“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
* Baars, E.W., Van Der Hart, O., Nijenhuis, E.R.S., Chu, J.A., Glas, G., & Draijer, N. (2011). Predicting stabilizing treatment outcomes for complex posttraumatic stress disorder and dissociative identity disorder: An expertise-based prognostic model. Journal of Trauma and Dissociation, 12(1), 67-87. doi:10.1080/15299732.2010.514846
Abstract: The purpose of this study was to develop an expertise-based prognostic model for the treatment of complex posttraumatic stress disorder (PTSD) and dissociative identity disorder (DID). We developed a survey in 2 rounds: In the first round we surveyed 42 experienced therapists (22 DID and 20 complex PTSD therapists), and in the second round we surveyed a subset of 22 of the 42 therapists (13 DID and 9 complex PTSD therapists). First, we drew on therapists' knowledge of prognostic factors for stabilization-oriented treatment of complex PTSD and DID. Second, therapists prioritized a list of prognostic factors by estimating the size of each variable's prognostic effect; we clustered these factors according to content and named the clusters. Next, concept mapping methodology and statistical analyses (including principal components analyses) were used to transform individual judgments into weighted group judgments for clusters of items. A prognostic model, based on consensually determined estimates of effect sizes, of 8 clusters containing 51 factors for both complex PTSD and DID was formed. It includes the clusters lack of motivation, lack of healthy relationships, lack of healthy therapeutic relationships, lack of other internal and external resources, serious Axis I comorbidity, serious Axis II comorbidity, poor attachment, and self-destruction. In addition, a set of 5 DID-specific items was constructed. The model is supportive of the current phase-oriented treatment model, emphasizing the strengthening of the therapeutic relationship and the patient's resources in the initial stabilization phase. Further research is needed to test the model's statistical and clinical validity.
Brand, B., Classen, C., Lanius, R., Loewenstein, R., McNary, S., Pain, C., & Putnam, F. (2009). A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specific patients treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 153-171. doi: 10.1037/a0016210
Abstract: The goals of this naturalistic, cross-sectional study were to describe the patient, therapist, and therapeutic conditions of an international sample of dissociative disorder (DD) patients treated by community therapists and to determine if community treatment for DD appears to be as effective as treatment for chronic PTSD and conditions comorbid with DD. Analyses found that across both patient (N = 280) and therapist (N = 292) reports, patients in the later stages of treatment engaged in fewer self-injurious behaviors, had fewer hospitalizations, and showed higher levels of various measures of adaptive functioning (e.g., GAF) than those in the initial stage of treatment. Additionally, patients in the later stages of treatment reported lower symptoms of dissociation, posttraumatic stress disorder, and distress than patients in the initial stage of treatment. The effect sizes for Stage 5 versus Stage 1 differences in DD treatment were comparable to those published for chronic PTSD associated with childhood trauma and depression comorbid with borderline personality disorder. Given the prevalence, severity, chronicity, and high health care costs associated with DD, these results suggest that extended treatment for DD may be beneficial and merits further research.
Brand, B. & Loewenstein, R. (2013). Does phasic trauma treatment make patients with dissociative identity disorder treatment more dissociative? Journal of Trauma & Dissociation, 15(1), 52-65. doi: 10.1080/15299732.2013.828150
Abstract: Proponents of the iatrogenic model of the etiology of dissociative identity disorder (DID) have expressed concern that treatment focused on direct engagement and interaction with dissociated self-states harms DID patients. However, empirical data have shown that this type of DID treatment is beneficial. Analyzing data from the prospective Treatment of Patients With Dissociative Disorders (TOP DD) Study, we test empirically whether DID treatment is associated with clinically adverse manifestations of dissociated self-states: acting so differently that one feels like different people, hearing voices, and dissociative amnesia. We show that, over the course of the study, there were significant decreases in feeling like different people and hearing voices. These results indicate that this form of DID treatment does not lead to symptomatic worsening in these dimensions, as predicted by the iatrogenic model. Indeed, treatment provided by TOP DD therapists reduced, rather than increased, the extent to which patients experienced manifestations of pathological dissociation. Because severe symptomatology and impairment are associated with DID, iatrogenic harm may come from depriving DID patients of treatment that targets DID symptomatology.
Brand, B., Loewenstein, R., & Spiegel, D. (2014). Dispelling myths about dissociative identity disorder treatment: An empirically based approach. Psychiatry Interpersonal & Biological Processes, 77(2), 169-189. doi: 10.1521/psyc.2014.77.2.169
Abstract: Objective: Some claim that treatment for dissociative identity disorder (DID) is harmful. Others maintain that the available data support the view that psychotherapy is helpful.
Method: We review the empirical support for both arguments.
Results: Current evidence supports the conclusion that phasic treatment consistent with expert consensus guidelines is associated with improvements in a wide range of DID patients' symptoms and functioning, decreased rates of hospitalization, and reduced costs of treatment. Research indicates that poor outcome is associated with treatment that does not specifically involve direct engagement with DID self-states to repair identity fragmentation and to decrease dissociative amnesia.
Conclusions: The evidence demonstrates that carefully staged trauma-focused psychotherapy for DID results in improvement, whereas dissociative symptoms persist when not specifically targeted in treatment. The claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID. Given the severe symptomatology and disability associated with DID, iatrogenic harm is far more likely to come from depriving DID patients of treatment that is consistent with expert consensus, treatment guidelines, and current research.
