12

The Rational Treatment of Dissociative Identity Disorder1

Over the past three decades, professional awareness has increased dramatically concerning dissociation as a response to childhood trauma. As a consequence, many more patients have been diagnosed as suffering from dissociative identity disorder (DID) and related disorders. The accurate diagnosis of DID and similar dissociative disorders certainly has proved to be of benefit to many patients. However, in many instances, the particular nature of DID and dissociative symptoms appears to have led some professionals to engage in therapeutic practices that are largely ineffective or misguided. Over more than 20 years of consulting with therapists, I repeatedly have observed the difficulties that even competent and experienced therapists have in understanding and treating DID and dissociative disorder patients. Many of these difficulties are generic to patients with complex PTSD and are described elsewhere in this volume. This discussion examines the specific areas of difficulty commonly encountered with patients with DID and dissociative disorders.

The manifestations of DID are often dramatic and difficult to manage. The switching of personalities, the dissociative and amnestic barriers, and the complexity of internal psychic structures and identity are often bewildering to clinicians when they first encounter DID. In addition, the periodic intrusions of posttraumatic reexperiencing phenomena, including flashbacks, nightmares, overwhelming affect, and even somatic sensations, lead a sense of chronic instability. Furthermore, comorbid characterologic difficulties including patients’ intense interpersonal disturbances, affective instability, and impulsive and self-destructive behavior add to the sense of ongoing crisis and chaos. In this context, many clinicians seem to ignore many of the established principles of traditional psychotherapy and engage in practices that appear to respond to the immediate clinical situation, but may be ill-advised in terms of the therapeutic process.

DID and the difficulties that are suffered by patients who have histories of severe childhood abuse sometimes do require therapists to make thoughtful modifications of certain psychotherapeutic techniques. However, most of the treatment of DID involves using the same traditional interventions used in the psychotherapy of all patients. Therapists should adhere to the basic principles of psychotherapy that have been established and proven as effective over generations of patient-therapist interactions. Not to do so can and does result in potential therapeutic impasses and negative outcomes. Treatments that are not founded on traditional psychotherapeutic principles risk becoming out of control and detrimental, not only to patients but to their therapists as well.

This chapter focuses specifically on the treatment of patients with DID and those similar, severe dissociative disorders that do not quite meet the criteria for DID—patients who experience themselves as fragmented but retain a single identity and/or do not have amnesia between personalities, for example, dissociative disorder, not otherwise specified (DDNOS). This discussion is intended as a practical guide to the management of adult patients and focuses on four areas of therapeutic difficulty that are common in the treatment of DID and related dissociative disorders: (1) etiology and diagnosis, (2) treatment goals and staging, (3) understanding severe dissociative disorders as system of personalities or self-states representing a fragmented sense of self within a single person, and (4) working with patients who have DID without undue focus on DID phenomenology. For more details and discussion concerning the treatment of DID, see Guidelines for Treating Dissociative Identity Disorder in Adults, 3rd Revision (International Society for the Study of Trauma and Dissociation, 2011) and Guidelines for the Evaluation and Treatment of Dissociative Symptoms in Children and Adolescents (International Society for the Study of Dissociation, 2004), available through the ISSTD and published in the Journal of Trauma & Dissociation. There are also numerous papers in the scientific literature concerning the treatment of DID and allied disorders—many of which are cited in this chapter—as well as several comprehensive texts for professionals (Dell & O’Neil, 2009; Michelson & Ray, 1996; Putnam, 1989; Ross, 1997; Vermetten, Dorahy, & Spiegel, 2007), and one written for patients with DID and the significant others in their lives (Haddock, 2001).

ISSUES CONCERNING ETIOLOGY AND DIAGNOSIS

Severe and prolonged traumatic experiences, especially early in childhood, can lead to the development of discrete, personified behavioral states (i.e., rudimentary alternate personalities) that compartmentalize intolerable traumatic memories, affects, sensations, beliefs, or behaviors. Elaboration and further structuring of these rudimentary alternate personalities occurs over time through a variety of developmental and symbolic mechanisms, resulting in the characteristics of the specific alternate personalities. The personalities may vary in complexity and sense of separateness as the child grows into adulthood (Kluft, 1984; Putnam, 1997). DID develops during the course of childhood and almost never derives from adult-onset trauma (unless it is superimposed on preexisting childhood trauma and latent or dormant fragmentation). Kluft (1984) has offered a four-factor theory for the development of DID: (1) the capacity for dissociation, (2) precipitating traumatic experiences that overwhelm the child’s nondissociative coping capacity, (3) specific psychological structuring of the DID alternate personalities, and (4) perpetuating factors such as lack of soothing and restorative experiences, which necessitate individuals to find their own ways of moderating distress.

As with any clinical presentation, evidence of DID must be carefully examined in terms of differential diagnosis. Specifically, patients must be examined for evidence of DSM-IV criteria (APA, 1994) for DID, including naturalistically occurring internal separate states, dissociative barriers between states, and amnesia. Etiologic issues concerning the necessary traumatic antecedents must be carefully considered. It should be determined whether there are comorbid conditions such as another Axis I diagnosis of an affective or psychotic disorder, substance abuse, an eating disorder, or somatization, and Axis II disorders such as borderline personality disorder. The possibility of self-induced elaboration of symptoms or iatrogenic factors should be considered, and embellished dissociative features, factitious or malingered DID should be ruled out; for a discussion of the latter issues, see Chapter 15.

DSM-IV criteria for DID require the following four essential features (APA, 1994, p. 487):

A variety of terms have been developed to describe the DID patient’s subjective sense of self-states or identities. Commonly used terms include personality, personality state, self-state, alter, alter personality, alternate identity, and part among others. Because the DSM-IV (APA, 1994) generally uses the term alternate personality and because of the traditional use of this term in describing DID, this term is used in this discussion.

