1. Accept that dissociative identity disorder is real
So the psychiatrist says it doesn’t exist, it’s an American fad, or it’s attention-
Those of us with it also deny it: “I haven’t got proper dissociative identity disorder” or “I’m making it up.” Denial and dissociation are two sides of the same coin, and why would we want to accept that we have a ‘mental health condition’ when there is so much stigma about mental illness? And why would we want to accept dissociative identity disorder in particular when it seems incontrovertibly to point towards the trauma history that we have spent our lives denying and avoiding?
After all, the opposite has been tried, and surely the evidence for that approach has been well and truly tested: how many people, when told that dissociative identity disorder doesn’t exist and that they have ‘borderline personality disorder’ or better still ‘unstable personality disorder,’ that they are schizophrenic or delusional or ‘just a bit depressed,’ that they are lying and malingering and attention-
So just to accept that dissociative identity disorder is real, just to be willing to work with someone who has this cluster of baffling symptoms, these little time-
And not just to believe that it is real but to believe that there is hope for recovery too – that is priceless.
2. You don’t need to be an ‘expert’
I’m wary of the ‘expert’ label, because it evokes power and authority, and for those of us who have suffered abuse at the hands of people with ‘power and authority,’ it’s a shaky way to start. I prefer the label ‘human being.’ I value the fact that people are trained and knowledgeable, that therapy is a ‘profession’ for ‘professionals’ and that the training is designed to safeguard the vulnerable. But treating dissociative identity disorder is not like chasing bacteria out of the bloodstream. It’s about a human being coming alongside another human being and giving them the courage to face the trauma and the abuse that has threatened to overwhelm them. In that setting, I don’t want some bespectacled expert who can quote chapter and verse. I want someone who at core is a thoroughly decent human being, who is willing to let me be the expert on me, who is willing to learn about me with me, and not assume that I am like every other dissociative identity disorder client he or she has ever previously known.
It is a way of coping with trauma by avoiding it. What that trauma is, what it has meant for me, how I have avoided it, what I need now, the sense I have made of myself and the world – all of that is unique to me and my history. Perhaps some therapists feel a little scared when faced with the prospect of working with people with dissociative identity disorder, as if the label is all there is to me and others like me. But I find that they are scared much less by the prospect of working with me as just a traumatised human being. It’s incredible how intimidating and off-
3. Believe our subjective reality and hold your objective reality
The core experience of dissociative identity disorder is identity confusion, or identity alteration. Those of us with DID don’t experience ourselves as singular at core; we don’t quite know who we are; we might experience ourselves at times as older or younger than we chronologically are; we might experience fluctuations between different aspects of ourselves that make us feel, quite definitely, that I am someone else. When these floating aspects of ourselves coalesce apart from each other, we call them ‘parts’ or ‘alters’ or any other name that describes the sense that they are alternate parts of this most intangible of states – ‘me’. These parts can be elaborate separate entities, with names and ages and genders and experiences and feelings and memories, or they can be an indistinctly-
Sometimes, in our need to feel accepted, we can become militant about our dissociativity, insisting that we are ‘multiples’ and that ‘singletons’ need to accept us as we are. I don’t share that viewpoint; I am glad that there are people in the world who didn’t suffer the trauma I did during childhood and who were able to integrate their sense of self. Because, actually, living like this isn’t in the slightest bit fun. I want to figure out the steps that I missed, and I want someone who is sufficiently integrated on the inside of them to mirror to me that inner togetherness that I am currently lacking.
Our parts are very real to us, but despite our protestations, we do just have the one body, and parts are part of a whole, not separate ‘persons.’Multiplicity is a trick of the mind to protect us from trauma. It’s trauma that tells us that we want to stay separate: most of the time it is far too overwhelming to consider ‘integration’ or ‘connection’ with these disowned, traumatised parts of ourselves. In therapy, I want to know that what I experience is valid and true for me. I want the freedom to be able to have my own point of view, and for that to be heard. But I don’t want to suck my therapist into my worldview, the one borne of trauma, the one that whispers that dissociative identity disorder is ‘just the way it is’ and that relegates me to living an unintegrated, painful existence for the rest of my life. So in my therapy I have wanted my therapists to validate my subjective experience but hold fast to their objective reality too. I don’t ever want to be cut adrift into a dissociative existence and be told that living separate from myself, full of torment and nightmares and flashbacks and the incessant heaving self-
4. Don’t freak out when parts appear
One very honest therapist, who hadn’t worked with dissociative identity disorder previously, sat in the Q&A at the end of one of my training days and patiently waited for his opportunity to speak. Then out he blurted with it: “So at times you act and talk and think as if you’re 12 years old?” – “Yes.” – “And at other times it’s as if you’re four years old?” – “Yes.” – “And this happens all within one session?” – “Yes, sometimes within a matter of seconds or minutes. One part can come out after another like musical chairs.” – He paused and cleared his throat. “I think I’d find that a bit difficult. I think I might be a bit freaked out by that.”
