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This is the initial phase of the therapy during which the therapist and patient first get to know one another. In this stage of the work, the patient is scrutinizing the therapist, examining whether the therapist is empathic, concerned, understanding, and sincere as well as knowledgeable. It is during this phase that the patient begins to develop a working alliance with the therapist and assesses whether the therapist is consistent and predict able. It is also during this initial stage of the therapy that the therapist begins to empower patients by supporting their efforts to gain mastery and true control over their behaviors, affects, and sensations. Boundaries are discussed and applied; it is also a time in the therapy in which patients actively struggle against these boundaries. The therapist establishes him/herself as a collaborator in a long, arduous process that is both psychoeducational and exploratory in basis.
1. The Personalities: It is in the suppression-of-affect phase that the therapist begins to deal in a more overt way with the preferred defenses of the DID patient: the personalities. Personalities represent ego states with strong and differentially impermeable boundaries. These boundaries, like the membrane of a cell, can be selectively and differentially permeable to affects, sensations, and knowledge of the host personality or other alternate personalities (alters). These amnestic boundaries will define the communication streams that exist between the personalities. Their permeability needs to be modified if changes in the system of mind are expected. The therapist must get to know the personalities or else the patient will be minimally understood and the defensive structure will remain puzzling. Therefore, it is essential in the course of the therapy to address directly all the personalities which the patient has created. The therapist must not only understand their conflicts but also learn with whom personalities, in the sphere of their inner world, relate, speak, and share. The therapist needs to learn whom the personalities avoid and whom they fear. The system of personalities is not stagnant, inert and unmoving; it is not like interlocking pieces of a jigsaw puzzle that once recognized by the therapist can be revisited, next time, unchanged. The DID patient's inner life, as defined by the personalities, is forever evolving, relational, and seemingly unpredictable. However, as time goes on, therapists can develop a "finder image" and thematic streams that predictably evoke certain personalities or certain groups/clusters of personalities. Personalities can be understood as personified adaptational strategies. They are representations, for instance, of conflicts, fears, and wishes. The formation in childhood of personalities is an extreme representation of a child's desire to not be alone to face overwhelming experiences and to either have a "buddy to take the hit," a "strong protector" to mediate with the outside world or a "friend" with whom to run away. Personalities are clever adaptations to abuse devised by high-hypnotizable children in crisis. The continued formation of personalities in adulthood speaks to maladaptive responses to stress, even if the stress is minimal. Inoculation theory that would suggest that being exposed to abuse would make an individual more resilient to stress or that it would build character is strongly rejected; abuse actually builds characters (personalities) that may initially interface in the outside world of the child but eventually become increasingly hidden in the adolescent and the adult. The secret of the existence of the personalities can be so well kept that even the main personality that is trying to function in the world may not know that other parts of the mind exist. The therapist needs to be a keen diagnostician and rely on established findings of masters in the field of dissociation, such as Braun, Kluft, Putnam, Wilbur and to screen for dissociation. Essential adjuncts to the diagnosis are the use of either the SCID-D or the DDIS which sketch a helpful chart of a subjects dissociative profile.
Because every DID patient's life is individual and everyone brings to therapy his/her story and experiences from the past there is not but one presentation style that can be expected in DID patients, nor is it necessarily the clear cut delineation of personalities as would be suggested by Wilbur and Thigpen and Cleckley. Only 6% of DID patients present in such clear cut ways, which probably explains why making the diagnosis of DID has remained so concealed and seemingly difficult. Indeed, DID is a disorder of secrecy and it may take time for the DID patient to let the therapist discover or uncover the various aspects of mind. Though not fool-proof, there are certain types of personalities that seem to emerge as natural adaptations to overwhelming life experiences for children who as adult will present with DID.
