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Section 17
Important Clinical Principles in Treating Clients with DID

Question 17 | Test | Table of Contents

Never work harder than one’s patient: Unless the patient is an active participant and willing to tolerate the pain and grief that are the necessary prerequisites for growth, little can change. Many patients may want some connection, yet at the same time are unwilling to realistically confront key contradictions in their life, including their ongoing exposure to the sorts of trauma that caused their dissociative defenses originally.

Playing the hand one’s been dealt: Life is exceedingly unfair. Not only have dissociative patients suffered years of abuse/neglect, from which in a just world they would be rescued and provided with restitution, they, in fact, if they are to grow the selfhood necessary to explore their potential, have only their own circumstances, talents and opportunities with which to achieve it. Although some might reasonably argue that they have suffered enough and that it should be someone
else’s duty to make up to them what they have lost/missed out on, assuming a victim mindset ensures stagnation.

Central importance of the therapeutic alliance: A core issue that perhaps defines human relatedness is that to address the damage done by the abuse and neglect experienced in relating to humans, it is necessary to relate to other human beings. In the transference, the therapist can almost simultaneously be the actual or potential abuser, a focus for attempted seduction, and a longed-for loving parent with intact boundaries. Providing a safe and integrative landing for such divergent emotions that frequently are embodied within a fragmented and unevolved self, is a central therapeutic objective and one particularly dependent on the strength of the therapeutic alliance, a facilitating resource that needs to be added to throughout therapy. The therapeutic alliance forged by empathy and protected by boundaries, provides the capital that sustains the hard work of daring to grow.

Boundaries: Dissociative disorders could alternatively and accurately be categorized as boundary violation disorders. Brought up in environments devoid of safety, security, and privacy, dissociative patients had to endure repetitive abuses. Many such patients when seen still remain enveloped to a greater or lesser extent in the boundaryless oppression they were brought up in. Firm and consistent boundaries are a guiding reference to safely negotiate situations where there is the potential to lose more than can be gained. They are essential to constructing the safety of the therapeutic frame such that abuse and exploitation are not re-enacted in the guise of ‘therapy’, while their modeling and discussion is central to patients growing and strengthening a sense of self based upon boundaries of their own.

Safety: Logically, one is in no position to deal with effects of past abuse and neglect if currently locked in the continuing
dynamic. Many patients presenting, even as adults, are still being repetitively abused by the same people who abused them as children, or by facsimiles of them. Alternatively, life circumstance in terms of accommodation, finances, support systems etc. are so precarious, that there is not enough basic stability in the patient’s life on which to base therapy. The starting point for therapy is thus a basic level of safety and security. Some active measures may be necessary in facilitating the cessation of abuse (e.g. a period of hospitalization) and in securing safe accommodation (e.g. social worker involvement etc.).

Personal responsibility
While neglectful, abusive environments deleteriously effect the development of selfhood in the growing child, so too do environments that are overprotective and which do not support a goal of achieving mastery of a balanced life. Seeing patients many times for prolonged periods of time (e.g. several hours), seeing them many times per week and encouraging repetitive phone contact out of hours, has more to do with the rescuing therapist’s needs to conform to a self-image of knowing more, doing more, caring more, than it does to any objective need of the patient. The cumulative message of such overinvolvement is to demonstrate to the patient that they are incapable of getting through a day without support or are incapable of making any decision for themselves without consultation. It also communicates an unwillingness on the part of the therapist to have reasonably firm boundaries around their own family life/out of work time.

Transference: In treating dissociative patients, who may recurrently be not orientated to present time and present place, and where most have experienced prolonged inconsistencies or neglect in the emotional responses of primary care givers, the therapist needs to be as real and well-grounded in current reality – and their communications to be as clear – as possible. Many patients came from environments characterized by ‘double-bind’ type communication, severe retribution if one spoke out or complained, and an absence of ever experiencing an apology from anyone. Paradoxically, the angry remonstrations to the therapist or the ‘bad-mouthing’ of him/her to others regarding things that conventionally might be viewed as fairly trivial, are frequently positive, a demonstration of fledgling selfhood in an environment safe enough to include the outward expression of anger.

