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Most DID patients are treated in therapies that have a psychodynamic or cognitive-behavioral orientation, and are facilitated by additional modalities and approaches. An addition to conventional approaches is "talking through", that is, talking to the personality system as a whole. In this manner the therapist keeps in mind that any and all parts of the mind may be listening, and by appealing to all parts of the mind, one encourages as many to listen as is safe and/or relevant. Also, the therapist develops a pattern of talking to both the individual alter or alters with whom the therapist is in conversation, and the person as a system and as a whole, at the same time. This both acknowledges the alters' experience of themselves as separate, and supports an appreciation that all the alters are aspects of a single human being.
Other techniques involve the use of constructive personalities as allies in the therapy and in stabilizing the system. For example, a patient who had spent years regressed in a series of child states was helped to return to function by arranging for protective personalities to attend to the child states in the world of the personalities, allowing more functional alters to come forward and resume the patient's occupational and social roles.
Mapping has been mentioned in passing, and can be done in many ways. However, one of the most straightforward was devised by Fine. The alter that is usually in control (the host) is asked to write its name on a piece of paper, sometimes at the middle of the page, and the other alters are invited to place their names, either by emerging and writing, or by instructing the alter in control what to write and where to write it. I modify the technique by asking alters that do not yet wish to declare themselves or who do not have names to make a mark to indicate their presence. One rarely gets all alters on an initial map, but the view that it gives of the alters and their relationships to one another is invaluable. This process can be repeated from time to time to see what alters and groups of alters not previously available are now declared. If one wishes to work in a tactical integrationalism manner, as described by Fine, mapping is essential, because in this approach the therapist tries to avoid allowing painful material to intrude into the alters that attend to day-to-day activities until late in the treatment, lest the patient's function be inadvertently impaired.
Not infrequently, it is useful to suggest that the patient keep a journal for 20-30 minutes per day in a free-associative manner. This often allows additional ventilation, communication among the alters, revelation of additional alters, and sharing by alters as yet unable, unwilling, or unprepared to enter treatment. Valuable material is often first revealed in this medium.
Hypnosis: Hypnosis long has played a valuable role in the treatment of DID, and remains the most commonly employed family of specific techniques. Recent concerns about the possibility of retrieving confabulated and concretized pseudo-memories with hypnosis have been allowed to obscure the fact that hypnosis can offer anxiety relief, the opportunity to create sanctuary for the beleaguered personalities in "safe place," and allied techniques, as well as unsurpassed opportunities to explore and influence the alter system, containment of affect, control of the abreactive process, facilitation of integration, and a variety of temporizing techniques used to quiet and protect unsettled personality systems. For more detailed information on the use of hypnosis in the treatment of DID, consult Braun, Frederick and Phillips, Hammond, Kluft, and Putnam.
EMDR: In recent years, EMDR has been used extensively with trauma victims, and increasingly for processing the traumas of DID patients, but, unless cautiously introduced, EMDR may prove an overwhelming experience for the DID patients. In workshop settings Fine, who is perhaps the most experienced clinician in the use of EMDR with dissociative disorders, advises that (with few exceptions) it be withheld until the therapy is well underway and the therapeutic alliance is strong. She rarely employs it in the first year of therapy. Paulson and Lazrove and Fine have described approaches to the use of EMDR with DID. In the author's experience EMDR is most helpful in a highly structured therapy, but can be used with caution in a more process-oriented treatment. EMDR used precipitously in the context of a process-oriented therapy can mobilize many types of traumatic material and traumatized alters at once, and prove disruptive.
Psychopharmacology: Medication does not address the core symptomatology of DID, but can be very effective in addressing particular target symptoms and in alleviating comorbid drug-responsive conditions. Since DID patients commonly have additional diagnoses as well, most DID patients receive medication. The art of medicating DID patients has been addressed elsewhere.
Group Therapy: DID patients often have difficulty participating in traditional therapy groups because they often are experienced as disruptive to such groups and in turn are vulnerable to being disrupted by them. In recent years groups for DID patients have been conducted by a number of clinicians and have proven useful. In such settings the DID patient is neither abnormal nor an outcast. These groups function most effectively when they focus on psychoeducational objectives, here-and-now coping, and problem-solving rather than the traumatic past.
Support groups for DID patients that are leaderless or facilitated by non-professionals have a very poor track record, suffering from contagion, the disruption of the members by one another, and by becoming such preoccupations to their members that their individual psychotherapies are derailed by dealing with the repercussions of their relationships with the group and group members.
Groups for family, friends, and the concerned others of DID patients can be a valuable support for these individuals and to the treatment of the DID patient.
Family Therapy: Family treatment with the DID patient's family of origin is an enterprise fraught with peril if family members are alleged to have been abusive. Confrontations about abuse in this context may be disruptive to the family and patient alike, and may lead to the therapist's being held to be responsible for the consequences of the confrontation to family members. Often the patient is repudiated, and families are alienated. The cost-benefit ratio of these meetings often is prohibitive.
Conversely, family work with the DID patient and concerned others and children of the DID patient can help these persons to cope with the DID patient and with their reactions to the DID patient and his/her condition.
Creative Arts Therapies; Functional Therapies: It is difficult to overstate how useful art, movement, music, poetry, and occupational therapy can be with DID patients. Often stymied in their verbal expression, these modalities may provide a forum for the expression of what cannot be said and acknowledged in words. Since many DID patients are very creative, they often are able to use these modalities with great ease. A discussion of the roles of these modalities is available in Estelle Kluft's text, Expressive and Functional Therapies in the Treatment of Multiple Personality Disorder.
Reflection Exercise #10