Colin Ross, a pioneer and authority on DID, proposes to consider DID as a type of schizophrenia with dissociative features. He made this decision because “two thirds of people with DID meet structured interview criteria for schizophrenia or schizo-affective disorders.” [p. 131 Trauma Model Therapy, Ross and Halpern (2009.)] While this approach enables one to conform to the DSM Criteria, in essence it is making a DID diagnosis more palatable to the general community of psychiatrists who are more comfortable identifying patients as schizophrenic than dissociative.

Despite my view presented in part 1 of this topic, of the logical inconsistency of merging a disorder that is classified as a neurosis (DID) with a disorder classified as a psychosis (Schizophrenia), there may be other tangible benefits to Ross’s re-definition of DID as a schizophrenia sub-type. Such an inclusion of DID as a subtype of schizophrenia may prove effective for heightening awareness of DID within the psychiatric community. As such, it may be very helpful to DID patients, so long as the therapy is correctly targeted to the DID rather than the conventional (and drug treatment related) approach to schizophrenic patients. Without that refinement in treatment understanding, this may prove difficult for practitioners to truly grasp and implement. Below, I have paraphrased Ross’s explanation of this view, and as such, any error in the paraphrase and explanation is entirely my responsibility.

1. “A proposal of having a dissociative sub-type of schizophrenia facilitates the technique of talking to the voices, otherwise therapists will never talk to the voices.” This is a reasoning that may have wide benefits in the treatment of DID, if it enables psychiatrists to grant themselves the permission to indeed engage directly with alters.

2. “A large number of schizophrenic or schizo-affective patients do not respond to conventional treatment using medication. The ethical burden or political barriers of talking to the voices are reduced when conventional treatment has not worked.” This is a subcategory of 1 above with an important added benefit of a specific criteria indicating the need for directly talking to the voices – that the medication that has been proven to work with schizophrenics has not worked for the patient in question.

3. “Talking to the voices often works.” As I said before, the proof is in the pudding. It seems to me the main purpose of including DID under the broad rubric of schizophrenia is to remove mainstream psychiatry’s roadblocks to the technique of direct engagement with alters. It is my hope that the more psychiatrists experience the treatment benefit of speaking directly to alters, the more they will understand the efficacy of that approach in healing the trauma that is at the root of DID.

Returning again to the ABCD of schizophrenic symptomatology, when speaking to the voice(s) respectfully, a genuine schizophrenic will likely respond with a statement that indicates a wide gap in his connection to reality while DID patients respond with contexts that make the content understandable in that specific context. The statement from the patient could be as simple as “ There is no way I can speak to you.” A true schizophrenic may give an explanation along the lines of “The clouds this morning were shaped like pumpkins so clearly I am unable to communicate with you.” No matter how you go at that kind of response, there isn’t a bridge to enable understanding. A DID patient would say something quite different that does indeed give a context that enables understanding.

This example comes from a DID patient that trusted me enough in our first meeting to tell me, unprompted, of her abuse history, Then, in a somewhat different voice, immediately said that she couldn’t continue therapy because there was no way she could speak to me. This made no sense as she clearly had just spoken to me on an extremely deep level revealing core trauma issues. A few moments later, when I asked why she felt she couldn’t speak to me, she gave the context: She had been abused by someone named David. Therefore, she (or one of the alters then presenting) simply could never trust me nor anyone else with that name. I immediately understood the issue and did not argue. Instead, I referred her to another therapist with a different first name.

Nevertheless, I could have mistakenly convinced myself of an ABCD analysis fairly easily. I could have presumed that the different sounding voice telling her she could never trust me was an auditory hallucination she was simply describing out loud, the non-trusting voice was broadcasting thought to the “actual” patient, the non-trusting voice was asserting control over the thoughts of the “actual” patient, and finally that the “actual” patient had the delusional perception that I was irrevocably related, solely through the link of my first name, to an abuser.

While this ABCD analysis may seem trivial or specious, I saw many such analyses in patients diagnosed as schizophrenic that were referred to me – even as their files indicated strong dissociative features. The impact on such patients of the incorrect diagnosis followed by the impact of inappropriate medications – often over long periods of time – was incredibly harmful to the patients and their families.

I included a few examples of success using the approach of speaking directly to alters in Volume One of Engaging Multiple Personalities. I also included failures when that approach was not used. Without talking to the voices, the patients who succeeded in healing would not have stood a chance of any recovery. In Volume Two of Engaging Multiple Personalities, I make recommendations to therapists concerning implementing the technique of direct engagement with alters.

Again, it is my aspiration that more therapists will at least explore directly communicating with alters in patients with DID, or suspected cases of DID, so that they will have their own experience to consider. They can then make their own assessment as to “the proof in the pudding.”