There are several key points a therapist supporting an individual with DID needs to keep in mind.
[1] As noted, a therapist must be aware of the dangers of showing favouritism towards specific alters in therapy. Therapy is not a warm social chat over tea. Supporting the patient’s healing to the task, which means not limiting the therapeutic alliance to alters that are attractive to you.
[2] When a patient engages in intimate sexuality with their partner, what should they do if another alter is switched with a retraumatizing flashback triggered by that intimacy? Once a therapeutic alliance is established, it is more likely that the patient will raise issues. If this is one of the issues, you need to have recommendations ready for them as well as recommendations ready for what they might say to their partner – knowing that their partner may or may not know they are DID. These topics have been addressed in my blog and are accessible in Engaging Multiple Personalities Volume 4 which is a free downloadable pdf or ebook that is easily searchable [https://www.engagingmultiples.com/ at the bottom of the page]. One key point is that they must raise the issue, not you in order to protect the therapeutic alliance and not be seen as trying to cross their personal boundaries uninvited.
[3] In general, DID individuals are capable of time loss and one should assume that alters will switch in or out at unexpected moments. There are some general guidelines that can be provided by the therapist for these situations, but they involve primarily ongoing grounding work rather than something to be done in the midst of such an event.
In DID, this notion of multiple identities or personalities remains a most troublesome locus of confusion. Many therapists mistakenly think that since this splitting into different alters in the definition of the pathology, alters should be eliminated. They even refuse to acknowledge the fact that splitting into fragments is a well established fact – certainly from the patient’s experiential point of view.
Alters think and feel that they are separate individuals, they know who they are just as ordinary people know themselves. While this may be argued till the cows come home, it is undeniably how they experience both the outer and inner world. Ignoring them or arguing that they do not exist is counter therapeutic. It is parallel to how one would waste time trying to convince a schizophrenic patient that the voices they hear are false, that they are just hallucinations. Don’t waste time and energy, and don’t undermine whatever therapeutic alliance you and your patient create.
In DID, each “personality” or “identity” demands to be treated as an individual. For the sake of communication, as a matter of basic empathy and human kindness, the therapist must honor that. Understand that the dissociation habit is firmly entrenched in DID patients over many decades. Therefore, it is absurd for the therapist to worry that he/she may be making the patient worse by “reinforcing” the pathology of dissociation by talking to individual alters. This is a most common worry in the uninitiated therapists. Refusing to relate to each alter as it experiences itself cuts you off from a golden on-ramp to communicate to the patient. Communicating to alters is the real work in DID psychotherapy.
Therapist need to engage in heart to heart talks with whatever alters engages them. I usually let the system decide who needs to talk to me in terms of urgency or priority. It worked quite well to trust the internal system. With few exceptions, I did not have to intentionally bring any specific alter out for therapy. When time is being wasted in therapy, it is often because the therapist seeks to control who “must” come out to talk.
