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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 7 of 7

[10] Only With Permission

With and subject to permission of their patient, therapists must consider the qualities of the spouse/SO. Then, if appropriate and permission is granted, they should forewarn the spouse/SO once a dissociative disorder is strongly suspected. Many of my DID patients showed their alters to their spouse/SO long before those alters showed themselves to me in my office.

Therapists can prepare the spouse/SO with guidance as to the supportive behaviour when an alter emerges in the event there is no professional person around to handle the situation.

[11] Caring for Oneself

For therapists, caring for oneself is critical to deal with the vicarious trauma you might experience speaking with your DID patients. Vicarious trauma is also an issue for the spouse/SO,

For the spouse/SO, your DID partner experiences unimaginably intense stress that is triggered far more often than you realize or can expect. When a person is in that level of distress, often in the early hours of the morning, or even when driving during the day, express warmth not panic and everyone will be in a better position to heal.

What I have written is simple but, at the same time, it is very, very difficult. For therapists, they can rely somewhat on their training and somewhat on their experience. For a spouse/SO, as I have repeatedly urged kindness, remember that you also need to be kind to yourself. Under the stress of your partner’s DID, having your own therapist may be the key to developing your own internal strength to continue to be supportive and kind.

You need to take a regular break, whether it be a walk, to meet with your own therapist, or to do your own grounding exercises. Just alert your partner, give the parameters for how long you will need your break, what you will be doing and where, and when you will be back. You need to be clear that it is a break for you to recharge your batteries, not a break in your affection for your partner.

*****

This post is dedicated to all of the spouses and significant others who express their words of love into actions of kindness.

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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 6 of 7

[8] Who Are You With

For the therapist, the question is, “Who is my patient?” Is it alter Joan, alter Eddie, or host Margaret, or all the alters? The answer is not complicated. Margaret is the registered client for therapy. But, in treating your client, you have to directly engage alters who decide to express themselves directly, in writing, or through other alters explaining what is happening. It actually doesn’t matter who you are talking to, all of the alters, the entire system, is listening. The system is where the therapy is applied.

For the spouse/SO, it is, again, more complicated. The question for them is, “Who is my partner?” That is a very different question that impacts daily life, intimacy, companionship and every other aspect of such a close relationship. Because the spouse/SO will often be present when an alters emerges, the question itself can be very confusing as can the various answers.

Based on my limited experience, I do not believe that the spouse/SO should view their relationships with individual alters as distinct from their relationships with other alters. While one may have an easier, more friendly relationship with one or another particular alter, one must always remember that all the alters are listening in – even if they don’t tell you so.

I have seen in social media many posts about a spouse or SO going on “private dates” with one alter to the exclusion of the rest in the system’s participation in that date. If it generates conflict among alters, as it seems to based on the posts and comments I have seen, then it is the opposite of helping your partner heal. If this is a pattern that has already been established, I would suggest inviting all the alters to join, if and only if they wish, by welcoming them to watch and listen. The idea would be to share the positive aspects of the experience with the goal of enhancing the sharing of communication rather than conflict.

[9] Speak To Alters Within Their Context

How to speak with an alter is an essential component both in therapy and in the spouse/SO relationship. For therapists, talk to each alter in the same way you speak to any non-DID patient in your practice – with respect, empathy and kindness. The adjustment in speaking to DID alters is to speak appropriately to that alter. This means that if the alter is a 4 year old, then your sentence structure and word choices should be age appropriate.

If an adult breaks down like a child sobbing in front of you, telling her to snap out of her apparent “childish” behaviour is clearly wrong whether you are a therapist or a spouse/SO. Shouting and demanding that the person behave appropriate to her age may be the worst response if the patient/partner is a 45 year old adult whose 4 year old alter has emerged in a flashback.

Discipline yourself and talk naturally as if talking to a real life 4 year old child, even if the patient is dressed in a business suit coming from their executive office. Doctors are not taught in medical schools to talk to a 50 year old using Kindergarten language. For therapeutic benefit, one has to adapt – even if you think it makes you appear undignified. Remember how you speak/spoke to your own 4 year child, niece, or nephew when your manner of speaking did not put your dignity at issue!

For the spouse/SO, if you are able to refrain from trying to protect your desired emotional marital/SO dynamic, it can become quite easy to engage with alters. It may even allow for a refreshing breeze of humor once trust is established with the alter you are engaging. So long as you remember that your relationship is strengthened every time you can lead your partner from a re-traumatizing flashback to the safety of the present moment with you, things will progress positively. It will likely never return to what it was prior to the emergence of DID symptomology to the level that required therapeutic intervention.