Psychiatrist Richard Kluft, MD (1996), perhaps the most preeminent investigator of DID over the past three decades, has described some of the classic presenting features of naturalistically occurring DID:

The personalities’ overt differences and disparate self-concepts may be striking. They may experience and represent themselves as being different ages, genders, races, religions, and sexual orientations; they may experience themselves as having different appearances and/or hold discrepant values and belief systems. Their awareness of one another may range from complete to nil. Directionality of knowledge is almost always found among some alters, such that alter A knows of doings of B, but B is unaware of the activities of A.… Differences in handwriting and handedness, voice and vocabulary, accents and speech patterns, and even preferred languages are encountered. Their facial expressions and movement characteristics, both when neutral and affectively engaged, may show impressive and rather consistent differences.… The classic host personality, which usually… presents for treatment, nearly always bears the legal name and is depressed, anxious, somewhat neurasthenic, compulsively good, masochistic, conscience-stricken, constricted hedonically, and suffers both psychophysiological symptoms and time loss and/or time distortion. While no personality types are inevitably present, many are encountered quite frequently: childlike personalities…, protectors, helper-advisors, inner self-helpers…, personalities with distinctive affective states, guardians of memories and secrets, memory traces…, inner persecutors…, anesthetic personalities…, expressers of forbidden pleasures…, avengers…, defenders or apologists for the abusers, those based on lost love objects and other introjects and identifications, specialized encapsulators of traumatic experiences and powerful affects, very specialized personalities, and those… that preserve the idealized potential for happiness, growth, and the healthy expression of feelings.… (pp. 345–346)

Kluft (2009) has cautioned that dramatic presentations are actually unusual, and that “only 6% make their DID obvious on an ongoing basis” (p. 600). Clinically apparent symptoms are only seen intermittently, sometimes referred to as moments of visibility or “windows of diagnosability” (Kluft, 1991b; Loewenstein, 1991). Instead of showing visibly distinct alternate identities, the typical patient with DID presents a polysymptomatic mixture of dissociative and PTSD symptoms that are embedded in a matrix of ostensibly non-trauma-related symptoms such as depression, anxiety, panic attacks, substance abuse, somatoform symptoms, eating-disordered symptoms, and so forth (Dell, 2006b). The prominence of these latter, highly familiar symptoms often misleads clinicians to diagnose only the comorbid symptoms as the primary condition. When this happens, the patient may undergo a long and often unsuccessful treatment for both the undiagnosed DID and the other comorbid symptoms (Putnam et al., 1986).

Despite the lack of obvious evidence of separate internal identities, careful clinical interviewing and thoughtful differential diagnosis can usually lead to the correct diagnosis of DID (Coons, 1984). As discussed in Chapter 3, every diagnostic interview should inquire about a history for trauma and screen for dissociative symptoms. At a minimum, the patient should be asked about episodes of amnesia and depersonalization/derealization, and if these are present, the clinician should inquire about identity confusion and identity alteration. Other useful inquiries include questions about hearing voices (usually heard inside the head and not attributable to psychosis) (Putnam, 1991), passive-influence symptoms such as “made” (i.e., that do not feel attributable to the self ) thoughts, emotions, or behaviors (Dell, 2009; Kluft, 1987a), and somatoform dissociative symptoms (Nijenhuis, 1999). Psychiatrist Richard Loewenstein, MD (1991), has published a comprehensive office mental status examination that inquires about many symptoms of DID, including evidence of amnesia, alternate personalities, autohypnotic phenomena, PTSD, somatoform dissociation, and affective symptoms. The diagnostic measures described in Chapter 3 may also be helpful for clinicians who are not familiar with the interviewing techniques and questions that elicit evidence of dissociative disorders.

In addition to the symptomatic expression of dissociative fragmentation, patients with severe dissociative disorders almost universally have historical evidence of trauma (Kluft, 1985d; Putnam, 1985, 1997; Ross, 1997) and long-standing dissociative symptoms. Particularly early in treatment, these patients have a reluctance to discuss, acknowledge, or reveal both evidence of internal separateness and past histories of traumatization, because the nature of their difficulties is based on the need to distance and disavow such experiences. There is frequently one-way amnesia between personalities, with the host personality having the least knowledge of other personalities. Given that the patient most often presents as the host early in treatment, the patient is frequently unable to confirm the presence of other parts of the self. Moreover, if the traumatization is caused by abuse or victimization, there is universally deep shame, guilt, and a wish to hide these experiences from others. Any clinical presentations that do not have these characteristics should be examined closely for evidence of an atypical dissociative disorder that requires modifications of treatment, another psychiatric diagnosis masquerading as a dissociative disorder, or a factitious or malingered dissociative disorder (see Chapter 15; Brick & Chu, 1991; Chu, 1991a; Kluft, 1987c; Thomas, 2001 for a more detailed discussion of the latter issue).

Comorbid diagnoses must be recognized. As discussed elsewhere in this book, any prominent Axis I diagnosis must be actively treated before instituting treatment for a dissociative disorder. Disorders such as depression, bipolar disorder, or psychoses will inevitably exacerbate and perpetuate any existing dissociative symptoms. Major substance abuse, eating disorders, or somatization should also be an initial focus for stabilization. Borderline personality disorder is diagnosed in up to 70% of the DID population (Boon & Draijer, 1993a; Dell, 1998; Ellason, Ross, & Fuchs, 1996). Axis II disorders such as borderline personality disorder must be recognized, as the patient’s deficits in affect tolerance, behavior control, and relational ability will have an enormous impact on the emphasis and pacing of treatment.

TREATMENT GOALS AND STAGING

The goal of treatment for DID is integrated functioning. The term integration is used here to denote progressively greater coordination and harmony among the alternate personalities. Kluft (1993) describes integration as

[An] ongoing process of undoing all aspects of dissociative dividedness that begins long before there is any reduction in the number or distinctness of the identities, persists through their fusion, and continues at a deeper level even after the identities have blended into one. It denotes an ongoing process in the tradition of psychoanalytic perspectives on structural change. (p. 109)

Fusion refers to the merger of two or more alternate personalities, resulting in the patient’s perception of their joining together, completely surrendering a sense of subjective separateness. Thus, progressive integration is the goal of therapy throughout the treatment process, whereas fusion occurs in the latter stages of treatment, usually in the middle and late phases.

