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Assessment of Ego Functioning in Multiple Personality Disorder Victor S. Alpher Published online: 10 Jun 2010.

To cite this article: Victor S. Alpher (1991) Assessment of Ego Functioning in Multiple Personality Disorder, Journal of Personality Assessment, 56:3, 373-387, DOI: 10.1207/s15327752jpa5603_1 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5603_1

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JOURNAL OF WRSONALlTY ASSESSMENT, 1991, 56(3), 373-387 Copyright 1991, Lawrence Erlbaum Associates, Inc.

Assessment of Ego Functioning in Multiple Personality Disorder Victor S. Alpher

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Houston, TX

The dissociativedisorder known as multiple personality disorder (MPD)presents a diagnostic challenge to psychological assessment techniques. A case example is presented in which a new self-report, multifactorial measure of ego functioning discriminated distinct profiles for four personalities within one multiple personality organization. Interpretations of characteristics of the prirnary and secondary personalities based on the Bell Object Relations Reality Testing Inventory (BOMTI) are presented. The relationship between these findings and other approaches to psychological testing for dissociation and MPD are discussed. It is suggested that this approach will facilitate the clinical assessment of suspected MPD subjects and contribute to affording appropriate treatment to this population.

Multiple personality disorder (MPD) involves a severe disturbance in the integrative functions of personality. It is well-recognized that this disorder involves a catastrophicreaction to early childhood trauma, frequently involving emotional and sexual abuse (Bliss, 1986; Kluft, 1985; Putnam, 1989).The clinical syndrome was described by early researchers in psychology and neurology (e.g., Prince, 1905/1913, 1906). However, the defining characteristics of MPD are still controversial. For example, the diagnostic nomenclature changed between the two recent editions of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980, 1987). The most recent formulation (American Psychiatric Association, 1987) involves these two criteria: (a) the existence within the person of two or more distinct personalities or personality states (each with its own rtelatively enduring pattern of perceiving, relating to, and thinking about the environment and self), and (b) at least two of these personalities or personality states recurrently take full control of the person's behavior (American Psychiatric Association, 1987,

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p. 272). It is apparent that this syndrome falls within the domain of personality assessment. This is the focus of the case study presented here. MPD, however, is now becoming recognized as a more prevalent disorder than once thought and is neither iatrogenic nor an artifact of hypnotic techniques (American Psychiatric Association, 1987). Estimates of prevalence are difficult to obtain and verify-Ross (1989) suggested similar prevalence to other major psychiatric syndromes (e.g., 1:50 to 1:500), with greater prevalance for the more benign forms of dissociative experience. There is a dearth of methodologically sophisticated findings, complicated by problems of consensus on diagnostic criteria. Unfortunately, the average number of years before a definitive diagnosis is made is nearly 7-with often three or four prior diagnoses (Putnam, Guroff, Silberman, Barban, 6r Post, 1986). However, unlike some diagnostic statements, the diagnosis of MPD has important practical treatment implications (see Steele, 1989). In addition to this prognostic issue, the outcome picture is much more favorable once the diagnosis is established, considering current thinking about the response of MPD patients to appropriately planned and executed treatment (e.g., Kluft, 1987; Putnam, 1989; Reid, 1989). Thus, advances in psychological assessment of MPD are likely to have important clinical value. Clear clinical manifestations of MPD are often quite striking and dramatic. Amnesia may figure in such presentations, as when the MPD "host" or "primary" personality claims no knowledge of some flagrant aggressive or sexual act. Such acts often bring the MPD individual to the attention of legal authorities or the psychiatric establishment. Recently, disturbance in early childhood memory was investigated by Schacter, Kihlstrom, Kihlstrom, and Berren (1989). This experimental approach documented autobiographical memory deficit for memories prior to the age of 10 in an MPD subject compared to normal controls. However, such deficits may not be unique to MPD. Other investigators have stressed the assessment of ego defense mechanisms, especially dissociation, in the differential diagnosis of MPD. The definition and formulation of ego defenses has advanced considerably from Anna Freud's (1936) classic work. Vaillant (1977) developed the concept of a hierarchy of defenses, ranging fram low-level "psychotic" mechanisms, such as delusional projection and distortion, to "mature" mechanisms, such as humor and sublimation. Vaillant considered dissociation to be a "neurotic" defense, at the level just below mature mechanisms, and synonomous with "neurotic denial," the "temporary but drastic modification of one's character or of one's sense of ~ersonal identity to avoid emotional distress" (p. 385). Cooper, Perry, and Arnow (1988) reported on the application of the defense hierarchy to the study of defensive functioning in the Rorschach. Yet, the presence of dissociation or neurotic denial on projective testing may not be a highly reliable discriminator of MPD. Clinical dissociation, however, tends to involve a complex phenomenology with

