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Section 23
Dealing with the Surround of DID Treatment

Question 23 | Test | Table of Contents

Practical Arrangements
DID is a difficult condition to have, and its therapy makes substantial demands upon therapist and patient alike. It is difficult to address significant trauma from the past while addressing issues in one's contemporary circumstances. Although supportive treatments and a minority of definitive treatments (usually or relatively stable patients) can be conducted in once-weekly psychotherapy, it is typically recommended that two full sessions a week, either as two separate sessions or as a single extended session, be understood as the appropriate minimum for successful therapy. Most of the rapid results reported in earlier contributions were achieved in patients seen 3-4 times per week. A patient usually cannot progress rapidly without the continuity, support, and security (due to greater containment and therapist availability) of a more intense treatment. Consequently, the treatment of DID must be carefully paced, bearing in mind both the patient's strength and resilience, and the actual logistics of the treatment, which may last for many years.

One of the most important aspects of the therapy of DID is ensuring that to as great an extent as possible, the patient leave the session in a relatively safe and contained frame of mind. Therefore, it is important for the therapist to master techniques that will allow the patient to be calmed at the session's end, and it is useful to respect Kluft's "rule of thirds". This rule holds that if one is deliberately planning to work with painful material, one should make sure that this work begins in the first third of the session and ends by the end of the second third of the session, preserving the last third of the session for processing what has been dealt with and restabilizing the patient. This is often difficult to apply in process-oriented therapies in which material may emerge gradually throughout the session, peaking toward the end, but is quite workable in therapies in which technical interventions are used to access, initiate, and conclude the work in question.

Access to the therapist between sessions is a major concern of DID patients. Their pain is often considerable, and their vulnerability to crises can be pronounced. It is important that they have access to some sort of coverage in between appointments, and it is important to frame this in a constructive way to prevent that coverage being abused. Early in treatment, during major clashes between alters, and during particularly upsetting trauma work, are times when this need may be highest. Many factors contribute to every therapist's decisions about his or her availability. Here I can only observe that it is difficult for a patient with DID not to have access to a clinician who is knowledgeable about DID and capable of dealing with difficulties in an informed and sensitive manner. Interim contacts with therapists unfamiliar with them and their condition may enhance rather than diminish their panic. My own practice is to respond to calls, but to confront my patients in session about occasions during which their calls do not represent true emergencies. In my experience, only a small number of DID patients will continue to abuse my availability after I clarify my stance a few times.

Informed Consent
Although informed consent from one alter can be applied to the patient as a whole, it is best to discuss issues concerning informed consent in an atmosphere that specifically encourages all alters to listen in to the discussion, especially those who see themselves as protectors of the patient . Litigiousness may be associated with trauma work in general, and with the treatment of DID in particular. Therefore it is important to document that the treatment is progressing under the aegis of informed consent, and, as per the recommendations of Appelbaum and Gutheil to regard informed consent as a process rather than as a moment in time. Subjects that should be addressed involve alternative approaches to treatment (and their pluses and minuses), the possibility of symptomatic worsening in the course of treatment, the vicissitudes of autobiographic memory (i.e., that recalled and/or recovered memories of trauma may or may not prove accurate), the techniques that may be used (and their possible benefits and drawbacks), and that additional alters may be encountered, or even created, in the course of therapy. Some experts advise the use of a consent form, especially with regard to recovered memory, while others advise the documentation of informed consent in progress notes. The interested reader is referred to more specialized sources. The circumspect contemporary clinician would do well to regard the informed consent process as an aspect of the therapeutic alliance in the 1990s rather than an arrogant intrusion into the therapeutic dyad. The costs to the therapist for omitting either such efforts or their documentation can be considerable.

Dealing with Alters
Many therapists are reluctant to actually elicit and/or work with the alters. They prefer to understand the alters as phenomena to be bypassed or suppressed, or they prefer to find another way of referring to the issues raised by the alters without having to address them as such. A longitudinal study of DID patients discovered that DID patients in treatments that did not address the DID directly, all had DID on follow-up. To date, I have not been able to find a literature describing the successful definitive treatment of DID without addressing the alters. In contrast, all available reports of successful treatments, whether in the lay or the scientific literature, have involved therapies in which the alters are addressed. Therefore, the clinician who undertakes to treat DID without addressing the alters is following a path likely to prove therapeutically futile and to expose the patient to danger and excess morbidity.