Many experts in the treatment of DID advocate complete fusion as the most stable treatment outcome (e.g., Kluft, 1993), resulting in a full merger of all personality states. Early in treatment, most patients with DID have a strong investment in the separateness of the alternate personalities, seeing them as separate and autonomous entities. They have difficulty in perceiving any value in merging the identities, seeing this as destructive or annihilating rather than a joining of forces. As the treatment proceeds and individual characteristics and jobs or functions of the personalities become less differentiated, patients often become more amenable to some type of unification. However, such complete merger or fusion may not be possible for all patients with DID for a variety of reasons, including ongoing situational stress, extensive comorbidity of other psychiatric difficulties, or continuing narcissistic investment in the alternate identities. The ultimate pragmatic solution is a maximal level of cooperative and integrated functioning, even if complete fusion is not possible for a given patient. Psychiatrist David Caul, MD, once remarked (as quoted in Kluft, 1985c, p. 3), “It seems to me that after treatment you want a functional unit, be it a corporation, a partnership, or a one-owner business.”

Perhaps the most common difficulty in the treatment of patients with DID has to do with failure to stage the treatment and pace the therapy. Kluft (1989a) has observed:

A common experience of the sophisticated therapist is to have difficulties with regards to issues of dosage in treating DID. The patient often experiences therapy as a guided tour of his or her personal hell without anesthesia. When a therapist fails to pace the treatment to the tolerance of the patient, the patient may become overwhelmed over and over. (p. 88)

All of the caveats concerning work with patients with complex PTSD are particularly relevant to patients with DID and similar disorders. Premature efforts to abreact past traumatic events generally result only in regression and retraumatization. Therapists treating patients with DID should be aware of and respect the need for establishing the necessary and proper psychotherapeutic foundations before engaging in exploratory and abreactive work. The major principles in treating severely traumatized patients are described elsewhere in this volume, including the SAFER model, which calls for the development of skills concerning self-care and symptom control, acknowledgment (but not extensive exploration) of traumatic antecedents, functioning, appropriate expression of affect, and maintaining collaborative and supportive relationships, as a preliminary stage before exploratory work. The profound difficulties that patients with DID often have in establishing a sense of safety and mastering the various tasks of early phase therapy may mandate a very long period of preliminary work before active focus on the etiologic abuse.

Failure to adequately pace treatment is also seen in premature attempts at integration and fusion. All too often, therapists and patients try to shortcut the treatment process by attempting fusion of personalities before adequate working through the underlying conflicts and traumatic events that led to their dissociation. Such misguided efforts have sometimes entailed strenuous efforts by therapists in the form of prolonged sessions and special techniques. These fusions usually either quickly disintegrate, or new personalities emerge to take on the functions of those who had been merged. Patients and therapists who are invested in this kind of practice often seem to persist in working in this manner, convinced that the next fusion will result in therapeutic gains and stability. Unfortunately, there is usually only a downhill spiral of regression, chaos, and exacerbated symptomatology.

WORKING WITH ALTERNATE PERSONALITIES

In DID, the alternate personality system is frequently organized and internally logical. The alternate personalities have failed to integrate with the presenting host personality because they hold knowledge, conflictual beliefs, unacceptable feelings, or memories of traumatic events that the host personality disavows and denies. The host is generally depleted and emotionally numb as a result and is usually amnestic for the experience of the other personalities. To the extent that the host disavows the other personalities, they generally become more autonomous in their function and self-perception. Effective therapy focuses on the alternate personality system as a whole rather than on specific personalities. In other words, the patient is comprised of all of the personalities, not just the host. Although this may seem obvious, it is all too easy to collude with a patient who, presenting as the host, does not acknowledge that the disavowed alternate personalities are part of the self. It is part of the psychoeducational process for patients with DID that all personality states (particularly the host personality) must begin to understand, accept, and communicate with all other relevant parts of the alternate personality system. Moreover, the patient as a whole must accept accountability for the behaviors of all of the alternate personalities.

Denial and disavowal of a unitary identity is not seen just in the host. For example, some alternate personalities deny that they share the same body as the other personalities, even to the extent of insisting that self-injury would not affect them. It is not unusual for angry persecutory personalities to talk about killing off the host or other personalities as a way of going off and finding their “real” bodies. Although this may appear to be delusional, it is actually a characteristic of DID patients’ trance logic. When such logic endangers patients’ safety, it is important to confront it directly: “I know you feel that this body isn’t yours and that you won’t die if you induce one of the others to commit suicide, but I must tell you that I am certain that you would also die.”

Effective treatment of DID almost always requires interacting and communicating with the alternate personalities. As a minimal sense of safety is established in the therapy, it is usually quite easy for a therapist to access the alternate personalities, for example, saying, “I need to speak directly with whatever parts have been engaged in self-harming activities.” However, there is one particular common trap through which the host can maintain the appearance of working in therapy, but can continue to remain to disavow the presence and meaning of the other personalities. In this scenario, the therapist is induced to contact and communicate with the other personalities—for example, to deal with difficult personalities or to hear about past traumas—while the host goes away and is amnestic for the experience. Little is accomplished in this scenario in terms of sharing experiences between personality states. It is often much more therapeutically effective to ask the host personality to internally communicate with the other personalities. For example, the patient can be asked to listen inside to hear what the other personalities have to say, or the therapist may suggest that the personalities engage in inner conversations with one another to communicate information or negotiate important issues. The therapist may insist that “all parts who need to know should listen” when crucial matters are being discussed, or can talk through to communicate with alternate personalities relevant to the current clinical issues. Although it is sometimes necessary for the therapist to first work with certain alternate personalities, this should only be a transition for the host to eventually assume the central role in internal communication.

The development of internal cooperation and co-consciousness between personalities is an essential part of early phase treatment that then continues into the middle phase. The therapist must emphasize the adaptive role and validity of all personalities and encourage the host to find adaptive ways to accommodate the wishes and needs of all personalities. In general, work with alternate personalities should occur as they appear naturalistically in relation to current clinical issues. However, if there are immediate safety issues or therapeutic impasses related to specific personalities, it may be essential to directly make contact with the alternate personalities associated with these difficulties.

