Recently, I was asked a pointed question: What are the qualifications needed for a DID therapist to be able to actually help someone? The questioner is a social worker in Asia who is acutely aware of the lack of awareness concerning DID in his community. He asked me to consider the question and post my response in my blog if it might help people.
The question arose from his frustration about the difficulty in finding a therapist competent to treat DID. The problem is by no means limited to Asia, it is a worldwide issue. But, I feel it is important to re-frame the question from “What are the qualifications needed”, to “What are the qualities needed” in a DID therapist.
For many psychiatrists, there is no further inquiry once symptoms are labeled. For example, once a person is labelled as suffering from depression, the inquiry generally does not extend to getting a wider understanding of potential causes of the depression. Why? Inquiry stops because there is medication available to treat that symptom. That is a mistake.
This approach does not even try to address the cause of the depression. The unstated presumption is that depression, in and of itself, is the illness to be treated rather than potentially a symptom whose root cause should be identified to ensure appropriate treatment. While there is a disease called endogenous depression which responds to medications like an SSRI (i.e. nortriplyline), without inquiry, it is difficult to distinguish endogenous depression from depression that is the result of living with and being unable to extricate oneself from an abusive spouse.
In other words, depression can be an appropriate emotional response to an adverse living situation. Herein lies the many problem of diagnostic bias, treatment bias, and/or lack of empathy on the part of the therapist.
Consider, by analogy, a patient that has a fever. A doctor might prescribe something to bring the fever down, but that is generally done in concert with making efforts toward identifying the cause of the fever. If the fever turns out to be from appendicitis, failing to even seek to identify the cause of that fever would be grounds for malpractice should the appendix burst and the patient possibly die.
Unfortunately, the failure to make substantial inquiries after diagnosing depression in a patient is not necessarily considered critical in the mechanistic view of modern mental health “therapy.”
The mechanistic view, primarily a medication based view of therapy, +predominates the profession. It does not matter if the person has good reasons, conventionally speaking, to be depressed. That view is the very problematic result of seeing mental health issues as primarily, if not solely, biochemically based illnesses. Mental health professionals need to acknowledge that many of symptoms that patients present could very well be related to current life situations as well as trauma and neglect, both current and often decades old.
I have witnessed many such cases, where there was a mixing up of depression as a symptom and depression as a disease, during my 4 decades of psychiatric practice in different parts in the world. Unfortunately there are no laboratory tests or x rays to differentiate these different causes of what is identified as depression. The patient is reliant on the sensitivity and empathy of the therapist. For the impatient therapist, who thinks their job is done once the medication is prescribed, many patients will suffer from that therapist’s default mode of treatment.
A more effective approach is based on a comprehensive review of the entire history of the patient rather than merely observing the patient’s current behavior pattern, giving it a diagnostic label, and offering a pill to alter their brain chemistry. Instead, the therapist should always on the alert of psycho-social factors that may need to be addressed rather than stopping with a chemical solution to suppress the presenting symptom. Using a diagnostic label to describe a patient’s problem does not mean the clinician has found the answer or solution. Really, saying a depressed person is suffering from Depression, is just a tautology – a play of words.
I have focused this section on the symptom of depression. There are many other symptomatic considerations to examine before diagnosing DID, but the basic principle of the need for empathy and compassion to be above and beyond mere chemical intervention holds true.
If the mainstream clinicians, in psychiatry and psychology, are not interested in DID or are unaware of it through bias and/or lack of training, is there an alternative path for patients seeking DID treatment?
The basic qualities needed in a DID therapist are not complicated but are not so easy to find. The basic qualities are common to all human beings, but not always so accessible to therapists or laypersons. Fundamentally, one must go back to Carl Rogers’ criteria: empathy, positive regard and congruence.
I might add that the therapist must have stability in their own mental health as well. While that is not often mentioned, it is critically important. This is because there is a known risk of vicarious trauma therapists might experience when treating a patient’s experience of the horrors of early childhood abuse.
For therapists, I would suggest starting with a highly informative book, Trauma Model Therapy, by Ross and Halpern (2009), It is a 300 page practical study manual for training therapists for those suffering from trauma and dissociation.
The trauma model of mental disorders, or trauma model of psychopathology, emphasizes the effects of physical, sexual and psychological trauma as key causal factors in the development of psychiatric disorders, including depression and anxiety as well as psychosis. This is applicable whether the trauma is experienced in childhood or adulthood. The model conceptualizes victims as having logical and therefore understandable reactions to traumatic events rather than suffering from mental illness.
The trauma model emphasizes that traumatic experiences are more common and more significant in terms of etiology than has often been thought in people diagnosed with mental disorders. Such models have their roots in the 19th Century with Sigmund Freud (early trauma) and Pierre Janet (PTSD), and in the mid 20th Century with John Bowlby (attachment theory). There is significant research supporting the linkage between early experiences of chronic maltreatment and severe neglect with later psychological problems.
