Theoretical and Historical Issues
The Myth of the Monolithic Self
Poets and philosophers have long been aware that the healthy individual’s personality or “self” is far from a monolithic structure free of inconsistencies and ambivalence, and the myth of the truly consistent self has been thoroughly challenged as well by the social and behavioral sciences. William James and the early self theorists (see Cooley, 1902; James, 1890) realized that much emotion, and indeed, much motivation, results from inconsistencies and conflicts within the self and especially within the self-concept. George Herbert Mead (1934) followed their lead in recognizing that not only is the self complex and to some degree conflicted, but it also is necessarily malleable by virtue of its variety of social contexts; fluid interactions between the individual and his or her social environment continually shape and modify the self.
Theoretical Metaphors
Throughout its subsequent history, psychology has wrestled with concepts of mental health, mental illness, and the diversity of human behavior by using a variety of metaphors to conceptualize and describe the self in all of its complexity and conflict. Freud (1923, 1933), for example, distinguished between the conscious, preconscious, and unconscious “levels” of the self, and developed the notions of id, ego, and superego as “parts” of the self with differentiated functions. Later, object relations theorists (e.g.,
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Winnicott, 1965) began to speak of cathected objects internalized and assimilated as self-parts. And perhaps the best known view of the self as composed of many significant introjects has been popularized by Harris (1967). Thus, transactional analysis speaks of the “parent,” the “child,” and the “adult” in laying out its diagram for understanding the mosaic of self. Indeed, it speaks of the “child within” the person and similar personified metaphorical constructs.
Recent work in cognitive theory has continued this tradition of understanding the multifaceted and dynamic nature of the self in metaphorical terms. Starting from Allport’s belief that the human mind is able to regard and consider itself as an object (Allport, 1961, p. 128), Kihlstrom and Cantor (1984) posit a self composed of a variety of “structures” or “schemas” that are constructed from past experiences, represent self-knowledge about self-relevant motivators such as goals, fantasies, and fears, and largely determine which external stimuli are attended to and remembered, as well as how they are interpreted. Markus and Nurius (1986) give these structures clearer metaphorical identities as “possible selves,” cognitive representations of hopes, fears, goals, and threats that motivate and organize the individual’s behavior.
Obviously, this is but a small representative sample of the proliferation of conceptual models available for discussing the notion of self, and inevitably, variations of such models will continue to develop. For our purposes, it is not so important to understand the differences between them as it is to acknowledge three important ways in which they are similar: first, they each acknowledge unequivocally that the consistent, conflict-free, and unambivalent “self” is a myth; second, they all suggest that the inconsistencies of the self are nevertheless organized (or are being continually reorganized) in such a way that the self is usually experienced as having some kind of coherence and wholeness; and third, they all ask to be understood not as literal “structures,” but rather as metaphorical frameworks, or, perhaps more usefully, as maps that should not be confused with the territory they describe.
While all of these “maps” of the self may vary in terms of the types of geography they represent and the boundaries they draw, as metaphors they all in some way reflect our abilities and disabilities, our hopes, fantasies, and fears—the stuff of which “self” is continually made and re-made.
Therapeutic Metaphors
The road between theory and practice is as treacherous as it is important, and we shall see that this is particularly true when theory is stated metaphorically. First, it is necessary to ask what clinical inferences we may draw from theoretical models that all suggest, whatever their descriptive differences, that the self is on the one hand multifaceted and
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internally inconsistent, and yet on the other is often organized in some way that is experienced as coherent and whole.
Patients may present with problems in either or both of these areas. For example, the always serious, compulsively neat worker may not have access to parts of himself that allow for humor and play, and may experience himself as quite one-dimensional. On the other hand, the alcoholic whose sober self cannot remember her “uncharacteristically” seductive behavior of the drunken night before has discovered a way to experience the various facets of her personality, but is unable to acknowledge them as parts of a single, coherent self. The extension of the metaphorical model into the practice of psychotherapy, then, might include references to the “inner parent” and the “inner child” to help the first patient understand and experience himself in new ways in the context of transactional analysis. Similarly, the second patient might be supported in understanding that her “seductive self” is as genuinely her own as is the superego she dissolved in alcohol.
It is not our intention here to belabor the specific theoretical metaphors, nor to work out yet another conceptual or clinical model, but rather to focus on the use and misuse of clinical metaphors generally, with specific references to one clinical disorder that has recurrently piqued the interest of psychology and psychiatry, as well as long fascinated the public at large.
