The approach I took to treating my DID patients is presented throughout the Engaging Multiple Personalities Series. The primary foundation of the approach is to engage those personalities as and when they present in therapy. The focus is to allow healing to take place while lowering the risk of re-traumatizaion. The risk is lowered by no calling alters out, challenging their existence, or demanding they disclose their memories. It is applying psychotherapy to the trauma as it presents right now in each session. It is remaining clear that the symptoms you see, the alters, are not the cause, which is ongoing early childhood trauma. Keeping that in mind, the alters hold the key to the path of healing.
As my readers know, I was and am averse to the use of psycho-active medications as anything other than an adjunct to psychotherapy. I am aware of, and have had questions from, people that seek help with their DID from alternatives to psychotherapy that are not based on psycho-active medication, such as hypnosis and EMDR.
With respect to HYPNOSIS, I have great reservations about it. There is often the suggestion that using hypnosis will enable the therapist to verify or help the patient retrieve a memory. This betrays the misunderstanding of dissociation as memory impairment rather than a protective device to shield one from being overwhelmed by trauma. It also betrays a general misunderstanding of the trauma that produces DID.
I did pursue training in hypnosis early in my career. I found it unnecessary, and potentially harmful, for those with DID if the sole or even primary purpose of using it is to get a picture of the original trauma(s) as a predicate to or part of treatment. I do not believe hypnosis is helpful because treatment does not require a detailed level of accuracy regarding the original trauma(s). The therapist really only needs to see how the trauma has affected the patient in the past and how it is affecting the patient in the present to move forward with therapy. Seeking details, parsing them or evaluating their accuracy, is of very limited value. Further, it runs the risk of being perceived as attacking the patient/alter expressing those memories and re-opening wounds that the patient may not yet be prepared to process.
There are numerous therapeutic techniques to help a patient get in touch with a present feeling of safety and comfort (grounding techniques.) These are less flashy and much safer for the patient than hypnosis. They take time and practice, but give patients tools they can use outside of the sessions. In short, they empower patients in their own healing journey.
Hypnosis is the inducement of dissociation. Because DID patients are already experts at dissociation, it is easy to induce dissociation in a therapy session through hypnosis. This can intensify the already hierarchical aspects in the relationship between the client and the therapist. Structuring therapy around hypnosis can accentuate both the issues and consequences for the patient’s panic of being out of control. It undermines the possibility of the patient’s self-empowerment to process past trauma.
Self-empowerment is key to a patient strengthening their ability to work with flashbacks while avoiding re-dramatization. Given that flashbacks will happen outside the context of a therapy session, further undermining a patient’s ability to deal with triggers they encounter in their everyday life, this is not something I would encourage.
If a therapist is comfortable in using hypnosis and is aware of the dangers that I have mentioned above, I suggest they discuss the issues with the client. That way there is more likely consent possible from the patient. Actively seeking that consent is at least an acknowledgement to the patient that they are in control. The patient being in control of the choice can encourage the sense of self-empowerment.
EMDR is another alternative treatment that people discuss and sometimes pursue. I don’t believe that any treatment, other than as an adjunct to psychotherapy, should be pursued. However, I am aware that there are people with DID who feel they have received great benefit from EMDR. Please do not stop any therapy that you believe is helping you simply because of my bias.
And yes, like all human beings, I do have my bias: I think it is erroneous to state that EMDR is a treatment specific for DID. While it may have benefits for some with DID or other disorders, and there are some studies showing that to be the case, it is like saying the scalpel is the specific treatment for cancer. Like a scalpel in skinful hands, EMDR is a tool which can be usefully applied. But in the wrong hands, like anything else, it is useless and may indeed be harmful. As always, it depends on the skill of the therapist to deal with potential re-traumatization issues, many of which likely will occur outside of any EMDR session. If you do explore EMDR as a treatment for DID, make sure that the EMDR therapist has an understanding of the dangers and risks of re-traumatization within and beyond the confines of the therapy sessions.
GENERAL GUIDELINE is that there are many disorders unrelated to DID that have symptoms that are common in DID as well. The message for therapists is the importance of retaining DID in one’s index of suspicion when working with patients. Without that, it is easy to misdiagnose those with DID.