There are child personalities who contain young experiences from childhood that are traumatic. It is common to encounter parts that represent themselves and believe that they are nonverbal or preverbal parts. They seem absorbed in affect and struggle communicating through words. In Transactional Analysis terms, these personalities "sit on" other personalities and through passive influence tend to distort, misunderstand, and interfere the most with the adult functioning of the DID patient. A therapy primarily geared to satisfying the needs of child personalities in order to give them a corrective emotional experience, in the reparenting sense, is usually misguided. They are the personalities that tend to disequilibrate the patient the most and which need to be hypnotically reconfigured until it is time in the dilution-of-affect phase of the therapy to address their abreactive work. Other closely linked personalities are those called "Internal Abusers." These personalities behave as if they were cognitive developmentally child personalities who have taken on from childhood an adult posture. Internal abuser parts copy those people from the environment of the child who were abusive. These personalities are understood as failed attempts at mastery over the effects of devastating adult figures. In order to preempt attacks from abusive adults, the child would learn to anticipate, with precision, the mind set of the external adult. As the boundary for the child between external reality and internal reality becomes less and less defined, the child will have "by accident" created an enemy within who as time passes will root for external abusers, mimic their language and advice, belittle the child, and promote flashbacks and retraumatizations into adult life. Internal abusers are the most sequestered parts of the mind; their existence is often initially denied by patients, because they are feared, but perhaps more importantly because they are the hubs of feelings of worthlessness and shame for the personality system as a whole.
Finally, there are more adult parts that seem to distribute among themselves the various roles to either attend to the inside world of the patient or to support functioning externally in the here and now. It is fairly typical to encounter a host personality which, by definition, is the part of the mind in executive control of the body most of the time; this personality, whether in its awareness or not often relies on the (hopefully) smooth gearlike imbrications of the behaviors of the non-host personalities. Like with a fine watch, time and life inclemencies bring the sensitive mechanism to a dead halt; decompensations under stress are common events for DID patients who need to be protected from ongoing overwhelming events as adults if they ever want to be integrated.
2. Stabilizing the Personalities: By the time DID patients enter therapy, the system of personalities and their smoothly imbricated functioning has often failed them. DID patients know about feeling out of control, experiencing mood swings, and not being able to count on themselves in ways that will promote three-dimensionality. It is essential that the therapist who enters into the autohypnotic world of the DID patient be focused on reinstating a nondramatic, balanced and here-and-now approach to the functioning of the personalities and the person as a whole. There is no glory for the therapy dyad in making a dissociator dissociate! It is only when life in the present is stabilized for the patient that the treatment dyad can consider exploring the origin of each personality with its concomitant BASKs.
The clinical skills of therapists come into play as they begin to meet personalities for the first time, forge relationships with them, and develop a working alliance. Therapists will need to negotiate for novel and stable functioning of the patient with the personalities, discouraging selfishness and irresponsible individualization to promote the needs of the One, rather than the wishes or fears of the many. To accomplish this preliminary goal, therapists need to know with whom they are negotiating. Therefore, getting to know the personalities is essential to stabilize the DID patient.
3. Mapping the Personalities: One manner that I favor to get acquainted with the various personalities is requesting that the DID patient do "a mapping of personalities". This request comes in the very early stages of the therapy; the mappings are fluctuating documents. They evolve and frequently resemble a scattergram by the end of the suppression-of-affect stage. The mapping of personalities involves requesting that the host personality write its name in the center of a page; I then request that the host or alternate personalities place their names on the page in a way that best reflects how similar or dissimilar they feel about one another. For those DID patients who do not recognize in themselves separate personalities, this exercise may be reworded in a way such that "feeling concepts" or "body sensation concepts," streams of thoughts or impulsive feelings are represented in ego-state form. The nomenclature of personality is less relevant than the abstraction of the differentially perceived experiences.
Once a mapping is done, it is fairly common to observe groups of personalities clustered together for reasons that may or may not be foreign to them or the host personality. I understand this initial mapping to be "a business card" from the system of mind; it is an invitation to therapists to get to meet the personalities or groups of personalities who have "signed on." Typically, these initial personalities are either desperate to get help, have given up on trying to remain hidden or are just the brave ones who are sent out as "therapy scouts." This mapping constitutes a first unifying step in DID patients' treatment.
