Second, there will be chaos/confusion in the patient when alters are in conflict. At the beginning of therapy, some of them may not have the capacity to understand the fact that they share the same body as other alters as well as with the host. Some alters do not even know of the presence of the others, and some simply don’t care. Often, they are caught up in competition with other parts for control of the body – looking for the chance to emerge, communicate or assert their will.
Some parts may focus on monopolizing control of the system as much as possible, while others come out briefly to make a point or react to something they are triggered by. Fighting for control of the body is a common indicator of DID. It can show up, for example, if the host is tired and needs to sleep. As the host tires, an alter may feel strong enough to hijack the body for a night out because that alter wants to go dancing. It can also show up when a trigger of some kind is encountered. When a retraumatizing trigger is experienced, the power of that retraumatization opens up such a powerful memory of trauma that the alter connected with that specific trigger takes over in an instant.
This hijacking of control may produce time loss, another common indicator of DID. Time loss is amnesia related to a chunk of time when an alter other than the host is out and in control. That chunk of time is often inaccessible to the memory of the host because the host was not co-conscious with the alter that seized control of the body. This is very distressing for the host. In fact, it is often the complaint/concern/confusion that drives someone with DID to seek therapy.
This lack of co-consciousness of the host and alters is a major difficulty that is to be worked through in therapy. It can only be worked with and through when the different parts begin to establish a therapeutic alliance with the therapist. In other words, healing can begin only when the traumatized alters begin to feel the possibility of safety in therapy.
Invariably, some alters are present who hold the original unresolved trauma and have been holding it since it occurred. It is true that the body keeps the score with respect to unprocessed trauma, both the original and subsequent traumas. Therapists can be confused by this in that the way unresolved trauma expresses itself is cloaked. It is usually not accessible to either the patient or the therapist.
The fact is that traumatic memory has likely been expressing itself as symptoms for decades, but the symptoms aren’t labeled “unresolved trauma.” More likely, they are physical symptoms or pain, discomfort, anxiety, depression and panic attacks, for example. These are all symptoms that may result from DID, from non-DID trauma, from car accidents and other difficult experiences. It is up to the skill of the therapist to establish a therapeutic alliance that will allow for clarity in diagnosis and successful
psychotherapy – whether the diagnosis is DID or otherwise.
Therapists can be confused as the patient may have no explanation or awareness for the triggers, or for the linkage between triggers and the trauma. For example, I have seen the pain from motor vehicle accidents bringing back fragmented painful flashbacks of the original trauma. A patient with that kind of pain, triggered by experiences that their general medical practitioner may not recognize as being based in old trauma can produce pain that is quite intense. The result is prolonged and unnecessary use of pain-killers that generally doesn’t solve the pain problem. Why? Because it fails to address the underlying source of the pain which, in the case of DID, is early childhood trauma that has not been healed.
Direct memories of trauma are excruciating, retraumatizing, and will often only return as flashbacks when the individual is triggered. The result is that a therapist sometimes has to spend time with one alter treating his/her PTSD, and then with the next presenting alter treating that one’s PTSD, and so on. At the same time, this does not mean that each and every alter needs to have direct psychotherapy.
Remember the original caution about who you are speaking with and that other parts of the system are always watching and listening? In my experience, this allows for alters that do not directly present themselves to receive the benefit of therapy being applied directly to a different alter.
People with DID often trapped in their hypervigilance. Hypervigilance is the result of having one’s sense of safety decimated by trauma. It is expressed by the continuous searching for threats regardless of any external metric of safety. There remains the ongoing fear that one might miss a dangerous threat that may be lurking about, waiting for the slightest relaxation on the part of the DID individual so as to pounce without warning.
If you can help one alter lower their hypervigilance down to ordinary levels of general vigilance, this will ease pressure experienced by many other parts of the system. This happens because those parts listening in on therapy directed to other alters will hear the therapeutic message as well. They will evaluate its impact on that alter and consider how it will impact them.
In order for this dialing down of hypervigilance to be effective, the therapist must always remind and caution the entire system that dialing down hypervigilance does NOT mean eliminating vigilance. It
means maintaining a watchful eye at the level of ordinary vigilance – like looking both ways before crossing a street.
As I mentioned, psychotherapy is focused on working through and processing early childhood trauma in each alter as they present it to the therapist. In this context, EMDR, Exposure Therapy, and other treatments may be used, but to maximize the effectiveness of any mode of treatment the therapist must understand the complexity of the relationship between early trauma and current flashbacks, depression or anxiety.
Understanding this context, therapy will then make sense to both the therapist and the patient. If the process makes sense, then the treatment will be far more effective than mechanistically applying EMDR, CBT, or DBT in targeting a symptom or even in the application of a medication. The positive aspect of remaining aware that all the alters are watching and scrutinizing you as the psychotherapist is that you can sometimes invite one or more alters to begin to function as an inner guide/helper, as a co-therapist, or even simply as a friend to another frightened isolated alter. When such invitations are accepted, which you can suggest even on a trial basis, it very much accelerates the healing.
The benefit of an alter accepting this role is that helpful alters can be present all the hours between therapy appointments, while the therapist is only present during that one hour of psychotherapy in the office. When therapy is going smoothly, this possibility often arises. This is one of the pleasant surprises in DID therapy. As a therapist, encourage this periodically after the therapeutic alliance is established and deepened. Please don’t waste this possibility of what can be a positive and powerful internal support.
