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Understanding and Treating Dissociative Identity Disorder A Relational Approach

Introduction

Despite the significant prevalence of dissociative disorders—rates ranging from 12–38% for dissociative disorders in outpatients (Brand, Classen, Lanius, et al., 2009), as high as 18% for dissociative disorders in the general population (Sar, et al., 2006), and a prevalence rate of 1.1—3% for DID in the general population (ISST-D Guidelines, in press), professional education has not usually included training in the treatment of dissociative disorders.

Because of this paucity of training, clinicians are often at a loss regarding how to recognize, diagnose, and work with their highly dissociative patients. All too frequently, when clinicians do recognize that a patient has a serious dissociative disorder, they fear that they will be unable to acquire the skills necessary to treat dissociation and that they must refer their patient elsewhere. A therapeutic relationship may thus be unnecessarily broken.

Working with highly dissociative patients, however, is not necessarily as daunting as it might first seem. Although the conceptual language about the organization of dissociated self-states and knowledge about working with these dissociated self-states need to be learned, it is not difficult to do so. This knowledge transcends theoretical orientation, adding to the clinician’s understanding of the human mind. Once therapists have worked with their first correctly diagnosed DID patient, the picture can become much clearer. Prior to having the nature of their problems understood, highly dissociative patients may simply seem to be extremely “difficult” patients, persons who are full of contradictions, unexplainable extremes of emotions, and inclinations to self-destruction. Yet, when it becomes apparent that the contradictory statements, extreme emotional states, and self-destructive behaviors are coming from different dissociated parts of the person, the overall presentation becomes less confusing and the prognosis far more hopeful.

A recent naturalistic study of the reports of 280 patients with dissociative disorders and their therapists indicates that the prognosis for people with dissociative disorders—when treated by a clinician who is knowledgeable about such treatment—is good. Patients in the later stages of treatment engage in less self-injury and have fewer hospitalizations; they report less distress and lower posttraumatic and dissociative symptoms; and their functioning is more adaptive overall than in those patients who are in initial stages of treatment (Brand et al., 2009). Although clearly it is challenging, work with highly dissociative patients is also some of the most rewarding psychotherapeutic work that one can do. Although treating DID does require specialized knowledge, this knowledge becomes general knowledge useful in understanding almost every patient a clinician sees—“the dissociative mind” is increasingly understood to characterize us all.

DID Is Frequently misdiagnosed as something else

Because DID has erroneously been thought to be rare (because highly dissociative people tend to present polysymptomatically and because the disorder is so often hidden), assessing and treating clinicians have often missed the diagnosis. As a result, patients have often been given other diagnoses that remain in their charts while the underlying highly dissociative structure of their personality continues to be missed. Research has showed that people with DID spend from 5 to nearly 12 years in the mental health system before receiving a correct diagnosis (as cited in ISST-D, in press).

People with DID have often been previously misdiagnosed as schizophrenic, schizoaffective, bipolar, or borderline. Many never recover from the effects of these misdiagnoses. What is worse, their real issue—DID—is less likely to be addressed, with the result that they may never receive the treatment they need. Instead, patients often have received inappropriate medications, nd they may have received unnecessary electroconvulsive shock therapy.

DID is often hidden

Although it is not rare, DID is often hidden. In contrast to the flamboyant and dramatic switches portrayed by Sally Field in the movie Sybil (Petrie, 1976), switches of identity states can often be subtle or even invisible to an observer. Kluft (2009) observed that only about 6% of those with DID exhibit obvious switching in an ongoing way. Another reason for DID to have been thought to be rare is that, to the extent that they are aware of their extreme dissociativity, many highly dissociative people work to hide it. Often, they are afraid that they will be considered crazy and will be put away if they are found out. Simply put, it is not socially adaptive to show one’s fragmented personality. In addition, many with DID are not aware of this fragmentation. All they know is that their lives are chaotic and hard to manage: They may often be overwhelmed by intense affects like terror, black despair, or fury that seem to come out of nowhere; they may lose huge chunks of time and not know what they did or thought; they may be unaware of their behavior and therefore be unable to explain it to others; they may find themselves in strange places with no explanation of how they
got there. Although as adults they look like grown-ups, when switched into a child identity they often feel like and can appear like helpless children (e.g., speaking in a childlike voice) and may be unable to negotiate important interpersonal matters with others. Their fragmentation may not be recognized until attentive emotional intimacy with another human being, often a therapist, allows it to be known.

What Is DID?

