David Yeung's Blog, page 5

Key Qualities For DID Therapists: PART 2 of 4 – The Process

This question, of what to look for in a therapist for DID, is a question I have asked myself as well for many years. There are clearly certain basic qualities any therapist needs in order to genuinely help their patients, but for survivors of any dissociative generating trauma and those with DID in particular, there are special concerns when considering working with any therapist.

A therapist treating DID individual needs dedication to the process, which is rarely a short term journey. It requires empathy toward the patients, positive commitment in the goal of helping another human being escape the clutches of past trauma intruding into the present, and the key ingredient of courage to do this difficult work. One thing I am confident about is that having a Master’s degree, a Ph.D, or an MD trained in providing psychotherapy, is not a guarantee that the therapist possesses any of these qualities regardless of their educational and training qualifications.

One critical aspect of DID therapy is that the depth of trauma for those with DID is beyond any conventional understanding because it is tied to the age at which the abuse occurred. Generally speaking, DID results from intense ongoing abuse that occurs at age of 5 or younger. This is not to say that other dissociative disorders do not arise when traumatic abuse occurs after that age. They do. But, it usually doesn’t result in DID but rather in another of the dissociative disorders. Because the trauma that expresses itself as DID happens to very young children, the vicarious trauma a therapist may experience is something one cannot prepare in advance for. Therefore, courage is required – the courage to keep your own heart open, to keep your own mind still, to be fully present with your DID patient as they process their trauma.

Since the 1950s, biochemistry has created specific drugs for treating the symptoms of anxiety, depression, and even delusional thinking. This has misled the public, general therapists, and even some specialists, into believing that drugs will one day adequately cover whatever we need to treat mental health disorders. Unfortunately, the more sophisticated the successes in biochemical pharmacology, the more psychiatry mistook treating symptoms for curing mental illness. This engendered a bias to rely more and more on pharmaceutical approaches to symptoms rather than to actually solving the root cause of any particular mental health problem. In fact, this approach often leads to long term misdiagnoses – and similarly long term incorrect treatment – because it easily conflates treating different disorders based on addressing primarily or only the symptoms they may have in common. It’s estimated (WebMD) that individuals with dissociative disorders have spent seven years in the mental health system prior to accurate diagnosis. This is common, because the list of symptoms that cause a person with a dissociative disorder to seek treatment is very similar to those of many other psychiatric diagnoses.

The term PTSD was first listed in the DSM classification manual in 1980. Although known to many through a few books and movies (The Three Faces of Eve as well as Sybil), it was the public attention that resulted from acknowledging the impact of war related trauma on veterans returning home that highlighted the consequences of experiencing ongoing trauma. I remember seeing a page in National Geographic showing a veteran suffering from PTSD. He was standing in front of a display of 15 bottles of pills that were supposed to help his war-trauma induced PTSD. DID, which was termed MPD even as far back as DSM-II in 1968, is now seen as a form of Complex PTSD that further engenders an internal household of multiple alters.

When looking for a psychiatrist to diagnose and/or treat DID, the chances are that you will be told one of two things. First, that DID is a “controversial” disorder, meaning that its very identification as a disorder is in question. If you find someone that acknowledges the validity of DID as a diagnostic category, you will likely be told that there are no qualified therapists to help you. You will likely get similar answers from the clinical psychology departments at Universities and from social workers with psychotherapy training. In some places, you might find a therapist with training in EMDR and CBT, approaches that are sometimes recommended (by their practitioners) for the treatment of DID.

From my point of view, EMDR and CBT are tools. When recommended for treatment of DID, it means nothing more than saying for a surgeon, a scalpel or surgical excision is one way to treat breast cancer. Depending on the circumstances, it might be helpful and it might not. I think that the qualities discussed in this extended post, if present, will push the use of any therapeutic tool to be more positive than otherwise.

A hopeful trend does seem to be emerging. Slowly, very slowly, some psychiatrists, psychologists and social workers with psychotherapy training are shifting towards understanding and adopting the theory that most mental health problems, including addictions, come from trauma and neglect.