One particular area of difficulty in the early treatment phases concerns how the alternate personalities emerge. Often after the acknowledgment of the existence of DID, personality switching begins to escalate with the appearance of an increasing array of different personalities, the most common sequence being first child parts, then depressed/suicidal and angry/self-destructive personalities. Therapists may soon find the process out of control as patients present a veritable parade of personalities, as they emerge to vent their feelings or to tell their stories to the therapist, but do not promote any interpersonality communication or co-consciousness. Moreover, the compartmentalized experience of the personalities sometimes results in denial of a sense of interpersonal vulnerability, and patients will prematurely expose intensely private aspects of themselves. They will then experience negative therapeutic reactions after showing aspects of themselves that then induce shame, repugnance, or fear. The following clinical example illustrates this scenario:

Cathy, a 23-year-old patient with DID, entered therapy with a long history of interpersonal instability and several failed past therapies. In the therapy hours, she was very cautious about exposing herself to her therapist, aware that she was not yet ready to cope with forming an intense attachment. However, outside of the office she began to write in a journal that she gave to her therapist to read. In the journal, various personalities began expressing strong feelings about the therapy and therapist, and began disclosing details of past abuse. Over the course of several weeks, Cathy began to appear markedly more frightened in the session, and she was either mute or made angry verbal attacks toward the therapist. The therapy became stalemated. The therapist finally realized that Cathy was exposing too much about herself in the journal and was feeling very vulnerable, and that she could not tolerate having her writings discussed in the sessions. Cathy and her therapist then agreed that the journal writing be limited in amount and that the content would be restricted to only material that could be discussed in sessions. There was an immediate improvement in her clinical condition, and the therapy then proceeded in a useful manner.

Early in the evolution of treatment models for DID, some authors have advocated the process of mapping the system of alternate personalities (Kluft, 1993; Putnam, 1989; Ross, 1989); that is, identifying personality states and clarifying their relationships to each other. This technique should only be used when it is clinically appropriate to do so, and therapists should realize that it is often only quite late in the treatment course that a reasonably complete understanding of the personality system is known. In fact, it is normative for therapists to have only a very incomplete knowledge of the patient’s alternate personality system and to lack a detailed chronology of the patient’s history until well into the treatment. The practice of actively eliciting personalities (sometimes assisted by hypnotic interventions) for the purpose of mapping—especially when patients are very reluctant to bring them into the therapy—is potentially destructive. Therapists can appropriately help patients overcome resistance, but the psychological dissection of patients with DID is an extremely questionable practice. After all, when working with other types of patients, most therapists would not consider extensive exploration of hidden and vulnerable aspects of the patient until therapeutically appropriate.

As patients with DID progress into the middle phase of treatment and begin the process of active work on traumatic memories, the need for separate personalities diminishes. Memories and feelings that were previously dissociated into different parts of the self are brought together and integrated. As with other survivors of severe childhood trauma, realizing the extent of personal losses and mourning what happened (or did not happen) become the central themes of the therapy. As traumatic experiences are worked through, the alternate personalities may experience themselves (and appear to the therapist) as less separate and distinct. Spontaneous and/or facilitated fusions among alternate personalities may occur in which personalities join together to have the subjective experience of becoming unified. Some therapists use fusion rituals—hypnotic or guided imagery interventions that mark a transition to a different sense of identity—to facilitate this process (see Kluft, 1993, for a fuller discussion). It is important not to see fusion as a way of promoting integration, with fusion rituals “merely formaliz[ing] the subjective experience of the work that therapy has already accomplished.…” (Kluft, 1993, p. 120).

In the late phase of DID treatment, patients make additional gains in internal cooperation, coordinated functioning, and integration. As with other severely traumatized patients, they begin to achieve a more solid and stable sense of self and to relate better to others and to the outside world. Patients with DID may continue to fuse alternate personalities. As they become less fragmented, they have fewer posttraumatic and dissociative symptoms, may better understand their past history, and cope more effectively with current problems. There is less of a focus on the past traumas, more interaction with the external world, and an enhanced ability to plan for the future.

TREATING THE DID SYSTEM

The sometimes bewildering presentation of many patients with DID may be confusing to therapists who are unfamiliar with dissociative disorders. Which personalities should be part of the treatment? How many personalities should be involved in a given therapy session? Is it necessary to call personalities forward into the therapy? Many of these kinds of questions can be answered by imagining how a DID presentation would appear in a nondissociative patient. For example, most therapists understand the model of intrapsychic conflict. Patients with DID manage conflict through segregating the conflicting views, feelings, or knowledge into separate identities. Thus, an understanding of the inherent conflicts in a given situation will determine which personalities are involved and must be in working through a current dilemma. At any given time in the therapy of patients with DID, the therapist should be working with a relatively small number of personalities who represent the current issues and conflicts to be resolved. The particular personalities working in the therapy will change as conflicts are resolved and the therapeutic process progresses. The following clinical example may illustrate these principles:

Marjorie, a 35-year-old married nurse, entered therapy for treatment of sexual dysfunction and depression. Over the first few months of treatment, it became clear that she had the diagnosis of DID. She had a long history of periods of amnesia with evidence of having done things she could not explain, and abrupt changes in her mood, appearance, and functioning reported by her husband, as well as a known history of brutal childhood abuse. Marjorie had been able to deny the significance of her symptoms and background until her therapist began to gently inquire about them. Several alternate personalities emerged in treatment, including childlike personalities who asked to be able to play with toys in the therapy room “because we were never allowed to play when we lived with our parents.” Over the course of a few weeks, the therapist played with the child personalities in therapy, and no adult personalities appeared except at the very end of sessions when they seemed confused and disoriented.

Finally, Marjorie’s husband called the therapist to complain that Marjorie was on probation at her job because of her absenteeism, that she had been very withdrawn, passive, and needy at home, and that she had driven off the road coming home from a therapy session (presumably because a child personality had emerged while she was driving). After some consideration, the therapist realized that she had unwittingly permitted the patient to focus on only gratification of her unmet childhood need to be cared for, at the cost of attending to the demands of work and adult functioning. Moreover, the increased intimacy with the therapist seemed to have brought up defenses that interfered with Marjorie’s ability to engage in and tolerate intimacy in her marriage. The therapist then tried to explain the situation to the child personalities, and despite their tearful recriminations, insisted that adult personalities appear regularly in sessions and use the time to solve problems concerning the current realities of Marjorie’s life. Balance seemed to be restored to both the therapy and her outside life. In retrospect, the therapist recognized the clinical situation as a DID version of fairly straightforward regression.