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behavior, affect, sensation, and knowledge variously affected (Braun, 1988a, 198813); its manifestations range on a continuum from the relatively mild "neurotic denial" to severe, catastrophic alterations in personality organization, such as MPD. However, neither the cognitive-experimental ~aradigmnor the defense hierarchy provide specific information for the diagnosis of MPD. The main ~roblem for the clinical assessment of suspected MPD is the demonstration of a distinct disturbance in the integrative functions of ~ e r s o n a l i organization, t~ leading to the occurrence of two or more distinct personalities within the same individ~~al. Before describing the present approach to this problem in detail, past efforts in the psychological assessment of MPD are briefly reviewed here. Some clinical investigators have used the Minnesota bdultiphasic Personallity Inventory (MMPI; e.g., Coons, 1986; Coons, Bowman, & Milstein, 1988; Coons & Sterne, 1986). Coons (1984) examined the literature on assessment: of MPD and concluded that most psychological test findings failed to differentiate MPD from borderline personality disorder. An alternative approach is to use several performance tests, such as the Wechsler Adult Intelligence Scale, as well as psychophysiological and neurophysiological ~roceduresto try to distinguish the behavior of primary and secondary personalities within the same individual. Some investigators have reported success with the method (e.g., Ludwig, Brandsma, Wilbur, Bendfeldt, & Jameson, 1972).However, such studies are extremely time consuming and do not necessarily yield personality data that would actually be clinically useful. More recent techniques, such as positive emission tomography, are promising in demonstrating neurophysiological correlates. Yet, as in the case of magnetic resonance imaging findings in contrast to a functional neuropsychological assessment, such data do not provide the kind of informlation that can be used directly for planning effective psychological treatment. Projective tests have also been used to study the perceptual-cognitive and psychodynamic properties of primary and secondary personalities. Wagner and Heise (1974), for example, described "simplification" tendencies in the Rorschach protocols of three multiple personality patients-in other words, the protocols of secondary personalities tended to be less complex and more affectively driven than primary personalities. However, I he kind of counterbalanced studies that could rule out the artifacts of fatigue, creativity, practice, and expectancy effects have not been done. The basic question is: Would the primary ~ e r s o n a l i exhibit t~ "simplification" if tested subsequent to some of the alternate personalities? An alternative approach to projective assessment with the Rorschach was presented by Lovitt and Lefkof (1985). Three MPD patients were assessed using the administration and scoring procedures of Exner's (1974, 1978) Comprehensive System. Patients were requested to identify a secondary personality for assessment. Through focusing on the interpretation of the Rorschach Structural

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Summary rather than single indices (i.e., a configurational rather than a sign approach; see Weiner, 1977), Lovitt and Lefkof reported that host and secondary personalities across all subjects were "clearly ambitent" (for the ambitent, the ratio of the number of human movement determinants [MI to a weighted sum of pure color [C], form-dominated color [FC] and color-dominated [Cfl determinants differs by no more than 1; see p. 291). The ambitent pattern is interpreted as suggesting inconsistency in dealing with intrapsychic and external stress; this vacillation is associated with impaired learning from experience (Exner, 1978). In addition, Lovitt and Lefkof also found that each patient's host or primary personality possessed appropriate and intact reality testing operations. Secondary personalities, however, tended to show diminished reality testing, although there was considerable variability. Also, the sequence of administration was not reported for secondaries so that covariation of reality testing indices (overall form quality [X+%I and pure form response quality [F+%]) with sequence cannot be evaluated. Lovitt and Lefkof concluded, nonetheless, that secondaries tended to evidence failure to integrate "less socialized" and "less acceptable" behaviors (p. 294) into the main structure of personality. Yet, secondaries were not consistently impaired across the Rorschach variables examined. For example, the ratio for one secondary on the ratio of formdominated to color-dominated color determinants (FC : CF C) for Patient B was the only color ratio that showed consistent form domination. The Egocentricity Index, a ratio of weighted sum of reflections and pair responses to the total [2]/R) for Patient C was in the "normal" range number of responses (3r (.30-.40; see Exner, 1978, pp* 130-134) for one secondary. The other secondary and the main personality showed values above this range. These findings suggest an alternative interpretation-that host and secondary personalities may show strengths and weaknesses in their functioning. Such strengths and weaknesses can have significant treatment implications (Lovitt, 1987). The results of the various studies of psychol~gicalassessment of MPD suggest the need for further research to develop methods that provide data relevant to different patterns of perceiving, relating to and thinking about the environment and self. Such data will contribute both to diagnosis and effective treatment of