There are many who suggest that DID is a fad diagnosis, not a real one. This is despite the fact that DID, under the acronym MPD, has been in the DSM since its 3rd edition in 1980. The most common logic I have been given is for the presumption that it is not a real diagnosis is, “Since I don’t remember what happened to me when I was 3 years old, I don’t believe that a patient could remember anything that happened to them at that age.”
This is foolish. If those same horrific things had happened to such therapists at the age of three, it is quite likely they would indeed remember,unless the memory is dissociated and stored in a separated part or an alter. Horrific experiences and the response to them are burned into a person much differently than say, the time your Aunt brought you a birthday cake at the birthday party when you turned three. The difference is that trauma may show up as symptoms, not readily accessible memory.
DID usually presents to the therapist as an individual suffering from depression, personality disorder, anxiety disorder, schizophrenia, and substance abuse. According to Colin Ross, author of a key textbook on DID in 1989, only 1/5 to 1/3 of DID patients are initially diagnosed as DID. If the initial diagnosis is depression and the psychiatrist is vigilant, with the proper index of suspicion, he/she will in due course identify the real diagnosis as DID and will apply the right kind of psychotherapy. This separates the conscientious therapist from those who just rely on blind faith in antidepressant medications.
Both traumatic memory and amnestic barriers within a mind’s system need to be taken seriously. Nevertheless, there are still psychiatrists who personally told me that childhood trauma is much exaggerated. They insist it is exaggerated, both in number and intensity, despite the ever increasing numbers of abused children showing up in studies, hospitals, and psychiatric wards. Some percentage of these children will show up again as adults with Complex PTSD and likely some DID when they are adults – just as was the case over the course of my career.
It is not dissimilar to the early days of what is now labeled PTSD from war related trauma – military and civilians both. Before anyone wanted to acknowledge it, this was happening – whether it was termed “battle fatigue” or some other term. Once acknowledged, clinicians heightened their index of suspicion and identity war related PTSD. But this was only acknowledged due to the overwhelming pain of veterans and their families dealing with their return.
If clinicians are taught to have the proper index of suspicion for DID, they will see, as I did, that DID presents alters suffering from past unresolved trauma that need healing.
In treating DID patients, my job was to regulate the outpouring of remembering. If anything, it was to titrate the patients’ exposure to their memories, rather than to dig around in the past. The only time I got details of abuse was when patients needed to express them. The abuse always displayed its impact through alters, hyper-vigilance, and other PTSD symptoms.
There was no urgency or even need to prove the accuracy of each and ever recollection my patient might hold. Again, that is because therapy is based on how past events resulted in present dysfunction – not about whether the patient remembered details of the abuse sufficient for a judge or jury.
Consider it to be analogous to treating a veteran with PTSD: Knowing that veteran was hurt in a roadside bombing, you know there is PTSD. That is all one needs to provide therapy. No therapist needs to ask about the details of that bombing to provide therapy. In fact, unless and until the veteran brings them up one shouldn’t push for them. DID clients need help in reducing the internal conflict among alters inhabiting that one body. In general, alters are in varying degrees of co-consciousness with the host and each other – from none to quite a bit.
If they are not, the therapeutic goal is to gently weaken the amnestic barriers step by step.
To do so safely, it must be done small step by small step. When they begin to find ways to co-exist peacefully, their previously violent clashes of individual claims of freedom and demands begin to ease. Slowly, slowly, healing is seen as more and more possible. And the path of healing is traversed.
Some therapists appear to be obsessed with the idea that therapy means convincing a patient that alters are not real, that they should be eliminated, or they should disappear into integration. This is wrong, a complete waste of time and counter-productive for a therapist to try to convince a patient that the alters are not real. Fundamentally, it is unkind and a barrier to establishing the critical therapeutic alliance necessary to working together.
To a custom officer at the border looking for a single passport, whether alters are real or not might be a relevant point of discussion if a DID individual shows up alone in a car and states that there are 30 people inside wanting to cross the border. But, in other situations patients may find themselves in, alters are as real as the painful sensation I feel when I bang my shin on a low table as I walk around my apartment.
No reasonable person would consider it helpful therapy to argue with a depressed patient that he/she should not be depressed because there are so many people around the world who are starving, dying from cancer, or in broken relationships? That is what people often try at home. It usually doesn’t work there which is why the patient with depression goes to a therapist. Let us be kind, be compassionate, and be a support for our patients’ healing, not a further obstacle.