Countertransference: In dealing with traumatized individuals whose selfhood is undeveloped in many ways such that they can be affectively unstable, prone to splitting or projection, readily triggered into dissociative re-enactments or who are struggling to recognize and respond appropriately to boundaries in general, it is salient to keep at the forefront of consciousness the dynamics that underlie Karpman’s triangle. This recognizes the relative ease with which the therapist in their countertransference reactions can switch from the role of therapist to that of abuser, at the same time as feeling victimized themselves. Early and clear enunciation of the principles of therapy and the joint responsibilities of patient and therapist in that process help build the therapeutic frame. The process needs to be safe for both participants. If it is not, the endeavor should be terminated.

Avoiding the rescuer role: Most parents know that in having their children negotiate the developmental challenges of adolescence, one of the most useful strategies to assist them is the judicious application of the ‘law of consequences’, applied in a non-punitive but nevertheless consistent manner. It is unhelpful to shield such individuals from learning by dealing with the results of their actions or to accept rationalizations for behaving badly. It is similar with those dissociative patients who would have their rescuing therapist buy into accepting poor behavior on the basis that it is not remembered, ‘done by a different alter’, or that as the patient has already experienced much past trauma, it should be overlooked. Particularly, one should be very aware of the dynamic in which the therapist accepts the role of telling the patient what to do as the immediate solution for what will prove to be the first of an unending series of crises. Having had their therapist assume responsibility for their life, they will then blame him/her for its failure. In any given situation, the patient may need to be directed at examining their options and after due consideration owning the course they chose.

Avoiding specialness: Narcissism has its origins in childhood hurt, humiliation and abuse. Dissociative patients did not have childhoods in which they were validated or made to feel special. If later in life they have a presentation that represents a focus for wonder or fascination, they risk engaging in therapy with a person who likewise has a particular need to also be special: whether as someone heroically treating a patient assumed to be poorly understood by their colleagues, or as someone treating a ‘fascinoma’ with the therapy destined for a best-selling book. Where there are agendas on the part of the patient and/or their therapist in which the pursuit of healthy functioning is not the primary goal, the therapeutic alliance is illusionary and a poor outcome is likely. ‘Having a life’ encompasses developing the multiple dimensions of selfhood so as to be able to love, work and play most effectively. Those who get well know that they need to deal with the unfinished business of their past and its impact on their present. As much as possible, they want to put behind them the identity of being a dissociative individual, not enshrine it.

Richard Kluft observed the centrality of empathy in the therapeutic process with dissociative patients. About the most powerful thing a therapist can do for any patient is to truly listen, and this applies in particular measure to dissociative patients who carry large burdens of shame and guilt, have very good reasons to be untrusting and who have frequently experienced first-hand disbelief, invalidation or blame and punishment from those whose primary role should have been that of their protector. The foundations of selfhood are stable positive introjects and it is far better to have them late than never. To live for even a little bit of time in a protected and safe space, and to live with constant boundaries, validation and positive regard, is to experience in a tangible way how the world could be ordered and to begin to assemble an introject that can start to neutralize the negative self-images derived from the experience of past abusers. Those whose birthright to access positive introjects as they grew up was denied, must, in order to achieve functional selfhood, assemble them later in life, if they find suitably empathic individuals.

Staging of therapy: It is wise not to try to run before one can walk. Therapists need to be very mindful of where their patient is in terms of safety and stability of environment, social and emotional supports, as well as their strengths and current capacity to deal with stress and change. The price of growth is pain but for many, particularly in the early stages, there are very few coping resources in reserve and a delicate titration exercise is necessary: too much focus on progressing the many unresolved issues (including past trauma) and the patient decompensates and abandons the attempt, too little and one is accepting a state of long-term stagnation. The focus of therapy should be integrative and to build step-wise on strengthening the foundations of emerging selfhood, for example the achievement of workable boundaries in one area of life can be extrapolated to all other comparable areas of life.