Given that studies show there is about 1% DID in the general population (approximately the same rate as schizophrenia), why does DID so rarely show up in medical records statistics? DID diagnoses are seldom found in medical records statistics because they are missed and misplaced into other diagnostic categories, most commonly mischaracterized as Bipolar, Schizophrenia, or Borderline Personality Disorder.

Psychoses, neuroses and personality disorders are not well defined psychiatric syndromes with clear parameters differentiating one disorder from another. We must remain open to the possibility that current symptoms of anxiety, panic, depression, self destructive behavior, dysphoria, risk taking behavior, emotional lability (rapid and, to outsiders, often exaggerated changes in mood), and even some psychosis may be the result of past trauma rather than being simply the patient’s current circumstance.

To avoid the massive amount of time, effort and financial resources we are wasting due to the difficulties for someone with DID to be accurately diagnosed, we need to train specialists in psychiatry, psychology and social workers to be able to recognize and diagnose accurately a case of DID. This means looking at the constellation of symptoms, not simply stopping at the symptom that has a corresponding pharmaceutical “solution.” With that, those patients could then be triaged to specially trained therapists in the field of trauma and dissociation.

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Key Qualities For DID Therapists: Part 1 of 4 – Overview

Recently, I was asked a pointed question: What are the qualifications needed for a DID therapist to be able to actually help someone? The questioner is a social worker in Asia who is acutely aware of the lack of awareness concerning DID in his community. He asked me to consider the question and post my response in my blog if it might help people.

The question arose from his frustration about the difficulty in finding a therapist competent to treat DID. The problem is by no means limited to Asia, it is a worldwide issue.  But, I feel it is important to re-frame the question from “What are the qualifications needed”, to “What are the qualities needed” in a DID therapist.

For many psychiatrists, there is no further inquiry once symptoms are labeled.  For example, once a person is labelled as suffering from depression, the inquiry generally does not extend to getting a wider understanding of potential causes of the depression. Why? Inquiry stops because there is medication available to treat that symptom. That is a mistake.

This approach does not even try to address the cause of the depression. The unstated presumption is that depression, in and of itself, is the illness to be treated rather than potentially a symptom whose root cause should be identified to ensure appropriate treatment. While there is a disease called endogenous depression which responds to medications like an SSRI (i.e. nortriplyline), without inquiry, it is difficult to distinguish endogenous depression from depression that is the result of living with and being unable to extricate oneself from an abusive spouse.

In other words, depression can be an appropriate emotional response to an adverse living situation. Herein lies the many problem of diagnostic bias, treatment bias, and/or lack of empathy on the part of the therapist.   

Consider, by analogy, a patient that has a fever. A doctor might prescribe something to bring the fever down, but that is generally done in concert with making efforts toward identifying the cause of the fever.  If the fever turns out to be from appendicitis, failing to even seek to identify the cause of that fever would be grounds for malpractice should the appendix burst and the patient possibly die.

Unfortunately, the failure to make substantial inquiries after diagnosing depression in a patient is not necessarily considered critical in the mechanistic view of modern mental health “therapy.”

The mechanistic view, primarily a medication based view of therapy, +predominates the profession. It does not matter if the person has good reasons, conventionally speaking, to be depressed.  That view is the very problematic result of seeing mental health issues as primarily, if not solely, biochemically based illnesses. Mental health professionals need to acknowledge that many of symptoms that patients present could very well be related to current life situations as well as trauma and neglect, both current and often decades old.   

I have witnessed many such cases, where there was a mixing up of depression as a symptom and depression as a disease, during my 4  decades of psychiatric practice in different parts in the world.   Unfortunately there are no laboratory tests or x rays to differentiate these different causes of what is identified as depression.  The patient is reliant on the sensitivity and empathy of the therapist.   For the impatient therapist, who thinks their job is done once the medication is prescribed, many patients will suffer from that therapist’s default mode of treatment.  