It is perhaps easier for a supportive spouse than for a therapist to take this approach as “professional dignity” is not something couples generally are concerned with at home. This approach is also a way to enhance your own affection for all parts of the system just at it enhances their affection for you. The more your understand and undermine your own antagonistic reaction to difficult alters, the easier it is for them to dial down their hyper-vigilance to ordinary vigilance. This means a less stressful, less mercurial, emotional life for all concerned.

A therapist with an appropriate index of suspicion who pays attention to the phenomenon of dissociation is able to see the DID pathology which arises from trauma and expresses itself as dissociation. This is critical as it suspends the therapist’s rush toward seizing upon symptoms of anxiety, depression, and panic that can lead to an erroneous superficial diagnosis, whether it be panic disorder, depression, bipolar, borderline personality disorder or schizophrenia. Remember, these are the common labels behind which DID is often missed.

For the spouse/SO, if you have a suspicion or confirmation that there has been abuse in your partner’s past, your own vigilance will likely allow you to take a step back before asserting that your partner simply needs to calm down, or simply needs to take an antidepressant. If you have seen flashbacks in action, or experienced what may be an alter emerging – particularly at the same time each day or night, or in repeated similar circumstances – convey that to the therapist. In other words, you can assist the therapist in coming to a proper diagnosis, DID or otherwise, by communicating what you have experienced as simply and non-judgmentally as possible.

For both the therapist and a spouse/SO, let the alters decide when they want to talk. This is true whether it is in a therapy session or at home after dinner. For example, a suicidal alter, or one threatening to break out into violence, should receive priority attention when they express themselves.

They do not need to be called out or pressured to emerge, but they certainly need to feel that they have the space to come out and express their pain within a compassionate kind environment. It is both counterproductive and dangerous to insist on talking to the host when this kind of alter announces their presence whether it is in a therapeutic session or at home.

Talking to some alters requires tremendous patience and perseverance. Therapy is not simply social chatting, it can be exhaustive, hard work. For a spouse/SO, whether you characterize it as therapy or not, warm patience and perseverance definitely affects the speed and outcome of healing. Personally, I would characterize those qualities in a spouse/SO as love and affection.

Unlike a therapist, the spouse/SO cannot ignore an alter at the end of the office session. You cannot say you are too tired to be present and awake when an alter is caught in a late night flashback because it may be an emergency or the best/only time to offer genuine support in healing. Since you are the anchor for your partner, you have to try to do the right thing on the spot.

As a decent human being, you would rescue a child that you see falling into a pool of water. It wouldn’t matter that you were tired or interested in reading the rest of your book on the beach. This is not about whether you are qualified as a therapist or not. The circumstances are such that you cannot assert your love and affection while seeking to disappear or claim ignorance.

This is why a spouse/SO needs to be prepared and know the simple yet tremendously difficult task of how to talk to and listen to an alter. Keep it simple. To the best of your ability, always be kind. This is what you would hope to experience from someone you think cares about you if you were in distress.

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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 5 of 7

Part 5

[5] Stay Open

It is important to also remain open to the possibility of all levels of amnestic barriers among the alters as well as between the alters and the host. This can range from the extreme of complete amnestic barriers, such as when the host cannot accept a diagnosis of DID, to cases where there is full awareness of having many discreet alters inside shouting and arguing all the time.

In this context, some therapists and spouses/SO may feel that DID may be faked. It is true that there are no objective laboratory tests, like blood work or brain scans, to confirm DID mechanistically. But, as a therapist or a spouse/SO, consider why this person might make something like this up.

For example, is there an ulterior motive to claim non-culpability or to use it as an excuse for one’s irresponsible behaviour? In the absence of the individual being in prison or facing prison, I have never encountered any patient with motives that would support making up a fake DID diagnosis.

For a spouse/SO, it can become more complicated as the relationship dynamic is quite different than that between the therapist and the DID individual. While a therapist might think it would be difficult in the beginning to have confidence that DID is the correct diagnosis, the experience of the spouse/SO can often confirm it. A supportive spouse is likely to have seen far more evidence of switching personalities even without having the framework to understand the context of the behavior.

With some of my patients, there were terrified young alters that were so different from the host, and that came out regularly at particular times of the night related to when the abuse had taken place. For those patients, spouses relating their experience at night was what raised the question for me. For the spouse/SO who may be uncertain about the diagnosis, stay open to the different possibilities.

The advice of simply listening with empathy and encouraging grounding in the present moment will likely serve both people well regardless of questions about the diagnosis. It will engender more trust in the relationship regardless of the intensity of the dissociative responses, and that will lead ever more clearly to the path of healing.

