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Section 14
Dissociative Identity Disorder Therapy Techniques

CEU Question 14 | CEU Test | Table of Contents | DID
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On the last track we discussed 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. 

On this track we will discuss therapeutic resolutions.  In his book, "Diagnosis & Treatment of Multiple Personality Disorder," Frank Putnam provides therapeutic resolutions consisting of techniques for fusion and integration, assessing fusion stability, therapeutic interventions for fusion failures, and post-fusion treatment.

4 Therapeutic Resolutions

#1  Techniques for Fusion and Integration
First, let’s discuss techniques for fusion and integration.  The therapy of DID proceeds stepwise through a series of issues and stages.  How do you determine if your DID client’s alters are ready to begin fusion and integration work?  I find that signs suggesting that two or more alters are ready for fusion usually indicate that the dissociative barriers maintaining separateness have eroded to a point where fusion is possible. 

The alters may report coconsciousness or other forms of simultaneously shared awareness.  A nondysphoric, persistent sense of simultaneous copresence is a strong indicator that two or more alters are ready to attempt fusion.  The alters may report an "identity crisis," in that they do not feel the way they used to and have a blurred or overlapping sense of identity.  The alters may also report themselves ready to fuse or request that the therapist help them fuse.  One client’s alters requested fusion from a colleague of mine because he claimed that continued separateness felt uncomfortable.

As you know, successful fusions can only occur after the dissociative defensive barriers that serve to separate the alters have been significantly eroded by psychotherapy.  This happens when the alters begin to accept each other and to develop a sense of mutual self-identification.  Each will also acknowledge memories possessed by the other alter, and other issues for which the alter in question was previously amnesic or denied knowledge.  

At this point, the alters will often indicate that they are uncomfortable with their separateness and report experiences of coconsciousness and feelings of being redundant.  The therapist then spends some time searching for residual areas of conflict between the alters. Each alter should be offered the opportunity to talk about any latent issues and probe for hidden conflicts.  If any problems remain, do you agree that these must be worked through until no further issues divide the alters to be fused?

The next step usually involves a formal procedure, sometimes augmented by hypnosis.  Most formal procedures used involve the use of visual imagery and metaphors and are generally performed while the alters are in trance-like state.  The image or metaphor employed should be discussed ahead of time with the alters and the client as a whole.  Some apparently innocuous images may have highly charged meanings for the alters or client and may thus be detrimental to the fusion process.  What types of images might you use to foster fusion or integration with your client? 

I find that using images of embrace, dance, and other shared activities can be productive.  My colleague George prefers images of the blending together of light or the flowing together of water.  George calls forth the two alters to be fused and asks that they "stand" side by side, and then incorporates them into the hypnotically enhanced imagery.  

The alters may then be told that they are surrounded by a glowing ball of light, and that as their light blends together, they also blend together to become a single glowing ball of light.  George stresses that images of blending in which all elements are preserved and represented in the larger whole are preferable to images or metaphors that suggest death, elimination, subtraction, or banishment.  

Do you agree?  DID clients seem to need and demand a fusion technique, although the fusion process usually appears to be taking place on its own with the development of coconsciousness, the erosion of dissociative barriers, and the alters’ increasing discomfort with separateness.  Final fusions—that is, fusions in which all of the alters are blended into a single entity—are simply extensions of the techniques described above.

Usually final fusions are preceded by a series of partial fusions that consolidate the alters into two or more composite personalities, which then undergo the final fusion. Final fusions may be accompanied by changes in sensory perception by the patient. I have heard several clients spontaneously report that sounds were clearer and "less muffled", colors were brighter, and vision was sharper following a final integration. 

#2  Assessing Fusion Stability
Due to a high rate of relapse and/or failure to fuse in the first place, do you test your DID clients actively for evidence of fusion/integration stability.  A formal interview protocol for assessing the stability of fusions in your clients may begin by inquiring about signs and symptoms of DID in general, and then focusing on signs and symptoms that were specific to the client during the course of treatment.  You might consider asking your client to provide a chronology of his or her interim history, and is also asked about the observations and opinions of others with regard to the fusion. 

In my practice, I then attempt to elicit every one of the client’s alters.  Consider using any of the techniques or cues that worked best in the past for the patient.  If these measures fail to demonstrate multiplicity, there are other ways to assess fusion stability.  As you know, final fusion should result in the recovery of relatively complete memory for traumatic events.  In clients claiming to be fused, one can attempt to take a complete history of the events associated with the early creation of alters. Non-fused clients usually have great difficulty in providing a coherent history of these events. One can also provide the client with sequential tasks, such as those used in diagnosis.