A more effective approach is based on a comprehensive review of the entire history of the patient rather than merely observing the patient’s current behavior pattern, giving it a diagnostic label, and offering a pill to alter their brain chemistry. Instead, the therapist should always on the alert of psycho-social factors that may need to be addressed rather than stopping with a chemical solution to suppress the presenting symptom.  Using a diagnostic label to describe a patient’s problem does not mean the clinician has found the answer or solution.  Really, saying a depressed person is suffering from Depression, is just a tautology – a play of words.

I have focused this section on the symptom of depression. There are many other symptomatic considerations to examine before diagnosing DID, but the basic principle of the need for empathy and compassion to be above and beyond mere chemical intervention holds true.

If the mainstream clinicians, in psychiatry and psychology, are not interested in DID or are unaware of it through bias and/or lack of training, is there an alternative path for patients seeking DID treatment?

The basic qualities needed in a DID therapist are not complicated but are not so easy to find. The basic qualities are common to all human beings, but not always so accessible to therapists or laypersons. Fundamentally, one must go back to Carl Rogers’ criteria: empathy, positive regard and congruence.

I might add that the therapist must have stability in their own mental health as well. While that is not often mentioned, it is critically important. This is because there is a known risk of vicarious trauma therapists might experience when treating a patient’s experience of the horrors of early childhood abuse.

For therapists, I would suggest starting with a highly informative book, Trauma Model Therapy, by Ross and Halpern (2009), It is a 300 page practical study manual for training therapists for those suffering from trauma and dissociation.

The trauma model of mental disorders, or trauma model of psychopathology, emphasizes the effects of physical, sexual and psychological trauma as key causal factors in the development of psychiatric disorders, including depression and anxiety as well as psychosis. This is applicable whether the trauma is experienced in childhood or adulthood. The model conceptualizes victims as having logical and therefore understandable reactions to traumatic events rather than suffering from mental illness.

The trauma model emphasizes that traumatic experiences are more common and more significant in terms of etiology than has often been thought in people diagnosed with mental disorders. Such models have their roots in the 19th Century with Sigmund Freud (early trauma) and Pierre Janet (PTSD), and in the mid 20th Century with John Bowlby (attachment theory). There is significant research supporting the linkage between early experiences of chronic maltreatment and severe neglect with later psychological problems.

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Trauma, Addiction and Co-Morbidity

In psychiatry, practitioners are often fixated on the DSM diagnostic classifications when working with patients – even as they often fail to consider trauma as an important precipitating and predisposing etiological factor.  This is not a surprise as trauma has been ignored as a major etiological factor for so many decades. So long as practitioners do not see such trauma as a problem worthy of emphasis in their index of suspicion, this ignorance will continue.

Treating patients with trauma, DID or otherwise, requires the therapist to understand the nature and depth of trauma, as well as both the short and long term consequences. Most of my DID patients and, from what else I have seen, for the DID community at large, had and have co-morbidities, including addictions, that often are the cause of the original misdiagnoses.

There are two psychiatrists whose work is important for any therapist treating trauma patients to read and consider. The first is Colin Ross, whose who has written many important books on DID based on his clinical work, research, and guiding other therapists in their DID and trauma work. In fact, his first major publication, Multiple Personality Disorder: Diagnosis, Clinical Features, and Treatment. New York: John Wiley & Sons, 1989, was one of the earliest and only texts that proved helpful to me in working with my MPD/DID patients at the time. The second psychiatrist to mention is Gabor Maté, who has done the same kind of in-depth clinical trauma work focused on communities that have long been marginalized.

In The Trauma Model, Colin Ross sees trauma as the central issue that will confront and confound us for decades to come. For Gabor Maté, trauma, whether in early childhood or otherwise, is seen as the root cause of so many of the co-morbidities. His view, correctly, is that without treating the root cause, the prognosis is bleak.

Changing the view of an entire profession, takes insight, time and commitment. While there are both positive and negative views of each of the mentioned psychiatrists’ both in the psychiatric community and at large, their core insight of trauma as the driver of a multitude of symptoms and co-morbidities is, in my opinion and experience, correct.

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Hope for Psychiatry

One could get discouraged at the state of affairs in psychiatry for treating DID, but please don’t.