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MPD. This case study describes the application of a multifactorial assessment of ego functioning, the Bell Object Relations Reality Testing Inventory (BORRTI), to the diagnosis of a suspected MPD subject. The disturbance in the integrative functions of personality lends itself to conceptualization in terms of the broad domain of ego functions (e.g., Bellak, Hurvich, & Gediman, 1973). This self-report method is efficient and provides multifactorial ego-state profiles for each of four personalities in this subject. In this way, it has the ~otentialto contribute substantially to tha usefulness of psychological assessment consultation in the diagnosis of W D in clinical settings.

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METHOD

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Subject Case information is presented in accordance with ~roceduresfor disguising identity recommended by Clifft (1986). Some background history is presented from the clinical interview here to ~rovidea context for evaluating the usefulness of the recommended clinical assessment technique; such information is not definitive, and much is typical of a variety of MPD patients. It is not unusual for some of the amnesia that some personalities have for selected alternates to be reduced at the time of a hospital admission; this increased awareness (called co-consciolmess) is often an antecedent factor in the admission. At the time of this patient's hospitalization, the primary and three secondary personalities had co-consciousness. Most of the interview information is reported from the primary, Corinne. This patient, Corinne, is 27 years old. Depending on which alternate personality is present, mood and affect range from depressed and constricted to euth~micwith normal range and variation. When hearing distressed patients on the unit, the primary personality, Corinne, shows a physiological reaction and empathic dysphoria-one secondary ~ e r s o n a l i tCeleste, ~, appears nonplussed. Sensorium overall is intact. One secondary, Celeste, claims to be an adolescent. Thought processes vary from highly circumstantial in the case of Corinne, to clear, coherent, and goal directed in the case of Celeste. Marked incongruities of thought content and affect are not noted except for the constricted affect just reported. Another secondary, Paulette, is silent. Information was obtained during the course of interviewing the main persjonality, Corinne, and two secondary personalities, Gwen and Celeste. The other secondary, Paulette, was silent but conscious during the interviews. Gwen reported that Paulette could not talk, but because they communicated empathically she could provide information for her. 'When other alternates spoke to the examiner, Corinne was not conscious; when she returned to consciousness, she appeared bewildered and confused. The patient was born in Alabama and lived on a farm there until she went to college. Her early childhood appears to have been unremarkable. When she was about 4 years old, a friend of the family, who was just released from jail on probation, came to stay with her family for about 1 year. She says that during this time he tried to approach her female friend sexually, but that girl resisted. Then, he approached the patient and repeatedly abused her sexually during this period. The secondary, Paulette, was subjected to most of the actual abuse, although Gwen "allowed" Corinne to experience one incident. When she entered primary school, Gwen assumed responsibility for coming out to begin dealing with some of the conflict with peers at school. In a later interview with Celeste, it appeared she may have been responsible for actual