Recovery of feeling: Van der Hart et al. offer a model developed from Myers’ observation of shell-shocked World War I combat veterans, in which a failure to integrate traumatic experiences results in the structural dissociation of the premorbid personality into two mental systems. This primary structural dissociation results in an emotional personality that is associated with re-experiencing the trauma, and an apparently normal personality that has failed to integrate the trauma, but which engages in matters of daily life. In many ways, the capacity to feel represents the richest facet of life, but for the severely traumatized, feeling may also be the most dangerous. Triggers may unleash dissociated feelings that would otherwise have been too overwhelming to have been expressed in the context of ongoing trauma at the time: short of risking suicide or psychosis. Although affectively unstable in terms of triggers that can precipitate dysphoria or fight/flight responses, they are generally avoidant of feeling and many learnt long ago that to react to their abuse, for example to cry, only made it worse. They have a sense that to release feelings is to risk relinquishing control of something that could destroy them. As with loss more generally, the key to not remaining incapacitated by it is to grieve it, and in the case of dissociative individuals this means accessing and expressing the sadness of a childhood lost. Safety, empathic connection and care in letting the patient gain confidence by not tackling too much, too early, facilitates the emergence of connected feeling.

Processing of trauma: The more integrated one is, the more accessible one’s memories and emotions are in any particular circumstance. The dissociative defenses include the sequencing of traumatic events in a compartmentalized fashion, with the walls of such compartments akin to levee banks precariously holding back flood waters. Attention to the growth of safety and selfhood allow for a lowering of the water level as the contents of compartments are progressively assimilated. The less there is that is held behind walls, the less need there is to continue to have the walls, and the less danger there is that an incapacitating torrent will be unexpectedly released by a particular trigger breaching a wall that is not directly observed. The more one can know oneself, the less exposed one is to precarious defenses, and the less vulnerable one is to further trauma. Additionally, one can more quickly and comprehensively respond when one is able to marshal one’s full internal resources. Confidence begets confidence. There is some truth in Nietze’s famous observation that that which does not kill us makes us stronger. However, to be overwhelmed by trauma, either acutely or in reconfronting it, is to be weakened, while resistance to subsequent attempts to deal with trauma is increased. If there is significant doubt regarding the patient’s current ability to process trauma within a spectrum of tolerable affect, then don’t attempt to; rather, concentrate further on building stronger foundations.

Memory: It is unhelpful to focus on memory in ways that give it more prominence than integrated selfhood. Some traumas are more verifiable than others, and some (but not all) dissociative patients have fairly accurate memories of traumas that occurred in early years. Two decades ago, Richard Kluft made the valuable and still applicable observation that ‘in a given patient, one may find episodes of photographic recall, confabulations, screen phenomena, confusion between dreams or fantasy and reality, irregular recollection, and willful misrepresentation. One awaits a goodness of fit among several forms of data, and often must be satisfied to remain uncertain’ (p. 40). Although not often referred to as such, it is useful to view memory as a boundary issue that challenges the required therapeutic neutrality. Generally speaking, we remember about as much about traumatic events as we are psychologically capable of dealing with. Therefore, it makes little sense to add to the load of someone already crippled and struggling with the incomplete memories they already have. In order to have a handle on who we are, we need to remember where we came from; thus, using memory extraction techniques on someone whose selfhood is not growing stronger can only unnecessarily traumatize them, trigger malignant abreactions and/or invoke previously used defenses to redissociate that which would otherwise remain too overwhelming.
- Middleton, Warwick; Owning the past, claiming the present: perspectives on the treatment of dissociative patients; Australian Psychiatry; March 2005; Vol. 13 No. 1.

Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder

- Brand, B. L., Sar, V., Stavropoulos, P., Krüger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating Fact from Fiction: An Empirical Examination of Six Myths Ab

Personal Reflection Exercise #3
The preceding section contained information about important clinical principles in treating DID.  Write Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Brand, B. L., Webermann, A. R., Snyder, B. L., & Kaliush, P. R. (2019). Detecting clinical and simulated dissociative identity disorder with the Test of Memory Malingering. Psychological Trauma: Theory, Research, Practice, and Policy, 11(5), 513–520.

Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology. Advance online publication.

Marsh, R. J., Dorahy, M. J., Verschuere, B., Butler, C., Middleton, W., & Huntjens, R. J. C. (2018). Transfer of episodic self-referential memory across amnesic identities in dissociative identity disorder using the Autobiographical Implicit Association Test. Journal of Abnormal Psychology, 127(8), 751–757.

Why does Middleton caution against focusing on memory recovery and memory extraction in therapy for a client with DID? To select and enter your answer go to Test.

Section 18
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