Multiple personality disorder (MPD) is a uniquely powerful example of what can happen if theoretical or clinical metaphors are reified and treated as if they were literally true, on the one hand, while at the same time, the myth of the monolithic self is accepted as if it were the normal state of affairs in the real world. In addition, a discussion of MPD is particularly relevant to a volume devoted to exploring notions of self, as it brings into high relief the questions of “self,” or “parts” of the self, and especially of “multiple selves.”
History of Multiple Personality Disorder
Various kinds of possession phenomena have been known from antiquity through the Middle Ages. St. Augustine’s confessions include references that describe his “old pagan personality of which nothing seemed to remain in his waking state, still must exist since it was revived at night and in his dreams. He wrote, ‘Am I not myself, Oh Lord, My God, and yet there is so much difference betwixt myself and myself within the moment wherein I pass from waking to sleeping or return from sleeping to waking.’” (Ellenberger, 1970, p. 126). As early as 1791, Eberhardt Gmelin described the dual personality of a 20-year-old German woman:
[She] suddenly “exchanged” her own personality for the manners and ways of a French-born lady, imitating her and speaking French perfectly and speaking German as would a Frenchwoman. These “French” states repeated themselves.
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In her French personality, the subject had complete memory for all that she had said and done during her previous French states. As a German, she knew nothing of her French personality. With a motion of his hand, Gmelin was easily able to make her shift from one personality to another. (cited in Ellenberger, 1970, p. 127).
Ellenberger cites and describes other such examples in the early 19th century.
William James (James, 1890), in discussing the multiplicity of selves that normally exist in the healthy individual, spoke of ways in which some of these selves might become “deranged,” resulting in a form of multiple personality disorder, and recommended that serious empirical work was needed to clarify the theoretical implications of such disorders for understanding the self. At the turn of the century, the clinical phenomena of MPD were described by Morton Prince (1905/1978). His cases began a lively and sometimes acrimonious debate regarding the nature and the reality of the disorder.
This controversy has been renewed in recent years concomitant with the increasing use of the diagnosis. Three times as many cases were reported between 1970 and 1983 than in the 150 years before 1970, and the number continues to grow geometrically (see Boor, 1982; Boor & Coons, 1983; Braun, 1986; Coons, 1986b; Greaves, 1980). Interestingly, concomitant with the dramatic increase in reported cases of MPD, there has been a striking increase in the number of “personalities” manifested by individual patients—ranging from two or three at the turn of the century to some patients who manifest well over 100 today (see, e.g., Kluft, 1988).
A polarization has now developed between a relatively small group of therapists who are reporting large numbers of cases (increasingly with large numbers of “personalities” in each case) and others who believe that if MPD occurs spontaneously at all, it does so extremely rarely. This latter group believes that the recent apparent remarkable increase in incidence of MPD can be explained in terms of the media’s interest in and portrayal of this fascinating phenomenon in the press, in films, and on television. Analogous questions were raised when Morton Prince and a few colleagues described MPD, and other physicians argued that iatrogenic factors were the basis of the disorder. This controversy continues to be articulated in the current literature (e.g., Bliss, 1988; Braun, 1984; Spanos, Weekes, & Bertrand, 1985; Spanos, Weekes, Menary, & Bertrand, 1986; Sutcliffe & Jones, 1962; Thigpen & Cleckley, 1984).
As one might expect, neither of these extreme positions really helps us to understand the disorder. Thus, we seek here to sort out the conceptual and theoretical implications that the disorder has for our views of “self” to understand the nature of this form of self-disturbance and to clarify the role of metaphorical demand characteristics in diagnosis and treatment.
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The Use and Misuse of Myths, Metaphors, and Memories
What is Multiple Personality Disorder?
Phenomenologically, MPD involves the existence of two or more independent personalities, that is, “selves,” if you will, that are autonomous and independent within a single individual (see American Psychiatric Association, 1987, pp. 269-272). The diagnosis is generally made on the basis of presenting problems that include the experience of “lost time,” with the individual being unable to remember what he or she did at a particular time; comments of significant others on uncharacteristic behavior of which the individual has no memory; and the discovery of strange items among the individual’s belongings or finding his or her own belongings in strange places.