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aggressive action in confrontation situations. For example, when she was in high school, Celeste once assaulted a boy who touched her at school. Corinne was left to attempt to talk herself out of expulsion. Gwen was apparently responsible for getting Corinne into difficult "intimate situations." She would disappear just at the most precarious moment, leaving Corinne bewildered and confused. Corinne was active in terms of dating, and these events occurred regularly. Thus, in the interviews, it was revealed that Gwen was responsible for getting Corinne into difficult sexual situations, whereas Celeste would steer her into problematic aggressive situations. Corinne dropped out of college when a teacher attempted to seduce her, after which she attempted suicide. She attempted suicide again after the sudden death of one of her closest childhood friends. Within weeks of the friend's death, she was sexually assaulted by a man who was visiting her town from a nearby large city. She decided not to disclose the assault. That fall, she returned to a local technical college and was introduced to the man she eventually married. She and the man dated about 4 years. She graduated and then helped put him through vocational school. However, their marriage has been relatively stormy, with occasional threats of divorce. She and her husband moved far from her childhood home, beginning what evidently was a relatively quiescent period. Regarding marriage, Corinne said that initially she felt an absence of other personalities. It was the increase in marital conflict that lead to the reappearance of Celeste. About 2 years prior to the hospital admission, Corinne stated that she became depressed, withdrawn, frigid, and dysfunctional in her domestic responsibilities. Corinne decided to commit suicide, eventually under the influence of Celeste; she ingested several bottles of prescription and proprietary medicines. Since then, she has upheld contracts with her physician not to commit or attempt to commit suicide. At the time of the interviews, the speaking alternates and Corinne all agreed that they were not suicidal for the first time; Gwen stated also that Paulette, the silent alternate, was not suicidal at that time. The present hospitalization was initiated to provide a setting for integrative therapy with the three secondaries.

Rating Materials Each personality completed the BORRTI (Bell, 1989; Bell, Billington, & Becker, 1985,1986).The BORRTI is a 90-item, self-report multifactorial inventory of ego functioning with a true-false format. Two general domains are assessed with this instrument-object relations and reality testing. The ratings are made for the subject's most recent experience. Bell and his colleagues developed the BORRTI in response to the need for an empirically based assessment instrument that reflected the broad construct of

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ego functioning (see especially Bellak et al., 1973). During the factor-analytic stage, the two general domains, object relations functioning and reality testing, were identified. The four Object Relations scales of the BORRTI are: Alienation, Insecure Attachment, Egocentricity, and Social Incompetence. Alienation involves basic trust and gratification in relationships as well as interpersonal instability, anger, and withdrawal tendencies. Insecure Attachment measures difficulties with separations, losses, and ~otential abandonment in relationships as well as maladaptive patterns evoked by these issues including jealousy, guilt, and vigilance for signs of threat to relationships. Egocentricity suggests mistrust of the motivation of others as well as tendencies to relate to others primarily in terms of one's own aims; a view that others are to be manipulated for such purpolses accompanies higher elevations. Social lncornpetence suggests shyness, nervousness, and uncertainty about how to interact with others, make friends, and relate to the opposite sex; relationships seem confusing and unmanageable, which may cause anxiety relieved by withdrawal, and low scores suggest a high internal sense or belief in one's social competence and mastery. The BORRTI has three Reality Testing scales: Reality Distortion, Uncertainty of Perception, and Hallucinations and Delusions. Reality Distortion suggests the presence of delusions of influence, thought withdrawal, thought broadcasting, and various depressive and grandiose belxefs. Uncertainty of Perception is related to a self-awarenessof a tenous grasp on reality, doubts about ithe perception of internal and external events, confusion about one's own feelings and the feelings and behavior of others, and extreme ambivalence; some degree of ego functioning is retained and accounts for concern about these experiences. Hallucinations and Delusions involves severe reality breaks, with endorsement of a variety of hallucinatory experiences and paranoid delusions. Some examples of BORRTI items include "I have someone with whom I c:an share my inner-most feelings and who shares such feelings with me" (Object Relations), "I am usually able to size up a new situation quickly" (Reality Testing), "I pay so much attention to my own feelings that I may ignore tthe feelings of others" (Object Relations), and "Sometimes I have dreams so vivid that when I wake up it seems like they really happenedn (Reality Testing). Items may load on more than one scale with different factor weights. Several validity studies have demonstrated the usefulness of the B O W in making discriminations between personality disorder groups and other clinical syndromes. Information on scale development is provided in Bell et al. (1955, 1986). The instrument, along with subsequent research on its reliability and validity, has also been reviewed critically by Alpher (11990).Factor structure, independence, and replicability are well within the usual expectations for an instrument of this nature; an additional strength is the conceptual-empirical method used in its development (cf. Loevinger, 1957).

