A person who has been repeatedly abused has a history of low self-esteem, depression, problems with intimacy, feelings of powerlessness, self-blame, and feelings of shame. This scenario is especially likely when the abuse occurred during childhood. Since the abuse has probably been shrouded in secrecy, the person is more often apt to seek intervention for depression, marital problems, substance abuse, poor self-image, somatic complaints, interpersonal problems, or anxiety. The clinician needs to be empathic, honest, and actively interested in listening to whatever the person feels able to discuss. He or she must also resist the temptation to try to hasten the process. These people are highly vulnerable, and it is believed that the diagnosis of dissociative identity disorder may in many cases be iatrogenic, because of overzealous practitioners who may jump to conclusions and also, unfortunately, because of the media’s current fascination with this diagnosis. Clinicians should be cautious about accepting this diagnosis; they should have the client evaluated by an expert, and while doing the initial assessment they should be especially careful not to direct the client toward considering the possibility of the existence of alters. If the diagnosis is confirmed, intervention must proceed with the clinician accepting the diagnosis but viewing it with some degree of skepticism.
As is true for all interventions, the first step is to engage the client and form an alliance with the goal of developing better coping skills. Because trauma is usually experienced during childhood and at home, the person has limited ability to trust. It will take time to overcome the client’s emotional barriers. The clinician should be available, reliable, and empathic when the person feels in crisis and should demonstrate an ability to listen when painful memories and feelings emerge. As the alters emerge in the course of the intervention, the clinician may find it necessary to establish separate, respectful alliances with each. A contract is helpful in establishing the clinician as predictable; it should include information about scheduling of sessions, what to do in crisis, and the possible consequences of self-destructive behavior. Since the disorder resulted from situations in which the person had no real control but could control only by dissociation, it is especially important that during intervention the person have a real sense of arriving at a mutually-agreed-to contract. Crises may be frequent, but they can also be anticipated once the person is known to the clinician and it is possible to identify events or people that will lead to emergence of alters as defenses against remembering the trauma. Crises thus can be prevented, or at least diminished in intensity. The intervention contract should include a plan to follow if the person feels suicidal and an agreement not to abruptly terminate the intervention.
Studies have shown that at the time that people present for intervention, 80 percent indicate no awareness of alternate personalities. A technique that has been helpful in identifying alters when dissociative identity disorder is suspected has been to extend initial sessions three to eight hours, so that as history is given, the alters emerge. Another technique used in the early stages of intervention is to ask the person to write about activities, thoughts, and behaviors in thirty-minute intervals to identify personality shifts and periods of amnesia. The host may be the most resistant personality to recognizing the presence of alters and, therefore, to accepting the diagnosis of dissociative identity disorder.
After a relationship of trust has been established and the clinician senses that the person is aware of a fragile, variable sense of identity, he or she may ask permission to talk with the “other part of you.” The host personality may see this as a threat or be competitive and not permit it. If the clinician begins to learn about an alter, but the alter has not emerged directly, it will be necessary to ask for the alter in terms of behavior, such as, “Can I speak to the part of you that likes to go to bars to meet people?” With persistence on the clinician’s part, the host’s denial of an alter will yield to discomfort and ultimately to introduction to the alter. Some alters may have a great investment in their autonomy and separateness; others may change function in the course of the intervention.
Almost all alter systems include at least one child alter, who retains the memories and feelings of early traumatic experiences. Child alters often have long periods of continuous awareness and may claim to know the other alters. While the child alter is often frightened and apparently suffering from the abuse, other child alters can be love-seeking and speak of the abuser in idealized terms. The child alter often resists integration until the trauma has been disclosed and the role of the alter identified.
Two other common alters are the protector and the persecutor, and they may emerge during sessions or outside of them. The protector serves a defensive function, while the persecutor may induce suicide attempts or self-mutilation. A helper alter may be present and serve as an adviser to the clinician. Interviewing the alters will reveal varying levels of awareness of each other, as well as alliances, relationships, and conflicts. Integration is enhanced by how much information one alter has about another. Alters usually have names that may relate to their function or their primary affect or may be a derivative of the person’s original name.
Integration of the personalities is developed through stimulating communication between alters, trying to establish common goals and an acceptable way to achieve them through a recognized decision process, and recognition of how, why, and when switching occurs, so that there can be less competition for time. Cooperative functioning also will diminish periods of amnesia. The clinician may have to function as go-between for the alters until they are able to communicate directly and, if so, must be very careful that these communications are accurate and neutral. Patient, slow work with each alter at each level will eventually lead to a coherent, chronological picture of the traumas.