Typically, some personalities are diametrically opposed behaviorally—for example, an inhibited, very proper “lady,” and a sexually promiscuous vamp, or, in literature, a Dr. Jekyll and a Mr. Hyde—and while some of them know each other, at least some of the personalities (and typically the “primary” personality) are unaware of the others.
The definitive diagnosis—and we shall see later that diagnosis and treatment are often synonymous for some therapists active in treating these patients—is often based on the therapist’s eliciting the appearance of the various “selves” or personalities in the therapist’s office.
The Supposed Rationale for and Consequences of the Multiplicity Model on Psychotherapy
Accepting the view of MPD as it is currently being conceptualized by the group of clinicians primarily responsible for the recent upsurge in the incidence of its diagnosis demands an approach to treatment radically different from essentially all other psychotherapeutic approaches. That is, to account for contradictions in patients’ behavior and feelings, the therapist assumes that within one body there are in fact, several true, independent individuals—independent in terms of their histories, beliefs, feelings, and of course, decisions and behaviors. To support such views, Braun (1986) describes patients whose eye color changes when an alternate personality is manifesting. Similarly, other patients are reported to have had allergies in one personality but not in others. And finally, neurophysiological studies by Putnam (1989) appear to demonstrate changes in brain function associated with different personalities.
Such reports would seem to justify the assumption that there are indeed two or more genuinely distinct personalities living within these patients. This assumption then radically changes the usual therapeutic
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model for treatment. That is, if there are truly different “people” within the individual patient, it is reasonable to find out how many and what kind of people are involved, to try to understand the complex interpersonal, intrapatient conflicts that result, to discover why one self would want to kill another, even if this means losing his or her own life, and to engage in the difficult struggle to reach consensus among these various selves and help them to coalesce into a truly coherent personality. Under these circumstances, treatment would appropriately focus on identifying the separate problems and strengths of the various selves, on negotiating agreements and alliances among them, and on other specialized procedures to help the patient to function better in the world, and to prevent possible suicide, which is a common feature of the contemporary MPD patient.
In fact, however, despite the fact that anecdotal data about physiological changes from one “personality” to another in these patients may be intriguing, alternative explanations are available for these phenomena and should be seriously considered and empirically tested before abandoning more generally accepted psychodynamic understanding. These data are raised here only to explain why some clinicians working with dissociative patients have felt little need to question a model so radically different from that in which they were trained.
Some interesting features of the disorder, less well-known among clinicians as well as among the general public, may be important in terms of differential diagnosis, including the detection of possible malingering in forensic contests. One of the more striking of these is that whereas differences between the personalities seem to be quite considerable, these differences do not typically include “splitting” of the individual’s cognitive skills. In fact, research on memory has shown that material learned by one personality facilitates learning by the other personalities tested, even when the order of presentation is changed to guard against sequence effect (Ludwig, Brandsma, Wilbur, Bendfeldt, & Jameson, 1972). A partial exception to this phenomenon, derived from experiments with age regression in hypnosis, may be that a “personality” who manifests as a 9-year-old boy will apparently not possess all the cognitive abilities expected of an adult. Interestingly, however, such a self will typically possess greater cognitive abilities than would be expected of a 9-year-old, especially if tested in ways not obvious to the patient (Orne, 1951; Young, 1940).
Second, although the currently accepted diagnostic criteria require the presentation of two or more “distinct personalities or personality states” to make the diagnosis (American Psychiatric Association, 1987, p. 279), and although the patient’s “primary” personality typically is differentiated and multifaceted, much as any healthy individual would be, the emerging alternate personalities are typically unidimensional caricatures of “selves,” with little independent differentiation. They usually begin to develop into
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differentiated individuals only as they interact with the therapist over time. Indeed, the very boundaries that delineate these particular “selves” become clarified in large part within the therapeutic interaction.
Thus, we begin to see that in the process of diagnosing the disorder there is a double risk—the risk of accepting the myth of the “normal” personality as monolithic, always consistent, and unambivalent, as well as the risk of reifying the clinical metaphors we use to describe and understand the complexity of the self, and treating them as if they were literally true.
The Use and Misuse of Myth and Metaphor
It should now be clearer that the vastly increased number of personalities purportedly manifesting themselves in recent reported cases of MPD raises serious theoretical and clinical questions. Consider a patient who might be seen twice a week for a year or 2 by a therapist who reports “meeting” 100 or more distinct “selves” during the course of this treatment. This would allow the therapist only 2 or 3 min to get to know some of these “selves,” assuming that at least some of them “show up” for treatment on some kind of regular basis. Only by reifying and taking literally the metaphorical structures of a conceptual model of personality in the process of diagnosis and treatment can a therapist identify or conceive of these glimpses as independent “personalities,” rather than as different aspects of a complex and conflicted individual.