While there are many negatives to consider, 15 years into my retirement as a psychiatrist working in one of the major cities in North America, there are some positives as well.

One negative is that there appears to be an ever-increasing emphasis on the use of medication to treat psychiatric disorders. This is based on a reductionist approach in psychiatry which presumes that every disorder has an organic and/or genetic basis. The result for DID patients is that they are often not even offered treatment, or even the acknowledgement that they are suffering from a legitimate defined psychiatric disorder.

The positive is that there are more (though not enough) therapists willing to work with DID patients. I believe this is a result of more public reporting and sometimes dialogue both about the extent of early childhood abuse as well as DID. This comes often from the bravery of those with DID writing books and blogs, as well as conferences organized by and for the DID community. Just as important, there is much more peer support than ever before. That peer support can be invaluable to those with DID that have no therapist and may simply need warmth, human empathy, to help them during a particularly difficult time.

Another negative, of which I am quite ashamed, is the failure of the profession to help veterans of the Gulf and Afghanistan wars along with their families, to get them the right kind of support/treatment for their PTSD. While I had limited experience treating veterans or their families, I am confident that psychotherapy conducted in a way which limits the risk of re-traumatization is a safer path to healing than focusing primarily on medication, or on medication alone. Further, the benefits of giving non-pharmaceutical tools to spouses of DID individuals to help the entire family deal with the consequences of PTSD would likely benefit spouses, children and the families of veterans.

The positive is, again, peer support – a critical component for veterans that is often part of military discipline – and the willingness for the military to acknowledge the ongoing impact of PTSD. While that is from a military perspective, it is a societal acknowledgement of dissociation – a key component to PTSD. This has led to at least some acknowledgement of the dissociation issues that those with DID confront as a result of their own Complex PTSD.

Another positive is that DID patients have been able to bring information to their own therapists in a safe way. They are able to bring books, articles and blog posts that allow them to say something to their therapist(s) along the lines of “This is like what I go/am going/have gone through.” Sometimes it is less re-traumatizing to give the therapist something written in a blog or book, or in a peer support group, rather than try to express it directly oneself. This is likely the case when the patient is not fully confident in their therapeutic alliance. It can allow for that alliance to develop further as well as to give the therapist another pathway to help their patient.

I have received many communications from individuals with DID that have used my books and blog posting in those circumstances and for those purposes. I am honored by their trust.

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Some Consequences of an Inappropriate Definition: Hysteria

The term“hysteria” has been used for centuries to belittle, subjugate, and control women. The word stems from the Greek hysteria, which means uterus. During the Victorian era, the term was often used to refer to a host of symptoms that were generally observed, or at least acknowledged, only in women. This conjures up a picture of the woman swooning in public on receiving some bad news. It became a somewhat socially expected behaviour in that era.

For hundreds of years,the pathology of hysteria was linked to the absurd belief that its cause was a “wandering uterus.” The word was then used pejoratively to describe a female response that was seen as disproportionately emotional for the situation – a determination that was made primarily by men.

An analogous category is seen in the description of “attention-seeking behaviour” which from time to time is associated with the old picture of hysterical personality. I find the term demeaning to the patient. Regardless, as a patient, it is a right to expect appropriate attention. This term may have been used to be able to include symptoms, similar to those of hysteria, that appeared in people without a uterus; in other words, men.

The concept of hysterical neurosis was deleted in the 1980 DSM-3. It was finally evident that the word carried with it so much ignorance and gender bias that it should be discarded. The word hysteria was replaced by the word dissociation. Unfortunately, dissociation is a term borrowed from chemistry. As a result, the word has its own constraints and awkwardness when used to describe psychological processes.

The fact that hysteria is no longer used in the DSM reflects how concepts can emerge, change, and be replaced as we gain a greater understanding, a greater appreciation, of how human beings think and behave following the stress of early childhood trauma.

Dissociation is often a feature of some conditions that involve people experiencing physical symptoms that have a psychological cause. Dissociative Identity Disorder is now conceptualized as a psychological response to a trauma suffered in the specific time frame of early childhood. It is a dissociative disorder that may be generated as part of a complex post-traumatic stress syndrome.