[6] Empathy and Compassion Are The Critical Supports

One way for a spouse/SO to deal with the appearance of alters, whether they are frightened, angry, paralyzed or beholden to any other emotion, is to clearly focus your own mind on understanding that the dissociation is a non-conceptual response to handle the horror of remembered trauma. In a flashback, that unconscious choice cannot be changed on your partner’s command or on yours. The immediate response is uncontrollable.

You might think of the dissociative response in a flashback as a dam breaking. In that analogy, water breaks through the dam because its power is far beyond the dam’s ability to hold it back. The consider that the way to release pressure on a dam is to open a flood gate – a safe alternative path for the water to exit in a way that bypasses the dam before or even after it has broken. If a flashback, that safe exit is grounding in the now, in the present moment, without criticizing the intensity of the emotional energy that has been unleashed. Criticism is irrelevant and not helpful, grounding is.

This means that the compassion and empathy of the spouse/SO to invite the partner to experience the safety of the now is not offered as a way to eliminate the fear and panic. Instead, it is offering and holding the emotional space to allow the fear and panic to subside, to come to rest, in the safety of the present moment. This can only happen when the space is protected within the compassion and empathy of the supportive spouse/SO.

Remember, trauma is defined as an overwhelming event that exceeds the normal coping mechanism of the individual. It is a natural reaction to that event. A deeper understanding of this will answer many therapeutic concerns. It will also give comfort and support to any spouse/SO seeking a path to genuine compassion for all the alters they may engage.

[7] Do Not Deny The Alters

For therapist and/or the spouse/SO, seeking to convince the patient that the alters inside are not real is a grievous error and will be experienced as a re-traumatizing attack. It cuts off any possible therapeutic or supportive communication because you are arguing against something the patient is experiencing directly, and has experienced for years and often decades. There is no need to fear that accepting the alters in context will strengthen any pathology of dissociation. Dissociation that arises from intense terror is an inherent adaptive, preservative and survival response to overwhelming trauma. It is what saved the patient at the time, and so should be respected. If you can communicate it genuinely, then it should be thanked.

The pathology that is problematic is the consequence of splitting which results in a disharmonious relationship among the dissociative parts. It is part of the Complex PTSD suffered by all with DID. Therapy should focus on helping the patient to live in the present, which means bringing them to the point where they are be able to identify the present as distinguished from the past.

In that way, the therapy undermines the power of past trauma to hold the patient hostage right now through re-traumatizing flashbacks, often decades after the fact of the original trauma. As that power is limited further and further, the disharmony within the system also tends to be quelled: The different parts are less likely to be triggered when the power and intensity of flashbacks are diminished. The protective function of dissociation is not roused to the same extent when the intensity is softened.

With the therapist and a supportive spouse/SO engaging alters in this way, the individual with DID will come ever closer to relearning and reclaiming that actual experience of “safe”, which was decimated by the trauma.

This foundation to working with DID is applicable whether the individual has ten alters or hundreds.

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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 4 of 7

Part 4

[4] Leading the System to Safety

Help ground all parts of the system as they emerge. Ground them in the now through identifying things about right here, right now. Even in the middle of a flashback, it can be as simple as pointing out gently that “The bad things happened in such and such place, at such and such time.” You can ask “Where are you now?” Let them answer. Then point out that this place right here is different from that place. Ask “When is this conversation with me happening?” Let them answer. Then point out that this is a different time from that bad time. Ask “Right now, you are here with who?” Let them answer. Then repeat that “You are here with me and that is another thing very different than the bad time and place.” Then breathe together. Slowly allow your partner to bring their breathing in sync with yours. It may take more than just a few moments or minutes. Don’t worry, don’t be pushy. Just gently remind them to breathe with you.

One must always strive to be sincere, respectfully treating the alters as separate individuals just as they experience themselves as separate individuals. This is what alters feel deeply. It is what they expect in all interactions with someone they are trying to trust. And, it is something they will test with someone they are considering trusting or someone. Remember that in the midst of a flashback, they may need to once again test you on the spot.

One must never forget that an alter is one part of the whole person you are facing and interacting with. This is particularly true for the Spouse/SO. You cannot supportively pick and choose, or otherwise determine that you want to be with this alter and reject that alter. You cannot decide to punish or abandon one of the paranoid/hostile/selfish ones. This is true for both the therapist and the Spouse/SO.

There is a Chinese saying, 愛屋及鳥 : Because I love that person so much that I love everything related to that person, even the crows that are perched on the roof of that person’s house.) The more you encourage that view, the more supportive you can be.

