The question of whether or not to involve a patient’s Significant Other in treating individuals with DID is sometimes raised by patients, and sometimes raised by their SO (“Significant Other”). From the vantage point of 10 years of retirement after 40 years as a psychotherapist, I believe the real question should be whether it is realistically possible to exclude the SO when treating individuals with DID. If the answer is yes, then the next question is how to evaluate the level of inclusion, which will depend on the individual qualities of both the patient and the SO.
This issue has been on my mind for many years. In traditional psychotherapy, therapy is conducted specifically between the client and the therapist. It is a relationship that is necessarily structured to be private and confidential between two individuals. Why is that structurally necessary? It is critical to engender the sense of safety in a patient so that genuine communication can take place without fear of exposure.
Occasionally, the therapist may deem it appropriate, with the explicit permission or request of the patient, to speak with the client’s significant other. This can be for the purpose of gaining additional information as well as insight into what happens outside the counseling sessions. It may also be for the purposes of assessing the potential support or danger to the patient resulting from the qualities of their SO.
In many cases, the significant other will be able to report symptoms, that the patient does not recognize as a symptom, which may be suggestive of DID or other pathologies, such as poor regulation of mood fluctuations. Signs suggestive of mood swings can be easily ascribed to a diagnosis of Bipolar Affective Disorder. Before I gained experience in the recognition and treatment of DID, I ran into such a situation.
In this patient, I saw what appeared to be a textbook description of hypomania. The patient, who came to see me for depression, presented a mood swing that was so convincing and infectious that I felt carried away with that sense of joy and happiness. I never considered the possibility that I was meeting one of her alters who emerged during that session.
In addition to misidentifying mood fluctuations as Bipolar rather than DID, manipulative styles of rage, meanness, and threats of harm can sometimes be ascribed to Borderline Personality Disorder. This shows the danger in making a diagnosis based on symptoms alone without an appropriate index of suspicion on diagnoses that may include the same or similar symptoms.
While the therapist and the DID client meet in the “therapeutic hour” once a few days or weeks, the client’s significant other will have much more opportunity to meet, knowingly or not, with alters of the DID individual. Alters come out when they feel safe, when they are under stress, or when they are triggered by some environmental cue. Most likely, alters have emerged in front of the significant other during the time they have been together.
The therapist is simply not present outside the therapy sessions, and is likely to miss alters that might appear at specific times during each 24 hours period, such as just before one goes to bed, or in the middle of the night. Often a DID patient’s husband has told me of a young child alter crying in bed at 1 am; clearly an alter emerging as a result of a PTSD flashback. Usually the child would shiver in fear crying, and saying “Please don’t hurt me!” as they mis-identified their spouse as the abuser of their childhood.
Therapists should be cognizant of this possibility, and realize the necessity of preparing the significant other with guidance on how they might respond in that situation. Ignoring the alter is not an appropriate option, while responding in a demeaning short-tempered way will be extremely counterproductive. Because the significant other is much more likely to meet alters in the privacy of the home, I believe that some context needs to be presented, with the permission of the DID patient, in order for the SO to be able to properly support the healing process.
