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Beyond matters of theoretical orientation and the selection of techniques, the stance or approach to treatment taken by the therapist (and at times by the patient) plays a major role in what can and will transpire. Although many therapists in past years approached the treatment of DID as if it were inevitably a wild and out-of-control process, desperately applied technique after technique trying to find something that worked, or tried to force the psychotherapy of DID into a treatment paradigm with which they were already familiar, these approaches have not proven effective. In each case they treat, current practitioners knowledgeable about DID implicitly or explicitly embrace one of the following stances: strategic integrationalism, tactical integrationalism, personality-oriented treatment, adaptationalism, or minimization.
Strategic Integrationalism: Strategic integrationalism is the attempt to treat DID in a psychotherapy that is consistent with the psychoanalytic tradition of resolving pathological defenses and structures and facilitating growth and development. From this stance the therapist generally attempts to create an atmosphere supportive of a process-oriented psychotherapy. Its goal is the integration of the personalities in the course of the recovery of the individual DID patient. Whatever additional techniques and specialized interventions may be employed in the course of the treatment are valued less for themselves than for the long-term goals to which they contribute. This approach focuses on rendering the dissociative defenses and structures that sustain [DID] less viable, so that the condition in essence collapses from within. Its ideal goal is the integration of the personality in the course of the overall resolution of the patient's symptoms and difficulties in living.
Tactical Integrationalism: Tactical integrationalism emphasizes the skillful orchestration and application of techniques in the service of attaining a series of discrete goals that lead to the superordinate goal of integration and recovery. This stance espouses the same ideal outcome as strategic integrationalism, the integration of the personalities, but the actual conduct of the therapy reveals a predominant concentration on tactics, and on discrete interventions that serve as adroit devices to accomplish a series of objectives .... Their planfulness and deliberateness may be conspicuous. At times these therapies take the form of a series of short-term therapies within the context of a long-term therapy.
Many interventions from many schools of therapy may be applied. Process is appreciated, but it is understood to be the context in which the therapist applies interventions which themselves are major vehicle of the treatment. Such approaches stem from the traditions of hypnosis, behavior therapy, and cognitive therapy.
Personality-Oriented Psychotherapy: Certain therapists do not regard dividedness per se as problematic. Their approaches often involve a problem-solving inner-group therapy or innerfamily therapy among the alters. Smoother collaboration is encouraged to effect a more harmonious and functional arrangement among the alters. Integration may or may not be pursued. This term has also been used to describe an approach in which the alters are understood to be genuine people who must be nurtured into health in a very tangible fashion. Although occasionally successful, many unfortunate outcomes have been noted. This latter approach is contraindicated.
Adaptationalism: This approach prioritizes the management of life activities and the maintenance and improvement of function over integration. It avoids concentration on trauma work or uncovering. It stems from the traditions of supportive psychotherapy. This is a suitable approach when a definitive treatment is contraindicated, but, since it has the potential to deprive a patient who is capable of engaging in a definitive treatment of the chance to make a full recovery, its use with such patients would appear to be inappropriate.
While most therapies are dominated by one of the above stances, the circumstances and stability of DID patients in treatment may vary considerably over time, and require flexible transitions from one stance to another to address particular situations. For example, a mother with DID in a therapy characterized by an exploratory strategic integrationalist stance who is suddenly confronted with the serious illness of her child may profit from a transition to a personality-oriented or adaptationalist therapy while her energy must be diverted from her treatment to the care of her child.
The complete resolution of DID psychopathology can be achieved from the stances of strategic integrationalism, tactical integrationalism, and personality-oriented treatment. It cannot be achieved from the stances of adaptationalism or minimization. The supportive psychotherapy of DID is incompatible with the full application of the strategic integrationalist or tactical integrationalist stance, although these may be adapted and modified for supportive purposes. Personality-oriented treatment and adaptationalism are compatible with the supportive treatment of DID. Minimization as an overall therapeutic stance is rarely indicated.
Matching Patients With Therapeutic Stances, Modalities, And Interventions
As noted above, a DID patient who appears capable of undertaking a definitive treatment and is motivated to do so should be offered such treatment, and that treatment should be conducted from a stance that is consistent with such a goal (i.e., strategic integrationalist, tactical integrationalist, or personality oriented). The choice of stance and selection of techniques often will be made in connection with a study of the patient's ego strength, track record, character style, and an appreciation of what tasks often accomplished by techniques can be accomplished deliberately by the alter system. For example, a very strong DID patient with good accessibility to alters upon request and good capacities for coconsciousness might be treated from a strategic integrationalist stance in a psychodynamic psychotherapy with only a few modifications. A similar patient with less certain accessibility to alters upon request and with poor capacities for coconsciousness might be treated from the same stance and with the same basic modality, but it would be anticipated that another modality, such as hypnosis, would be a useful adjunct in addressing the less certain accessibility and the problematic coconsciousness.
It is very important to appreciate that the therapist should review the treatment plan on a regular basis, and whenever either a crisis or an unexpected development in treatment suggests that the patient's situation should be reassessed. I do this regularly in my own practice, and have found it an invaluable exercise. A checklist for this process is available. DID patients are very complex, and often much is going on below the surface. In one recent case, an apparently chaotic and hopeless patient who appeared to require supportive treatment pulled out a list of complaints about my work with her. Chief among them was that I had not appreciated that major changes had occurred in her system (about which I had not been told) that made her able to commit herself to work in a definitive treatment. After completing a rigorous reassessment, it became clear that she had many strong alters that had not made themselves evident or available when I evaluated the patient, but had now decided to participate in the therapy. We are now moving along well in the processing of her traumatic material.
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