Dissociative disorders also include other functional disabilities, potentially affecting the motor function of a limb, sensory function such as numbness (sense of touch), or memory. In other words, dissociation can affect many spheres of a person’s ability to function. This is the result of a disconnection, or discontinuity, of the subjective integration of behaviour, memory, consciousness, emotion, perception, body representation, and motor control that together is seen as a conventional unitary identity.

Dissociation is no longer considered to be a gender specific condition, as hysteria once was. While the larger percentage of DID diagnoses involves females. I presume this is the result of some specific social conventions. For example, males with DID are more likely to end up in the criminal justice system when alters act out with violence, because that is society’s most common response to male violence. Females with DID are more likely to end up in the social service system; a carryover perhaps of the original bias about women and hysteria to see their difficulties as warranting social intervention rather than judicial/criminal. Again, I believe this is due to the mistaken view that DID is uncommon. Therefore, DID is not on the index of suspicion, the radar if you will, of most psychiatrists whether they are providing psychiatric services for males in prison or females in the social services network.

Because of the myriad presentations of DID, it is hard for mental health professionals to fit differently appearing symptoms into any pigeon-hole like diagnostic category. Eventually, one has to resort to awkwardly adding other specified and unspecified conditions to embrace the whole spectrum of dissociative disorders, as in DSM 5. This is quietly acknowledged by including, “Other Specified Dissociative Disorder DSM5 code 300.16 (ICD-10 F44.89) and Unspecified Dissociative Disorder DSM5 code 300.15 (ICD-10 F44.9).

Definitions have power, for good and for ill. Inappropriate or unclear definitions are not helpful. Please remember that Multiple Personality Disorder is not a personality disorder. The term should be written and read as Multiple-Personality Disorder. I have come across this misunderstanding among mental health and medical professionals. For me, this to me is another reason why it may be preferable to adopt the revised terminology of Dissociative Identity Disorder.

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Anxiety

Anxiety


Anxiety is an underlying symptom common to almost all psychiatric disorders. Dr Hazel Claire Weekes was an Australian research scientist and physician, considered by some as the pioneer of modern anxiety treatment.

We might benefit from listening and reading what she had to say about psychotherapy for many mental health problems— anxiety, panic attacks, reaction to stress and distress. She was ahead of her time in seeing the connection between trauma and its after-effects in the body.

Simply put, her approach to the treatment of anxiety is learning how to experience the oversensitive alarm system in the body, what I andothers often refer to as hyper-vigilance. It is the nervous energy that arises in response to current life stresses but remains tied to and triggered by previous traumatic stresses we have experienced.

Today, psychiatry increasingly is paying more attention to the body in relation to the psychiatric symptoms. Bessel van der Kolk in his bestseller The Body Keeps the Score (2014), recognized that there is a physiology of trauma.

It is refreshing to know that in the last century, we already had been given a much more lucid explanation than what we are now taught.

Today, you can google “Treatment of anxiety” and you are likely to get words such as cognitive behavioural therapy and references to medication. These are in some way missing the central issue. Weekes distilled her understanding of what was then termed “nervous illness” into a simple slogan for overcoming anxiety: Face, Accept, Float, Let Time Pass.

In short, it is a four step path. This treatment of anxiety encourages the patient to face their anxiety as the predicate to accepting it as simply an over-sensitized protective nervous mechanism in the body. We can escape the entrapment
of the anxiety cycle by learning to simply experience it and in that way float with it. It is a step by step process that, once we can float with it, we can watch it flow away. Paradoxically, anxiety is something that gets stronger if we run or fight with it but weakens and goes away if we accept and float with it. The formerly helpless individual learns that they have power over their anxiety when they truly learn to change the habitual response of running or fighting with it to being with it and letting go. In that way, patients can tame and harness their anxiety for healing, rather than wasting their energy fighting it and succumbing to it.