In summary, both the therapist and the spouse/SO have to go beyond their own bias toward unitary personalities so as to treat the alters as real discreet parts as well as integral parts of one individual, one system so to speak. Those who cannot accomplish this will fail as a therapist or as a supportive spouse/SO.

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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 3 of 7

[2] Interacting with Difficult Alters

There may be alters that express the intense desire to kill another alter – perhaps including the host. Understand that such emotion and rationale are driven by deep trauma and likely walled off by amnestic barriers. For example, if “Juliet” wants to kill “Julian”, no matter what the therapist says, Juliet still experiences Julian as a separate person. This is the nature of dissociation. In some DIDs, Juliet may think she can kill Julian without harming herself. This logical gap is one that the therapist is unlikely to be able to correct with reasoning. But this is often accompanied or followed by a suicidal alter that believes everyone will be better off, both inside and outside, if she commits suicide and the entire system dies.

The therapist has to have the strength, warmth and flexibility to accommodate a phenomenon in their work that is not subject to intervention by logic. The therapist must not apply their own logic as superseding the DID individual’s subjective reality. I think this is one of the reasons that some clinicians find it hard to accept dissociation as a pathological concept, because they see it as based on a false logic. Remember that the DID individual is experiencing ongoing trauma and re-traumatization, regardless of logic.

More difficult than the experience of the therapist is the experience of the spouse/SO that likely confronts such situations at home alone with their DID partner. If they have no guidance/suggestions from the therapist regarding how to respond, the terror will go from the DID individual to their partner and back again. Leaving a supportive spouse/SO without guidance is a tremendous disservice to a supportive spouse and to the patient.

At the same time, part of the consideration is whether or not the spouse/SO is supportive. If they are not, then giving such an unsupportive spouse/SO information on the diagnosis of DID may endanger the patient. It is truly something that can only be considered on a case-by-case analysis with the patient being the ultimate decision-maker. Guidance from the therapist must include consideration of the risks if the spouse/SO is potentially not supportive.

[3] Dealing With Multiple Alters

Another problem associated with therapists who accept DID as a potential diagnosis is that they often become obsessed in trying to find out more about each and every alter. It is a waste of time and energy as well as being counterproductive to therapy. It is sufficient to listen deeply to what the alter you are engaging is expressing. Very often an alter is simply created to hold a traumatic experience or an emotion, nothing more. Such alters generally do not have the executive capacity to emerge and interact beyond the emotional context they are expressing. Talk to and listen deeply to each and every alter without prying or trying to call them out. For the therapist, focus on making a trusting therapeutic alliance with the alter. That is the key. With that, you don’t need to explore more than what the alter wants to tell you.

For the spouse/significant other, the guidance is to avoid obsessing about individual alters. Engaging them is critical but don’t obsess about them. Obsessing about alters and demanding their stories to “understand” them is a sure way to re-traumatize those alters and the entire system. It also communicates to the DID individual that you might care for one alter far more than another, that you want a relationship with one rather than with the system in toto.

Do not focus on your desire to know all of the alters. The only thing that needs to be understood is that the alters all arose as a result of dissociation in the midst of hideous trauma. If one or more of the alters wants to talk about such things, no problem. But therapists, spouses and significant others need to listen when alters want to talk without pushing for details. The key point is to help them experientially establish that the right here and right now is safe.

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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 2 of 7

How To Be With Alters
Whether you think an alter is annoying, angry, threatening or childish, don’t ignore them. Once you recognize the context of your interaction has changed, that an alter has emerged, you can start by responding appropriately to what is happening with that alter. If the alter is in a panic, perhaps caught in a flashback from childhood, you have a choice. You can leave her to her agony or you can comfort her. If you are a spouse/SO without training as a therapist, remember that you do not need a therapist to tell you how to comfort a child. In that same way, if you understand that you are now with an alter, you can use your own compassion and love to listen deeply with empathy and to soothe with your voice.

Some physical contact, such as a gentle touch on the shoulder or offering a hand to hold may be appropriate. But beware, physical contact at the beginning, middle or end of a flashback absolutely must not be or become sexual. The risk of re-traumatization is far too great. The intimacy of genuine friendship, of genuine affection unattached to sexuality, has tremendous positive power without that risk.

[1] General considerations in talking to alters

Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal flow of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative symptoms have the potential to disrupt every area of psychological functioning.

Many people are unable to accept that in DID patients, there are discreet self-identifying “personalities” (often called parts or alters) in their one physical body. I use the term personalities because it fits more precisely how alters feel within a DID individual – at least in my DID patients. Despite how it affronts our conventional views, there are these alters/parts/identities within the DID system – regardless of what term we use to refer to them.

