Treatment: Phases

Image: "courage on 10 March 2010 - day 69" by Len Matthews

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Individuals with dissociative identity disorder (DID) are on average in therapy for almost a decade before they are diagnosed and spend an additional decade in therapy for their DID. Despite this, proper treatment for DID is known to be effective. Comprehensive DID therapy is associated with reduced self harm, fewer hospitalizations, fewer medications being needed, reduced symptoms of dissociation and posttraumatic stress disorder (PTSD), higher functioning, increased engagement in productive and social activities, less overall distress, and an increased sense of well being (see these studies).

The ISST-D recommends a phase-oriented treatment approach, with the most common approach having three stages. The first phase in this approach involves focusing on safety, stabilization, and symptom reduction. The second is trauma processing. The final stage helps the individual to adjust to coping with the world as a more integrated individual. These stages alternate as needed; for example, an individual who has reached the second phase of treatment may still need to revisit coping skills from the first phase and may be able to integrate some alters before really moving on to the third. Often, intense trauma processing needs to alternate with sessions focused on everyday life and functioning in order to avoid overwhelming and re-traumatizing the individual.

Phase 1 is all of the work that must be done in order for the individual to be capable of more advanced trauma work and healing. If the individual is not in a safe environment, is still being abused, or is at risk of additional harm, that needs to be addressed first. Steps may need to be taken to ensure that the individual is not at risk of harming anyone else, either directly or through an inability to properly care for dependents. It also must be determined if the individual is a risk to themselves due to suicidal ideation, self harm, destructive alters, addiction, an eating disorder, or impulsive risk taking. Crisis planning or hospitalization may be utilized. If a DID system has some awareness and communication between alters, alters can be asked to work together to protect the system as a whole. Positive coping mechanisms and grounding techniques are taught, and the individual may also be helped to learn better social skills, emotional awareness and regulation, distress tolerance, and problem solving. Co-morbid disorders are also addressed at this stage, and the individual may be put on medication to manage these.

Finally, the individual might need to be educated about their dissociation and alters during phase 1, and basic communication and cooperation should be established between alters. It is important that no alter should be valued over other alters; the individual must be helped to see how all of their parts are necessary to their well being as a whole. At times, specific alters may need to be addressed due to their behaviors or their unique abilities to help, but the clinician should be careful not to enable delusions that alters are literally separate or to accidentally suggest more separation than is shown to be present. Throughout this stage, a therapeutic alliance should be forged between the individual and their treating professionals.

Phase 2 is when traumatic memories are addressed in more detail. The individual must be helped to remember, tolerate, process, and integrate into their life history memories of traumatic experiences in order to fully come to understand that the trauma happened in the past, that the trauma is done, how the trauma affects the individual's life, and what the individual's self is when phobic avoidance is no longer needed. Often, this involves alters directly working with the therapist about the traumas that they hold. Alters may present individually or in groups, may or may not identify themselves, and may work alongside host parts or cause complete amnesia for the duration of their presence. The therapist may help to encourage alters to share trauma memories with other alters who are ready to know about that particular trauma or who need to know for their own safety or in order to heal. When the other alters accept the trauma as something that happened to them in the past, this is known as synthesis and is the basic level of trauma processing for systems.

Having alters’ cooperation is important because it’s the trauma that alters hold that most needs to be addressed. Not every traumatic memory needs to be individually worked with in order for overall progress and healing to occur, but working only with what the host knows upon entering therapy or what alters are willing to share directly with the host is unlikely to lead to real healing. Likewise, if alters are opposed to therapy for whatever reason, they may try to block the host from attending or participating in therapy, punish any alters who engage in therapy, mislead or frighten the therapist, or any number of other counterproductive behaviors. It's very common for alters to have significant attachment disturbances, and this is why it's so important for the therapist to have an alliance with their client, to be mindful of transference or counter-transference, and to keep therapy as safe for the client as possible.

