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Section 18
Guidelines for Treating Clients with Dissociative Identity Disorder

Question 18 | Test | Table of Contents

Suicide: While untreated patients with DID have very high suicide rates, in the order of several thousandfold in excess of the American national average, there is a marked reduction in suicide risk when they are in any form of soundly based therapy incorporating a stable therapeutic alliance. Enquiry will reveal that, for many, thoughts of suicide are so frequent as to represent a constant option that over time seems like ever-present background scenery. It makes sense and feels less alarming when it is appreciated how threatened, powerless and immersed in double-bind communications such individuals usually were in their childhood circumstances. To have the option of suicide means that whatever happens they at least can exercise some personal power. Suicide as a potential but unused option is a more powerful position than submitting without the possibility of exercising choices. The goal of therapy is to substantially widen this option base.

The body: For many dissociative patients, their body represents the front line of an enduring conflict and it bears the scars and the disposition of battle. Negative introjects, self-deprecating internal commentary, shame, humiliation, fear, internally directed anger, distressing flashback phenomena, the need for self-soothing using self harming options, recurrent frightening disconnections associated with depersonalization/derealization or sexually connected triggers, collectively result in a person who holds his/her body in low regard. It can be the recipient of repetitive cutting, burning, overdosing, unsafe and harmful sexual practices, anorexia, bulimia, as well as drug and alcohol abuse. At the same time as being empathic to, and validating of, the person, the message from the therapist has to be that the goal is to cease such self-harming and to progressively replace such strategies with adaptive ones that enhance body image. Loneliness and lack of connection play a big role in self-harming. Facilitating healthy activities involving the body, particularly in group contexts (e.g. aerobics, tai chi, sport etc.) can only assist. As with twelve-step programs, the underlying message is that, hard as it may be and despite the multiple undeserved traumas of the past that can be incorporated into rationalizations for continuing, if the patient wants to be better they have to get serious about progressively ceasing the multiple forms of self harm that in reality are forms of addiction.

Alters: Alters are not people, and although at times they may demonstrate a sense of separateness approaching delusional intensity, they are never integrated personalities. They are a solution arrived at, using what seems to be to a greater or lesser extent a universal potential to dissociate. At an age where selfhood is not well developed, and particularly so in abusive, ‘double-bind’ environments, identity states are incorporated that provide semipermeable walls that hold the otherwise overwhelming memories, affects and somatic foci, at the same time as providing a means of satisfying the impossibly contradictory demands of abuser/attachment figures. In someone where all components of personality are subjected to fragmentation and compartmentalization and where fear, shame and invalidation have been constant companions, it is logical that treatment is integrative (i.e. building internal communication, shared affect, collective responsibility and better informed decision-making), and that it encompasses an equal acceptance of all parts of the patient (i.e. there is no split that favors certain parts and ignores others). Treatment should not potentiate separateness and it is wise to refer to named identity states as ‘parts’, to emphasize that, whatever their representations, one is ultimately dealing with a single individual. Kluft points out, ‘The therapist’s consistency across all of the different alters is one of the most powerful assaults on the patient’s dissociative defenses’ (p. 37). Alters, whatever their initial descriptions, are usually ultimately revealed as attached to the core sadness and associated wish that childhood could have been loving and non-abusive.

Cognitive restructuring: Embedded in the therapy of dissociative patients is empathic confrontation with the distorted logic that is encompassed by denigrating and invalidating parental figures, as well as the mutually incompatible beliefs that are encompassed within the system of alter states. In order to maintain a minuscule sense of power, the dissociative individual had to assume that there was something that they could have done to alter their abuse, a source of enduring guilt and self-criticism. In order to maintain such a belief system, they have to transpose the options and abilities of an adult into a small child. The logical inconsistencies of this position will need to be repeatedly and empathically addressed. At the same time, the abuse experience is reframed as one of pain and sadness in which courage and ingenuity were used to ensure survival.

Involvement of partners: Dissociation can contribute to particular relationship challenges that can range from individuals in dissociated states continuing sexualized relationships with primary abusers and/or strangers or with others known to them, through to masochistic submission, or repeated crises involving self-harm in all its forms. It is a mistake to assume, however, that the primary focus of concern in relationships is always the dissociative individual. Indeed, there is usually a complementarity of emotional and developmental issues for both parties in enduring relationships, while in relationships that do not endure, there can frequently be abuse and exploitation on the part of the non-dissociative individual that mirrors behaviors
of previous abusers. Functional partners are a major resource to the patient’s life and to the therapy, while the fact that they exist is indicative of the growth potential.