Based on our conventional logic, it is clear that the patient is a single person with one physical body, holding one passport, and is generally identified as that person. On the other hand, when the patient speaks with the therapist or their spouse/SO, she may say, “I am Jill (an alter). I have nothing to do with Jane (the host) and I don’t want to having anything to do with her.” Alters may make hostile statements about themselves, the host, or other alters. Our conventional logic of people having a unitary consciousness or personhood will not benefit anyone in an interaction with alters.

Acknowledging an alter that has emerged, reminding her that right now you are listening to her, that she is safe, and will not be judged. This is, initially, much more difficult when an angry/mistrustful alter emerges. That alter may appear to you as completely unreasonable. Try not to argue. Remain stable and understand that the unreasonableness has its roots in an unimaginable background of pain and hurt. Through your consistent genuine empathy and caring, the anger, mistrust, pain, and despair of the alters will begin to diminish in power when and as they begin to feel it is possible that you might be able to understand that she holds her own source of suffering, which may be quite distinct from the trauma of other alters or the consciousness of the host.

As a spouse/SO, you are effectively functioning as a quasi co-therapist. Listen deeply without judgment, which will engender a path to the critical sense of safety for all the alters – not just the one that has emerged but all the alters that may be quietly watching and listening in. This is a very different message than the DID individual and any alter within that DID system has likely heard before. I say quasi co-therapist because you, as a spouse/SO must not insert yourself into a hierarchical position of providing therapeutic advice to your partner. The power dynamic of having one’s spouse/SO as therapist will be too dangerous for everyone involved. But you can be kind, and actually more kind than any therapist.

Perhaps someone can suggest an alternative method for spouses/significant others but, for example, when a 4 year old alter emerges hysterically at 3 am in bed, this is the safest and most potent suggestion I can make in terms of guidance for a spouse/SO who might encounter such a situation. In fact, this was the experience of Joan’s spouse discussed in Volume 1 of Engaging Multiple Personalities: Contextual Case Histories.

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Including a Spouse/Significant Other in Therapy – Critical Considerations: Part 1 of 7

I received many responses to my 4-part post suggesting that those with DID should consider the question of whether or not to include their Spouse/Significant Other (“SO”) in their therapeutic path. With appropriate consideration, if the decision is yes, then the next question relates to the extent should they be included, and what they need to know to be supportive.

Feedback on the question of whether to include a Spouse/SO ranged from absolutely yes to absolutely no, and included many versions of a qualified yes and qualified no. So it seems that my wish to raise the issue for consideration was successful and produced a wide range of opinions. Please keep in mind that one of the fundamental points I made was that control of the decision has to remain in the hands of the patient, and that the therapist has to be prepared to aid in the patient’s assessment process.

That being said, I feel it is both necessary and appropriate to put my own thoughts out there, my personal views as to the considerations and advice I deem important as part of this process. The result is quite a long post in multiple parts, the equivalent of a long chapter in a book. I apologize for its length and the delay in posting. I also apologize for repeating things I have said in earlier posts, but this is an opportunity to condense many of those points into a single presentation.

The purpose of this post is to offer a summary of my thoughts, opinions, and recommendations. I hope you consider these before making a decision. Please remember to discuss this topic with your therapist before making any decision about what to share with your Spouse/SO, when to share it, and to what extent to share it. I hope it is helpful to those with DID who have a Spouse/SO as well as to therapists who may benefit in reformulating, after consideration where and when appropriate, a more beneficial therapeutic plan that may include that Spouse/SO.

Both you as someone with DID and your therapist as an educated guide, need to consider to what extent your Spouse/SO is supportive, not supportive, or somewhere in between. I would encourage you to listen to your protector parts for their input as part of the process. Do not bypass those parts. As I have said in multiple posts and in my books, the idea is to lower the hyper-vigilance of the protectors to ordinary vigilance, but never to eliminate their vigilance or dismiss their feedback out of hand.

When an alter emerges at home, it is often the case that the Spouse/SO is the only one around. Given that they often emerge, whatever the circumstances, in the company of the Spouse/SO, the Spouse/SO is more likely than the therapist to encounter alters – knowingly or not.

As the Spouse/SO, what do you do? First, always remember that an alter is a part of the whole DID system, part of the whole person who is important to you. Having no training as a DID therapist is not a sufficient reason to ignore an alter that comes out.