Given that no one—the man in the street, patients, or therapists, for that matter—displays a truly consistent personality (and in fact, that if one does, one is likely to be considered at least neurotically rigid, if not pathologically constricted), it is not unusual or surprising for patients to deal with feelings or behaviors that are incongruent with their “ideal selves” by forgetting (or as some would say, repressing), distorting, or rationalizing such affect or behaviors. If the individual has a tendency to dissociate, it is even more likely for him or her to use trance as a coping mechanism (Frankel, 1976) and to report, “This is not something I could have done. It’s simply not me.”
When a patient says that a particular behavior is not something she could have done, the usual approach would be to support the patient in facing and directly experiencing the discordant feelings and behaviors that she is having trouble accepting as her own. On the other hand, however, if the therapist says to the patient, “I want to speak to that part of you which is NOT you,” the patient (particularly a patient who has developed a dissociative defensive style) may then respond, “Yes, what do you want?” and when asked, “Who are you?” may then give the therapist a novel name. At this point, the patient has provided what is accepted by many as clear evidence that she is truly not one self but multiple personalities.
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In this way, the therapist has effectively legitimized and reified for the patient and for the therapist another “person” created from what may well have been an unacceptable recollection, wish, fear, hope, or fantasy. Instead of helping the patient to become aware of and to tolerate previously unacceptable feelings, thoughts, or behaviors, the therapist accepts the metaphor of multiplicity literally, reinforces the patient in “splitting off” material that is difficult to deal with, and postpones to the future the necessary presumed integration of the new “self” that has been brought forth. The use of hypnosis, incidentally, is important to consider here, because clinical evidence suggests that patients with dissociative tendencies also tend to be highly hypnotizable, making them therefore particularly vulnerable to suggestions for reification of metaphorical constructs as “real” (Bliss, 1988; Frankel, 1976).
Having assisted the patient in reifying a metaphorical personality fragment into a separate “self,” the therapist may further reinforce the “reality” of the split by colluding with one of the “personalities” against the others—potentially the most compelling demand characteristic to the patient in this situation. How more convincing can a therapist behave than when agreeing to the patient’s typical request to share a secret with one “personality” and to keep it from the other “selves?” Agreeing to keep the confidence of one self from other selves clearly indicates to the patient that the therapist genuinely believes that the “parts” or “selves” are truly separate and autonomous and, further, that the thoughts, feelings, or behavior of some are genuinely intolerable to the others, or to the “whole” patient.
This approach has serious implications for treatment outcome. Rather than helping the patient to accept thoughts and feelings he feels to be intolerable and giving him the message that the therapist will work with him to understand, accept, and integrate them, the patient is encouraged to blame a different “person” in himself for his distress. In a true sense, the therapist encourages the patient to avoid self-responsibility and validates his shifting blame and control to a different independent, supposedly uncontrollable “self” —much as in earlier times, individuals would literalize the myth by saying, “The Devil made me do it!” “Demon Rum made me do it,” and so on.
Consequently, the classic goal of psychotherapy—that the patient ultimately must be responsible for his or her behavior (see Halleck, 1990) and must come to accept the sometimes conflicted variety of his or her feelings and thoughts—is largely undermined by validating the notion that within the patient are truly different personalities who are autonomous and capable of independent action.
The Use and Misuse of Memories
Having seen how the misuse of myth and metaphor may have contributed to the recent dramatic increase in the incidence of the MPD diagnosis, as
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well as to the increase in the numbers of “personalities” reported in individual cases, it is now important to consider another major diagnostic and treatment issue in this disorder: the uncovering of traumatic memories. As it relates to the often confounded issues of diagnosis and treatment of MPD, as well as to the power of therapist expectations in psychotherapy, the issue of recovering memories of childhood abuse in adulthood deserves special attention.