It is important to understand that many anxious patients have no memory or idea what it is like to feel peace and comfort in their body. With few exceptions, when I was practicing psychiatry, I considered the best use of medication to help them to regain the knowledge that peace and comfort in the body is possible. Using medication like that on a short term or intermittent basis can be a way to encourage patients to understand that their body actually does
know what it needs, and what it is searching to recover: the sensation of safety.

Dr. Weekes’ work is one potential way to seek to regain that critically important sensorial experience without medication.

https://www.smh.com.au/lifestyle/health-and-wellness/face-accept-float-let-time-pass-claire-weekes-anxiety-cure-holds-true-decades-on-20190917-p52s2w.html

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More Thoughts on Alters – Part 5 of 5

There are several key points a therapist supporting an individual with DID needs to keep in mind.

[1] As noted, a therapist must be aware of the dangers of showing favouritism towards specific alters in therapy. Therapy is not a warm social chat over tea. Supporting the patient’s healing to the task, which means not limiting the therapeutic alliance to alters that are attractive to you.

[2] When a patient engages in intimate sexuality with their partner, what should they do if another alter is switched with a retraumatizing flashback triggered by that intimacy? Once a therapeutic alliance is established, it is more likely that the patient will raise issues. If this is one of the issues, you need to have recommendations ready for them as well as recommendations ready for what they might say to their partner – knowing that their partner may or may not know they are DID. These topics have been addressed in my blog and are accessible in Engaging Multiple Personalities Volume 4 which is a free downloadable pdf or ebook that is easily searchable [https://www.engagingmultiples.com/ at the bottom of the page]. One key point is that they must raise the issue, not you in order to protect the therapeutic alliance and not be seen as trying to cross their personal boundaries uninvited.

[3] In general, DID individuals are capable of time loss and one should assume that alters will switch in or out at unexpected moments. There are some general guidelines that can be provided by the therapist for these situations, but they involve primarily ongoing grounding work rather than something to be done in the midst of such an event.

In DID, this notion of multiple identities or personalities remains a most troublesome locus of confusion. Many therapists mistakenly think that since this splitting into different alters in the definition of the pathology, alters should be eliminated. They even refuse to acknowledge the fact that splitting into fragments is a well established fact – certainly from the patient’s experiential point of view.

Alters think and feel that they are separate individuals, they know who they are just as ordinary people know themselves. While this may be argued till the cows come home, it is undeniably how they experience both the outer and inner world. Ignoring them or arguing that they do not exist is counter therapeutic. It is parallel to how one would waste time trying to convince a schizophrenic patient that the voices they hear are false, that they are just hallucinations. Don’t waste time and energy, and don’t undermine whatever therapeutic alliance you and your patient create.

In DID, each “personality” or “identity” demands to be treated as an individual. For the sake of communication, as a matter of basic empathy and human kindness, the therapist must honor that. Understand that the dissociation habit is firmly entrenched in DID patients over many decades. Therefore, it is absurd for the therapist to worry that he/she may be making the patient worse by “reinforcing” the pathology of dissociation by talking to individual alters. This is a most common worry in the uninitiated therapists. Refusing to relate to each alter as it experiences itself cuts you off from a golden on-ramp to communicate to the patient. Communicating to alters is the real work in DID psychotherapy.

Therapist need to engage in heart to heart talks with whatever alters engages them. I usually let the system decide who needs to talk to me in terms of urgency or priority. It worked quite well to trust the internal system. With few exceptions, I did not have to intentionally bring any specific alter out for therapy. When time is being wasted in therapy, it is often because the therapist seeks to control who “must” come out to talk.

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More Thoughts on Alters – Part 4 of 5

There remains much misunderstanding regarding the phenomenon of alters. Many people are simply not able to get past the dramatic aspect of an alters suddenly appearing. This is based on a lack of understanding coupled with a lack of empathy. They somehow cannot see the pain and suffering of what DID individuals faced in the past as well as what they face in the present. They are stuck on the suspicion that the DID patients are fakes, perhaps trying to use the alters as an excuse to get out of their responsibilities.

Many psychiatrists cannot get over the dramatic and theatrical aspect of child alters switching out of a mature woman. I had one University staff psychiatrist openly call my patient a “fake” when he found the diagnosis on that patient’s chart from a previous admission. Under such hostile circumstances , I decided that in-patient treatment was not an option for my DID patients.

