an environment conducive to expressing disbelief, frustration, and anger.  Treatment goals and methods should be clearly outlined for all staff to follow.

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