For both therapists and the spouse/SO of DID individuals, there are several key points to supportively engaging an alter.

[1] One has to overcome the initial feeling of “inappropriate behaviours” of one, therapist or s/o, talking to an adult as if talking to a 4 year old child. Yes, it is quite a challenge doing this for the first time. While it may feel uncomfortable initially, it is not inappropriate. I insist that this is the only appropriate behaviour if we understand what dissociative identity really means. I think one of the problems some psychiatrists basically cannot overcome is thinking one is doing something wrong in “encouraging regression” or “encouraging dissociation.” They are missing the point of the nexus between dissociation and trauma.

[2] Repeated corrective experience offered to the alter(s) underlies the healing process for the DID patient. Sometimes the process is called “metabolizing” the trauma. That addresses part of the difficulties experienced by DID individuals. The other difficulties are related to the chaos experienced by them when their alters, rather than working together, act like a divided household.

The treatment of DID is accomplished through empathic talking to alters, whether at home or in the therapist’s office. Treatment of DID through cognitive behaviour, or EMDR as suggested by the popular literature one can find by googling, are but tools. But genuine healing requires engaging alters, not avoiding or trying to manipulate them.

I view DID therapy, going forward, as involving the following steps:

First, the therapist must come to the DID diagnosis. Be prepared that certain individuals with possible early traumatic experience may be suffering from dissociative identity disorder Remember this is roughly about 1% in prevalence in the world among diverse cultures and social backgrounds. It is not uncommon, just as early childhood trauma is not uncommon. Only a high index of suspicion will help therapists avoid missing such a diagnosis. Even experienced therapists who fail to identify indicators of such trauma will miss such a diagnosis.

Second, the therapist must ask the patient whether they trust their spouse/significant other with the diagnosis information. If no, then that ends the discussion concerning notifying and/or including the spouse in therapy – at least for the moment. If later on in therapy, it appears that the spouse is potentially trustworthy from the point of view of the patient, the therapist can raise it again in the context of giving tools to both patient and spouse/SO for use outside of therapy sessions.

Third, if there is permission from the patient to discuss the diagnosis with spouse/significant other, the therapist must first meet with the patient and the spouse together so as to be able to make an assessment as to whether or not the spouse has the interest and capacity to support their DID partner. This assessment must be made before disclosure of the diagnosis by the therapist. Then, a private conversation with the patient and without the spouse, must take place to review both positive and negative indications from the conversation between the spouse/SO and the therapist. The patient always retains their agency so as to decide on their own whether they wish to notify their spouse/SO of the diagnosis.

Fourth, the DID notification conversation needs to take place with the patient and spouse/SO together in the therapist’s office. This conversation needs to include the diagnosis, the basis for the diagnosis and a discussion of the general etiology of DID – early childhood abuse. This needs to include the severe warning to the spouse/SO that the actual history is something that is never, repeat never, to be inquired about by the spouse/SO. If the patient wishes to share anything, that is their decision and non-judgmental deep listening by the spouse/SO will be critically important.

Generally speaking, the specifics of the history are irrelevant to the therapy. Pursuing specifics will likely be extremely re-traumatizing. It will run the risk of undermining all therapy to date. Why? It is because pushing for disclosure or additional details will make the patient question whether or not they are safe right now, or perhaps are being set up for yet another betrayal. The only relevant information one needs to know as a spouse is that trauma is there.

Fifth, giving tools and guidance to the spouse/SO. All of this must be done with the patient present. This is again encouraging the patient to reclaim their agency in life. No decision is made without them signing off on it.

Sixth, ongoing therapy may or may not include the spouse/SO. It is critically important that both the patient and the spouse/SO understands that this is DID therapy for the patient only. It is NOT in any way shape or form marital therapy.

Difficulties the spouse/SO may have in the relationship might be relevant to the DID therapy but the DID therapist needs to be able to insist that the spouse/SO address marital issues separately with their own therapist. The patient’s therapist cannot be both the DID therapist and the marriage counsellor. Sessions should begin just with the patient. The spouse/SO should be included as and when the patient deems it appropriate.

If the spouse/SO has a question, a concern, or additional information they think is relevant for the therapist, they should write it down and give it to the therapist at the beginning of the session. They should then excuse themselves unless and until they are subsequently invited in. This allows for the therapist to give, with permission, feedback to the spouse/SO while being able to explore/address the concerns raised with the patient first.

It is possible, again in my limited experience including a spouse/SO in the therapeutic journey, for both the SO and the therapist gain insight into effective engagement with particular alters through feedback from the SO. If done, it should always take place with the patient present. This is key to ensuring that the therapy session remain a place of safety for the patient and all alters.

Again, there are strict boundaries that are necessary to maintain. The SO must, absolutely, simply report on their interactions without without attacking, being defensive or creating any emotional shading in the discussion. If the patient disagrees, even with a different memory of the patient regarding the interaction, that needs to be acknowledged without moving to a “who is right/who is wrong” debate.