I am writing this because, in my psychiatric practice, I made many mistakes over the course of learning to work with DID. From the perspective of having been retired for the last 9 years, I have reviewed my patient histories so that others may learn from those mistakes. This is the core of my purpose in publishing Engaging Multiple Personalities Volumes 1 and 2.
The education and training I received as a psychiatrist gave me no clue as to how to identify and treat DID patients. In particular, there was no guidance or even discussion of how to relate to a DID alter that might appear in a client session. Because the first encounter with an alter is critical to establishing the necessary therapeutic alliance required for treatment, psychiatrists and other therapists need to be aware of the pitfalls of not being prepared for such an event as well as the benefits that can arise from proper preparation.
In general, DID is rarely diagnosed during the first many therapeutic sessions. According to various authors and studies, most DID patients are only diagnosed after cycling in and out of the mental health care system for several years. This is because, unlike other disorders, DID cannot be discovered through questioning or “digging out” information from the patient.
The foundation of therapy is understanding that the diagnostic procedure is a mutual process: The therapist is assessing the patient just as the patient is also assessing the therapist. Until the patient feels safe with the therapist, and thinks the therapist is or may possibly be trustworthy, the patient is not going to share their innermost secrets or confidential material with the therapist. The DID patient, in particular, due to amnestic barriers between the host and alters, will likely be barred from even being able to access that information. Through decades of experience interacting with people, alters are hyper-vigilant in evaluating who is likely or unlikely to understand their plight. They will not risk being ridiculed by someone unlikely to listen with empathy, although they may conduct themselves with aggression if they feel threatened by the therapist and/or therapeutic environment.
In the event that the DID system deems the therapist worthy of being shown an opening to those innermost secrets, an alter may suddenly “jump out” in the middle of a therapeutic session. In such a case, at least for me in every case in which this happened, the therapist will likely feel “a shiver up the spine” sensation. It is a somewhat indescribable experience. To see a little boy suddenly appear in the body of a 45 year old woman in a business suit, with a young boy’s posture, manner of speech, and emotional presentation, amounts to more than a simple surprise. I developed a code of behavior for myself to follow when first knowingly encountering an alter.
These are the rules I established for myself (the therapist) in such a situation. I hope they will be of benefit to others.
1. I shall remain stable in my own mind, calm and non-reactive.
2. I shall treat the alter with respect and appreciation that he/she is willing to be seen by me and to talk to me directly.
3. I shall contain my curiosity and refrain from asking for a complete personal history of the alter as that could be interpreted as an interrogation.
4. I shall just wait in a silence of empathy. The alter will likely tell me all he/she wants me to know, with minimal leading questions.
5. The ultimate guideline of decorum is that I behave as if I were being introduced to a new person at a social event: I metaphorically shake his/her hand and sincerely say, “It is nice to meet you.”
The most common mistake therapists make is based on the idea that getting rid of the alters is the prime goal of treatment. In fact, the therapist should realize that the appearance of an alter is a golden opportunity to access and clarify the confusion created by the dissociation. The alter is the main path, the highway so to speak, to access the information needed to enable the alter(s), and the system overall, to process the trauma. Because of amnestic barriers, in many cases the host is not even cognizant of the abuse history. The alters hold the keys to the mystery of what is hidden behind the compartmentalization of the alters, what is being blockaded by the amnestic barriers in the personality structure of the patient.
Avoid seeing the appearance of an alter as the pathology. The amnestic barrier of dissociation is the real pathology. The priority now is to get acquainted with that sequestered part, which is essential in the healing process. That part may hold much information about the abuse history. Be prepared that there may be an abreaction in detailing the abuse history. So, do not demand details of the trauma and do not provoke the patient to recount them. Letting the alters feel comfortable and secure enough to establish a proper therapeutic alliance is the best, quickest and safest approach to avoid retraumatization. With a proper therapeutic alliance, therapy can generate a positive cathartic experience. Without it, there is only retraumatization.
The first question to ask is not about the personal history of the presenting alter. Rather, it is to find out the age and function of this alter. The age is important so that you use language that is age appropriate to the alter. If the alter doesn’t wish to say their age, then take your cue from how they are speaking to you in terms of how you respond to them. In my experience, the alter will usually tell you whether he/she is, for example, a protector, a persecutor, or perhaps a fearful and suffering child still holding the abuse memory so that the system can function in some capacity without the constant burden of the trauma. The alters generally are quite aware of their function, and sometimes can phrase it exactly in that way.