Whether you see the alter as adorable, annoying, angry or childish, do not choose to ignore them. Once you recognize that an alter has emerged, you can start with what might easily be seen as common courtesy by responding with kindness to what is happening with that alter. If the alter is in a panic, perhaps caught in a flashback, don’t simply leave that alter to their agony. You do not need a therapist to tell you how to comfort a child or any other age alter. Just as you would do if you were to encounter someone in crisis other than your Spouse/SO, extend compassion, speak soothingly, and listen deeply with non-judgmental empathy.

Do not tell them that their pain is not real, that it doesn’t hurt. Pay attention to what you are seeing and hearing, listen with your body senses rather than your logic. You will see that the alter is obviously in pain, whether it is expressed as physical pain, anger, terror or any other intense emotion. So long as you acknowledge that pain and assure them that you will support the alter in working with the trauma they hold, you can say that the hurt will eventually diminish, that it will gradually cease to be so overwhelming, and that you will be there to offer support to all parts of the system on their journey of healing.

Most importantly, you can say that you will do what you can to create within your relationship a sanctuary in which that alter can express what they need to express without fear of judgment or negative feedback. In other words, you will do what you can to provide them the opportunity to re-learn the actual experience of safety that was hijacked by the trauma.

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Considering Spouses/Significant Others in DID Treatment Part 4 of 4

As my readers know, I am not happy with the short term news cycle attention that is generally given to early childhood trauma. The negativity expressed toward,dissociative diagnoses in general, and DID in particular are very unhelpful. I think it is important to note that in some circles of psychiatry, dissociation is now much higher on psychiatrists’ index of suspicion. This is primarily due to the Herculean efforts of veterans with wartime related PTSD and their families.

The dissociation that veterans with PTSD experience, and the difficulties their families deal with upon their return from service, forced the Veterans Administration to look at dissociation and PTSD. Why? Because there were government, military and family advocates forcing the issue. This brought an understanding of the frightening levels and intensity of PTSD with which veterans were returning.

There recently appears to be the beginnings of a change beyond the military-related PTSD community. It is instructive to consider some of the reasons why that is happening. In capitalist societies, opportunities to make money are often the primary drivers of health care. Simply put, this is why the pharmaceutical industry successfully sought to control mental health care education, with the extreme focus on chemical treatments for psychiatric disorders. The potential change is, as is often the case, heralded by marketing professionals.

I having been seeing many many ads for trauma courses targeting therapists. Yesterday, I saw one ad promoting a well-known trauma psychiatrist/author using the following language: “…an industry leader in studying and treating trauma.” I am not mentioning this to criticize that psychiatrist. I am confident his work has helped many many trauma survivors. I am merely pointing out that once trauma counseling is see as an “industry”, it is clear that there is an understanding once trauma counseling is an industry, there is money to be made in it – just as in any other industry. I remain concerned that the term “trauma informed” is being applied in all directions and throughout society – hence the idea that it is an industry definitely is taking shape.

I am not denigrating considering the impact of trauma throughout segments of society. Rather, I think it is important to retain the distinction and understanding of early childhood trauma, with its consequences, from older individuals that experience trauma, with those consequences, and one-time trauma survivors, with those consequences, and refugee trauma survivors, with those consequences. There is a common thread throughout all of these, which is the lack of the experience of safety which one had before being traumatized. But, the etiology, consequences and treatment may differ in various ways.

People participating in any trauma training need to be focused on stability, insight and compassion – not just the technique being promoted. With stability, insight and compassion, one will not see any technique as immutably applicable in all treatment. Without stability, insight and compassion, you will be like a hammer seeing the whole world as a nail to hit. Engendering stability insight and compassion must be the foundation.. This means that it is important to attract people that desire to help others, rather than people that are simply acquiring a credential to bill patients.

Mental health professionals, individually and collectively, need a forceful push to recognize how misdiagnosed as well as improperly treated Dissociative Identity Disorder causes a massive waste of societal resources in addition to the ongoing suffering of the patient(s) and families. DID still remains erroneously viewed by many professionals and lay people as a rare disorder, or worse, a controversial disorder. This continues to happen even as undisputed world statistics tell us its prevalence rate is 1% irrespective of the social or cultural background. Schizophrenia, which is not seen as particularly rare or controversial, has a worldwide rate of point 32% of the population – 1/3 of the rate of DID!

We know that early childhood trauma based DID, a complex form of PTSD unrelated to wartime service, has been generally ignored since the beginning of psychiatry. I think that the reason is that there has never been a groundswell of support from advocates of those with DID forcing the issue. Why? It is likely based on the fact that early childhood trauma is usually connected with sexual and physical abuse by family members and close friends of the family. It is rooted in heinous conduct people don’t want others to know has happened in their family and the perpetrator us likely in the family – so family members unit usually don’t want to confront or identify to police or mental health authorities.