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Procedure Selection of the secondary personalities for assessment was conducted in consultation with the patient's attending psychiatrist. This was done to facilitate assessment of secondaries that would be involved in the therapeutic work of this particular hospitalization and to maximize the clinical relevance of the assessment to treatment goals. Each personality completed the BORRTI, along with other instruments, in separate testing sessions. The sequential order of administration was: Corinne, Gwen, Paulette, and Celeste. The host personality also completed other testing instruments, including the MMPI, Rorschach, and Thematic Apperception Test. Access to the secondary personalities was easily established after a clinical interview with the main personality. Verbal contact was made through a request to speak with a particular secondary. No hypnotic induction or other specialized technique was necessary. In the case of Paulette, who was mute at the time of assessment, contact was mediated by the secondary Gwen. Based on an understanding of the history of each secondary and overall organization of the system, there appeared no a priori reason to suspect tendentious or misleading mediation with that particular dyad. In addition, a variety of clinical observations of facial affect, muscle tonus, body posture, prosody of speech, and other features unique to this patient was consistent with the observations of professional and clinical staff who were familiar with the behavior of the main and secondary personalities.

Data Analysis and Interpretation BORRTI data can be scored by hand or analyzed through a computer program.1 Computer scoring provides exact computation of factor scores; these scores are compared with nonpathological norms to generate T-scores and graphic profiles. The nonpathological normative sample (N = 934) consisted of 60 community-active adults (members of the board of directors of a social service agency and a business organization; age range from 19 to 79 years old ;M = 38.47). The remainder of the group consisted of students (age range from 18 to 48 years old; M = 25.86). Tentative interpretive statements for high-point codes are included in Bell (1989); these statements are derived from extensive research with the BORRTI in diverse clinical samples validated with current research-based diagnostic procedures (see Bell et al., 1985, 1980). Cutoffs of 33% (T = 60) for six of the scales and 15% for the Hallucinations and Delusions scale (T = 65) have been recommended as criteria for object 'Scoring materials are available from Morris Bell, PhD (senior author of the test), West Haven VA Medical Center, Psychology Service 116B, West Haven, CT 06516.

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relations and reality testing pathology and are reported to maximize discrimination of clinical syndromes and personality disorders in validity studies of the BORRTI (see Alpher, 1990).

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RESULTS Multidimensional analysis of ego functioning showed substantial variation among the host and three secondary personalities (see Figure 1). Corinne's ratings suggested the greatest amount of ego strength, with no pathological elevations on Object Relations and Reality Testing ego function factors. However, Gwen and Celeste both showed Object Relations patterns suggestive of bitter "turning against the other" with a profound mistrust of other's motivations and the belief that interpersonal gratifications can only occur through manipulation, coercion, and demandingness at the expense of the other (significant elevations on Alienation and Egocentricity).Rather than suggesting T-SCORE

FIGURE 1 Profiles for four personalities Corinne, Gwen, Paulette, and Celeste on the Bell Object Relations Reality Testing Inventory.

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painfulness of unmet psychic longings, there is more a sense of the protest and retaliation against the other for deprivations. The pattern suggests efforts at defending a sense of self from profound feelings of helplessness through grandiosity and egocentricity. Celeste experiences a substantially greater degree of the sense of instability and lack of relationship gratification, feeling even less sense of connection and belonging than does Gwen. Anger and hostile withdrawal would characterize both. In addition, each perceive themselves as highly competent in social relations (low Social Incompetence), able to "con" others (i.e., "smooth operators" who can easily fool and manipulate others). Reality Testing differs between Gwen and Celeste. Although neither of them indicated that they have any doubts about their perceptions of internal and external reality, Celeste showed the presence of active delusional beliefs and hallucinatory experiences (significant elevations on Reality Distortion and Hallucinations and Delusions). This includes delusions of influence (being controlled externally), thought withdrawal, thought broadcasting, and paranoid beliefs of being watched, plotted against, condemned, and victimized. She may harbor grandiose and depressive beliefs, become disoriented, and have hallucinatory experiences. She is likely to distort the meaning of internal experience leading to bizarre somatic concerns, confusion between waking and dream states, experiences of unreality, and difficulty understanding her own feelings and the feelings and behavior of others. Paranoid projection of impulses, wishes, fears, and consequent feelings of vulnerability and helplessness are suggested. Gwen cooperated in the assessment by mediating and providing ratings for the secondary Paulette. These ratings showed Paulette to be the most actively and pervasively disturbed, the only rater who substantially elevated all Object Relations and Reality Testing factor scores. In addition to the psychopathology suggested for Gwen and Celeste, she also showed keen sense of doubt about her perceptions of internal and external reality and severe difficulties with attachment and social competence. She is quite sensitive to rejection and easily hurt by others. Desperate longings for closeness are indicated; separations, losses, and loneliness are poorly tolerated. Worry, guilt, jealousy, and anxiety pervade her concerns about relationships and about being liked and accepted by others. She is probably vigilant for signs of ~otentialabandonment by others. Her selfexperience is of social incompetence-relationships appear bewildering and unpredictable and may cause anxiety relieved by avoidance and escape from the interpersonal field.

