DID is not a Weakness, but Rather a Strong Desire to Survive

 This is quoted from an anonymous survivor of DID. Dissociative Identity Disorder or DID was previously known as Multiple Personality Disorder. There are many different treatment methods, but the main focus in this paper is on the individual psychotherapy process.

Symptomology

Dissociative Identity Disorder is when one experiences a disruption of identity by two or more distinct personality states. People with DID may have a noticeable disturbance in their sense of self. They also tend to experience dissociative amnesia, or large gaps in their everyday memory, and find it difficult to recall important personal information or specific time periods in their life. These symptoms impact the individuals’ daily functioning socially, occupationally, and in other major areas in their life. An alteration in one’s sense of self may come about with a sense of a loss of control. One may feel like an observer of their “own” speech and actions and feel powerless to do anything about it. 

Additionally, strong emotions, spontaneous actions and other impulses may suddenly appear, with no sense of ownership to the individual. There may be a shift in attitude and personal preferences, such as what food they like, or what style clothing they prefer. Some individuals even report a physical switch, such as feeling like a different gender, or age. Lapses in memory can be one of the most frightening symptoms for individuals suffering from DID. Gaps in memory can be on a large scale such as completely forgetting childhood years, or death of a loved one. It can also manifest itself as lapses in dependable memory, such as forgetting a well-learned skill like driving, finding unexplained injuries, or “coming to” in middle of doing something. Many people with DID find themselves in places and don’t remember how or why they got there. They may possess numerous alternate personalities, or alters, without them being aware of it. The alters tend to come out, or go through a ‘switch’ during dissociative flashbacks, but they can come out at any time and any place (American Psychiatric Association, 2013).

Prevalence

The prevalence of Dissociative Identity Disorder in a twelve month study in a small community for adults was 1.5%. For males it was 1.6 % and females it was 1.4% (American Psychiatric Association, 2013).

Comorbidity

Typically, individuals suffering from DID experience symptoms of depression, anxiety, substance abuse, self-injury, and non-epileptic seizures. They also tend to have some comorbid disorders, the main one PTSD. Other comorbid disorders include depressive disorders, trauma and stressor related disorders, conversion disorders, somatic symptom disorder, eating disorders, substance-related disorders, obsessive-compulsive disorders and sleep disorders (American Psychiatric Association, 2013)

Etiology and Risk Factors

DID is most closely associated with traumatic events and/or recurring childhood abuse. It is best understood as a defense mechanism created subconsciously by an individual to attempt to prevent the overwhelming reality during a trauma to enter their conscience (American Psychiatric Association, 2013). There is a case study of a girl named Kerry who endured recurrent sexual abuse by her stepdad. During the abuse, she imagined it was happening to someone else. She imagined it strongly enough to completely remove herself from the situation, thereby creating an alternate identity. Over time, she created more identities, and was completely unaware of them (Ringrose, 2011).

 One risk factor is the environmental aspect. Physical and sexual abuse increases the risk of DID. In the US, Canada and Europe, 90% of people with DID have experienced some form of childhood abuse and neglect. Many reported other traumatic experiences such as medical procedures, war, childhood prostitution, and terrorism. There is a large suicide risk for people with DID. Over 70% of patients with DID have attempted suicide, and majority have had self-harming behaviors at some point (American Psychiatric Association, 2013).

Treatment

Although dissociation serves an important purpose during a trauma, its long-lasting psychological effects can lead to a desperate need for treatment. Similar to individuals suffering from complex PTSD, treatment for those with DID is likely to be long term, and can take anywhere between two to ten years (Ringrose, 2011).

The most common and effective form of treatment for DID is individual psychotherapy (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011). This paper focuses on the use of psychotherapy for the primary treatment of DID. Other treatment methods are less effective, and not usually successful (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011).

Group therapy, for one, is usually not very popular for individuals with DID. Many people with DID have a hard time tolerating the strong emotions elicited by traditional groups, or the encouragement of discussion of the participants’ traumatic experiences (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011). Additionally, DID is very individualized. No two people sharing the same diagnosis will have the same experience, in terms of alternate personalities. Psychotherapist Jo L. Ringrose (2011, p. 298) on the discussion of treatment of DID writes “…approaches are like one-size T shirts, they fit surprisingly few”. This further demonstrates the point that groups cannot be as effective in working through the consequences of DID as individual therapy. Although group therapy is not a practical primary treatment method, it can assist with the development of specific skills such as learning to create healthy coping strategies (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011).

Another example of a treatment method is pharmacotherapy. Although clinicians tend to use medication at some point with clients suffering from DID, the meds generally target the symptoms of the accompanying comorbid disorders. They may give an individual medication to help with the intrusive flashbacks from PTSD, or medication to alleviate anxiety related to the disorder, but as of today there is no medication specifically to help DID itself. Surprisingly, medication for individuals with DID is usually not advised, as there is a possibility that alternate identities within a DID patient may have different reactions and side effects to the same medication. It is unclear how that happens, but it is generally known that medications are likely only effective when the symptoms are reported across the ‘whole human being’ (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011).

Eye Movement Desensitization and Reprocessing, or EMDR, is another therapeutic approach and it often shows pronounced results. However, it must be modified from the standard EMDR for cases of DID. There were reported incidences of individuals with DID who underwent standard EMDR therapy, and experienced serious clinical problems such as unintended breaches of dissociative barriers, or emotional flooding. Modified EMDR procedures can be used for exact work on specific traumatic material, and should only be administered by clinicians familiar with the treatment of DID (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011).