It is grossly negligent that our mental health system fails to support a DID sufferer when they are finally able to gather enough strength to seek therapy. But, therapists use excuses to avoid taking them as patients, such as lack of experience – or even having doubt about the validity of DID as a diagnostic classification – despite its presence for decades in the DSM. It often takes months years for them to find a therapist that will accept them for therapy.

Perhaps too many psychiatrists prefer to craft a diagnosis from the DSM5 that offers a proposed solution that entails medication rather than the effort required for genuine psychotherapy. For instance, quickly prescribing medication for depression rather than first seeking to uncovering the root cause of the depression.

DID patients are commonly labelled as depressed and prescribed antidepressants. Then, when he/she does not get better because the diagnosis fails to consider dissociative symptomology, the usual course is to increase the medicine or change to a “better” antidepressant. The doctor reviewing the case of someone without improvement should be reviewing the diagnosis. In reality this is not done.

It is far easier to increase the dosage of medications, than to adopt a new approach. How often does a psychiatrist have the courage to say that the patient is suffering from dissociative disorder and requires intensive psychotherapy instead of continuing the same medication but at a higher dose? According to the textbook by Putnam published in 1989, the average time for a DID patient to reach the correct diagnosis is 6 years. From the social media I have seen, it remains the same. So, if you are living in the USA, write to your senator, in Canada and the UK, your MP. Unless you express yourselves out loud, repeatedly and unflinchingly, no one is going to hear you. Having your spouse/SO do the shouting may be the more effective approach. Hence another reason for considering including the spouse/SO in the therapeutic journey.

The power of kindness, of compassion, is not anecdotal. It is woven throughout our human history. Even those therapists focused primarily on psycho-active treatment should try to include kindness and compassion, even if it is just 5 minutes of actually listening to their patients about their difficulties, before dismissing such inclusion as a waste of billable time.

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Considering Spouses/Significant Others in DID Treatment Part 3 of 4

For both therapists and the spouse/SO of DID individuals, there are several key points to supportively engaging an alter.

[1] One has to overcome the initial feeling of “inappropriate behaviours” of one, therapist or s/o, talking to an adult as if talking to a 4 year old child. Yes, it is quite a challenge doing this for the first time. While it may feel uncomfortable initially, it is not inappropriate. I insist that this is the only appropriate behaviour if we understand what dissociative identity really means. I think one of the problems some psychiatrists basically cannot overcome is thinking one is doing something wrong in “encouraging regression” or “encouraging dissociation.” They are missing the point of the nexus between dissociation and trauma.

[2] Repeated corrective experience offered to the alter(s) underlies the healing process for the DID patient. Sometimes the process is called “metabolizing” the trauma. That addresses part of the difficulties experienced by DID individuals. The other difficulties are related to the chaos experienced by them when their alters, rather than working together, act like a divided household.

The treatment of DID is accomplished through empathic talking to alters, whether at home or in the therapist’s office. Treatment of DID through cognitive behaviour, or EMDR as suggested by the popular literature one can find by googling, are but tools. But genuine healing requires engaging alters, not avoiding or trying to manipulate them.

I view DID therapy, going forward, as involving the following steps:

First, the therapist must come to the DID diagnosis. Be prepared that certain individuals with possible early traumatic experience may be suffering from dissociative identity disorder Remember this is roughly about 1% in prevalence in the world among diverse cultures and social backgrounds. It is not uncommon, just as early childhood trauma is not uncommon. Only a high index of suspicion will help therapists avoid missing such a diagnosis. Even experienced therapists who fail to identify indicators of such trauma will miss such a diagnosis.

Second, the therapist must ask the patient whether they trust their spouse/significant other with the diagnosis information. If no, then that ends the discussion concerning notifying and/or including the spouse in therapy – at least for the moment. If later on in therapy, it appears that the spouse is potentially trustworthy from the point of view of the patient, the therapist can raise it again in the context of giving tools to both patient and spouse/SO for use outside of therapy sessions.

Third, if there is permission from the patient to discuss the diagnosis with spouse/significant other, the therapist must first meet with the patient and the spouse together so as to be able to make an assessment as to whether or not the spouse has the interest and capacity to support their DID partner. This assessment must be made before disclosure of the diagnosis by the therapist. Then, a private conversation with the patient and without the spouse, must take place to review both positive and negative indications from the conversation between the spouse/SO and the therapist. The patient always retains their agency so as to decide on their own whether they wish to notify their spouse/SO of the diagnosis.