Abuse in childhood, especially sexual abuse, is currently widely believed to be a causative factor in the development of MPD. It is postulated that patients with this disorder typically first dissociated in response to these intolerable experiences in childhood, when at least some of the "selves" came into existence to protect the "primary" personality from the abuse and from remembering it. Thus, these first dissociated "personalities" remember incidents for which the primary personality allegedly has amnesia (Coons, 1986a; Kluft, 1985a,b). This assumption provides a rationale for diagnosing the disorder by reported history (a rationale that itself provides a syllogistic trap if "forgetting" and "remembering" are both required for the diagnosis!) and implies that the illness can be accurately diagnosed and successfully cured only if the patient remembers the abuse by manifesting the various selves who are the repositories for most of the memories. Once this is accomplished (often by the process of reification that we have discussed earlier), the "selves" are fused into one personality in the next phase of treatment, often with the aid of hypnosis.
Because this process of combining diagnosis with treatment through reification and "remembering" (often with hypnosis) has serious implications for the patient, for the therapist, for significant others in the patient's life, and ultimately for the outcome of the treatment itself, it is well worth considering two relevant theoretical issues with regard to human memory—one relating to empirical research in the area of human recall, especially when "aided" with hypnosis, and the other an important and currently controversial concern in psychoanalytic theory.
First, there is a large body of research evidence that demonstrates that it is not possible to distinguish accurate from confabulated memories that are hypnotically retrieved without independent corroboration, at the same time that the amount of recall of both is significantly increased with hypnosis (Laurence & Perry, 1988; Orne, 1979; Orne, Whitehouse, Dinges, & Orne, 1988; Perry, D'Eon, & Tallant, 1988). Further, people generally, and patients prone to dissociation and trance phenomena especially, tend to fill in gaps in memory with fantasies to render the memories meaningful (Laurence & Perry, 1988; Orne, 1979) and with hypnosis are more likely to have confidence in both real and confabulated memories equally (Sheehan, 1988). These research data call into serious question the acceptance of adult memories of childhood abuse as historically accurate, especially with patients prone to dissociation or with whom hypnosis has been used.
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Second, while some healthy skepticism regarding Freud's retraction of the seduction theory (see Masson, 1984) may have merit in that it has encouraged the serious consideration of children's contemporary abuse allegations, there are serious problems with the current drift toward accepting all abuse memories, especially those "recovered" many years later in adulthood, as literally true. Besides encouraging a superficial reading of the theory itself (see Garcia, 1987a, 1987b), such a posture puts therapists in the untenable position of completely ignoring the role of fantasy in their patients' psychodynamics, as well as the essential distinction between narrative and historical truth in psychotherapy (see Spence, 1982).
The implications of possibly misconstruing reported memories as historically factual are several and serious. First, having "uncovered" memories of abuse that are presumed to have occurred many years in the past, some therapists are focusing their efforts on encouraging patients not only to become aware of the abuse but also to confront the presumed abuser as a necessary step to become whole. This often includes bringing lawsuits against the presumed abuser based exclusively on memories obtained during psychotherapy, usually with hypnosis. It is important that the patient recognize that she is not to blame for what was done to her—a serious problem for victims of all kinds. By the same token, care must be taken to prevent serious miscarriages of justice that may occur if hypnotically elicited memories are introduced in courts of law as "facts."
Second, and perhaps more important for the patient, he or she must not be discouraged from the important therapeutic work of "owning" and taking responsibility for his or her feelings and behaviors in the present. In this context, the uncovering of presumed "memories" of abuse and unthinkingly validating them as veridical truth may reinforce and reify a victim role or "personality" for the patient and encourages the blaming of others for unacceptable thoughts and actions.
Finally, patients have an inalienable right to expect that the therapist is committed to staying grounded in reality, as well as the right to expect that they will be respected and taken seriously. To honor and meet both of these legitimate expectations, the therapist can afford neither to mistake metaphor for reality, nor to become trapped into abandoning a serious interest in the patient's self-reports, whether or not they are in fact historically and literally "true."
Conclusions: The Delusion of Fusion Versus the Demand Characteristic for Self-Responsibility
The conceptual model that underlies MPD is, as we have demonstrated, a radical departure from the generally accepted psychodynamic therapeutic model. The therapeutic problem as it is presented in the multiplicity
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model involves bringing together truly distinct autonomous selves. The very procedure of evaluating a patient for MPD, and for eliciting these "selves," however, may involve the facilitation of the malady itself. Thus, the therapeutic goal of the clinician treating MPD has in large part a function of the belief that it is ultimately necessary to fuse the various "selves" and that before doing so, it is essential for them to first become known to the therapist as separate individuals. We consider it possible that it is a delusion that such fusion is necessary if we believe that the healthy individual has many "selves" in his or her repertoire of inconsistent behaviors and beliefs. Indeed, the problem that appears to be at the root of MPD is a lesion of memory. Understanding the difference between describing behaviors that one may wish in retrospect had never occurred and describing them as if another "person" inside oneself had participated in them depends on understanding such memory lesions and their psychodynamic functions. Without the ability to forget, repress, or dissociate, MPD would not exist.