The person with DID essentially lives with various simultaneously active and subjectively autonomous strands of experience that are rigidly and profoundly separated from each other in important ways, such as in memory, characteristic affects, behavior, self-image, body image, and thinking styles. These different segments of experiencing have their own sense of separate identity—their own sense of an “I”—including a sense of personal autobiographical memory; they may have different names. Putnam (1989) described these different identities as “highly discrete states of consciousness organized around a prevailing affect, sense of self (including body image), with a limited repertoire of behaviors and a set of state dependent memories” (p. 103). This division of the self into different dissociated subjectivities puts people with DID at a loss regarding how to understand or explain their experience, and it often makes their lives difficult to manage.

The term dissociative identity disorder, currently used in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) and its text revision (DSM-IV-TR; APA, 2000), is an improvement over the previous term multiple personality disorder (MPD), which was used in the third edition (DSM-III; APA, 1980). MPD was, as a term, misleading in its suggestion that there were literally separate personalities, rather than interrelated though differentially dissociated parts with separate subjectivities that are all facets of one person. The dissociative parts are not separate persons—they are part of one person. Even though individuals with DID may experience their dissociated identities as different persons, even as having separate bodies, it is important that clinicians (while
understanding and empathizing with their patients’ subjective reality) not reify a delusional sense of separateness but help the patient understand that dissociated identities are all part of who they are.

The extent to which these separate strands of experience (involving a sense of self-in-relationship, certain dominant affects, a sense of history, subjectivity, and relative sovereignty) are linked with or dissociated from other aspects of mental life varies among patients. Different dissociative parts may or may not have knowledge of the affects, behaviors, histories, motives, and thoughts of other parts. How coconscious patients are also varies—that is, the extent to which they have knowledge of and are privy to the thoughts, history, and affairs of the other parts varies. Often, the part of the self that is in executive control is unaware of the thoughts and activities of other parts (often called one-way amnesia). However, this is a tricky topic to try to make clear. For example, coconsciousness may be minimal before beginning psychotherapy
for DID but tends to increase considerably in the course of appropriate psychotherapeutic work. Although parts other than the part who is most often in executive control (often called the “host”) are more likely to know of each other and of the host, this is not always the case and is not always the same for different parts of the same patient. Some parts may be unknown by many of the others. The dissociative structure of each patient is different.

Switching

The phenomenon generally considered most characteristic of DID is switching: Different internal identities can be prone to suddenly taking executive charge, in effect pushing the identity that had previously been in charge, out of charge. This generally results in amnesia on the part of the identity that had been pushed aside for the events that occurred while the other identity was in control. Switching is also known as full dissociation (Dell, 2009c).

Clearly, switching is a problem when people do not remember portions of their activities and thoughts. To compensate for this lack of memory, people with DID will often try to fill in the blanks with something they think makes sense given the context, especially in social situations. However, because their compensatory version of events may not match what did happen, and because their behavior may have been different in different identity states, persons with DID may be accused of lying and may indeed
come to feel that they are liars. Amnesia can be even worse when people do not know they have amnesia—or that they have dissociated identities—for them, life is and feels even more chaotic.

The current diagnosis in DSM-IV-TR (APA, 2000) places the primary emphasis on the phenomenon of switching and provides the following diagnostic criteria for dissociative identity disorder (300.14):

A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).B. At least two of these identities or personality states recurrently take control of the person’s behavior.

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. (p. 529)

There Is not only full dissociation but also partial dissociation

Full dissociation (i.e., switching) is not the only problem in DID. Switching, when an identity state has disappeared from consciousness and another has taken its place, can indeed be quite a problem. However, there is a larger set of problems that has to do with the influence of dissociative parts who are “beneath the surface” on the part that is in executive control at a given time. Such partial dissociation (Dell, 2006b, 2009a, 2009c, 2009d) includes the following phenomena: intrusive visual images; auditory experiences (including hearing voices in the head); olfactory experiences; somatic experiences; unbidden, unsettling, and unexplainable thoughts and emo-
tions; experiences of “made” volitional acts, impulses, and thoughts; and the withdrawal of perceptions, thoughts, and emotions.

In cases of made volitional acts, parts of the body—a hand, an arm, or a leg—may not be in the person’s control and can seem to have a life of its own. For example, a person may feel that her hand, not herself, performed a certain motion. In addition to experiences being intruded into consciousness, aspects of experiences may also be withdrawn: Vision, hearing, bodily sensations, emotions, and thoughts may be “taken away” either in part or in whole from the person’s experience (or from the experience of the identity that is in executive control). Withdrawn experiences may include “hysterical” symptoms such as functional blindness or can manifest as partial
blindness for certain things, as in negative hallucinations (something or someone who is there is not perceived). For example, one of my patients reports that when she goes into the grocery store, she does not see any other people. (Seeing the other people would make her overwhelmingly anxious.)

