GOALS AND METHODS OF DID THERAPY

When I first began experiencing significant symptoms from DID, I was really sure I "needed therapy". I wasn’t quite sure exactly what for, but I knew if anyone ever needed "professional help" I definitely qualified.

After a while, however, I began to have questions about what I was trying to achieve in the therapy, and just how we were going to get there. As it turned out (SHOCK!), I was seeing a therapist who didn’t actually know the answers to those questions either. Fortunately, after some time, and just when I was getting ready to give up because I didn’t see the point, I found a therapist who had expertise in the treatment of DID, and I began to learn something about the goals and methods.

Since then, I have changed therapists once more, but to a person who also had extensive DID expertise, and I have spent a great deal of time in medical libraries reading everything I could find on the subject. (I have more than one diagnosis, and one of the others is- can you guess- OCD). Based on my own experiences, reading several of the most widely accepted clinical texts, and several dozen articles on DID therapy, I have tried to summarize the general consensus among clinicians who treat patients for DID as to the goals and methods.

The main references I used can be found at the end of the article. One other comment I’d like to make that I hope may help a few people who might otherwise be ready to stop right here read further: speaking for myself, if I even try to type the "I" word (that would be integration), parts inside of me say very loud and clear "don’t you even DREAM of that", so I too know how that may not feel like an option for some people. However, there are approaches in use that are not based on that, and for the other methods, it may be helpful to at least see the ideas underlying the approach.

There are only two fundamental, overriding goals of any DID therapy: first; to reduce the patient’s suffering, and second; to restore the patient to a high level of functioning. Everything else is only important in whether it contributes to these goals. This is helpful to keep in mind, since some of therapy used in treating DID may be very painful to experience, and may also leave the patient feeling worse and less functional for a period of time. It’s only our willingness to trust and risk that this is the path to those goals that allow any of us to continue with therapy. (Some of us may be crazy, but we’re not that crazy).

Just being able to focus on those two goals helped me somewhat. There was another thing I came upon in my reading that made it possible to totally commit to the long and painful therapy process. This was a set of principles for therapists undertaking the treatment of someone in DID. It made me feel as if there was some understanding of what happened to us and what it feels like. This list of principles evolved from an article first published in 1971 on Therapy of Multiple Personality, that has since been revised and updated by several others. The principles are:

1. DID is usually created by abuse and violence within the family which is a violation of customs and laws, and a major breaking of the person’s boundaries.
Treatment must be done with a secure treatment frame and firm, consistent boundaries.

2. In most patients, unwanted and unwelcome experiences were imposed on a child who had no choice but to endure them. The person may have little sense of mastery or control. Therefore, there must be a focus on mastery and the patient’s active participation in the treatment process.

3. DID is a condition of involuntariness. People who suffer from it did not choose to be abused and their symptoms are beyond their control. Therefore, the therapy must be based on a strong therapeutic alliance, and efforts to establish this must be undertaken on a regular basis throughout the entire treatment process.

4. DID is a condition in which trauma and feelings have been buried and sequestered away. Therefore, what has been hidden must be uncovered, and buried feelings must be experienced.

5. There is a condition of perceived separateness and conflict among alters. Therapy must emphasize their collaboration, cooperation, empathy, and identification with one another.

6. DID is a condition of auto-hypnotic alternative realities. (In fact, Multiple Reality Disorder has been seriously proposed as a better name than DID). The therapist’s communications must be clear and straight, with no room for confusing or changing communication.

7. DID develops in an environment where important people in the person’s life behaved in a very inconsistent way. The therapist must treat all of the alters fairly, consistently, and with equal respect. It is very important to not "play favorites".

8. People with DID have had their sense of security, self-esteem and hope for the future shattered. The therapy must make efforts to restore morale and encourage realistic hopes.

9. DID stems from overwhelming experiences. Pacing of the therapy must be done so that the intensity and pain is not so extreme that the patient de-compensates.

10. DID usually results from the irresponsibility of others. The therapist must be very responsible, and also hold the patient and all alters to a high standard of responsibility.

11. Most people with DID have come from a situation where people who could have protected a child did nothing. The therapist must be able to take a warm, more affective stance towards the patient. Being clinically neutral and bland will probably feel uncaring and rejecting.

12. People with DID have many distortions of reality and cognitive errors. The therapy must address these and attempt to correct them.

These principles apply regardless of the specific approach or techniques used by a particular therapist. In addition to these principles, and the two broad goals described at the beginning, there are different specific goals DID therapy can have. Different patients and different therapists have different preferences among these goals, and most practitioners feel strongly that the patient’s wishes should be respected and followed. The goals determine the approach. Some of these approaches have been shown in clinical research studies to lead to a significant improvement in symptoms and functioning. A couple of them, which are still in use by some therapists, have not. Although these are not considered effective ways to treat DID by almost anyone with experience and knowledge in the field, some of us encounter therapists who still use them, so they will be described briefly.