DISCUSSION This case study demonstrates the usefulness of a self-report measure of ego functioning in the discrimination of distinct personality states in MPD. The findings in the case of Corinne, Gwen, Paulette, and Celeste suggest the internal

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organization of these states involves the mobilization of different ego functions within each. Although narcissistic, egocentric, and antisocial object relations characteristics and traits were reported by Gwen anid Celeste, these two personalities nonetheless differed in the reality testing domain. These characteristics were consistent with interview data, especially in terms of how they related to the primary personality and how they actled out conflicts over sexuality and aggression. Frequently, aspects of the self that are split off in MPD patients are just those characteristics that might be identified with an abuser; these secondary personalities, especially in this case with Celeste, may relate to the primary in a paradoxically abusive manner. Paulette, subjected to the repeated sexual and ~hysicalabuse, was blatantly psychotic and demonstrated disturbance on all Reality Testing and Object Relations scales. Celeste, Gwen, and Paulette appear to assume most of the ego pathology measured by the BORRTI, which seems to be associated with a protective function, but Corinne elevated no scale beyond the pathological criteria (see Figure 1). Also, although Paulette's ratings were not obtained last in the sequence, she rated herself the most disturbed, which suggests that administration order effects do not explain progressively increasing pathology. It appeared that there was no distortion in the self-reports of Paulette mediated by Gwen. It must be acknowledged that some degree of clinical judgment and familiarity with the individual is needed when such modified procedures are used in assessment. These factors are implicit in the usual assessment process, even when more formal indices of test-taking attitudes are available (e.g., Greene, 1989). In this context, it is useful to note that the BORRTI has been shown to be relatively free of social desirability resplonse bias. Main and secondary personalities manifest a variety of pathological processes evidenced in the Rorschach Structural Summary (Lovitt & Lefkof; 1985). The clinical experience of the author suggests that secondaries identified by the treating clinician as important personae to a particular phase of treatment are typically well-motivated and eager to have an opportunity to be involved in the assessment process. The finding of relatively intact reality functioning in the host personality is consistent with the Rorschach-based findings of Lovitt and Lefkof (1985) with three MPD patients. In addition, Rorschach data using the Comprehensive System showed the main personality to be an ambitent, with relatively intact reality testing (five Populars, F+ % = .80) except under affective stimulation (X+% = .57; more unusual than minus poor form responses). The latter finding is probably interpretable as a function of acme distress; Lovitt and Lefkofs two adults were outpatients. This provides he~teromethodevidence, albeit with a small group of individuals, for the proposition that the defensive processes seen in dissociative disorder patients function to maintain an effective, though maladaptive, core of ego function. Another tentative hypothesis is that the BORRTI not only allows the differentiation of different ego organizations within the MPD individual, but also may provide preliminary suggestions about