Such intrusions and withdrawals, especially when constant, can have the potential to make a person’s life chaotic indeed. There are occasions when intrusions or withdrawals may be visible or known to others—as in the case of a paralysis or a reported hallucination—but for the most part these experiences remain unknown and contribute to private turmoil or agony (Dell & O’Neil, 2009).

This last aspect of DID—partial dissociation—has often been misunderstood as schizophrenia. Dell (2001, 2002, 2006b), Kluft (1987a), Putnam (1997), and Ross (1989) have outlined the ways in which dissociative disturbances have often been misunderstood as indications of psychosis or schizophrenia. Kluft reported that patients with DID endorse 8 of the 11 first-rank Schneiderian symptoms (Schneider, 1959, as cited in Kluft, 1987a)  that are considered pathognomonic of schizophrenia. These symptoms are voices arguing, voices commenting on one’s action, influences playing on the body, thought withdrawal, thought insertion, made impulses, made
feelings, and made volitional acts. In DID, rather than as indications of schizophrenia, the hallucinated voices and the made actions are understood as due to the activities of a dissociative identity. The psychotic person is more likely to attach a delusional explanation, such as “The CIA has implanted a chip in my brain.” In contrast, the person with DID, although probably unaware of the source, often knows that these experiences are not normal and does not seek to explain them in a delusional way (Dell,
2009c). In addition, the person with DID—as opposed to someone who is psychotic—often has the ability to be in two states of mind at once: While the person experiences the self as having the “crazy” thought, the person is able to hold the tension and know that it is just that, a crazy thought. Of course, this knowledge that one is having thoughts that others would consider crazy only tends to contribute to the highly dissociative person’s fear or belief that he or she is crazy!

DID is confusing to everyone

The phenomena of full and partial dissociation are highly confusing to the person with DID as well as to those who notice them. Unlike someone who suffers primarily from depression or anxiety and who can label the problem, the person with DID generally suffers from amnesia about the very symptoms experienced and often cannot specifically identify the problem. For the person with DID, the sense of self, of continuity of being, of identity, is highly discontinuous. As noted in DSM-IV-TR (APA, 2000), “the essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception” (p. 519).
This emphasis on disturbance in identity is an important one. Because there is more than one identity, our linguistic descriptions often imply, but do not state, differences in the perspectives of the different identities.

Understanding DID can be complicated, and it is hard to escape the considerable awkwardness that ensues when we try to speak and write of such things as consciousness, disruptions of consciousness, intrusions into consciousness, even amnesia. Especially as when we speak this way, we are often speaking from the perspective with which we, as “singletons,” think. For instance, consider the amnesia requirement of Criterion C: “Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (APA, 2000, p. 529). One might ask, “Who (which part) fails to recall?” “Whose consciousness?” or “Whose thinking has been disrupted?” These questions are especially relevant when the host, the part of the self that usually presents to the world, is a collection of several parts who pinch hit for each other or when the host is primarily a shell who faces the world while other parts “fill in” as needed. From the perspective of dissociative parts who want to be in executive control but who are not currently “out,” their bids for time to be in control of the body or for attention are not intrusions. However, the part that is in executive control most of the time may experience these bids as intrusions and disruptions, and an observer may classify them as such. The perspective one takes—part or whole, looking out or looking in—makes all the difference.

Multiple self-states and dissociated identity states

When we speak of partial dissociation as an important aspect of DID, it is important to note that partial dissociation is not specific to DID or even to dissociative disorders. It also characterizes posttraumatic stress disorder (PTSD): The flashbacks and intrusions so characteristic of PTSD are examples of partial dissociation. In addition, partial dissociation can be an aspect of everyday life for most people. The self of all of us is not a unity but consists of multiple self-states that emerge and alternate in accordance
with which self-state is in the forefront of consciousness at a given time.

Current research in neurobiology, cognitive psychology, and developmental psychology indicates that the brain, the mind, and the self are normally multiple (Dennett, 1991; Erdelyi, 1994; Gazzaniga, 1985; Kirmayer, 1994; Siegel, 1999). Neurobiologists increasingly understand the brain as organized into neural systems that to some degree function independently of one another (LeDoux, 2002). Such parallel and multitrack processing help to explain dissociative phenomena on a neurological level. Furthermore, as Siegel (1999) maintained, “the idea of a unitary, continuous ‘self’ is actually an illusion our minds attempt to create. . . . We have multiple and varied
‘selves,’ which are needed to carry out the many and diverse activities of our lives” (p. 231).

