| PHASE ORIENTED TREATMENT APPROACH https://www.isst-d.org |
Over the past two decades, the consensus of experts is that complex
trauma-related disorders–including DID–are most appropriately treated
with a phase or stage oriented approach. The most common structure for
this is a treatment consisting of three phases or stages: |
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| The most common structure for this is a treatment consisting of three phases or stages: |
| 1. safety, stabilization and symptom reduction, |
| 2. working directly and in depth with traumatic memories, and |
| 3. identity integration* and rehabilitation." |
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| DEFINING INTEGRATION |
| At the most basic level, integration simply means acceptance/ownership of all thoughts, feelings, fears, beliefs, experiences and memories (often labeled as personalities) as me/mine. |
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| What are the treatments for dissociative identity disorder? |
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| "Psychotherapy is generally considered to be the main component of treatment for dissociative identity disorder. In treating individuals with DID, therapists usually try to help clients improve their relationships with others and to experience feelings they have not felt comfortable being in touch with or openly expressing in the past. This is carefully paced in order to prevent the person with DID from becoming overwhelmed by anxiety, risking a figurative repetition of their traumatic past being inflicted by those very strong emotions. |
| "Mental-health professionals also often guide clients in finding a way to have each aspect of them coexist, and work together, as well as developing crisis-prevention techniques and finding ways of coping with memory lapses that occur during times of dissociation. The goal of achieving a more peaceful coexistence of the person's multiple personalities is quite different than the reintegration of all those aspects into just one identity state. While reintegration used to be the goal of psychotherapy, it has frequently been found to leave individuals with DID feeling as if the goal of the practitioner is to get rid of, or "kill," parts of them. |
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| Hypnosis |
| Hypnosis is sometimes used to help increase the information that the person with DID has about their symptoms/identity states, thereby increasing the control they have over those states when they change from one personality state to another. That is said to occur by enhancing the communication that each aspect of the person's identity has with the others. In this age of insurance companies regulating the health care that most Americans receive, having time-limited, multiple periods of psychotherapy rather than intensive long-term care provides what may be another effective treatment option for people with DID." |
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| "Over the course of time the use of hypnosis in the therapy of MPD has waxed and waned." source |
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| "Patients with multiple personality disorder are, as a group, highly hypnotizable. No significant evidence has been published which causally links judicious heterohypnosis to either the creation of multiple personality disorder or the creation of new personalities, though the demand characteristics of the situation in which hypnosis is used may aid in the creation of a fragment. Hypnosis is a useful tool when used with multiple personality disorder, for diagnosis and both for pre- and post-integration therapy. The major limitations to its use are the skill and experience of the hypnotherapist." |
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| "Treatment of Dissociative Identity Disorder typically includes the following components: a strong therapeutic relationship, a safe therapeutic environment, appropriate boundaries, development of no self- or other-harm contracts, an understanding of the personality structures, working through traumatic and dissociated material, the development of more mature psychological defenses, and the integration of states of self. Guidelines for treatment of adults and children are available from the International Society for the Study of Trauma and Dissociation, www.ISST-D.org. |
| "Integration of traumatic memories is an essential aspect of treatment (Fine, 1999; Kluft, 1999; Lazrove & Fine, 1996; Maldonado et al., 2002). Hypnosis can aid in allowing the client to gain control over the dissociative episodes and in the integration of memories (Fine & Berkowitz, 2001; Maldonado et al., 2002). Treatment of Dissociative Identity Disorder is typically long and challenging. Spontaneous remission will not occur (Kluft, 1985b, 1999). Studies have shown that cognitive behavioral treatment of Dissociative Identity Disorder can be beneficial (Fine, 1999; Maldonado et al., 2002). |
| "Electroconvulsive therapy (ECT) is not generally recommended (Maldonado et al., 2002). Eye-Movement Desensitization and Reprocessing (EMDR) can be used in the treatment of DID although it needs to be implemented with great caution (Fine & Berkowitz, 2001). EMDR is a newer psychological treatment designed to accelerate the processing of information and to facilitate integration of fragmented trauma memories (Fine & Berkowitz, 2001; Lazrove & Fine, 1996)." references |
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| Principles of Treatment |
| By: Elaine Ducharme, Ph.D. |
| The following are 12 basic principles for treatment. |
| Maintain and secure firm boundaries. Patients with DID may consciously or unconsciously push boundaries. It is important to remember that very often their lives are in chaos and, if you are not careful, they can pull you into their world. They may miss or be late for appointments, try to extend a session, call during non-office hours etc. While it helps to have some flexibility with these patients, the more structured you are the better it is for everyone. It is important to remember that their lives may be in chaos. If you are not clear and boundaries are fuzzy, you will only make the chaos worse. |
| Focus on achieving mastery and stress their accomplishments. |
| Establish and maintain a strong therapeutic alliance. Without a solid alliance treatment cannot be accomplished. A common mistake with inexperienced therapists is to rush into dealing with trauma memories. Watch for signs that the patient is feeling overwhelmed or pulling back from treatment. |
| Deal with buried traumatic events and affect unless there are contraindications for intense memory work (to be discussed below). Not every single traumatic event needs to be discussed. After awhile some generalization will occur. |
| Reduce separateness and conflict among alters. Emphasize their collaboration and identification with each other so their separateness becomes redundant. |
| Work to achieve congruence of perception. Their reality is often confused. So, it is important to be clear in your communications. |
| Treat all personalities even-handedly, consistently and with respect. Some therapists find mapping or having patients draw pictures of who the alters are and where they exist in the system to be a helpful technique. This can be modified as new alters emerge, a common occurrence in treatment. |
| Restore basic shattered assumptions, for example: "life is meaningful…I can see myself in a positive light". This involves changing cognitive distortions. Statements such as "Based on what you and I have discussed and been through together, I am reasonably certain that you will, despite your fears, come through this alright," can be very helpful. |
| Minimize avoidable overwhelming experiences. This includes, pacing the therapy and making sure the patient leaves your office in control (they may need to sit in the waiting room for awhile after session). Don't begin discussing traumatic material at the end of a session. And if you are in doubt about whether or not the patient is ready to tolerate something…wait! |
| Model, teach and reinforce responsibility. Although patients with DID may have more problems with being on time, missing appointments and needing between session support, and therapists may need to have increased tolerance for some of these behaviors, some things must be very clear. One patient of mine refused to honor any contracts agreed upon in therapy. She would frequently call me from a pay phone and then hang up after saying she had just taken an overdose of pills. There was no way to trace her call and find her to send help. When she was hospitalized, another alter would come out and convince staff she was not suicidal. Ultimately after numerous attempts to deal with this I had to terminate her treatment. |
| Take an active, warm and sensitive but very structured stance. |
| Address and correct cognitive errors and distortions. One patient would not look me in the eye for years because she was sure I would see the "shit" she felt was in her eyes. Patients often feel they were responsible for their abuser's behaviors. This can be a difficult distortion to correct, even in patients who were abused but do not have DID." |
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