In a similar way, common issues such as addressing interpersonal concerns, coping with stress and impulse control, maintaining functioning, and expressing dysphoric affects, among many others, will be manifested by the various personalities that hold the relevant affects, attitudes, experience, information, and abilities concerning the issues.

Therapists treating patients with DID commonly find themselves highly involved (and sometimes overinvolved) in the emotional experience of their patients. As with other patients who have fundamental problems with basic trust, their difficulty with maintaining a sense of interpersonal connection and their vulnerability to feeling abandoned and abused often makes it necessary for therapists to be more active in the therapeutic relationship in demonstrating their empathic understanding of patients’ experience. This necessary level of involvement has some potential untoward effects in that therapists are vulnerable to becoming so empathically identified with their patients that they lose therapeutic perspective about the personalities. With patients with DID, it is a particular risk that therapists become so attuned to patients’ sense of internal fragmentation that they accept the patients’ various alternate personalities as virtually independent, autonomously functioning entities. In this situation, therapists begin to treat the personalities themselves, rather than treating the whole system of personalities, as in the following clinical example:

Stacie, a 32-year-old woman with DID, progressed well in her therapy for over a year. She struggled to understand her diagnosis and worked productively with her therapist to develop appropriate skills to stabilize her life. She began to have more of a sense of an internal personality who she called the Evil Father. The host, Stacie, was terrified of this personality, who appeared to be angry and persecutory, and who apparently “made” her lacerate her arms and genitals. The therapist was similarly alarmed by this personality, who seemed to be the personification of Stacie’s sadistic and abusive father. The therapist tried to help Stacie with strategies to block the behaviors of this personality, but to no avail. Finally, the therapist used a hypnotic intervention and managed to induce the Evil Father to emerge in a session. This personality did emerge and insisted that he needed to “teach” the other personalities to behave through his actions. The therapist tried to point out the destructiveness of his behavior and urged him to cease such behavior. Stacie then returned and reported amnesia for the previous several minutes. That evening, she again lacerated herself, and the Evil Father wrote a threatening note in Stacie’s journal challenging the therapist to try and control his actions.

This kind of interaction ignores the psychological validity of the father introject, as well as the functioning of the personalities as part of a system. It also assumes that the therapist (rather than the patient) should primarily have the omnipotent position of dealing with difficult alternate personalities, a task that is both inappropriate and therapeutically untenable.

The outcome of these kinds of clinical dilemmas depends on the therapist’s ability to understand the psychodynamic underpinnings of the clinical presentation, to help the patient negotiate the resolution of the inherent conflict, and to insist on the active involvement and collaboration of the patient. In working with so-called difficult alternate personalities, the therapist must understand the psychological development and role of each of the personalities and must respect the validity of each personality. The whole personality system must work toward the resolution of conflict that the difficult personality represents, because the conflict made the dissociative splitting of identity necessary. Finally, the therapist should engage other personalities in working with the difficult personality.

The conceptual model of family/systems theory (Bowen, 1966) is of great assistance in negotiating difficult DID dilemmas. In family/systems theory, the family as a whole is seen as the patient rather than any particular family member being the identified patient. For example, in a family situation involving an acting-out adolescent, the family as a whole is asked to look at family conflicts rather than focusing on the adolescent. Are there issues between parents or other family members, or projective identification from parents, or major disturbances in other family members that are covertly driving the acting-out behavior? The family as a whole takes on the responsibility of understanding, resolving, and containing the behaviors of each family member. In patients with DID, family/systems theory is applicable to the internal family of alternate personalities or identities. Using this framework, there are no bad personalities, only personalities that are compelled to behave in a particular way because of past events and in reaction to or to compensate for the actions and behaviors of other parts of the personality system. Increased internal communication, collaboration, and empathy are the key elements of this kind of family/systems work with patients with DID.

The psychopathological process in DID depends on the separation of apparently irreconcilable conflicts through fragmentation into alternate personalities. Hence, patients are understandably resistant to increase internal communication, because this process intensifies awareness of intrapsychic conflict. As a result, patients are generally uncomfortable about promoting co-consciousness, and they often will not provide the primary impetus for resolution of intrapsychic conflict. However, the therapist can provide reasons for increasing communication, can suggest safe mechanisms for doing so, and can point out potential positive gains and the negative consequences of not doing so. In the previous case about Stacie, the impasse was resolved as follows:

Following consultation, the therapist approached Stacie somewhat differently. She said to her, “I know that you are frightened of the Evil Father who seems to represent much of what you’ve hated about your father. However, you must begin to understand that this Evil Father is part of you. I know you will find this hard to accept, but this part of you actually helped you survive by becoming like your father.” The therapist went on to underscore the survival value of identification with the aggressor, as well as the potential value of being able to express aggression, albeit in a more controlled manner. The therapist then suggested a type of bargain or truce: “If I help you to understand this part of yourself that you are so frightened of, I would like to ask that the Evil Father stop hurting your body. I have no way of forcing this to happen, but if you, Stacie, are willing to work hard at accepting and understanding, perhaps your safety can be maintained.”

When the Evil Father emerged, the therapist said, “I know you have played an important role in Stacie’s life in the past, and that you are upset at not being recognized. I will work with the other parts of you so that they will acknowledge you and will begin to bear the burden of your angry feelings. I hope you understand that some of the threats you have made and the destructive behavior are not necessary or productive, and if you can work together with me and the other parts of yourself, we may be able to avoid more extreme measures such as hospitalization.” After a considerable period of negotiation, internal stability was restored.

It is not always necessary to have relevant underlying personalities actually emerge in the therapy as in the previous example. The technique of talking through to underlying personalities can be very useful in allowing the patient the control of when to expose previously hidden parts. All that is usually required is for the therapist to make it clear that he or she is addressing all parts that are relevant to the situation (e.g., “It is very important that all parts involved in the current problem listen to what I have to say.”). Sometimes, therapists can communicate by talking through with personalities who are reluctant to emerge in sessions. For example, in the previous situation, the therapist might have talked about the importance of the Evil Father with the host personality, Stacie, emphasizing his role in her life: “I hope that the Evil Father will listen to what I have to say and know that I understand his important role in your life and all he has done to protect you.” This is heard throughout the personality system and often results in the persecutory personality emerging to make the acquaintance of the therapist, albeit sometimes leading with suspicion and mistrust: “I don’t believe you care about me! Stay the hell away from us!”—a persecutor personality’s version of “Hello.”

