[1] Therapists Need to Stop Protecting Their Own Ego
Many psychiatrists and other therapists continue to question whether DID exists as a clinical disorder. Maybe they fear that by making such a diagnosis or that they will get laughed at by colleagues and be denigrated both publicly and privately. I speak of this from experience.
As I have written before, at the same time as my approach to treating DID was sneered at and demeaned by other local psychiatrists, I was referred a number of patients whose clinical files included the word “dissociative” when referring to the patient’s symptoms. And yet, not a single one was given either a primary or contributing diagnosis involving dissociation.
Given the statistics, it is extremely unlikely that any psychiatrist with a general practice has never seen someone with DID. However, it is quite possible that they never recognized it, given the training they likely received. For example, when I was trained decades ago we were told that DID was so rare that no one in the class would likely ever see anyone with DID.
A rough way to assess whether or not a psychiatrist has missed DID cases might be to see how many patients they diagnosed with “treatment resistant depression.” In my experience, treatment resistant depression actually means “drug resistant depression” – a very different thing. In my opinion, the odds are that most of the cases in that group are DID. Imagine how embarrassing it would be for a psychiatrist to publicly admit that, throughout a long career, he likely misdiagnosed DID cases because he didn’t recognize what he was seeing.
Therapists need to get over those fears in order to do what they are called upon to do – to help patients heal.
I find it heartbreaking and enraging that professionals would identify dissociative characteristics in a patient simply because they lack the courage, or even common decency, to make an obvious dissociative diagnosis. The result is that those patients likely endured years of misdirected and harmful pharmacological interventions rather than psychotherapy. When they reached my office, that harm, and the wariness of psychiatry as well as of psychiatrists in general, made it difficult for a genuine therapeutic alliance to be established. The negativity needed to be undone before we could begin to work on healing their early trauma.
[2] Bias Toward Integration
There is the question of whether integration is or should be seen as the final goal of DID. Putting it simply, I would never encourage this for my patients. To be clear, I have seen patients who had made strong recoveries, processing deep old trauma, and have accomplished much healing. While they were able to navigate the world safely, perhaps for the first time, they were still subject to being re-traumatized by an encounter that was simply too triggering.
Intense triggers can result in re-traumatization and the resumption of dissociative defense patterns. Whatever integration has been accomplished will simply fall apart under enough triggering stress. For patients that didn’t cling to the idea of integration, the re-traumatization were aware of as a risk and was something that they have worked with in the past.
Without clutching at integration as the goal, re-traumatization doesn’t have to undermine hope, nor does it destroy the understanding that there was healing and progress. For patients that cling to the idea of integration as the definition of healing, under the power of intense re-traumatizating triggers, I fear that alters will consider the idea of hope for healing as another gas-lighting tactic by the world to hurt them again.
[3] Holding to a Fuzzy Definition
Dissociation is the term chosen to refer to something that is common and poorly understood, The concept of dissociation is borrowed from chemistry and means the breaking up of a compound into its simpler constituents which, under certain conditions, can re-form as the compound. For example, it can be used to refer to the breaking up of water into the elements of hydrogen and oxygen.
In psychology, one is unable to be so precise because of the inability to define what whole is breaking down up into what constituent parts. In the same way, there is the inability to define what can be re-formed. Perhaps the problem can be clarified by asking: Can we explain “trust” in chemical terms. This kind of borrowing a word from one discipline to be used in a different discipline that has no real analogous qualities is never accurate or satisfying.
Further complicating the meaning of dissociation is that it may be used to refer to several quite different experiences. It is a loosely applied concept to denote the following conditions:
[a] Splitting sensation from awareness: Walking on fire and not feel the burning heat; or seeing a needle piercing the skin and not feeling the pain.
[b] Spitting the memory from the awareness: Genuinely not remembering being under gunfire until it stops. A soldier only hears the “silence” after a period of artillery bombardment ends.
[c] Escaping immediate pain: A child being beaten by an abusive father, who escapes by watching someone else being beaten – which person/personality is later termed an “alter” – rather than himself.
Dissociation is much more commonplace than is generally acknowledged. In fact, I believe it is both a universal and normal occurrence. It only becomes pathological when, due to a state of ongoing extreme distress, it becomes a habitual defense mechanism that causes dysfunction. It is the poorly defined boundary, a vagueness, that separates the normal ability to occasionally dissociate from the abnormal habitual dissociation coupled with hyper-vigilance that makes it so confusing to many therapists. This is how the misunderstanding arises that dissociation is by definition pathological and must be eliminated.