Yes, we all have multiple self-states. For all of us, our mental life is characterized by constant changes in self-state to match the current context. Much of the time, most of us are aware (although less often than we think) of the matches of self-state to context, and we remember both (or we think we do). For example, we may wear a “therapist hat” while in the office, have a caregiving orientation when in contact with our children, and respond in a different way, involving early attachment system internal working models, when speaking to our parents. What is important for psychological health is the degree of dissociation between self-states or, to put it more
positively, the degree to which we experience our multiple self-states as contextually interrelated and part of what comprises the sum of who we are. Or, as Philip Bromberg (1998) has put it, health is the ability to “stand in the spaces between realities without losing any of them” (p. 186).

Contextualization

As humans, we adapt to the varying contexts of our lives. However, we may not always be aware of the extent to which our lives are bound by context. For example, when I go to my gym, I have to recite a certain eight-digit number to get in. When I stand in front of the admission desk, I remember this number, but only then. If someone were to ask me my number anywhere else in the building or outside of it, I would not be able to recite it. This is a mild version of what DID is like. My point is not that I have a “gym self,” but that my memory for how to get in to the gym has to be triggered. Away from the front desk, I have no conscious memory of that number. Although
this may mean that my gym self is in great need of support and integration with the rest of me, the point here is that there is a piece of memory that has to do with my internal world that is not usually available to me. To access it, I have to deliberately and physically trigger it.

Although this is not representative of a dissociative disorder (a dissociative experience alone does not constitute a dissociative disorder), I am called to access a memory that is related to only a specific context. A person with DID has more and larger modules of self-contained experiences that are not easily accessible to consciousness, but the basic organization of context dependency is the same. In infancy, behavior is organized as a set of discrete behavioral states, such as states of sleep and waking, eating, elimination, and so on. These behavioral states become linked over time and grouped together in sequences (Putnam, 1997). Psychological trauma impedes this
linkage; as a result, individuals who have been severely neglected or highly traumatized in childhood have not had the interpersonal attention, support, and encouragement necessary to interconnect their self-states and the varying contexts of their lives.

Therapist training for DID

Therapists who work with dissociative patients should have solid skills and knowledge in general psychotherapy, such as in assessment, boundary management, ethics, transference and countertransference, general therapeutic skill, as well as concern and empathy. Although working with highly dissociative people does require solid therapeutic skills, a specialized understanding of the highly dissociative mind is also necessary. Specific theoretical and technical approaches may vary, but those that result in facilitating psychic health derive from an understanding of the psychic structure underlying DID.

The first step needs to be arriving at a correct diagnosis. It is important to remember that DID is a problem of hiddenness. Therapists treating patients with DID should be aware of the signs of switching from one identity state to another as well as the signs of intrusions or partial dissociation. Untrained clinicians may be unaware of the switching in the session and assume that they are meeting with only one identity state throughout.

This deprives them of important information. For instance, if the patient cannot remember or make sense of what was said in the session, this may well not be due to resistance or anxiety as we might normally understand them but could be due to dissociation. When it is understood that different dissociative identities not privy to the experience of other identities may have been present, the behavior of the patient makes more sense. As clinicians, we strive to be alert to when the patient’s experience has radically changed either through a switch or through partial dissociation. Working with highly dissociative people requires familiarity with trauma treatment
as well as the ability to deal with traumatic transferences and to tolerate strong emotional pressures in the consulting room.

The ISST-D has a training program for clinicians for work with dissociative disorders. Training information may be found at http://www.isst-d.org under Training and Conferences.

Organization of this book

In the chapters that follow, I explain the nature of dissociation and dissociative disorders and how I work psychotherapeutically with people who are highly dissociative. I use examples from my practice liberally to illustrate various principles.

Chapter 1 introduces three of my patients who have generously given me permission to use descriptions of their lives and their psychotherapy in an ongoing way in this book. Their stories serve as anchoring points for understanding what the experience of having DID is like and for understanding ways to work with DID psychotherapeutically.

Chapter 2 explores the topic of the dynamic unconscious and the dissociative structure of mind. The interrelationships of dissociation, relationality, and multiplicity are examined, and finally the historical context of the waxing and waning of recognition of dissociative processes and dissociative problems is explicated.