The DID patient’s perception of separate personalities with different characteristics, such as age, gender, and appearance, has been thought to be an autohypnotic trance phenomenon. Thus, hypnotic interventions may be particularly effective with patients with DID. Guided imagery and formal trance induction can facilitate many interventions in working with patients with DID, particularly in managing symptoms and accessing experiences and personalities as appropriate. It is worthwhile for therapists to have some training in hypnotherapy, if only to understand altered states of mind and trance logic. The use of formal trance can be helpful but is not necessary to treat DID, and many hypnotic techniques that do not involve trance induction are useful. For example, the technique of hypnotic suggestion can be used to facilitate new skills: “I want you to take a moment and sit quietly and listen inside. I think it’s likely that you may be able to hear what other important parts of you have to say.” An attitude of calm assurance (even if the therapist is uncertain of what to do) assists in the effectiveness of this type of intervention.

Though all parts of the patient with DID must participate and cooperate in the therapy, the host personality has a special role, a concept that has been called the “centrality of the host.” It a major goal of the therapy to have the host personality achieve an awareness and understanding of the other personalities that have been disavowed, and to increasingly achieve control over the executive functioning of the entire personality system. However, this can only be achieved by having the host personality acknowledge the painful and overwhelming thoughts, feelings, knowledge, and memories that are held by the other personalities that have previously been disavowed. In almost all instances when an impasse is reached in patients with DID, it is caused by the resistance of the host to understand and accept the unacknowledged alternate personalities and what they represent. To the extent that these personalities remain disavowed, they begin to take on more autonomous functioning.

Somewhat paradoxically, if the host personality is able to begin to acknowledge and accept disavowed personalities, they can be more controlled and integrated into the self as a whole—somewhat analogous to the adage, “Keep your friends close and your enemies even closer.” However, it can be difficult to get the host personality’s cooperation in acknowledging realities that have been disavowed and disowned. Psychoeducation plays a major role in this kind of therapeutic work, and I have sometimes used stories and analogies as a way of teaching patients what needs to occur in the therapeutic process. For example, in trying to work out internal cooperation with persecutory personalities, I often tell patients the following story:

I’d like to tell you something about me that might help you understand your current dilemma. It’s a story that’s partly true and partly pretend (and I’ll tell you what parts are true and what parts I’ve made up). When I was a child, I was a very good child, generally obedient, polite, and well-behaved as my parents required. My next-door neighbor, Paul, was my best friend, and he was a good kid too, but he was definitely more adventurous, mischievous, and outspoken. Paul was the one who induced me into playing games like spying on our neighbors, stealing strawberries and tomatoes from neighborhood gardens, and playing telephone games such as randomly calling numbers and pretending to be a long-distance operator (only to hang up giggling uncontrollably).

When I was in the 6th grade, I had Mrs. Turner as my teacher. She had the well-deserved reputation as the strictest and scariest teacher in the middle school. She tolerated no misbehavior, and we students met her expectations—except on one occasion when she had to be away and we had a substitute teacher. Released (temporarily) from Mrs. Turner’s repressive control, we behaved badly and could not be controlled from talking to each other, passing notes, and throwing spitballs. The next day, when Mrs. Turner returned, she was furious, informing the class that she was very disappointed in our behavior and that she would enter an adverse note in each student’s permanent record. I was terrified, envisioning a future when I would apply to college or try to get a job only to be turned down because of this note in my record.

Unlike me, Paul was highly amused and had a plan of action. After we went back to his house that day, he called Mrs. Turner at home and yelled, “Rabbits! Rabbits! Rabbits! You old bag!” into the phone and hung up. I was both appalled and highly gratified. Now, let’s imagine that as Paul and I grew up, he took on this role of protecting and defending me, perhaps even more aggressively to the point of being chronically angry and rude. And let’s imagine that when we were teenagers that I said to Paul, “I know we’ve been friends for a long time, but you’ve really become an angry, unpleasant, and difficult guy. I don’t want to be friends with you and I don’t want you around me anymore.” What do you think my friend Paul might have been feeling at that point?

Patients almost always understand that Paul would have been hurt and angry—at me. And they almost always understand the analogy that their persecutor personalities have played a similar role in their lives but have been rejected and have become retaliatory. And they almost always understand the need to acknowledge the critical significance of the persecutory personalities and to begin the process of reconciliation.

Psychologist Ruth Blizard, PhD, has written eloquently about the dilemmas of working with persecutory personalities (1997, 2001). Her 1997 paper offers a sophisticated and pragmatic approach to treating abuser alternate personalities:

Abuser alters present a dilemma in the treatment of adults with dissociative identity disorder, because they often undermine the therapy as well as re-abuse the patient. They are paradoxical because they were created to help the child survive abuse, and continue to do so by abusing the self. They were often modeled after an abusive primary caretaker to whom the child was attached.… By understanding how abuser alters function to maintain attachment, contain overwhelming memories, and protect against abuse, therapists can better engage abuser alters in a therapeutic alliance. Empathy, cognitive reframing, and gentle paradoxical techniques can help host and abuser personalities become more empathic toward one another, develop common purpose, and begin integrating. (p. 246)

The crisis in the former country of Yugoslavia in the 1980s offers an interesting analogy to the DID system. Under authoritarian rule of president Josip Broz Tito, the many different ethnic factions in Yugoslavia functioned as a single entity, albeit with considerable repression of personal freedom for its citizens. This political situation is not unlike some trauma survivors who function in a state of rigid control in a chronic benumbed state. However, when the control breaks down, there is an irreversible fragmentation similar to the reemergence of the Balkan States following the death of Tito and the collapse of Communist Europe. Yugoslavia was fractured into Serbia, Slovenia, Croatia, Bosnia-Herzegovina, and Macedonia with renewed conflicts, warfare, and genocide. Peacemaking efforts with these states of the former Yugoslavia failed utterly, and an uneasy truce was only restored when the warring parties agreed to a truce with NATO forces acting only to facilitate their agreements. In a similar fashion, no therapeutic efforts can bring about internal agreements within the conflicted personality systems of patients with DID unless the whole patient is clearly motivated to do so.