The final aspect of treatment that will be discussed is the individual psychotherapy. Usually, the ultimate goal in therapy for those with DID is integrated functioning. The objective is to combine all of the individual personalities and form one solid, healthy character. The process of merging all of the personalities together into a unified self is known as ‘final fusion’ or ‘complete integration’ (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011).

Unfortunately, a large number of DID patients will never have the opportunity to experience this end result. One reason for this is that it is very costly (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011). Psychotherapy for DID patients can stretch for years on end, and they tend to need longer, more frequent sessions (Ringrose, 2011). Other factors can contribute to not reaching the end goal such as chronic or serious situational stress, avoidance of unresolved painful life issues, and comorbid medical disorders (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011). However, one does not need to come to a ‘final fusion’ in order to properly heal. Just working with an experienced clinician can achieve sufficiently integrated and coordinated functioning between individual personalities (Volume 12 Reviewers for the Journal of Trauma & Dissociation, 2011).

In beginning the therapy process for an individual with DID, a therapist must keep a few key elements in mind. Although the ‘host’, or the main identity, has agreed to share a trauma, it does not mean the other alters agree. A clinician must attain permission from all of the alters before agreeing to hear the trauma. Without doing this first, there is an increased risk that one of the alters will attempt suicide or self-harm. In a case study, one female with DID landed up in the hospital with a slit throat after a therapy session. She had a male alter that tried to get her to be quiet about a traumatic event, and did not realize that trying to kill her would ultimately kill him. 

This is where a therapist would have to step in and act as a communication board between alters. In some cases, alters can communicate with each other, and others not. J.L. Ringrose (2011, p. 298) gives an analogy that can make it clearer to understand. The body is compared to a house with the alters representing the rooms. Some have the door open, and have open communication with each other, while others have the door firmly shut. It is the therapists job to foster communication and cooperation between the host and all of the alters. The more the therapist can create a relationship between alters, the greater the exchange of information will be, which reduces memory loss and encourages unity. As therapy progresses, the more “co-conscious” the alters will be with each other, and they may be encouraged to call on each other in time of need (Ringrose, 2011).

Another piece that is important to realize as a therapist, is that in order for a client with DID to properly work through traumas, the therapist must map out the alters and really get to know them. Only once all the alters are stabilized and settled in therapy, can the therapist have direct conversations with them. Trauma disclosure should be up to them and the trauma should be paced according to all the alters capabilities. Should the client eventually choose to integrate all the personalities into one, and all the alters agree, the therapist will have to get all of the alters to work together and push hard to pursue their goal (Ringrose, 2011). Many clinicians feel that the primary goal is not integration. They believe that more realistically, the objective is to create a stable sense of unity and understanding between alters (Rothschild, 2009).

There was a case study of a woman named Sara, who only realized she had DID at age 43. Throughout her therapy process she used a notebook to communicate with her alternate personalities, and interestingly enough, all of her personalities had different handwritings. She came to recognize various aspects of herself, as she got in touch with her inner workings. She found the cause of her unexplained injuries when she discovered that one of her protective alters slept with a knife under her pillow to ward off intruders, while another alter used that knife to self-mutilate. Through the journal and their therapist being the moderator, the two alters agreed to put the knife away (Rothschild, 2009).

Discussion

There was a study done to examine what clients with DID consider to be effective qualities of counseling (Jacobson, Fox, Bell, Zeligman, & Graham, 2015). The applicants were asked about their perspectives on what was effective about counseling and what qualities of counselors were effective or ineffective, both in regard to DID. When asked “what has helped you recover from your disorder?” DID participants gave 17 effective approaches they benefitted from during therapy. One was the pacing of sessions, and the secure structure it gave them. Other common ones were grounding processes, coping skills, identifying and assigning alter roles, reviewing sessions, and self-disclosed insight. 

The grounding process seems to be one of the most important ones for the participants. In between therapy sessions, during a moment of high emotion, some clients felt the need to call their therapist and hear his/her voice to ground them. Learning proper grounding techniques was a skill many found to be super effective. Another great stress reducer mentioned, was the ability to properly identify and assign alter roles. Once identified, an alter can be given a specific task, thus limiting its power over the host. One participant said “the other parts report to me and everybody has their own job. And if we have someone that’s having a difficult time coming into the team, we try to find a job that they can do” (2015, p. 313) (Jacobson, Fox, Bell, Zeligman, & Graham, 2015).

Some ineffective techniques mentioned by the participants of the study are, lack of safety, confrontation, and lack of therapeutic plan. One participant said “what’s not helpful for me is we can just talk about whatever you want whenever you want, doesn’t matter. I need a little bit of a push, a little bit of a focus” (2015, p. 315) (Jacobson, Fox, Bell, Zeligman, & Graham, 2015).

The study next discussed the positive counselor qualities that the participants agreed on. The main one was empathy. Others included validation, unconditional positive regard, genuineness, and life experiences. Participants described genuineness as their therapists’ ability to tune into their clients emotional process. The participants also mentioned some common negative counselor qualities which included lacking empathy, and lacking unconditional positive regard. Another big one was when they were being treated by inexperienced counselors. The end results of the study proved that effective relationship building was key, and empathy and non judgement played crucial roles. (Jacobson, Fox, Bell, Zeligman, & Graham, 2015).

In conclusion DID is a disorder that affects ones sense of self greatly. It is usually best treated through individual psychotherapy. When the different personalities are harnessed with the help of a competent therapist, any individual with DID can learn to cope with what they were given, and carry on to live healthy, happy productive lives.  

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