Brand, B. L., McNary, S. W., Myrick, A. C., Classen, C. C., Lanius, R., Loewenstein, R. J., Pain, C., & Putnam, F. W. (2012). A longitudinal naturalistic study of patients with dissociative disorders treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 5(4),301-308. doi: 10.1037/a0027654
Abstract: Severe dissociative disorders (DD) are associated with high levels of impairment, treatment utilization, and treatment costs, yet relatively little systematic research has focused on treatment for these challenging patients. The goal of this naturalistic observational 30-month follow-up study of an international sample of patients with dissociative disorders was to determine if treatment provided by community providers was associated with improvements in symptoms and adaptive functioning. The patients were diagnosed with dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS). The patients and their therapists completed surveys at study entry and at 6-, 18-, and 30-month follow-up. At the 30-month follow-up, 119 of the original 226 patients completed the surveys. According to patients’ reports, they showed decreased levels of dissociation, posttraumatic stress disorder symptoms, general distress, drug use, physical pain, and depression over the course of treatment. As treatment progressed, patients reported increased socializing, attending school or volunteering, and feeling good. According to therapists’ reports, patients engaged in less self-injurious behavior and had fewer hospitalizations as well as increased global assessment of functioning scores (American Psychiatric Association, 2000) and adaptive capacities over time. These results suggest that treatment provided by therapists who have training in treating DID/DDNOS appears to be beneficial across a number of clinical domains. Additional research into the treatment of DD is warranted.
Chu, J., Dell, P., Hart, O., Cardeña, E., Somer, E., Loewenstein, R., ... Brand, B. (2010). International Society for the Study of Trauma and Dissociation Guidelines for Treating Dissociative Identity Disorder in Adults. Journal of Trauma & Dissociation, 12, 115-187.
Cronin, E., Brand, B., & Mattanah, J. (2014). The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. European Journal of Psychotraumatology, 5. doi: 10.3402/ejpt.v5.22676
Abstract: Research has shown that the therapeutic alliance plays an important role in enhancing treatment outcome among individuals with a variety of disorders, including posttraumatic stress disorder (PTSD). However, the therapeutic alliance and treatment outcome has not yet been studied in dissociative disorders (DD).
The current study sought to investigate the impact of alliance on treatment outcome for DD patients.
Data from a naturalistic, longitudinal international treatment study of DD patients and their therapists were analyzed to determine if the alliance, as reported by patients and therapists, was associated with treatment outcome.
Patients with higher self-rated alliance had fewer symptoms of dissociation, PTSD, and general distress, as well as higher levels of therapist-rated adaptive functioning. Over time, self-rated alliance scores predicted better outcomes, after controlling for patient adaptive capacities including symptom management at the time when the alliance ratings were made. Patient-rated alliance was more strongly associated with outcome than therapist-rated alliance.
Therapists who work with DD patients should understand the importance of the alliance on treatment outcome. These findings are consistent with previous literature demonstrating the importance of developing and maintaining a strong therapeutic alliance, although the effect sizes of individuals with DD were stronger than what has been found in many other patient groups. A greater understanding of the impact of the alliance in traumatized individuals may contribute to better outcomes for these individuals.
Ellason, J. & Ross, C. (1997). Two-year follow-up of inpatients with dissociative identity disorder. American Journal of Psychiatry, 154(6), 832-839.
Abstract: Objective: A patient group of 135 inpatients with dissociative identity disorder was followed for two years to monitor treatment outcome.
Method: Fifty four of these patients were located and re-assessed after a two year period, by using the same self-report measures and structured clinical interviews that had been initially administered.
Results: The patients showed marked improvement on Schneiderian first rank symptoms, mood and anxiety disorders, dissociative symptoms, and somatization, with a significant decrease in the number of psychiatric medications prescribed. Patients who were treated to integration, were significantly more improved than those who had not yet reached integration.
Conclusion: Our findings, though preliminary, provide empirical validation of previous clinical impressions that patients with dissociative identity disorder may respond well to treatment.
Gentile, J.P., Dillon, K.S., & Gillig, P.M. (2013). Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Innovations in Clinical Neuroscience, 10(2), 22-29.
Abstract: There is a wide variety of what have been called “dissociative disorders,” including dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and forms of dissociative disorder not otherwise specified. Some of these diagnoses, particularly dissociative identity disorder, are controversial and have been questioned by many clinicians over the years. The disorders may be under-diagnosed or misdiagnosed, but many persons who have experienced trauma report “dissociative” symptoms. Prevalence of dissociative disorders is unknown, but current estimates are higher than previously thought. This paper reviews clinical, phenomenological, and epidemiological data regarding diagnosis in general, and illustrates possible treatment interventions for dissociative identity disorder, with a focus on psychotherapy interventions and a review of current psychopharmacology recommendations as part of a comprehensive multidisciplinary treatment plan.
Howell, E. F. (2011). Understanding and treating dissociative identity disorder: A relational approach. New York: Routledge/Taylor & Francis Group.
Summary: Building on the comprehensive theoretical model of dissociation elegantly developed in The Dissociative Mind, Elizabeth Howell makes another invaluable contribution to the clinical understanding of dissociative states with Understanding and Treating Dissociative Identity Disorder. Howell, working within the realm of relational psychoanalysis, explicates a multifaceted approach to the treatment of this fascinating yet often misunderstood condition, which involves the partitioning of the personality into part-selves that remain unaware of one another, usually the result of severely traumatic experiences.
Howell begins with an explication of dissociation theory and research that includes the dynamic unconscious, trauma theory, attachment, and neuroscience. She then discusses the identification and diagnosis of Dissociative Identity Disorder (DID) before moving on to outline a phase-oriented treatment plan, which includes facilitating a multileveled co-constructed therapeutic relationship, emphasizing the multiplicity of transferences, countertransferences, and kinds of potential enactments. She then expands the treatment possibilities to include dreamwork, before moving on to discuss the risks involved in the treatment of DID and how to mitigate them. All concepts and technical approaches are permeated with rich clinical examples.