Phase 3 is when integration of alters is a focus. Some individuals with DID choose to integrate, or accept all parts of themself so that they have one remaining personality, but others choose cooperation and communication instead. More information about those options can be found here. Other focuses of phase 3 include helping the individual to reconsider how they relate to themself, the outside world, their past, and their future. At this point, therapy may be able to focus on concerns more common in healthy individuals, such as relationships and the individual's chosen family, the individual's job, the process of aging, physical health, and coping with life's basic stressors. The individual may need help to rely on non-dissociative ways of approaching and coping with the world.

Treatment: Types

There are several common approaches to therapy for dissociative trauma survivors. The most common trauma focused therapies are eye movement desensitization and reprocessing (EMDR), prolonged exposure (PE) therapy, and cognitive behavior therapy (CBT). EMDR and PE therapy are both types of exposure therapy in which specific traumatic memories, themes, emotions, or cognitions are addressed. EMDR involves thinking (or talking) about the specific traumatic material while making bilateral movements, watching bilateral blinking lights, or similar. PE therapy involves talking about the memory extensively with increasing detail until the individual is talking about it as if it’s happening to them in real time. Both can get very intense but can be incredibly helpful if the individual is stable enough to handle them.

Between EMDR and PE, EMDR may be slightly easier to tolerate due to not requiring trauma to be vocalized or processed as if it’s still happening. As well, the bilateral stimulation at worst serves as a distraction, potentially making the trauma work a little less overwhelming; at best, it may provide additional benefit of its own, though if this is true or why it might be true is hotly debated. Again, however, it’s still intense and risks flooding of traumatic materials for individuals who aren’t already sufficiently stable. It and PE therapy may also be difficult for systems to manage if trauma is still strictly contained by certain alters who are unable or unwilling to participate in therapy themselves.

In contrast to EMDR and PE, CBT is focused less on the trauma itself and more on helping the individual to understand how the trauma affects their behaviors through their thoughts and emotions. It helps them to work on negative beliefs and perceptions that they may have gained as a result of the trauma. For example, an individual can be helped to break out of a cycle of expecting everyone to hurt them and subsequently not picking up on genuine red flags of abuse and so getting hurt. CBT can also help an individual to learn to manage stress, educate them on normal reactions to trauma, and address anxiety and poor self perceptions. One trauma specific type of CBT is cognitive processing therapy, which focuses on how trauma impacts one's view of their self and the world. Cognitive behavioral type therapies can help an individual to react to reminders of their trauma in more nuanced and present-oriented ways.

Other types of therapy are possible and may be better fits for some individuals. For example, a much more gradual and patient directed talk therapy style might suit some individuals well. Some practitioners do focus on a more psychodynamic approach, which seeks meaning from the trauma and focuses on how the trauma impacted one's sense of self and relationships with others. Treatments aimed specifically at comorbid conditions may also help. For example, DBT for individuals with comorbid borderline personality disorder (BPD) or exposure and response prevention for individuals with comorbid obsessive compulsive disorder (OCD) may also directly or indirectly touch on traumatic reactions or cognitions and directly or indirectly reduce PTSD symptoms. These therapies may occur individually or in a group setting.

As well, less structured forms of therapy may be used. For example, different types of art, music, or play therapy (for child parts especially) can help survivors to communicate and begin processing their trauma. Hypnotherapy is also an option, but it may be inappropriate for individuals with DID due to the risk of strengthening the dissociative barriers between alters, changing or falsifying memories, flooding the individual with flashbacks, and invalidating the individual’s testimony in court. Therapy aimed at internal family systems may also be inappropriate if the therapist is not well prepared to distinguish between normal parts of the self and more strongly dissociated alters, and attachment therapy can also cause problems if the therapist is not educated on how to ensure that the client's boundaries are being respected even if the client is unable to clearly communicate their boundaries. That said, with the right therapist, these treatments may prove helpful for certain individuals.