The first comes from the belief some therapist’s have that DID is either not clinically "real" or that it is not important to address in therapy. Studies on over 250 patients evaluated over 18 years demonstrated that only 3% of people diagnosed with DID who were in therapy where it was not addressed, improved. In that same group, 81% who received DID-based therapy did improve significantly.

In another study, done in a state hospital setting, where therapy was only once per week, and usually conducted by inexperienced residents, but the treatment was based on specifically approaching DID, and where the residents were supervised by an attending with DID expertise, over two-thirds of the patients improved significantly. To date, there has not been a single scientifically-valid published study that shows that a group of patients who meet the criteria for the diagnosis of DID, treated with therapy that does not involve any acknowledgment of the DID, show any clinical improvement.

The second unproven stance, that is probably at least partly a product of managed care and a shrinking of the resources for mental health, involves focusing totally on improving the patient’s functioning, without addressing the underlying issues of DID. Therapists doing this do not necessarily discount the DID or it’s importance, but because of insurance reasons, or, in some cases, their own personal time restraints, may work on only very modest goals in treatment. While function will definitely improve initially with any competent therapy, it has not been demonstrated that this improvement persists for any significant length of time.

This leaves the two broad schools of thought on what is the best goal to pursue in the treatment of DID. The first is sometimes described with the term Personality-focused". This approach does not see multiple personality as the problem, but rather the conflicts among alters and their inability to work together. Treatment is therefore focused around resolving specific issues different alters have, and achieving specific ways they can collaborate successfully. This specifically considers recovery to be complete in a person with multiple personalities. There have been studies showing that people who have successfully completed this therapy have significantly reduced symptoms and are a much- improved functional level.

The other school, in terms of the goal, is, of course, the one that sees integration of the alters into one blended personality as the desired end-point. The personalities are not eliminated, but are combined so that the person incorporates all of them, but not as separate parts. The difference between these two approaches becomes important mostly near the end of therapy, and at certain points along the way when conflicts with alters must be addressed. Otherwise, however, most of the techniques used in DID treatment apply in either situation.

These techniques are the final thing to be described. These are therapeutic steps that most DID experts consider essential to recovery. About ten authors have written extensive descriptions of their summary of what these steps are and how to carry them out. There is some variation from one to another. However, several authors have combined and summarized the techniques from each into a single list, and described below is my own distillation of these summaries.

With any psychological or psychiatric treatment method, there is always a great deal of variation from one individual to another, and from one therapist to another, and the presence of other disorders as well as DID, the history of past treatments, the issue of medications, hospitals, the patient’s life situation and other factors all affect the exact way in which therapy is done. The list of steps below is not meant as the guide to doing DID therapy, and most certainly is not a "check-list" of what ought to be happening with you right now. I mention this, because at one point (well, actually, almost all the time) I will read something and go to my session and tearfully ask why my therapist isn’t doing it with me, and doesn’t he like me, and am I not worth it, and I’m never going to get better, am I, and………

So, this is a fairly general outline. However, it still incorporates the basic way in which it is agreed DID treatment should tend to proceed.

TREATMENT TECHNIQUES IN DID

1. Establishing the therapy relationship, making the diagnosis, and developing trust.

First and foremost, the patient needs to develop a sense of trust and safety. There should be mutual agreement that both patient and therapist are choosing to try the therapy. The therapist should explain enough of the treatment plan to give the patient a sense of realistic hope. If it has not already been done, the therapist and patient need to work together so that they both agree on the diagnosis.

2. Initial Stabilization and Agreements

Besides the usual agreements about the time and frequency of the sessions, and the clarification of what both the patient and therapist are comfortable with (for instance, the therapist establishing that s/he does not plan to answer personal questions), there is also the major issue of safety. (I want to remind any readers here that I am a patient and have confrontations, disagreements and other tensions over this issue with my therapist. I am not one of "them" taking sides).

Few, if any therapists will be willing to work with a patient they feel is reasonably likely to hurt themself, or someone else after leaving a session. Thus the therapist is going to insist on some assurance of safety. Most commonly, this involves a "safety contract". There actually is a standard safety contract for people with DID that was developed for the American Psychiatric Association’s course on the treatment of MPD. All of the authors emphasize how extremely specific and concrete the contract must be, covering all loopholes, and all alters. There should also be some understanding about the consequences of the patient making and not keeping a contract. It would be at this time that any issues involving medication, additional diagnoses, and hospitalization would be discussed.

3. Preliminary Interventions

The major work in this step involves the therapist communicating with the most readily reached personalities, working on controlling symptoms, resolving the immediate conflicts among alters, and managing the intense difficult feelings that arise. These are primarily punishing alters, and shame. The patient should be reassured that they are not shameful, and on minor issues where shame occurs, it can be discussed rationally to try to present an alternative. Punishing or angry alters can be talked to about agreeing to allow any part to speak without fear of retaliation.

A detailed conscious history is gathered in this stage (things that the patient clearly remembers) and some therapists also use system mapping here. Hypnosis is often used to facilitate communication with alters.