#3  Therapeutic Interventions for Fusion Failures
Multiples often view fusion and the failure thereof as a tremendous test.  Unfortunately, clinicians may reinforce this attitude by an overemphasis on fusion at the exclusion of other aspects of therapeutic progress.  If you found out that a final fusion had failed, how might you respond?  I feel it is productive to share this information clearly with the patient.  In a case where the multiple is deliberately feigning fusion, there will be resistance or an argument about the "facts."  Perhaps you could share with the client the observations supporting your assessment that the client remains divided.  

The next steps in working with a failed fusion are really the same as before.  Newly discovered alters should be individually met, and information should be gathered on their life history, function, and place in the personality system as a therapeutic alliance is nurtured.  Previously known alters who came unfused or feigned fusion must be directly addressed, and any unresolved traumas must be worked through completely.  Residual traumatic memories and affects that have not been adequately explored are the major causes of fusion failures.

 The failure of a fusion does not indicate a major setback; it just underscores the fact that the therapy must continue to uncover and work through the massive amount of trauma suffered by the patient.  Would you agree that the process of repeated final fusions can be likened to rounding off the burrs along the edges until the parts fit tightly?

#4  Post-Fusion Treatment
There is general agreement among experienced DID therapists that final fusion of all of the alters, although an important milestone, does not mark the end of treatment.  Do you agree that clients should continue in active treatment until a new sense of identity is firmly rooted and the issues and reactions evoked by fusion/integration have been worked through?  The patient’s new status as a fused multiple requires a readjustment in his or her sense of self.  

The issues raised by a new sense of identity are usually most apparent and problematic when the patient is faced with a readjustment in important relationships. It often becomes obvious to the patient at this point, if not sooner, that many of the significant others in the patient’s life would prefer him or her to remain fragmented. Multiples, with their strong tendency to recapitulate old trauma in current relationships, often are involved in pathological or at least problematic relationships that exacerbate this process of readjustment.

Therapists can help clients to critically examine the overt and covert demands to be multiple made upon them by significant others.  In their new and fragile state of unification, most patients continue to see themselves as completely at fault for problems in their relationships and often feel that it is they who must change to please the other persons.  How can you help you client work through the necessary readjustments in relationships and help them to recognize when inappropriate and pathological demands are being made by others?

You might also consider the need to continue work with your client in recognizing and coping with trauma and grieving over losses as necessary to prevent relapse into a dissociative coping style.  As well, one area in which newly fused/integrated patients seem to need a great deal of help is the recognition and identification of feelings.  In the past, strong affects were sequestered behind dissociative barriers creating alter personalities.  Newly unified clients typically have difficulty even in simply identifying their feelings and are frightened by the intensity of some affects.  

How can you be alert to this problem and help your client label feelings and make connections between those feelings and life events?  How can your client learn how to appropriately express and respond to feelings, particularly strong affects?  Clearly, the ability to experience, identify, express, and appropriately respond to strong feelings in a non-dissociative way is one of the most important tasks facing the client during the post-fusion period.

As a multiple, the client handled mixed feeling states and ambivalence by switching between or among a number of alters, each of whom relatively personified one particular feeling or point of view.  The client usually did not have to tolerate the simultaneous experience of intense contradictory feelings.  Now, as a fused multiple, the client must experience the anxiety and inner turmoil that come with mixed feelings.  The intensity and distress of mixed feelings may at times be mistaken for new dissociative splitting.

The socialization of a newly fused or integrated DID client is a complex and all-encompassing task that the therapist should not undertake alone.  Would you agree that this is a good time to get the client involved in groups that seek to address specific problems, such as assertiveness training, socialization, and parenting?  How can your client be encouraged to actively expand social networks and to renew contact with old or estranged friends?  

On this track we discussed therapeutic resolutions.  In my practice, therapeutic resolutions generally consist of techniques for fusion and integration, assessing fusion stability, therapeutic interventions for fusion failures, and post-fusion treatment.

Peer-Reviewed Journal Article References:
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., Pain, C., & Putnam, F. W. (2012). A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 490–500.

Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology. Advance online publication. 

Cautilli, J. (2018). Introduction to the special section on clinical and applied behavior analysis and ethics. Behavior Analysis: Research and Practice, 18(4), 416–418.

Cavicchioli, M., & Maffei, C. (2020). Rejection sensitivity in borderline personality disorder and the cognitive–affective personality system: A meta-analytic review. Personality Disorders: Theory, Research, and Treatment, 11(1), 1–12. 

MacIntosh, H. B. (2015). Titration of technique: Clinical exploration of the integration of trauma model and relational psychoanalytic approaches to the treatment of dissociative identity disorder. Psychoanalytic Psychology, 32(3), 517–538.

Rees, C. S., & Pritchard, R. (2015). Brief cognitive therapy for avoidant personality disorder. Psychotherapy, 52(1), 45–55.

Online Continuing Education QUESTION 14
What are four techniques for achieving therapeutic resolutions when treating dissociative identity disorder? To select and enter your answer go to CEU Test.

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