Chapter 3 examines the organization of the personality system in DID, the “We of Me.” This includes the most commonly active dissociative identities and how they are organized in relationship to each other, trance logic, the closed system, and the third reality as described by Kluft (2000). It also explains different conceptual schemes for understanding the organization of  dissociated parts of the self.

Chapter 4 describes how DID is a trauma disorder. It also explains why trauma is best defined as “that which causes dissociation.” It explains the meaning of complex trauma, relational trauma, and the proposed working diagnosis, disorders of extreme stress not otherwise specified (DESNOS).

Chapter 5 covers the development of DID as understood both through the trauma model and in terms of disorganized attachment. The self does not begin as a unity. Consequently, the dissociative fragmented self is not so much a “shattered self” as one in which early attachment dilemmas dictated disorganized attachment while the early interpersonal environment did not facilitate integration.

Chapter 6 covers some neurobiological correlates of the structure and psychodynamics of dissociated self-states.

Chapter 7 addresses understanding the organization of dissociated selfstates under the rubric of the Karpman triangle of victim, persecutor, and rescuer. It also covers the creativity of creating self-states and the importance of contextualization within the self in healing.

Chapter 8 covers assessment and diagnosis. It addresses the importance of assessing both switching and intrusions in DID. Face-to-face interviews as well as screening and assessment instruments are discussed.

Chapter 9 deals with a frequently covered topic in trauma treatment: phase-oriented treatment. Important topics are avoiding retraumatiztion, stabilization, grounding, and so on, as part of Phase 1. It also covers what I call “the central conflict,” which concerns the tendencies of some dissociated parts to want to tell about the traumas while other parts do not want to be bothered with their feelings and are afraid of being destabilized. This chapter also covers the topic of abreaction, which is viewed as an interpersonal and integrative activity.

Chapter 10 covers facilitating coconsciousness and coparticipation in the treatment. Many different kinds of problems and solutions, with illustrations from my practice, are presented.

Chapter 11 deals with working with persecutory alters and understanding how they have come into being. This chapter includes an extensive case vignette.

Chapter 12 includes multiple dimensions of coconstruction in the therapeutic relationship, including multiple transferences and countertransferences, traumatic and erotic transferences, and issues of boundary management that stem from disorganized attachment. It also includes the topics of projective identification and dissociative attunements.

Chapter 13 covers dreams in DID and in trauma, including how they are both very different from and also similar to more ordinary dreams. Some of the important differences are spelled out, including how the same dream may be dreamt from different perspectives by different dissociative identities. It includes two vignettes about the use of dreams in therapy with DID patients.

Chapter 14 discusses the topic of suicidality, which is a significant risk for those with DID. The complicated meaning of suicidality is covered, including the many ways that what looks suicidal from the outside may be construed by parts of the system. For example, some parts may be homicidal toward other parts, engaging in activity that from the outside looks suicidal. Although this is delusional because the physical death of the body includes all parts and the behavior is not intended to be suicidal to the part
that is out, the danger of lethality is just as high.

Chapter 15 covers the dissociative structure of the mind across diagnoses, including the topic of comorbidity. I examine a case of “psychosis” that was in fact about somatoform and dissociatively held memories. The psychosis was resolved when the dissociated material was pulled together in a story. I also examine the particular way in which I think that borderline personality disorder is dissociation based. Finally, I suggest that the universality of some archaic superego problems stems from dissociation and cuts across diagnostic levels.

In this book there are many excerpts from sessions that are intended to illustrate various principles. Obviously, I have my own particular style in the way I work and interact, just as everyone has their own style; so these excerpts are not meant to be prescriptive. Everyone working with DID will develop their own style.
Secondly, for the reader unfamiliar with DID, the switching, the various cast of characters who come forth in one body, and the trance logic may seem strange, perhaps even too strange to initially take in. Trance logic could be described as a waking dream logic, in which the ordinary rules of logic do not apply. To some degree, we all operate with trance logic—and to say so is not pejorative. We accept and value trance logic in art and some religious ceremonies. Or, for example, a person in mourning may expect the dead person to enter the room. In the personifications of the inner world of DID, thinking is more concrete, contributing to the trance
logic. Instead of “I feel so sad I can hardly stand it,” The Sad One appears, newly in central command of the body.

Despite this patina of strangeness, when you think about the psychic system and its psychodynamics, this basic structure of multiple self-states is universal, although its elaboration varies with the person. Perhaps it is like talking about quarks when the prevailing theory is atoms: The intricacy of the structure that characterizes us all is simply more manifest in DID.

Once you accept this proposition—not so difficult when it is before you, the experience is comprehensible and compelling.