While there may be benefit to the many You Tube videos of DID individuals and their alters, I think having repeated videos on YouTube, or making movies of actual switching will only emphasize the dramatic aspect. It may have benefit for those with DID by forcing at least some people to acknowledge the truth of the disorder, it doesn’t highlight the critical point that DID arises because a young child has no other way to defend their mind under the pressure of horrific ongoing abuse.

Curiously, questions have come up regarding the phenomenon of showing favouritism regarding alters.While there is no doubt alters are very different, we naturally find some alters are more attractive or comfortable to be with than others. For example, a therapist may “prefer” talking to one alter who is engaging & charming rather than an enraged alter certain that the therapist is yet another potential assailant. Beware of favoring some alters over others!

There a reason to speak with such angry alters. It is because they are the one who need therapy most. Another horrible but true fact. In talking with such an angry protective alter, you can acknowledge that their fear is not unfounded. With that acknowledgement you can begin to foster a therapeutic alliance with that alter – allowing them in time to dial down their heightened vigilance to ordinary vigilance. This will benefit the engaging and charming alters, the angry enraged alters and the therapeutic journey of healing.

But understanding trauma and the dissociative process is key to maintaining professional boundaries and inviting patients to establish their own personal boundaries that were likely decimated by early abuse. At the same time, therapists are only human and will be drawn towards talking to certain alters, while dreading or avoiding talking to other alters. But, as the therapist, it is our duty to examine our own conduct even more closely than that of our patients to ensure their experience of safety in therapy.

We need to examine our own conduct because this is how the world works, in or out of therapy. Some alters are humorous, knowledgeable, and socially charming, e.g., Leila, Chapter 4 of Engaging Multiple Personalities Vol. 1, while others are definitely not. For example, Leila’s alter told me later on in therapy about her clandestine behaviour in which she could turn on her charm and pick up men. This was a problem for her host who was shy, extremely prim and proper. It would be an enormous problem for anyone with DID if the therapist does not maintain proper boundaries with charming and seductive alter or avoids the critically important angry alters.

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More Thoughts on Alters – Part 3 of 5

While many cases of DID present with perhaps ten to fifteen alters and total/near total amnestic barriers between them, there are many variations and deviations from this usual presentation. I have seen well defined cases of DID with a large number of alters, up to hundreds. I don’t think the number is critical, whether it is a few or several hundred because I did not intend to make every alter my patient. I only spoke to those who wished to speak to me, or those I might help to address their specific issues. At the same time, it is important to be aware that they are always there, that whenever you are talking to one alter, the others are there – behind the curtain, so to speak. In DID therapy, the therapist never really speaks to one alter alone.

Oxnam brings out a point that may be helpful for therapists to get a better sense of the phenomenon of multiplicity. In considering a house, one can look at the number of rooms as the key quality, or the way the house is internally partitioned by walls. He suggests that it is useful to think of the walls, rather than the number of rooms. So, instead of considering the number of alters, let us think of the walls between them. It is the amnestic barriers that are blocking the communication and creating the internal experience that each alter needs to be fighting for its individual right to exist.

This fight is what renders the DID person partially or totally dysfunctional. There may be frequent clashes over time use. For example, one alter may insist on her right to go out partying at night when the host, another alter, may feel strongly that sleep is needed because she has to work the next day. In that same way, there may be intense emotional clashes, such as when one alter wants to start, continue or return to a retraumatizing relationship that another alter is terrified about and yet another alter may be enraged about. I have also had patients with alter(s) who kept on sabotaging the therapy. What can you do with a patient who is motivated to come for treatment but keeps missing appointments?

There are exceptions I have come across. These exceptions are when someone has DID but whose alters are all there in the open, with minimal amnestic barriers or partitions. However, they still have a will of their own sense of individuality. They fail to see the need to compromise, communicate and coordinate. They do not see such conduct, to do what is good for the common good of the one individual whose body they all share, as beneficial for them. When they each insist on individual rights because of a sense of separateness, the system will run into trouble.

