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One of the most important aspects of the therapy of DID is ensuring that to as great an extent as possible, the patient leave the session in a relatively safe and contained frame of mind. Therefore, it is important for the therapist to master techniques that will allow the patient to be calmed at the session's end, and it is useful to respect Kluft's "rule of thirds". This rule holds that if one is deliberately planning to work with painful material, one should make sure that this work begins in the first third of the session and ends by the end of the second third of the session, preserving the last third of the session for processing what has been dealt with and restabilizing the patient. This is often difficult to apply in process-oriented therapies in which material may emerge gradually throughout the session, peaking toward the end, but is quite workable in therapies in which technical interventions are used to access, initiate, and conclude the work in question.
Dealing with Alters
This is hardly surprising. The alters are not merely curious phenomena. They express the structure, conflicts, deficits, and coping strategies of the DID patient's mind. As Coons and Kluft have observed, the personality of a patient with DID is to have multiple personalities. Bypassing or disregarding the alters creates a therapy in which major areas of the patient's mental life and autobiographic memory will be denied an empathic hearing. Furthermore, it is rarely sufficient simply to address the alters as they emerge. The alters are aspects of a process of defense and coping. It would be naive in the extreme to imagine that the patient will predictably present in those alters most relevant to the conduct of the therapy. Considerations of facilitating day-to-day function, shame, guilt, and apprehension dictate otherwise. Therapists who await the emergence of alters in order to work with them may prolong the treatment considerably. The need to elicit the alters in order to do the work of therapy is one of the factors that motivates the process of mapping, or understanding the structure of the system. For example, the late Cornelia Wilbur, M.D., observed that in many DID patients one personality knows the entire structure of the system, but such a personality usually stays within the inner world of the alters and does not emerge. Simply asking whether such an alter is present can lead to information that simplifies treatment considerably in those patients who answer in the affirmative. Also, many times dangerous symptoms are related to alters unknown to either the therapist or the more easily accessible alters, yet can be easily addressed if the alters associated with such symptoms are elicited and their concerns addressed. A more detailed discussion of the usefulness of talking with the alters is available. Some useful forms of therapy, such as Watkins and Watkins' ego-state therapy, a productive personality-oriented approach, depend upon accessing the alters in order to move forward.
Dealing with the Surround of DID Treatment
It is hard enough to treat and to be treated for DID in a supportive atmosphere. In an atmosphere of polarized contention, the task becomes more complicated. In the treatment of DID in the 1990s, the therapist can expect that the patient will hear that DID does not exist, that it is an iatrogenic creation, that those who treat DID are practicing a dangerous "recovered memory therapy," which constitutes malpractice, and that all or most recovered memories of trauma are false. These opinions will be voiced on prestigious mainstream television programs by experts and professors of apparently impressive credentials. Furthermore, there are web sites on the Internet in which the above views are expressed with conviction and venom. Also, in chat rooms for dissociative disorder patients on the Internet, it is easy to find contributions that vilify prominent dissociative disorder therapists, and that advocate remaining dissociative.
In this atmosphere, it is important to appreciate that no matter how dedicated the therapist and how motivated the patient, these factors may exert an influence. An apparent straightforward agreement to avoid and/or remain uninfluenced by such pressures may inadvertently contribute to a collusion to leave doubts and negative perceptions unexplored. In my experience, it is more productive and less defensive to invite the patient to bring all experiences that reflect such impacts into the therapy, and for the therapist to acknowledge the controversies that surround the issues of concern, and to state his or her best understanding of the particular situations or issues in question. If this is not done, the influence of infinite third parties to the treatment may go unappreciated as they undermine the therapy. A small percentage of DID patients will use the doubts raised by external factors in the service of an ongoing resistance, but most will not. For those who do, the characterologic aspects of such a defense must be addressed. In any case, it is important not to do anything that will result in the therapist's forcing the patient to accept the therapist's point of view, or precluding the patient's exploration of his or her own misgivings.
Reflection Exercise #9
Online Continuing Education QUESTION 23
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