Thus, rather than viewing MPD as a problem of having multiple selves, the disorder can be thought of as a problem of memory. If it is treated as such, the patient becomes empowered by learning to recall events even if they are very painful. On the other hand, if the patient is treated as unable to control his or her destiny, because some other part of himself or herself is in charge, the patient's feelings of helplessness and victimization are confirmed.
The therapeutic approach of encouraging the patient to bring forth a multitude of selves with the intent of ultimately fusing them into a healthy personality is a dubious strategy reminiscent of the nursery rhyme, "All the King's horses and all the King's men couldn't put Humpty together again," and unfortunately, patients do not necessarily stay fused. Having once been taught that they are not responsible for the feelings and behavior of their other "selves," patients will continue to find in dissociation a tempting escape from any unacceptable stressor. Thus, when the conceptual and metaphorical model of multiple selves is reified and legitimized by the therapist and accepted by the patient, the patient may be virtually untreatable if problems arise in the future.
We see, then, that the therapist's conceptual model may have serious consequences for his or her patient that go well beyond academic or theoretical concerns. The demand characteristics that can result from a conceptual model of the self whose metaphors are reified and taken to be literally true can, in patients capable of dissociation, help to produce the serious clinical condition we call MPD.
On the other hand, using the notion of "parts of the self" can be a useful metaphor if the therapist accepts and communicates to the patient that these presume "parts" in fact represent conflicting feelings, thoughts, or behaviors. The therapist can recognize with the patient that there are problems with distressing memories that the individual wishes to disown,
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rather than reifying the metaphor by "naming" these feelings as different "selves" and facilitating the experience of multiplicity. The demand characteristics that are operative for the therapist concerned with helping the patient to take responsibility for his or her behavior involve the conviction that the patient is one person with a variety of difficult and often painful feelings and experiences and a commitment to the view that the integration of these feelings is possible and necessary to the patient's mental health.
This approach allows the therapist to avoid becoming a coopted party to the intrapersonal conflicts that are involved and to thereby be in a position to empower the patient to accept and work through feelings and behaviors that are difficult or frightening. Dissociative splitting of material that is hard to tolerate, will, of course, occur and may be experienced as alien to the individual. The therapist's task is to help the patient to integrate these feelings, rather than to treat them as if they were independent homunculi.
Hypnosis may be used effectively in this approach, if it is used with the recognition that a metaphor cannot be allowed to be reified and treated as an independent entity. It is helpful to a patient to learn that we are all inconsistent, that our feelings are often puzzling and sometimes disturbing, and that we can learn to tolerate—even perhaps, to enjoy—our inconsistencies and, as best we can, to discover some coherence even in our confusion.
In summary, then, it is important to remember that the notion of the "self" as stable and consistent is a myth. Indeed, our richness as human beings is due to the "multiplicity" of personal styles, roles, feelings, and behaviors of which we are capable. For some individuals, on the other hand, some feelings and behaviors are frightening and may seem to be intolerable. Given problems with memory or dissociative tendencies, these feelings and behaviors may not be readily accessible to conscious memory. In a therapeutic context whose demand characteristics include the belief that the patient is one person with a variety of inconsistent and conflicting feelings and actions, the metaphorical notion that there are "parts" of the self that the patient may be unable or unwilling to acknowledge can be useful, with or without hypnosis, in bringing them into awareness and facilitating self-responsibility and healing.
What we have said about myths, metaphors, and demand characteristics with regard to MPD is perhaps especially dramatic in the context of this very serious malady. The general principles, however, probably hold true for psychotherapy of all kinds with all types of patients. Thus, in a very important sense, the therapist helps to create reality for the patient. The models the therapist chooses for understanding that world and his or her patient, and the ways in which the therapist uses the metaphors generated by those models will in large part determine whether treatment will be successful.
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Acknowledgments. We are grateful to David F. Dinges and Emily Carota Orne for their comments and suggestions for improving this chapter.References
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