Treating DID

My three small volumes of “Engaging Multiple Personalities” were written with the intention of introducing to the public to Dissociative Identity Disorder, the often forgotten and neglected mental disorder arising from early childhood trauma. Since early childhood trauma is often ignored by professionals and the topic trauma/dissociation often misunderstood, there is unfortunately an enormous pool of individuals at large suffering from these conditions. Often, they remain misdiagnosed by therapists and bounced around within the mental health systems.

Many people erroneously regard this condition as rare. Others believe it to be “controversial” diagnosis, which is actually saying that they don’t believe it exists. Such misunderstandings continue to cause untold suffering in many individual with DID, keep many therapists from considering such a diagnosis or caring for an individual who has been so diagnosed. In short, competent DID therapists are difficult to find.

Looking back on my career, I encountered these patients early in my practice but failed to recognize their plight. Even if I had recognized them at the time, I did not have the training or skill to help them – despite my medicine degree and protracted training in psychiatry at some of the best centres in London, England. For the first decade of practising psychiatry, I remained ignorant as to how to recognize and help patients suffering from DID.

Eventually, I learned the hard way – directly from my patients, from both my failures and successes. I learned from each one of them something of how to work with those suffering from DID. Eventually, I developed some skills in helping patients suffering from trauma and dissociation. I wished I had some guidance, a mentor, when I was struggling as a therapist to find ways to help the DID patients more than a decade after I was considered a DID specialist.

Although at this point in my life I cannot be a personal mentor to other psychiatrists/therapists, the Engaging Multiple Personalities series is an attempt to provide some guidance to those with DID, their therapists and their potential therapists.

Treatment of DID begins with the recognition and understanding of the psychopathology of trauma and dissociation. Digging deeper, one must recognize that trauma and dissociation can indeed begin at a very early age, a horrifyingly early age. Trauma like that can culminate in fracturing the mind of a child, resulting in the condition now called Dissociative Identity Disorder, formerly termed Multiple Identity Disorder. It is difficult to learn how to treat DID through reading textbooks. It would be somewhat like reading the Oxford dictionary to learn the English language. It is not completely impossible, but for most people, it is not a particularly helpful approach to learning a new language. Therapists dealing with DID patients must learn these key points. Otherwise, the therapist will be unprepared to handle the appearance of an alter in a patient suffering from DID. That lack of preparation will lead to a cruel failure in therapy and damage any potential therapeutic alliance.

Here is a summary of the guidelines I recommend in the treatment of DID:

[1] We can use empathy to understand.

DID is a condition with an extreme form of dissociation, with the mind fractured into parts that are referred to as “alters,” or “alternative identities.” The host personality is usually the patient that initially comes into the office. But, the host personality is part of a system of alters that each experience themselves as individuals separate from the host. They have a separate sense of self, and display a separate personality. Based on their experience, the alters insist that they are individuals inside the patient that either remain inside or sometimes emerge to take over the body of the patient. When they emerge, they function for a period of time – ranging from a few minutes to several months in my patients’ experience – like any other individual you might meet out in the world.

How does empathy help a therapist understand DID? First, know that the dissociation is a survival mechanism. It arises instantaneously so that the child can escape in some way from the experience of an insurmountable trauma. Without the dissociation, going through the traumatic experience as a whole, the child would have been over-whelmed and destroyed. Simply put, the immature developing ego has found a way to circumvent the trauma by dissociating from it. This manifests as the experience “this is not happening to me.”

In short, an alter goes through the trauma while the remaining parts of the system – other alters and perhaps the host – experience the trauma quite differently, something like, “I am hiding here safe and floating up towards the ceiling.” This is a verbatim statement made by one of my patients describing the experience of being severely beaten by her sadistic father when she was an infant.

While I don’t have the first hand experience of someone with DID, based on the communications I have had with my DID patients, this is how I envisage the way an alter is formed. Therapists with a limited capacity of empathy might think this is a theatrical way of exaggerating the suffering of an abused child.

We must consider the truly horrific nature of a helpless infant encountering repeated trauma to generate real empathy. Truly imagine yourself as an infant being beaten, again and again and again. There is no way to escape. If you genuinely listen to a patient’s experience of early sexual abuse, repeatedly with no way to escape, how quickly could you “get over it”? To presume that you could ever get over it without tremendous help and your own herculean effort, is an egregious and cruel lie.

[2] The slogan to remember is “Engage the alters.”

The alters are not the pathology, so do not think of ignoring them to hope they will disappear. They have the primary functions of protecting and stabilizing the system. One must always remember to treat each alter with respect and to appreciate their important roles within the system.

There are 2 ways such extreme dissociation generally cause dysfunction in later adulthood.

(a) Each alter may have their own issues that require therapeutic intervention. Many of them can be identified as suffering from PTSD. Those with self-harm or potentially violent acting out behaviour should receive priority treatment. The approach is simply determined by the urgency of the problem presented by the alters. Attend to each problem as presented by each alter, according to severity.

While each alter may have issues that might need therapeutic intervention, this does NOT mean that therapy requires directly working with each alter. It is not the case that the therapist needs to identify each and every alter, and seek to address each and every issue they may have. What has happened with my patients is that treatment of even one alter eased the difficulties of other alters who were watching, so to speak, from the sidelines. In other words, providing therapy to the presenting alter had a positive cascading effect on other alters. To seek to identify the trauma each alter may have, in the absence of a presentation by that alter, would like lead to retraumatization rather than benefit.

Alter generally have some PTSD flashbacks as traumatic memory rises to the surface. However, once a therapeutic alliance was established, I was always amazed that there was much cooperation among the alters as well as a sense of urgency to work hard in the healing process. It is as if the system truly appreciates it when, finally, it has found hope that healing is possible. The system of alters, both individually and as a whole, becomes ever more approachable and ready for change when they are listened to with respect by the therapist. It is often the first time in their life that any outsider genuinely listened to them.

(b) Many alters are secondary elaborations arising from the primary splitting. It is critical to understand that identifying them as secondary elaborations is absolutely not to diminish them in any way. They arise to perform their protective functions. They nevertheless can cause friction to a system by exerting each of their own individuality, which individuality likely has its own trauma triggers as well as its own quality of hyper-vigilance.

Seen in a narrow perspective, an alter may appear to be extremely angry, paranoid, mistrustful or controlling and dictatorial. They jealously guard their individuality, which makes sense in the context of their emergence in the midst of specific traumatic events as they are hyper-vigilant about the potential for similar trauma that might come up.

Most alters have never learned compromise or genuine cooperation. If X wants to go dancing, and Y wants to study, there may be an ongoing clash and confusion that is impacts the entire system. In the early phase of therapy, many alters share varying degrees of co-consciousness. Consider how often a conflict or clash will occur in one single body holding several sets of will and desire. It is no wonder that a single choice may take an incredibly long time, whether shopping for a dress or choosing where to eat.

Treatment can be likened to negotiating for some harmony and corporation among a group of different aged people housed in a single dormitory, who may be complete or partial strangers to one another. The therapist has to be resourceful, for example suggesting that the alters elect a director for shopping who makes the final decision of items being bought which director alter is required to ensure that all alters get their way occasionally. Therapists will be amazed that the alters do listen and appreciate help in this way.