Realistic goals: It is imperative to appreciate that the extent of some individual’s trauma and the damage it has wrought on all aspects of developing selfhood are such that for some there are not enough strengths, nor is there enough time remaining in their lifespan to ever process their trauma, grieve the losses and develop integrated functioning. Chronically fixated by their traumas, they cannot move past them, nor can they develop new aspects of life outside the prison of their past. Appelfeld observed that such individuals live life ‘on the surface of consciousness’ (p. 18). Kluft coined the term the ‘mathematics of misery’ to help conceptualize those individuals subjected to major sexual trauma, perhaps more than a thousand times. Some dissociative patients seize the opportunity given by therapy and make major gains within relatively short times (e.g. a year); others have much lower treatment trajectories although they make sustained and steady progress over years. With the very traumatized, chronically suicidal, self-harming individual with very little self-hood, treatment of necessity has to be primarily supportive in nature, with immediate goals being more in terms of maintaining connection, support and staying alive. It also needs to be recognized that there is a significant minority of dissociative patients who are essentially untreatable, for example because of an inability to maintain enough boundaries to ensure the safety of the therapist, inability to maintain any permanent residence, psychopathy or extreme hostility.

Beyond therapy: No one gets well by therapy alone, although a positive therapeutic experience mobilizes fledgling selfhood and supports its consolidation in regard to the multiple tasks in ‘having a life’. Relying less on dissociation and avoidance means more engagement with respect to work, study, creativity and relationships. Boundary issues dealt with within the therapeutic frame provide a template for dealing with such issues in relationships outside of therapy. The need for poor outcome attachments grasped at while in the grip of loneliness or abandonment feelings, becomes attenuated, leading to increased patience and self-restraint and better quality relationships, which in turn enhance confidence and support structures. The growth of selfhood is nicely encompassed in the reflections of one patient, ‘You don’t think your way to a new way of living. You live your way to a new way of thinking’ (p. 32). In attracting interest and support in work or relationship ventures, it is very advantageous to have saleable commodities in the market place of life. It helps if one is intelligent, attractive or talented, such that skills or opportunities can be forged that augment the work done in therapy. Pierre Janet observed long ago that as patients resolve the effects of their trauma and engage life, they begin to forget to turn up for therapy.

Being real: Lemma examined the use of humor in psychotherapy, observing ‘that so little has been written on the subject of one of the most ubiquitous means of communication in our repertoire’ (p. 4).50 Grofjan stated that although psychotherapy deals with serious business, it does not necessarily have to take on the solemnity of a ‘Wailing Wall’. To quote Ross, ‘Humor helps form a treatment alliance, disrupts negative transference, has an antidepressant effect and may even benefit the immune system’ (p. 340). Dissociative patients may find it difficult to remain grounded in present time and place. It follows, then, that it is helpful if their therapist is identifiably distinct, real and able to share encouragement, validation and even humor. It needs to be borne in mind that many patients, in order to survive, had to create alternative realities, something that can be a potent source of derailment if their therapist also has a vulnerability for merging with elusive spaces populated by the modern representations of 18th century demons. Opaque settings, contemplative silences and a focus on transference and associated interpretations, however, well intended, serve to make it harder to remain grounded and can evoke distress when associated with the past use of silence, criticism or incarceration by abusive/emotionally depriving attachment figures. As Kluft, Putnam and others have pointed out, therapists need to be real, with a usual range of affective response. John Briere has made the comparison that the effective therapist role is somewhat akin to that of a personal trainer (pers. comm. 1996). The fragmented patient with impaired selfhood has a particular need for a therapist with healthy selfhood. Unfortunately, such a vulnerability is readily and harmfully exploited by those without it. Schnarch puts it well: ‘When therapists have sex with patients, it reflects a commingling of their respective pain and pathology, not unbridled passion’ (p. 61).
- Middleton, Warwick; Owning the past, claiming the present: perspectives on the treatment of dissociative patients; Australian Psychiatry; March 2005; Vol. 13 No. 1.

Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective

- Şar, V., Dorahy, M. J., & Krüger, C. (2017). Revisiting the etiological aspects of dissociative identity disorder: a biopsychosocial perspective. Psychology research and behavior management, 10, 137–146. doi:10.2147/PRBM.S113743

Personal Reflection Exercise #4
The preceding section contained information about guidelines for treating clients with Dissociative Identity Disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Chiu, C.-D., Ho, H. L., & Tollenaar, M. S. (2021). Relational self-evaluations in dissociation: Implicit self-rejection? Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Conger, K. J., Neppl, T. K., & Scaramella, L. (2021). Special section on personality development: Testing environmental and genetic associations across generations. Developmental Psychology, 57(2), 139–146.

Garcia, D. J., Waugh, M. H., Skadberg, R. M., Crittenden, E. B., Finn, M. T. M., Schmidt, M. R., & Kurdziel-Adams, G. (2021). Deconstructing criterion a of the alternative model for personality disorders. Personality Disorders: Theory, Research, and Treatment, 12(4), 320–330.

QUESTION 18
What is one technique suggested by Middleton for helping clients with DID identify the therapist as distinct and real? To select and enter your answer go to Test.

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