I know what he means. In the early months, having dissociative identity disorder with practically no co-
But if my therapist gasped every time I switched, it wouldn’t lead to the therapeutic gains, the facing and processing of traumatic material that it preludes. Switching is ok: it’s where you do it that matters, so it needs to be somewhere safe. A friend of mine with dissociative identity disorder was looking for a new therapist to work with and met with one who seemed to tick all the boxes. The initial session was going well until she asked what proved to be a double-
There are good times to do this – at the end of a session, or when as clients we are being assaulted by emotions and we are tumbling out of either the top or the bottom of our ‘window of tolerance’; when flashbacks are too intense and we are losing simultaneous touch with current day reality. But this therapist was, I assume, working under the false assumption that parts being ‘out’ is a bad thing and that recovery comes by stopping it happening. That’s not recovery – that’s suppression and denial, and it won’t work, at least not in the long-
Perhaps the best response to parts appearing is to welcome them genuinely, get to know them, figure out their ‘role’ or ‘function’ in the personality system as a whole, and work slowly towards making a bridge between them and the adult host. They have been, generally speaking, disowned and cut-
5. Treat all parts equally
It’s easy to like some of our ‘younger’ parts, the attachment-
But of course if you side with the younger ones, then you’re missing a great opportunity. Because for many of us – certainly for me – a major driver for change has been when one of my therapists has been able to sidle up to ‘Dark’ or ‘The Big Ones’ and engage their energy for good. Our placatory parts, the attachment-
But if you can engage with these angry parts, the parts that are feeling exactly what they ought to be feeling for the things that were done to them, if you can treat them the same way that you treat the loveable little ones, then they can begin to change. What I have found is that while my attachment-
And of course, the whole time, while you’re responsive to the ‘little ones’ but standoffish with the aggressive ones, you’re being watched. Maybe not at a conscious level, maybe not at a level that forms an explicit memory for us to pick over afterwards, but at the very least at an implicit level, all of the parts of us are watching how you relate and they are all asking the same questions: Are you going to accept ME? Are you going to be here to help ME? Because maybe I’m not good enough – maybe I don’t deserve it: because I’m too shameful, too damaged, too toxic, too bad. When you show unconditional positive regard to all of us, however that manifests, we learn a vital lesson – that all these disowned parts of us can actually be accepted; they can be heard; they can say what they want to say and not be sent away; they can have the feelings and the memories that they hold like unstable isotopes. If you accept them, then maybe we can.
6. Teach grounding skills for our benefit, not just for yours
‘Grounding’ is a wonderful thing. We use that term to describe an array of skills and techniques and activities that we use to bring us ‘down’ from being hyper and frantic, or bring us ‘up’ from being too hypo and numb. Grounding gets us back in the ‘here and now’ rather than the ‘there and then’ of trauma. Grounding gets us back in our bodies, back in our selves, back in the present, back in a place where we are in control. As I say, it’s a wonderful thing.
But sometimes, the words “Let’s ground” are spoken not for our benefit, but for yours. Trauma processing sounds of course as if it should have nice, clear limits around it – “This is processing trauma; this is not.” Trauma processing sounds as if it should be logical and linear and controlled and full of deep belly-
But in reality, many of us just need to be able to feel these feelings that spurt up out of nowhere on the inside of us. It’s such a blessed relief, at last, after all this time, to experience the sensation of emotion. Everything has been so suffocated and blacked-
James Chu (2011) said that one of the hardest things to bear in trauma is the aloneness of it. I agree with him, and I have found that one of the most healing aspects of processing trauma is not doing it alone. Right here, right now, I am in the room with someone who is listening and bearing witness and supporting and empathising and caring. What I am experiencing in my mind and my body is the memory of trauma, and the memory of that aloneness. Bringing it out in the here and now, even though it comes through sobs or gasps or incoherent rambling, means that I am no longer alone, and it is just a memory. That’s not the time to ground me, because although I look distressed, I know where I am and I don’t want to avoid this trauma any longer. If we don’t do this here, in the therapy room, it will explode out of me when I’m not safe and contained.