The core work of intervention is understanding the original trauma and the adaptive role of dissociation in mitigating it. Much of the intervention is concerned with control. The alters vie for control, and in the course of the intervention there is a struggle between the person and the clinician over the continued repression or the emergence of the trauma. Intervention involves uncovering secrets that the person kept in order to survive, and thus it requires that the clinician not be secretive, but as open and truthful as possible with respect to intervention. The secrets have often involved loose boundaries within families, so the intervention must also include the establishment of rules and boundaries. Secrets emerging during the intervention should not be kept from any of the alters and whatever the clinician interprets, suggests, or comments on should be addressed to all of them. In this way, the clinician is continuously moving the alters toward integration. Since the dissociative identity disorder developed as a survival mechanism, the person’s personality system may try to keep from certain alters information that is perceived as intolerable; the clinician’s practice of always addressing all of the alters will make this more difficult. Getting in touch with, and revealing, the secrets will be very difficult, and the person may test the clinician to see if his or her knowledge of the secrets can be tolerated or if it will result in abandonment of the person. The clinician must not rush the process of bringing the traumatic experiences and the associated feelings into conscious awareness and must be alert to the fact that the events may be experienced physically as well as emotionally. In any case, the revelation is very difficult for the person suffering from dissociative identity disorder and for the clinician; it will not really be possible without the development of sufficient stability and integration to overcome the defensive function of the alters. Some people never achieve complete integration but settle for communication and cooperation between the alters. In these cases, the extent and effect of the trauma have not been entirely worked through. Some clinicians have chosen not to strive for integration but rather to enhance cooperation and communication between alters, using family intervention techniques to work with the “family” of alters. Integration must include the realization that the fate of any alter is inextricably linked to that of all the others. Finally, intervention must identify and establish new, adaptive ways of coping and of conflict resolution.
Medication is not used to treat dissociative identity disorder, but it may be necessary to treat secondary symptoms such as anxiety or depression. A problem can occur if an alter opposes taking medication or has some idiosyncratic response.
Group work is usually contraindicated, particularly if it is a heterogeneous group that may not be able to adjust to shifts in personalities. Data on homogeneous groups are sparse. Some report that such groups are helpful in accepting the diagnosis, while others report competition over number of alters and control of the group. Group members also may inadvertently elicit the emergence of additional alters within the session and may not be able to handle more than one abreaction at a time.
Members of the family of origin are usually involved in the trauma, and their actions may have resulted in the development of dissociative identity disorder. The family, with its sanctioned right to privacy, has kept the abuse a “secret” and may have even viewed it as a normal part of family life, reinforcing parental, primarily paternal, authority. Usually it is not helpful to initiate family intervention, especially not until there is some integration, as the family is equated with the traumatic experience. Rather than helping with integration, involving the family may actually reinforce the dissociation and fragmentation. Alters may seek to blame and punish, or want to reconcile and be loved. In either case, disappointment is the usual result. Some people seek out siblings or other relatives to validate their memories of the abuse, but this too can prove disappointing. The family may sabotage the efforts to make the person recognize that the victim is not responsible for the abuse and that the abuser may even have committed criminal acts.
Working with the significant people in the person’s current life is an essential adjunct to the person’s individual work. The focus needs to be on the present, in order to monitor change that results from the move toward integration and later to help the partner/family understand and handle the results of abreaction. Assessment of the partner is important, in order to determine if there is any secondary gain: for example, one of the person’s alters may do things that the partner wishes to do but that the other alters (or the integrated personality) will not do. Education about the disorder and the goals and stages of intervention is also important. It is important to help the children of a person with dissociative identity disorder understand that the disorder probably caused the parent to appear inconsistent and unpredictable. It is also necessary to investigate the possibility that one of the alters may have abused the children.
There is some disagreement about whether dissociative identity disorder is a viable diagnosis; similar controversy surrounds contention about the prevalence of the sexual abuse of children. Critics feel that both ersatz dissociative identity disorder and recovered memories of sexual abuse can be prompted by overzealous clinician suggestions. In addition, dissociative identity disorder could possibly afford a defendant an insanity defense. Very good assessment skills are necessary, and initial intervention planning must be based primarily on facts, not intuition. It must be cautioned that there has been a proliferation of “recovery specialists,” who may not have specialized training and who elicit “memories” through techniques, including hypnosis and suggestion, that at times result in false charges of sexual abuse. Initial assessment must be confirmed by a clinician who has training in assessing dissociative identity disorder; only after that confirmation should a plan for intervention be determined.