This is hardly surprising. The alters are not merely curious phenomena. They express the structure, conflicts, deficits, and coping strategies of the DID patient's mind. As Coons and Kluft have observed, the personality of a patient with DID is to have multiple personalities. Bypassing or disregarding the alters creates a therapy in which major areas of the patient's mental life and autobiographic memory will be denied an empathic hearing. Furthermore, it is rarely sufficient simply to address the alters as they emerge. The alters are aspects of a process of defense and coping. It would be naive in the extreme to imagine that the patient will predictably present in those alters most relevant to the conduct of the therapy. Considerations of facilitating day-to-day function, shame, guilt, and apprehension dictate otherwise. Therapists who await the emergence of alters in order to work with them may prolong the treatment considerably. The need to elicit the alters in order to do the work of therapy is one of the factors that motivates the process of mapping, or understanding the structure of the system. For example, the late Cornelia Wilbur, M.D., observed that in many DID patients one personality knows the entire structure of the system, but such a personality usually stays within the inner world of the alters and does not emerge. Simply asking whether such an alter is present can lead to information that simplifies treatment considerably in those patients who answer in the affirmative. Also, many times dangerous symptoms are related to alters unknown to either the therapist or the more easily accessible alters, yet can be easily addressed if the alters associated with such symptoms are elicited and their concerns addressed. A more detailed discussion of the usefulness of talking with the alters is available. Some useful forms of therapy, such as Watkins and Watkins' ego-state therapy, a productive personality-oriented approach, depend upon accessing the alters in order to move forward.

Dealing with the Surround of DID Treatment
By the surround, I mean the atmosphere of influences and information, both constructive and problematic, in which one conducts the psychotherapy of DID. This includes the flow of commentaries and data on DID and relevant subjects, such as "recovered memory" and trauma to which the patient is subjected, and the impact of these influences upon the patient, the therapist, and concerned others in the patient's life.

It is hard enough to treat and to be treated for DID in a supportive atmosphere. In an atmosphere of polarized contention, the task becomes more complicated. In the treatment of DID in the 1990s, the therapist can expect that the patient will hear that DID does not exist, that it is an iatrogenic creation, that those who treat DID are practicing a dangerous "recovered memory therapy," which constitutes malpractice, and that all or most recovered memories of trauma are false. These opinions will be voiced on prestigious mainstream television programs by experts and professors of apparently impressive credentials. Furthermore, there are web sites on the Internet in which the above views are expressed with conviction and venom. Also, in chat rooms for dissociative disorder patients on the Internet, it is easy to find contributions that vilify prominent dissociative disorder therapists, and that advocate remaining dissociative.

In this atmosphere, it is important to appreciate that no matter how dedicated the therapist and how motivated the patient, these factors may exert an influence. An apparent straightforward agreement to avoid and/or remain uninfluenced by such pressures may inadvertently contribute to a collusion to leave doubts and negative perceptions unexplored. In my experience, it is more productive and less defensive to invite the patient to bring all experiences that reflect such impacts into the therapy, and for the therapist to acknowledge the controversies that surround the issues of concern, and to state his or her best understanding of the particular situations or issues in question. If this is not done, the influence of infinite third parties to the treatment may go unappreciated as they undermine the therapy. A small percentage of DID patients will use the doubts raised by external factors in the service of an ongoing resistance, but most will not. For those who do, the characterologic aspects of such a defense must be addressed. In any case, it is important not to do anything that will result in the therapist's forcing the patient to accept the therapist's point of view, or precluding the patient's exploration of his or her own misgivings.
- Kluft, Richard P.; An Overview of the Psychotherapy of Dissociative Identity Disorder;  American Journal of Psychotherapy; Summer 1999; Vol. 53 Issue 3

Personal Reflection Exercise #9
The preceding section contained information about dealing with the surround of DID treatment.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Buer Christensen, T., Eikenaes, I., Hummelen, B., Pedersen, G., Nysæter, T.-E., Bender, D. S., Skodol, A. E., & Selvik, S. G. (2020). Level of personality functioning as a predictor of psychosocial functioning—Concurrent validity of criterion A. Personality Disorders: Theory, Research, and Treatment, 11(2), 79–90.

Matz, S. C., & Harari, G. M. (2020). Personality–place transactions: Mapping the relationships between Big Five personality traits, states, and daily places. Journal of Personality and Social Psychology. Advance online publication.

Oltmanns, J. R., & Widiger, T. A. (2019). Evaluating the assessment of the ICD-11 personality disorder diagnostic system. Psychological Assessment, 31(5), 674–684.

QUESTION 23
According to Kluft, what is important to consider regarding informed consent while working with a client with DID? To select and enter your answer go to Test.

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