Sometimes I think it’s the distress of seeing this trauma come alive, the unbearability of the suffering that it represents, that causes you to seek and grab for ‘grounding.’ Let’s put a stop to it; let’s close this thing down; let’s not look at it – you’re too upset. It’s a fine line, but it’s a vital one. You have to remember that we didn’t just remember this trauma – we endured it. When we talk of rape or torture or incessant aloneness or the stench of sweat and alcohol, we went through it. If we can’t get just a little bit upset, in the here and now, with you safely here with us, then it will continue to haunt us. Are you really so scared of the emotions – they’re just feelings! – that you need to ‘ground’ it away? Or can you bear to sit with us in the agony of remembering, so that the agony is just a memory, just a feeling, just the memory of a feeling, and nothing more? What I’ve found is that when it’s been allowed to come out, its power fades. And when you can learn when I need to be grounded, and when you need me to be grounded, then the work can continue apace.
7. Accept that you don’t know
We may tell you that Uncle James was there, that he gave us gifts, that we felt afraid of him. But if we haven’t told you that he abused us, then you can’t make that leap for us. Sitting with the unknown is hard, I expect, for both therapist and client. We all want to make meaning out of patterns, we all want to just know. But unless you let us sit in the dim, dark confusion of not knowing, we won’t know that we know, only that you know and then, once again, it will be someone else’s reality forced upon us, and that won’t help us at all. If we are coerced into a full-
We need to start simply by trusting our own perceptions, our own awareness of the world, our own bodies. We need to tune into what we think and feel, rather than letting you finish the sentence for us. We need to figure it out for ourselves. You can’t know whether what we glimpse and call a ‘memory’ is real or not; you can’t know whether it actually happened just as recalled; and neither can you know that it definitely didn’t happen either. You weren’t there. Surely the most unhelpful response is not to be believed when we share horror and atrocities. But perhaps just as damaging is when you leap up to colour in the dim-
8. Hold your boundaries, and then flex them too
What are boundaries all about? The 50-
Working with DID means working with people whose boundaries as children were chronically invaded – either through active acts of abuse, or passive acts of neglect, or sinister mind games and manipulation and inverted caregiving/careseeking roles. There are a multitude of ways in which we grew up not knowing what it was to be respected, to have choice, to be heard, to have a separate sense of self in an intimate relationship. The boundaries in the therapeutic relationship protect that.
But many therapists flex the boundaries in working with dissociative identity disorder and I agree wholeheartedly with that: you can’t cram 50 parts of the personality into 50 minutes; you can’t squeeze the trauma of disorganised attachment into six sessions. And in most therapeutic dyads, contact between sessions is part of the contract: it is hard for dissociative survivors, especially when in crisis, to contain their distress without support or a ‘safe haven’ for 7 long days and 7 even longer nights. And working with it is prolonged work, and intense work, and many of us have missed out on a raft of tiny but normal human interactions so that being offered a cup of tea can model self-
Flexing the boundaries is a good thing as long as it’s not a reactive thing, as long as it’s a decision that you’ve reflected on and you’re comfortable with and you can maintain it and not offer it and then retract it: we know of too many people with dissociative identity disorder whose therapists have given ‘too much,’ only to realise months down the line that they can’t cope with what they are giving. To escape from their promises, they then quit altogether – please don’t do that. Flexing the boundaries is a good thing if it’s truly in the client’s best interests and it’s not just there because you can’t hold the anxiety of how we are between sessions. Flexing the boundaries is a good thing if it’s a mindful act that comes from a deep-
Above all, hold the boundary of your self and don’t become enmeshed and try to rescue. In order to heal from boundary violations, most of all we need you to avoid replicating the dynamics of intimate invasion we encountered in childhood. We need you to remain you, and for us to be allowed to become us.
