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Understanding and Treating Dissociative Identity Disorder (or Multiple Personality Disorder)

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This book provides all of the information a practitioner needs in order to begin work with clients with Dissociative Identity Disorder (DID). Drawing on experiences from her own practice and extensive research conducted with the help of internationally acclaimed experts in the field, the author describes the development of DID and the structure of the personality of these clients. The reader is guided through the assessment process, the main phases and components of treatment, and the issues and contentions that may arise in this work. Throughout the text there are case examples, practical exercises, techniques, and strategies that can be used in therapy sessions. The resources section includes screening and assessment instruments, as well as information on techniques for managing anxiety and self harm, both of which can be major problems when working with clients with DID.

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CHAPTER ONE. The dissociative disorders and the presentation of Dissociative Identity Disorder (DID), or Multiple Personality Disorder (MPD)

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The vignettes I outline in this book have been based on an amalgamation of several clients’ experiences. They aim to depict the two main underlying issues, that of attachment problems and repeated trauma, which clients with DID have experienced. Any likeness to someone’s true life story is purely coincidental.

Kerry is twenty-eight years old and currently lives alone. She lived with her mother and stepfather until she was fourteen when she ran away from home to escape sexual abuse by her stepfather and her uncle. In addition, her mother is an alcoholic and often got angry and violent with Kerry when drunk. The sexual abuse and violence had gone on for as long as Kerry can remember. Her biological father left the marital home when Kerry was two and had been out of contact since. Kerry had never got on well with her mother but the relationship broke down completely after she had told her about her stepfather’s abuse and her mum had not believed her.

At school, teachers reported that Kerry seemed a very bright and able pupil who had achieved some high grades on occasion but lacked concentration and consistently good results. She was also branded a troublemaker after apparently being the ringleader in a binge-drinking episode in the school. At twelve, she was found passed out in the school toilets, after she had cut both wrists having been raped by her stepfather the previous day. She was seen by a psychiatrist who asked about her family but she felt unable to tell anyone. She returned home after treatment having nowhere else to go and went back to school but from the age of thirteen missed more days than she attended.

 

CHAPTER TWO. Assessment and diagnosis

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Specialist practitioners working with clients with DID typically place considerable importance on screening, assessment, and diagnosis and will sometimes repeat tests throughout therapy to see how clients are progressing (Ringrose, 2010). Psychotherapy assessments are usually used to guide therapy. However, in the case of clients with DID, aside from facilitating the devising of a therapy plan, the work is likely to be long term and involve outside professionals. Therefore, in the UK, often diagnosis is used to make a plea for funding through the National Health Service (NHS), as well as being useful for liaising purposes. In this case, a detailed diagnosis is needed in order to make such a plea. Further to this, clients with DID pose a high risk of harm to themselves and sometimes other people, which practitioners want to feel competent they can work with.

However, the most important reason for a strong focus on assessment and diagnosis relates to practitioners’ awareness of clients frequently receiving incorrect diagnoses. Kluft (1991) reported that the average length of time it takes for a client to receive a diagnosis of DID is just short of seven years. Nonetheless, diagnosis with these clients is vital because the client is multiple. Practitioners need to take all of the identities into account. Without this, clients are unlikely to significantly improve.

 

CHAPTER THREE. Beginning stage of psychotherapy

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The beginning stage of psychotherapy is one of stabilisation, containment, and strengthening the client’s resources to the extent possible. It is too early to look at trauma. Even though there may be identities wanting to talk about what happened to them, at this stage this can be dangerous. This is because it can be too much for the host to manage and can result in an increase in self-harming, suicide attempts, increased drinking, worsening of an eating disorder, or some other harmful behaviour. I explain this to all the identities through the host very early on in therapy.

In this initial stage, psychotherapy needs to focus on strengthening the host so that eventually the trauma events can be shared amongst all of the identities. When clients first attend therapy, there is likely to be a lot of intrusion from one or more of the identities who are stuck in the era and at the age when the trauma took place. This means that current events remind the identities of past trauma, causing these memories to be triggered and partially relived. The host may experience some of the alters’ felt experiences, often anxiety, or she may lose time. However, the host dissociated from the original trauma in order to be able to cope with the feelings at the time and therefore has never had to fully realise all that has happened to her. The ego strength of the host therefore needs to be sufficiently robust in order for her to be able to learn to cope with the memories the alters desperately want to share (Ringrose, 2010). Hence, initially, therapy work is restricted, as far as possible, to working on everyday topics, for example, day-to-day living with DID, current relationships, and work issues.