4. Metabolism of the Trauma

This is a lengthy and complex step of accessing deeper and more blocked memories, feelings, and ideas relating to possible traumatic events. Because traumatic images/ideas cause the symptoms many people with DID experience, the exact historical accuracy of each one is not a key factor. The patient has the feelings and the perceptions in her/his mind, and unresolved, they will continue to create serious symptoms. In fact, most studies show that the majority of repressed trauma has a strong basis in fact. However, many patients are highly resistant to "believing" what seem to be their own memories, because they are too horrible or their family couldn’t possibly be that bad. Emphasizing that this is not a courtroom, and therapy is strictly between the therapist and the patient can help the patient express what they feel and think without first subjecting it to "tests" of whether it could really be true.

If this process is attempted too early in the therapy it usually creates a serious crisis from the intense nature of the material and may result in a hospitalization that could have been prevented. Different methods are used in this step, including use of journaling, art work, hypnosis, direct attempts by the therapist to ask specific alters about their experience and age-regression.

For the therapist, it is essential that adequate time to re-orient to the present and to feel safe be set aside at the end of the session. There must also be a discussion and understanding of what is to be done during emergencies that occur outside of therapy.

It is during this work that "abreaction" of trauma sometimes occurs. This is the virtual re-living, through a complex flashback, of actual events with most of the sensory input affected. Not all therapists specifically use this technique; some do.

There are other techniques that are used by different therapists during this stage including EMDR (rapid eye-movement sensitization re-processing), amytal interviews, among others. These depend entirely on the experience of the therapist with these methods and the clinical impression as to their possible use.

5. Work Across Alters

In this stage, the different perceptions of the alters, their conflicts, the degree of separateness, and the barriers to their mutual cooperation are addressed. Depending on the goal, this can be as a preliminary step towards resolution/integration, or towards a more effective system. Co-consciousness and improved communication among alters is developed. Grief and mourning are a large part of this step for the patient.

6. Resolution/Integration

When this is chosen as the goal, it is usually approached in one of two ways. In the "strategic" approach, the dissociative coping mechanism, and the splitting into separate personalities is focused on as it relates to the patient as an adult in the current time. Ways in which this is not constructive, and where distorted thinking is occurring is examined with the idea that the patient will find their present system no longer meeting their needs, and unnecessary, and the system will become unviable.

In "tactical" integration, specific tasks are developed for the patient, involving very focused work for a specific period of time to resolve one distortion, or address one problem behavior, so that over time, the person is learning a different way to be.

Stable integration is considered to be achieved when:

[1] there is continuity of contemporary memory

[2] behavioral symptoms of DID are absent

[3] the person has a subjective sense of unity

[4] alters do not appear to re-emerge

[5] the person is aware of attitudes and states that previously were only known when a separate personality was out

No matter what the goal worked to has been, once it has been achieved, there is, to my very great dismay, a period of learning new coping skills. Basically, one must address the kinds of issues most people have but which for us have never been addressed before because our coping was basically to dissociate or to switch. This period can also take a fairly long time.

There are books and articles that cover each of the topics touched upon here briefly in hundreds of pages. However, hopefully, this is a fairly accurate summary of the main goals that DID therapy is directed towards, and the means that the therapist will use to try and get there.

For us, the treatment is painful and destabilizing. Examining memories and feelings is traumatic. Our only means of surviving in the past is under question. It is very hard not to retreat to the familiar and safe feeling of what worked before.

But for me, and almost everyone I know who has DID, the time since I became ill has not been happy. My life is nowhere near what I wish it was (or what it used to be). I am tired of hideous flashbacks, body memories and not knowing what happened two hours ago. I don’t care so much about being resolved or integrated or more like other people’s view of what a "personality" is supposed to be. I want to feel better. I want to be happier. I want my friends and others with DID who I consider my peers and some of the finest people in the world, to be able to live their lives the way they want. For me, those are the only goals that matter.

REFERENCES

1. Kluft R: "Initial Stages of Psychotherapy in the Treatment of Multiple Personality Patients", Presented at the Amsterdam Meeting of the ISSMP&D, May 20, 1992.

2. Spiegel D: "Psychotherapy of Traumatic Dissociation", DISSOCIATIVE DISORDERS: A CLINICAL REVIEW, Sidran Press, 1993

3. Putnam F: Diagnosis and Treatment of Multiple Personality Disorder, Guilford Press, 1989

4. Kluft R: "Treatment of Dissociative Disorders: An Overview of Discoveries, Successes and failures", DISSOCIATION, VI (2/3), June, 1993.

5. Bowers M, et al: "Therapy of Multiple Personality", JOUR OF CLIN AND EXP HYPNOSIS, 19, 1971.

6. Fine C: " A Tactical Integrationalist Perspective on Treatment of Multiple Personality Disorder", CLINICAL PERSPECTIVES ON MULTIPLE PERSONALITY DISORDER, American Psychiatric Press, 1993.

7. Special Issue: "Multiple Personality Disorder", NORTH AMER CLINICS IN PSYCHIAT, 1984(b)