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On this track we will discuss resistance to treatment. We’ll examine manifestations of resistance as fugues, trances and depersonalizations, acting out, internal uproar and acute regressions, flights into health, and techniques for overcoming resistance.
As you already know, in the case of dissociative identity disorder, dissociated memories and affects may create resistance to therapeutic interventions. Clearly, resistances occur in all psychotherapies, and treating multiples is no exception. In DID clients, however, resistances are most frequently expressed around uncovering work.
Would you agree that resistances may also be important manifestations and indices of therapist error? Putnam states that incorrect or inadequate therapeutic interventions may heighten current manifestations of resistance or elicit new forms. A therapist must always bear in mind his or her possible contribution to a client’s suddenly increased resistance following a "therapeutic" intervention. Not all expressions of resistance threaten the therapeutic alliance, but all disruptions of the therapeutic alliance are major expressions of resistance.
Manifestations of Resistance
A number of typical resistances seen early in treatment with DID clients may include blaming others, mistrusting or having paranoid feelings, acting out, using a significant other to oppose treatment, denying emotional problems, having financial or time problems, or fearing treatment and the therapist. Think of your DID client. Does he or she exhibit any of these classical manifestations of resistance? What unique manifestations of resistance does your client exhibit?
Fugues, Trances, and Depersonalizations
Selma, age 41, often left treatment sessions and then wandered in a dissociated state for several hours until she finally "came to" in an unfamiliar place and called her therapist in a panic. During sessions, Selma sometimes bolted for the door in a panicked or dissociated state. These experiences, which usually produce significant discomfort for both Selma and her therapist, often dampened the active uncovering of traumatic material. Do you have a Selma who experiences manifestations of resistance through fugues such as dissociative wandering or fleeing?
Internal Uproar and Acute Regressions
He stated, "In many instances, these infant or child personalities seem to be sent out by the personality system to thwart uncovering work. If a personality cannot talk, he or she also cannot disclose highly charged material. Such a regressed state would be disturbing to the therapist who perceives this as a deterioration in the client’s condition." A mistake I have made is to respond to acute regressions with "supportive" interventions or medication. Would you agree that responding to these regressions with ‘supportive’ interventions only reinforces the efficiency of the child or infant personality as a smokescreen to thwart uncovering work?
Internal uproars, in which the personality system degenerates into a screaming mob within the client’s (usually the host’s) head, often prevent further work by overwhelming the client with internal stimuli. Have you treated a client whose personality system becomes entirely active at once? How do you respond? As you know, internal uproars in DID clients are usually highly symbolic of the material they conceal. Perhaps you can find the origin of the material your client is concealing by paying close attention to displays of internal uproars.
Flights into Health
Selma’s therapist stated, " I thought I should be cautious in accepting such good news. Spontaneous total fusion may rarely occur in DID patients, but is highly unlikely to occur in the middle of a turbulent therapy that is beginning to work with unrevealed trauma." Selma’s therapist instead carefully sought the reasons why this "fusion" has occurred. In particular, he asked about how the "fusion" had occurred: the circumstances, the reports of other personalities, and the mechanism of final decision making. Selma’s therapist found that she may have been acting out her unconscious wish to be rid of the other personalities.
Alternatively, a DID client may "admit" that he or she "made it all up." Frequently, however, this denial is immediately preceded or followed by some clear demonstration of the client’s multiplicity as one or more alters break through the internal suppression to demonstrate their continued existence. Would you agree that neither "spontaneous fusion" nor denial of DID constitutes grounds for discontinuation of treatment. Even if the client has truly fused, there remains the important post-resolution stage that is necessary to successfully conclude the client’s treatment.
4-Step Overcoming Resistance Technique
a. The first step in overcoming resistance is for the therapist to recognize that there is a resistance and that it is interfering with the core work of therapy. For example, is your client acting out, presenting with acute regression, or experiencing internal uproars?
On this track we discussed resistance to treatment. We examined manifestations of resistance as fugues, trances and depersonalizations, acting out, internal uproar and acute regressions, flights into health, and techniques for overcoming resistance.
On the next track we will discuss mapping the personality system. Three steps to mapping the personality system are choosing a form of map, identifying useful information, and using maps as final integration tools.
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