 

CHAPTER FOUR. Middle stage of psychotherapy

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By the middle phase of therapy clients will have a good level of understanding of their multiplicity. They will know that they have identities and their approximate ages, and have a limited amount of information about the events that gave rise to their creation, although this will not have been gone through in any detail. They may not know all of their identities but, in the main, they will have learnt methods to manage their emotions in times of crisis and know many of the triggers to them feeling unwell. The host (or hosts) will be more stable and their adult ego will be sufficiently strong to cope with everyday living. Self-harming behaviours and suicide attempts will be significantly reduced. That is not to say that the crises will be over. Therapy in my experience rarely runs this smoothly, and nor is there normally a clear uniform demarcation between the stages. At this stage, however, clients tend to be able to be more productive as less time and energy is taken up just surviving. Clients may be working or parenting more effectively and with fewer crises. Social activities may also increase.

 

CHAPTER FIVE. Final stages and integration

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Integration is the process whereby the host accepts all her thoughts, feelings, and behaviours (past and present) as her own. Therefore, integration means the host needs to let go of the belief that something is “not me”. Whilst we can all say, “I wasn’t myself when I did that” or something similar, the difference is that the integrated person knows there is only one self. Although she may feel she acted out of character, she still knows and accepts the behaviour was induced by a part of her and that this is always under her control.

Beyond this definition statement, there is controversy as to what integration means. For some practitioners, integration means that the alter personalities become one unified whole. I personally am unsure whether or not this is necessary. I argue that functioning can remain divided, although I have some major caveats (see below).

Kluft (1984) argues that integration is a reasonable goal for the majority of clients with DID, although this will not be achieved by some (Putnam, 1989). Kluft and Fine (1993) found that clients who elect to live as multiples often relapse under stress or if painful material is re-stimulated by current events. They state that most clients then return to therapy for integration work as they have found functional division a myth.

 

CHAPTER SIX.Considerations for psychotherapy

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This chapter begins by outlining some of the main differences to the structure of therapy sessions when working with clients with DID. The second part details some of the problems encountered when practitioners adhere to their therapy approach too closely when working with these clients and mentions some of the therapy approaches specialist practitioners working with DID advocate. The chapter ends by outlining some of the techniques and strategies that can be adopted by therapists and clients which aim to help clients cope with anxiety in particular.

Although therapists differ as to precisely how long therapy will be, there is agreement that therapy with these clients will be long term. Coons et al. (1988) suggest approximately twenty-two months, whilst Kluft (1984) argues anything from two to ten years. Therapy is long term because clients tend to have experienced repeated abuse by several people, or suffered from poor attachments, or both, and these tend to be particularly grave in nature and have occurred throughout childhood. In addition, it may take clients a longer time to establish a relationship and it may take them a while to stabilise, as they tend to come to therapy when they are in crisis. Accepting the diagnosis takes time. Clients need time to accept their alters, there needs to be time for the alters to learn to communicate and begin to support one another, as well as time for them to achieve a way of working together, or where clients choose it, to integrate. Therapy duration is an important consideration for therapists who are considering a career break or retiring in the next couple of years (Ringrose, 2010).

 

CHAPTER SEVEN. Problems and issues

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Working with clients with DID is likely to be more stressful for the practitioner, than working with clients who see themselves as individuals because the former are multiple. The therapist is not working with one but many identities and this factor on its own makes therapy harder to manage. However, given that one identity may not be aware that there are other identities, or of what another identity is doing, this makes therapy confusing to client and therapist alike. As mentioned previously it can make for a fine juggling act trying to take each identity into account when issues are discussed, particularly when it is evident that two or more identities hold contrasting positions.

In addition, a respondent in my research mentioned that therapy can be like backstitch in so far as an identity may talk about an event or issue and then forget the incident for a while. This may result in the account needing to be told on several occasions, sometimes by different identities and who may give slightly different accounts. Progress can thus feel frustratingly slow, particularly where issues have been addressed with one alter but remain problematic for another. At these times it can feel like therapy has reached stalemate, as similar issues come back around again in a very similar form. This can be hard to manage when the relationship is long term and at a minimum of once a week, often twice.

 

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