The most common DID complaint is the symptom of “time loss.” In time loss, the patient cannot account for periods of time when he/she is not sleeping. But, there is no memory of what happened during those periods. For people without dissociative pathologies, it is hard to imagine having zero recollection of what had transpired while awake and conscious.

This might seem incomprehensible. After all, when we forget what we did yesterday, once we get a few cues for our memory – the new shoes that were purchased, or the wine stained shirt – we usually remember. So, the first reaction of ordinary individuals is that perhaps this person is faking it. This degree of dissociation is hard to grasp, until someone you trust tells you, “yes, that indeed happened.”

Dissociative symptoms are much more frequently encountered than people are willing to acknowledge. Therapists should change their index of suspicion to overcome that general lack of awareness of this DID.

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More Thoughts on Alters – Part 2 of 5

Therapists may come to the diagnosis of DID in very different ways. It is important for all therapists to retain a high index of suspicion that includes DID when seeing patients that might be diagnosed with clinical depression, Bipolar Disorder, or Borderline Personality disorder. Why? It is because early childhood trauma that is the etiology of DID is both common and easily hidden.

DID is not rare, that is a straw man argument that has led to misdiagnoses and lost years of ineffective therapy. Being treated for depression with medication will not address or heal depression if it is the result of unprocessed early childhood trauma – even though it may take years to come to that conclusion. Reputable studies from various countries and cultures offer similar data: They all end up with approximately 1% of the general population suffering from DID.

Remember, dissociation ranges from normal to pathological so a therapist must be able to navigate that range. A highly functional surgeon needs to be able to dissociate from temporary personal troubles while he is performing a surgery. This kind of dissociation is beneficial for both patient and doctor. After all, you don’t want a surgeon operating on you who is in the middle of an angry divorce if he cannot keep that rage out of the operating room.

While there are high functioning individuals with DID, it may be characterized as pathological when the individual dissociates out of the present moment overwhelmed by either emotional recollections, conceptual or bodily memories from the past trauma(s). The diagnosis of DID is confirmed on the therapist meeting or being convinced of the presence of an alter or alters.

In the last pages of Oxnam’s book, there are 24 pages by his psychiatrist, Dr. Jeffrey Smith, summarizing his views on treating DID. It is a low-keyed account of the DID condition, far removed from the usual dramatization of dealing with alternate personalities which are usually distracting, which overshadow the trauma, heart ache and struggles in the early childhood period. It is a gem of a summary.

Dr. Smith pointed out 3 kinds of trauma: [1] the shouting, screaming and outright physical violence [2] the lack of support and emotional unavailability of the primary caregiver; and [3] the kind of horror that is so far removed from our ordinary concepts or daily like. This 3rd kind is of unimaginable evil and cruelty, an unthinkable horror that can befall a child in the earliest times of life.

There is a reluctance of society, and within psychiatry in particular, to come to grips with the idea that such evil would ever take place. It seems easier to deny when such horror does happen, than address the causes and consequences. From the very beginning of psychiatry, Freud was aware of early childhood sexual trauma in several of his patients. When he first presented this to his Viennese colleagues, the reception was ice cold. They were not ready to believe that such conduct could ever happen – certainly not within their own social class and environment.

The vitriol forced Freud to change his analysis to call the phenomenon of childhood sexual violence /abuse a “seduction” and forced him away from talking about trauma as the etiology of what was then named “hysteria.” Using the term seduction allowed the medical community of the time to place the blame on the victim of the sexual violence rather than the perpetrator. This was at the end of the 19th Century, in the Germanic scientific era.

But today, well over a hundred years later, we still face strong resistance to acknowledge the reality of early childhood trauma and how it impacts people their whole lives. While the prevalence of incest is now acknowledged to be far greater than previously assumed, early childhood sexual trauma remains a taboo subject that is not willingly acknowledged by many of my colleagues. With my own ears I have heard my colleagues assert that early sexual abuse is overly dramatized! I wonder exactly how “dramatized” they believe early sexual abuse should be before they would acknowledge it.

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