Fourth, the DID notification conversation needs to take place with the patient and spouse/SO together in the therapist’s office. This conversation needs to include the diagnosis, the basis for the diagnosis and a discussion of the general etiology of DID – early childhood abuse. This needs to include the severe warning to the spouse/SO that the actual history is something that is never, repeat never, to be inquired about by the spouse/SO. If the patient wishes to share anything, that is their decision and non-judgmental deep listening by the spouse/SO will be critically important.

Generally speaking, the specifics of the history are irrelevant to the therapy. Pursuing specifics will likely be extremely re-traumatizing. It will run the risk of undermining all therapy to date. Why? It is because pushing for disclosure or additional details will make the patient question whether or not they are safe right now, or perhaps are being set up for yet another betrayal. The only relevant information one needs to know as a spouse is that trauma is there.

Fifth, giving tools and guidance to the spouse/SO. All of this must be done with the patient present. This is again encouraging the patient to reclaim their agency in life. No decision is made without them signing off on it.

Sixth, ongoing therapy may or may not include the spouse/SO. It is critically important that both the patient and the spouse/SO understands that this is DID therapy for the patient only. It is NOT in any way shape or form marital therapy.

Difficulties the spouse/SO may have in the relationship might be relevant to the DID therapy but the DID therapist needs to be able to insist that the spouse/SO address marital issues separately with their own therapist. The patient’s therapist cannot be both the DID therapist and the marriage counsellor. Sessions should begin just with the patient. The spouse/SO should be included as and when the patient deems it appropriate.

If the spouse/SO has a question, a concern, or additional information they think is relevant for the therapist, they should write it down and give it to the therapist at the beginning of the session. They should then excuse themselves unless and until they are subsequently invited in. This allows for the therapist to give, with permission, feedback to the spouse/SO while being able to explore/address the concerns raised with the patient first.

It is possible, again in my limited experience including a spouse/SO in the therapeutic journey, for both the SO and the therapist gain insight into effective engagement with particular alters through feedback from the SO. If done, it should always take place with the patient present. This is key to ensuring that the therapy session remain a place of safety for the patient and all alters.

Again, there are strict boundaries that are necessary to maintain. The SO must, absolutely, simply report on their interactions without without attacking, being defensive or creating any emotional shading in the discussion. If the patient disagrees, even with a different memory of the patient regarding the interaction, that needs to be acknowledged without moving to a “who is right/who is wrong” debate.

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Considering Spouses/Significant Others in DID Treatment Part 2 of 4

In my experience, which I acknowledge is limited, effective DID therapy must involve the alters. Consider that that alters are far more likely to show themselves when the patient is at home with their spouse/SO, than when the patient is with their therapist at most usually once per week. The opportunities for the therapist to provide warmth and empathy to those alters is thereby limited. For my DID patients, the most common time their alters emerged was at night in bed or when he/she was having a difficult day. The spouse/SO is around the patient 24/7 and therefore has far more opportunities to engage with alters.

Without guidance, how does a spouse/SO know how best to respond to an alter suddenly appearing? Even a therapist without experience will find it challenging to respond appropriately in the absence of their own mental preparation. I would like to state categorically that therapists must be prepared for such events. Further, I suggest that therapists take it upon themselves to seek permission of their patient to warn and prepare the spouse/SO of the appropriate behaviour necessary when engaging an alter. I have not been able to find such information in the psychiatric literature and would be grateful if any readers can forward any such reference they have. I would also point out that therapists who deny that DID exists at all will likely be unable to ever respond appropriately, and will likely be unable give appropriate guidance to a spouse/SO.

So, how should the SO of an individual with DID respond to an alter that has decided to, or been triggered to, come out? Anyone who does not understand the correct context is likely to consider the behaviour of an alter as “inappropriate.” This happens because the observer does not see the alter on its own terms, as another identity within the system of that whole person. The alter’s age, manner, speech, emotional expression may completely different from their usual experience of that person. The automatic conclusion for the observing person is that the person in front of them is a “fake,” inexplicably behaving inappropriately, “being childish” etc.

If the situation is handled with insight, empathy and kindness, great healing progress can be made. If it is not handled correctly, think of the many opportunities missed in helping this person to heal. One cannot say that engaging the alter is the sole responsibility for the therapist, that the SO should ignore the alter(s). Why do I say that? It is because the alters will come out with the SO far more often than with the therapist. With a supportive and educated spouse/SO, far more rapid and substantial progress can be made.

It is my view that to help a DID individual to heal, it is essential to do work through Engaging the Multiple Personalities, as the title of my book series suggests.

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