It is critical to understand that an improper reaction on the part of the therapist can lead to disastrous results and will probably close off any future communication. The unwary therapist taken by surprise may make inappropriate demands when a 45 year old patient starts behaving like a toddler, and blurt out an admonishment like, “Don’t play games with me. Act your age. Go back and sit on your chair.” In other words, harshly denying the alter right in front of you! Such a reaction, spontaneous or otherwise, is negating the person-hood of what appears in front of you. There can be no therapeutic alliance if you deny that alter.
An alter sincerely considers him/herself a separate identity. Why not just accept the alter on his/her own terms, exactly the way you would when meeting any patient who first comes into your office? No therapist can dismissively brush off a client and expect to work with that same client in any genuine way. You are going to have to work with this alter so treat him/her respectfully. This is the first rule.
In chapter 1 of Engaging Multiple Personalities Volume 1, the suicidally-depressed woman patient in her business suit suddenly morphed into an arrogant and proud 5 year old boy, boasting about his bravery and dismissing me as an idiot. I reacted calmly, and respectfully thanked him for talking to me. I addressed him in a matter of fact way inquiring for his name and purpose in being there. The result was to establish a therapeutic alliance with that alter but also to all the other alters that were listening in and watching. It was the key to the system preparing to trust me.
Conventionally speaking, of course the boy is not a separate person. But we are not meeting the alter in a circumstance where a government ID is required for entry into our office. We are talking about meeting an alter in the context of psychotherapy. Psychiatrists should have the flexibility of mind to accept that if there has been severe ongoing early childhood trauma, DID and the consequent appearance of alters, is reasonable, logical and appropriate to the circumstances. In this context, it is ridiculous to hold on to some argument about whether or not alters truly “exist” at all!
Don’t argue with an alter, trying to convince her that she is really the host. You may be legally correct but therapeutically it will be a disaster. We need to remain focused on what works as therapeutic intervention for healing from such trauma rather than trying to force our understanding of our own experience onto the patient.
Therapeutically, the boy alter should indeed be treated as a person in need of healing in his own right. For those therapists that simply cannot wrap their head/mind around the notion of an alter, perhaps an analogy would be helpful. To refuse to treat the DID patient because the alters are doing the talking rather than the host that you think you should be speaking with is ludicrous. It would be like saying you won’t treat a mute patient because they can’t tell you how they contracted their illness. You would not feel justified in denying treatment to a mute because someone else in their household told you they were running a fever, vomiting and sobbing all night long.
Please respect to bravery of the alters to come out and communicate directly. Anything other than that will ruin the therapeutic contact. Treat the alter as if he or she were a completely separate identity and the result is that you will benefit all the others, including the massively unhappy frightened host.
The other common mistake is to be anxious to learn the details of what is hidden. In the past, therapists were so focused on getting that information, on an almost gossip level, that injections of sodium amytal, hypnosis, or outright interrogations were used. Instead, by preparing the alter by letting him/her know that you are ready to listen, and providing a milieu of reassurance and support, a cathartic experience will naturally follow. You will get all the information you need to conduct psychotherapy.
There is no need to push. A cathartic experience is only therapeutically useful if done in a secure environment making sure the patient is not re-traumatized in the process. It should be done in a gentle way, as if the therapist is holding the hand of a child revisiting the trauma scene. The role of the therapist is bearing witness to a crime often committed decades ago, guiding and comforting the survivor as he/she goes through the journey once more, but this time with the critical difference being that he/she is no longer going through it alone.
Another task the therapist has to perform is to gently remind the survivor that the “here and now” is where safety is found. This has to be repeated many time until it hits home. There are all kinds of ways to convey this message. Mostly I would point this out through the “touch sense” (the kinesthetic sensation), reminding the alter that the traumatic experience happened in a different place, at a different time, and with people that are not now in the room. Often the alter is stuck in the past, usually decades past, and feels surrounded by the enemies that were the original abusers. Replacing the palpable fear of the past with a comfortable bodily sensation of warmth and relaxation, of heaviness in the limbs and so on, is often quite helpful. The therapist is now helping the system process the PTSD symptoms. This pointing out of “the past and the present” is essential. I would use all kinds of signs and clues to point out the passage of time and the difference in location.
Trust your own experience but be prepared so that you remain stable should an alter jump out to meet you. Know that it is a sign that the patient is showing his/her trust in you. The alter is giving you, the therapist, the chance to prove that you understand and will treat the alter with respect and acceptance, that you will not laugh at him/her, and that therapy will now take a positive turn. The alter is sharing with you a deep secret. Don’t waste this golden opportunity for therapy. Do the right thing!