Work with personalities who present as young children often brings a different kind of vulnerability to making errors in psychotherapy. Therapists are frequently confronted with situations in which child alternate personalities ask to be cared for, held, or nurtured by the therapist. Some child personalities are able to present in such a believable and disarming manner that the therapist sometimes loses sight of the fact that the child personalities exist as only a part of an adult patient. In fact, these child identities are personifications of the patient as a child—not actual children. As psychologist Sheila Shusta-Hochberg, PhD (2004), has described, treating these identities as if they are real children carries the real danger of allowing them to become fixated in childlike identities, as well as overall regression and impasses in the therapy. I do not use special ways of talking and relating to child personalities. I use a normal adult conversational tone and my usual vocabulary. If the child personalities do not understand me, I suggest that they “ask inside” for help. In this way, I try to model the expectation that they are to grow and develop. It is also critically important that family and friends who are aware of the child personalities do not overly nurture them. Although significant others—and the other internal identities—should have respect for their psychological validity and their contributions to the whole person, child personalities will not grow and mature simply with a simplistic focus on meeting their needs and wishes.

Therapists should keep in mind that child personalities need to conform to the constraints of reality, including the reality that the patient must function as an adult for the most part outside of the therapy, and usually in therapy sessions as well. Child personalities cannot rely on their therapists as the primary source of gratification and nurturing. In practical experience it seems inevitable that therapists have some role in providing care for the child personalities of the patient. However, any such nurturing should be viewed only as modeling to help patients begin to take care of themselves. Extensive reparenting schemes are always ill-advised and countertherapeutic. Any kind of reparenting should come predominantly from within the patient, with adult personalities taking on this responsibility. Promoting internal soothing and nurturing is often difficult, as the adult personalities in patients with DID are often resistant to internal caretaking of child personalities. After all, early abusive experiences often seem to have resulted in patients having to disavow and dissociate their identities as children and their legitimate childhood needs. Often, the DID system reinforces this separation. For example, it is common to find angry and persecutory personalities who punish child personalities in order to “teach” them that it isn’t safe to trust others. Therapists must insist that adult personalities begin to have empathy for the distress of internal child parts and to care for and internally nurture them as part of learning self-care and self-soothing.

The intense ambivalence of childhood abuse survivors about important issues (e.g., wanting to live/wanting to die, wanting to trust/fearing relationships, remembering the past/blocking out the past) may be apportioned to the various personalities in patients with DID, with dissociated parts holding radically different views and feelings. It is all too easy for therapists to forget that they are dealing with only a part of their patient at any given time, and not to consider the omnipresent internal ambivalence and conflict. Thus, therapists may find themselves understanding the patient with a very narrow perspective and advocating certain stances that are at odds with the patient’s interests as a whole. This kind of situation is frequently aggravated by the patient’s understandable wish to disavow conflict and ambivalence, as in the following example:

Anita, the host personality of a patient with DID, began arguing persuasively for more aggressive exploration of past traumatic experiences. The therapist had the sense that exploration was premature and was reluctant to pursue such a course. Anita became angry and accused the therapist of blocking her psychological healing, of not wanting to hear about her abuse, and of not being able to handle the stressful emotions associated with the abuse. Although he denied this, the therapist began to wonder if this were true. However, after some thought he said to Anita, “I know you feel strongly that you want to deal with the abusive events of your childhood. However, are you aware that there may be other parts of you who would almost certainly be completely overwhelmed by these memories, and that other parts of you would be frightened and angry by talking about secrets at this point? I will be much more comfortable working on the memories when you have much better internal communication and an overall better sense of safety and stability.”

The transference-countertransference dilemmas discussed in Chapter 9 are heightened in the treatment of severe dissociative disorders because the diverse and conflicting feelings are held in the different personalities and, at any given time, are not readily apparent. For example, it is common for the DID patient’s system of personalities to view the therapist as a savior, a perfect parent, a demanding disciplinarian, a harsh critic, a dangerous and devious enemy, and an incompetent and useless helper, among others. In understanding these patients’ transferential feelings, the motto should be: “What you see is never all you get.” In her workshops, trauma expert, Kathy Steele, MN, CS, advises that in situations of positive transference, the therapist should accept and not interpret the transference, but understand it as often being appeasement-based and deriving from the intense need to remain attached to the therapist. Positive transference is often followed by negative transference, a situation in which Steele advises therapists to stay attuned and grounded, to “step aside” from the intensity of patients’ feelings, to modulate one’s intensity in responding, to help contain patients’ affect, and to be genuine and honest in discussing the relational situation.

In the treatment of patients with DID, increasing internal communication through promoting co-consciousness is a crucial task. The amnestic and dissociative barriers are significant liabilities. These barriers not only preclude a sense of continuous awareness but also predispose patients and therapists to make decisions and act without awareness of the full range of patients’ thoughts and feelings. Thus, even from the beginning of treatment, the therapist must encourage and reinforce the relationship of various personalities to the personality system as a whole (e.g., “I know you have the experience of just going away, but I want to encourage you to stay and feel painful feelings, or to try and stay close when other parts of you emerge.”).

In addition to standard interventions that encourage sharing information among personalities, a variety of techniques can be used to promote communication across the alternate personality system. The use of a journal in which all personalities can write can be helpful when used with appropriate structure (e.g., what can/can’t be written, agreement on where it is kept, commitments not to hide or destroy it, etc.). Internal communication can also be encouraged through specialized techniques, for example, Fraser’s Dissociative Table Technique (Fraser, 2003), a hypnotic intervention in which the various personalities can visualize themselves sitting around a conference table and negotiating conflictual issues. The patients must see themselves as a kind of family system (albeit dysfunctional) that must find a way to act in concert and in harmony without exploiting, scapegoating, or attempting to destroy any member of the family. Of course, the need for helping the DID family system to achieve some sense of cohesion and harmony is particularly urgent, because ultimately this family cannot literally separate or split up.