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dynamic issues (e.g., narcissitic and antisocial trends) as well as areas of strength and weakness in ego functioning that will be important when planning treatment. BORRTI data could strengthen and refine treatment recommendations based on clustering of Rorschach variables. Lovitt (1987), for example, identified Structural Summary variables related to the following five personality processes with treatment implications: conflict and anxiety, pathological internal life, disrupted ideational resources, poorly controlled discharge, and lack of insight. BORRTI factors are relevant, although certainly nonredundant with respect to these categories, and tap many of the more interpersonal and phenomenological dimensions mediating behavior and environmental response. Further research into these relationships would seem warranted both for dissociative disorder patients and other diagnostic groups. The BORRTI offers several advantages over other self-report personality measures for the purpose of differential diagnosis of MPD. First, the item content of the BORRTI involves aspects of personality functioning for which primary and secondary personalities are likely to have relevant experiences. The item content of other inventories, which are developed to discriminate criterion groups, may omit some dimensions of ego functioning (e.g., the Ego Strength subscale of the MMPI has produced conflicting research findings, possibly due to constraints on item content during the selection process). Instead, the BORRTI was developed to assess the domain of ego functioning; its utility in discriminating criterion groups was assessed later in the research program, Second, the BORRTI is also likely to provide treatment-relevant information for personality integration specific to MPD. Reduction of specific areas of ego dysfunction could be an important goal of a given phase of treatment for one or mare secondaries. It could be speculated that the main personality would show some ego dysfunction during the course of effective treatment and integration of personalities. The BORRTI offers some advantage over projective techniques in terms of efficiency for this kind of periodic reassessment and reevaluation; this does not diminish the clinical richness of such data used in conjunction with projective techniques. Symptom inventories and adjective check lists do not necessarily provide accurate samples of the types of information discussed here. However, they may nonetheless provide some indices of clinical distvrbance useful for treatment-outcome research. Third, because the BORRTI has shown unique characteristics for discriminating borderline from other forms of personality psychopathology (see Bell, Billington, Cicchetti, & Gibbons, 1988), the finding that not all personalities within the MPD patient reported here elevated the most discriminating scale (Alienation) may be diagnostically significant for differentiating MPD patients from borderline personality disorder individuals. Finally, note that the discrimination of MPD from schizophrenia is another potential benefit from this approach to assessment. The voices of alternate personalities, often heard by primary ~ersonalitiesin MPD, can easily be

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mistaken for those of schizophrenia-many MPD patients are found to have prior diagnoses of psychotic disorders (Putnam et al., 1986; see also Kendler, Spitzer, & Williams, 1989). However, not only is it important to demonstrate that the MPD "voices" can conduct discourse with the clinician (Rathburn & Rustagi, 1990)-not typical in psychotic disorders-but also it is necessary to demonstrate that the voices represent coherent, organized, and distinct psychological factors in the personality organization that can "take over" behavior. Administration of the BORRTI contributes data supporting such a critical distinction. The findings reported here seem to support exploration of the BORRTI in a psychological test battery for the clinical assessment of MPD. In addition to generating information useful for the diagnosis, the BORIXTI can also efficiently produce data about the secondary personalities that aire revealed or formed during the course of integrative treatment (see, e.g., Braun, 1986, 1988a, 1988b; Steele, 1989). The BORRTI may be useful in describing the ego functioning of the "integrated" personality and provide information for planning further ego-develalping (see, e.g., Blanck & Blanck, 1974) treatment interventions for the former MPD individual. Clinical use of the BORRTI for such diagnostic purposes requires experience with MPD individuals. There is no need, however, for hypnotic induction or other special procedures for the purpose of collecting self-ratings with this instrument. Use of the BORRTI norms is recommended to produce interpretive statements for alternate personalities. On the other hand, diagnosis of clinical disorders for any primary or alternate on the basis of BORRTI data is not recommended and, in fact, is inconsistent with the purpose to which the instrument is put in this special application. The use of the BORRTI recommended here is to apply the test as a method of making inferences (Cronbach & Meehl, 1955) for specific clinical functions of psychcvlogical testing outlined by Meehl(1973):formal diagnosis, prognosis, and personality assessment. It seems likely that the BORRTI may contribute substantially and efficiently to all three task domains. It is hoped that this article will encourage other investigators to explore the contributions of this method to the assessment of individuals with characteristics of multiple personality organization.

ACKNOWLEDGMENTS Thanks are expressed to Frank Chesky, John Galloway, Claudia Dick and staff of Belle Park Hospital (Houston, TX), Gerard Connors (Research Institute on Alcoholism, Buffalo, NY), Steve Benson (Marathon Health Care Facilities, Wausau, WI), Morris Bell (West Haven VA Medical Center, West Haven, CT, and Yale University), and Les Wolf (JetSetters/Stats Unlimited, Houston, TX). Anonymous reviewers provided helpful comments on an earlier draft of this article.

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Victor S. Alpher P.O. Box 300141 Houston, TX 77230-0141 Received May 29, 1990