4. Talking with Personalities: There are a few essential elements to keep in mind when you begin to address the various alternate personalities (alters). They do not know you and you do not know them; therefore, treat them with respect and expect to be treated similarly. On an initial encounter, you would not presume for anyone to tell you his/her most shameful or scary experiences; do not expect this from personalities either. As a matter of fact, therapists may need to help personalities either elicit or modulate the flow and amount actually told by the DID patient. True to their obsessive-compulsive defenses, the personalities may lean in the anal-retentive direction; in this case, their sharing of any information is frankly laborious. Conversely, other personalities are more anal explosive; they tend to share too much, too soon, and can unexpectedly precipitate an abreaction for themselves or a proximal personality; they may reveal "secrets" too rapidly and an internalized abuser alter may feel attacked or vulnerable and hence bombard the patient with flashbacks and strong affect from the past. If these spontaneous abreactions occur, it will obviously make the patient and many of the personalities reluctant to resume the therapy as proposed. It may in addition reinforce the affect phobia of the DID patient.
In this initial phase, therapists will carefully listen to the DID patients and refrain from unsolicited attempts to rescue the patients from themselves (unless of course there is imminent danger). It is even more essential to carefully examine the solicited requests for "salvation from -----" as they rapidly emerge from the newly discovered personalities; these "deliverances" may be due to countertransferential responses in the therapists who are reacting to the impact of the trauma-based cognitive distortions of the DID patient and their concomitant affects. These distortions will surface as the personalities tell their story; addressing them judiciously and cautiously is part of the cognitive restructuring which predates the abreactive work. This cognitive restructuring will involve having the various personalities notice the connection between how they think and how they feel, as well as how their cognitive-effective understanding of the world determines their behaviors. The personalities need to appreciate that adaptive responses from the past no longer serve them and can actually hinder them in the present. Their main injunction in the present is "to notice."
It is empowering for DID patients and their personalities to note, assess, and change the faulty beliefs from the past. The therapist will help them devise a structure and a predictable system of verification. This methodology borrows from the Socratic process, which is valued in the experimental model championed by most cognitive therapies. The therapist is fundamentally promoting dissonance within and between traumatically entrenched beliefs. Indeed, at the beginning of treatment, the therapist should expect that the DID patient will have some degree of consonance within each personality and much dissonance across personalities. As the therapy progresses, therapists strive to establish increasing cognitive dissonance within each alter, tapping into all the BASK dimensions. As systems theory would predict when one part of the system changes, the rest of the system must change as well; therefore, the other personalities will respond and eventually adapt to the revised understanding of each alter. Microdisequilibrations, which occur when dissonance is instilled, are followed by temporary restabilizations. Eventually the evolving beliefs and goals of the personalities will crystallize in a parallel direction and will coalesce.
Therefore, dealing with the dissonances within and between the personalities serves several functions: 1. it helps the personalities begin to notice their internal and external realities; 2. it subsequently helps them establish hypnotic duality which is a prerequisite for abreactive work; 3. it brings to the forefront and to their attention, the dissociatively established double binds and the complex double binds that had been promoted since their childhood; 4. it also becomes a dynamic foundation that is increasingly mastered over time and from which the personalities can reflect, deliberate, and progress. The message is that "change is not necessarily bad (traumatic expectation), and can actually be good." Repeated negotiations of established distortions foster the notion that they (the personalities) are instrumental in making these changes; this restores hope in alters who lack a sense of self-efficacy and future orientation. It is at this particular level of the infrastructure that homogenous psychotherapy groups for DID are helpful. This foundational work is the prerequisite for the second phase of the pre-integration work for DID, which is the dilution-of-affect stage where the actual abreactions occur.