DID PHENOMENOLOGY

DID is a disorder that can be dramatic in its presentation and can be a fascinating phenomenon. Even to sophisticated professionals, DID is striking as a model of the human psyche. In DID, one sees the separation of psychic structures, where hypothesized phenomena such as introjects and the punitive superego present as distinct entities. DID is also a model for understanding how overwhelming life events affect the human mind and how dissociative mechanisms can provide at least temporary adaptive protection. In addition, the dramatic changeability of patients with DID and their stories of tragic victimization arouse the interest of virtually all persons. However, excessive fascination or preoccupation with DID phenomenology can also have several untoward effects. Sensing their therapists’ interest, patients may become invested in prolonging their dysfunctional symptomatic presentation or may even play up the differences in the manifestations of their personalities.

Therapists’ overt fascination with DID phenomenology clearly leads to considerable secondary gain for patients in terms of maintaining their therapists’ attention. The clinicians who, in past years, have appeared on television or radio talking about their patients with DID, have written books with their patients, or have featured their patients in research or teaching may have allowed their patients to develop and solidify a primary identity as patients with DID, which is far from an ideal outcome. However, even more subtle preoccupation with the phenomenon of DID can sidetrack or obscure the main work of the psychotherapy, as in the following example:

Katie, a 21-year-old woman with DID, was admitted to the hospital. The outpatient therapist informed the inpatient team that the patient had a total of 76 alternate personalities. He was able to describe the personalities in detail, citing differences in appearance, age, gender, mannerisms, and other characteristics. Katie showed frequent and precipitous personality switches on the ward, and she was generally out of control with flashbacks and other dissociative symptoms. The inpatient treatment team introduced a treatment regimen to help the patient achieve a sense of control over her behavior. As her behavior stabilized, it became clearer that Katie had focused on her personalities as a way of ignoring (and hiding from her therapist) her continued frequent contacts with her father who had been a perpetrator of abuse. She and her outpatient therapist were urged to focus on issues of personal and psychological safety, as opposed to a focus on the manifestations of DID. Although both Katie and the therapist were somewhat resistant to this idea, they were eventually able to find a way to work with the patient’s personalities in the context of rational overall treatment goals.

There is considerable evidence against the notion of iatrogenesis of DID in patients who do not already have dissociative symptoms (see Chapter 15 for more discussion of this topic). However, patients who do have dissociative symptoms, but who do not have DID, may consciously or unconsciously exaggerate their symptoms. Particularly in settings such as inpatient milieus and outpatient groups, an identity as a patient with DID, with distinct, well-defined, and dramatic symptomatology, may seem appealing. Therapists must help patients to understand and cope with existing symptomatology, and they must not even subtly encourage patients toward developing a greater degree of dissociation. For example, therapists should not label ego-state phenomena (Watkins & Watkins, 1997) as alternate personalities. Therapists should use unifying language consistent with the least degree of fragmentation that the patient is able to accept (e.g., “part” or “aspect” being preferable to “personality” or “person”). Overall, careful attention to the patient’s needs as a whole should be a priority, with the clear therapeutic intent of decreasing the level of dissociative fragmentation.

There are some particular issues concerning the names of personalities. For the most part, it is necessary and useful to use the names that the various alternate personalities have already adopted for themselves. However, therapists should avoid naming of personalities who do not already have names as this promotes more separateness. Instead, unnamed personalities can be referred to according to their characteristics or roles (e.g., “the one who deals with the parents” or “the part who goes to work”). It is permissible, however, to agree with the patient to change pejorative personality names. For example, in the previous clinical illustration of Stacie, it might have turned out that the Evil Father eventually self-identified as a 14-year-old girl who had to defensively take on a persecutory role. As the need for this role diminished, perhaps her name could have been changed to something similar but more benign, such as Evie.

Specialized treatment modalities that have been useful in DID treatment have been described in a variety of papers and texts. However, the use of any specialized treatment modality or intervention should conform to the following criteria: (a) the use of any treatments must adhere to the general principles of understanding and treating traumatized patients; (b) clinicians must be skilled in any modality utilized (e.g., hypnosis, expressive therapy, sensorimotor therapy, EMDR); and (c) principles of good psychotherapy must be respected. Clinicians must be clear that a majority of the interventions used in the treatment of DID and complex dissociative disorders involve the same fundamental skills that are used with all patients. Only a relatively few specialized perspectives and interventions are essential in the treatment of patients with DID.

In summary, the successful treatment of patients with DID depends on a thoughtful and rational approach. As with all severely traumatized patients, patients with DID must be encouraged to build solid coping skills before moving on to abreaction and eventual integration. Premature abreaction has little value other than venting dysphoric affect. Until patients can control dysfunctional behavior, tolerate intense affect, and maintain good collaborative relationships, they cannot work through traumatic events, so premature abreaction is largely retraumatizing. Therapists must also respect the need to proceed carefully in the process of uncovering personalities. DID patients’ intense interpersonal vulnerability should be respected, and therapists should use good clinical judgment to guide the therapeutic process.

The rational treatment of DID must always primarily focus on the treatment of the patient who has DID and not on the personalities or on DID phenomenology. The various personalities should be acknowledged, and therapists need to be skillful in working with them. However, the various personalities must always be considered as part of an overall family system, and the goals of the work should be toward increased communication, cooperation, and integration. Therapists should keep in mind that excessive fascination or preoccupation with DID may interfere with patients’ treatment or even encourage the development of further fragmentation.

Dr. David Caul once observed, “Therapists should always remember that good basic psychotherapy is the first order of treatment regardless of any specific diagnosis” (Chu, 1992a, p. 101). This sage advice should be heeded by all therapists involved in the treatment of dissociative disorders. The treatment of patients who have survived profound childhood abuse is a challenging task for even experienced therapists, and the difficulties these patients present have the potential to lead to serious pitfalls and impasses. However, good clinical judgment and the use of sound psychotherapeutic practices permit rational and productive treatment for even the most challenging patients with DID.

1 Portions of this chapter were adapted from the article, “The Rational Treatment of Multiple Personality Disorder” (Chu, 1994).