Treatment: Finding a Therapist and Financial Assistance

Sidran offers a list of considerations for choosing a therapist and offers to help individuals find local therapists. The International Society for the Study of Trauma and Dissociation maintains a list of therapists who work with dissociative clients here, and the International Society for Traumatic Stress Studies has a similar list for trauma therapists here. It is important to note that not all therapists who treat trauma or dissociation are on these lists. Sometimes, additional options may be found by contacting the nearest options and asking for more local referrals. For European individuals, the European Society for Trauma and Dissociation has a list of contacts in each country who may be able to provide assistance.

In some cases, it may be difficult or impossible to find a close enough therapist who has experience treating complex trauma and dissociation. Thankfully, even if a professional has no prior experience assessing and treating dissociative disorders, they may be able to provide basic help for comorbid disorders or may be willing to learn how to treat complex trauma. They may benefit from resources such as consultations with experts, therapist study groups (including virtual study groups), and seminars for continuing education. As well, there are many books that provide information and advice for professionals who wish to treat complex trauma and dissociative disorders. Particularly well known and lauded examples include Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists, Treating Trauma-Related Dissociation: A Practical, Integrative Approach, Intensive Psychotherapy for Persistent Dissociative Processes: The Fear of Feeling Real, Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders, and Understanding and Treating Dissociative Identity Disorder: A Relational Approach.

That said, trauma therapy and mental health treatment can be difficult for many individuals to afford. Luckily, many organizations, outpatient programs, and professionals offer free screenings, sliding scale treatment, or even free treatment. Mental Health America has a list of different sources for finding treatment, including treatment that’s affordable to individuals without insurance. Health Central has a page focused just on free or low cost treatment, including a link to a finder for sliding scale and free clinics. NAMI and the NIMH also try to help people find affordable support, and NAMI lists other resources here. BetterHelp provides online counseling for a lower price than most in-person counseling sessions, and it offers financial assistance to those who need it. (However, do note which payment plan you're signed up for; some charge after every week while others charge for the full month upfront, and the latter is the default for anyone who signs up, meaning that the default is to charge for the upcoming month as soon as the trial period expires.) A similar online counseling option is TalkSpace. Community health centers and group therapy often offer cheaper services than independent therapists working one on one with a client. For individuals still in school, their institution’s counseling services are free to access. Individuals who are employed might be able to access short term healthcare, referrals, or financial assistance through an Employee Assistance Program. One's church, synagogue, or temple might offer free counseling. Local teaching hospitals or graduate programs can often provide help for reduced fees or free. If an individual has a general practitioner but not a therapist, GPs can diagnose many conditions and prescribe medication if necessary. Crisis lines and peer counseling services can address some immediate needs. There are also tricks to getting needed medication at affordable prices (see PsychCentral and ADAA). (Please note that not all resources are available to minors.)

Informational Resources

More information about the types of treatment can be found here, here,  here, and here.

The ISST-D treatment guidelines for those with DID can be found here. The ISTSS treatment guidelines for PTSD can be found here. The ISTSS treatment guidelines for complex PTSD can be found here.

In the past we've worked with CBT, which helped at that moment but didn't have any lasting effects because there's so much to address. Plus we never really had a CB therapist who was willing and able to listen to different alters, so it was all from the host's point of view. That wasn't always helpful because the host doesn't do everything and isn't present in every situation.

We also had a form of psychotherapy, but that didn't really work for us because our emotions are often dissociated from our memories, so we could talk about certain memories without feeling anything about it.

We did a course on C-PTSD which was designed to get grips on your everyday life. This was a group therapy and it did help us on several points.

Now we have a hypnotherapist who's also a child therapist. We don't just have hypnosis sessions. Right now the hypnosis is used to support us in daily life, to help us through anxiety or depressive thoughts, or to help us sleep better. Besides that we talk a lot about different things, from both the present and the past. Sometimes we play games, and sometimes she challenges us to do something new, to take a step forward. The diversity of this approach seems to help us.

-Selene