9. Just be a good therapist
Sometimes it must feel so confusing and overwhelming. Here is this person with this most controversial of labels, and maybe even your colleagues are raising an eyebrow that you’ve got sucked into this work. You’re doing things differently, you’re working at the edge of your competence, your supervisor is asking awkward questions and you go to bed at night wondering if you’re doing the right thing. Or are you making things worse and should you be struck off for your preposterous hubris in thinking that you can help this label-
I know for many therapists, the pressure to ‘refer on’ (regardless of the fact that there is no one to refer on to), the pressure to ‘look after yourself’ (meaning, don’t go out of your comfort zone and just work with ‘less distressing material’) can be overwhelming. Research consistently shows that it is the relationship between therapist and client that is the greatest factor in successful therapy, but surely they weren’t talking about this kind of clientwere they?
I may have a ‘label’ – although who put it there and what right they had to do so is another question entirely – and I may at times have overwhelming symptoms of unhealed suffering. But I am not some other class of human being, and I don’t need another class of therapist to work with me. And after all, what is therapy really all about? Is it about theories and neuroses and complexes and contracts and transferences and core conditions, or is it about a human being coming alongside another human being to help them work through their suffering and their distress so that they can live again? In my view, therapy shouldn’t get clogged up in schools of thought or ‘rules’ for practice. It should focus first and foremost on our humanity.
In 1966, in The Psychology of Science, Abraham Maslow said, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” It sometimes feels as if conflicts between different therapeutic approaches or schools of thought boils down to proving that the hammer is better than the screwdriver. Doesn’t it depend on whether it’s a nail or a screw that you’re trying to deal with? And in working with DID – as in fact in working with every other ‘label’ – the client is a person, a human being, not some rusty piece of hardware protruding from a lump of rotten wood. Treat your clients first and foremost as suffering human beings, and then treat them as clients to protect them and to help them – not so that you can stand back at a ‘professional distance’ in order to keep you safe from their supposed ‘contamination’ – but so that you don’t forget that you are there to help them. Use every tool at your disposal to help them, and do the basics of therapy well – be reflective, listen, empathise, show respect, encourage autonomy, be confidential. Use every single tool you can lay your hands on to help the human being in front of you, but don’t mistake your client for a screw with a rotten thread.
And above all, perhaps, don’t get in the way. This is about your client, not you. We are not coming to make you feel good about yourself, to fulfil a need to be needed, or to improve your professional prestige because now you work with ‘complex cases.’ Trust the process of therapy, because it works, and trust yourself to come alongside us, the clients, whose recovery it is. Seek attunement, seek to empathise, seek to bear witness, seek to encourage and affirm, seek to listen, seek to care, and ‘progress’ will come. We are hardwired both to survive and to heal, and we will recover.
10. Get a life
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Thank you Carolyn.
I am a therapist working with survivors of childhood sexual abuse and have recently started working with a new DID client. Reading your articles has brought enormously helpful insight, especially this one, full of practical help. Thank you
Wow! So helpful and well explained.
This is so helpful. I am an Assistant Psychologist working with women with DID or dissociative disorders.
Unfortunately, throughout my undergrad and masters degree, dissociation wasn’t touched upon, therefore, I have entered a completely new challenge. Working with individuals with DID is both challenging but fascinating and I am so glad to start my clinical journey within this area.
Thank you so much for writing this. I am a mental health counselor treating my first individual with this diagnosis. I found this to be so helpful.
Excellent explanation of what good therapy should and could be, regardless of DID, but even more importantly when working with a client with DID and their many parts.
With 25 years experience as a therapist and supervisor, I become disheartened by the now greater emphasis on the academia and the loss of sight of the absolute need for good safe human interaction.
Having supervisees with PhDs, I have quickly learnt that academic intelligence is no substitute for core conditions of empathy, non judgment and unconditional positive regard for the client (be it both together can be very useful).
In DID especially, a client does not need a genius, they need a safe reliable, empathic person to support all of their parts.
Thank you Carolyn for giving those without ‘specialist or advanced training’ the courage and tools to help people they might otherwise shy away from.
Such a valuable, useful article – a timely read for me as I’m currently working with a client in this space. Thank you for (always) making room for your vulnerability, and being willing to share your phenomenological experiences and draw on the wisdom gained from your journey to soak your words and work with richness and meaning – and great credibility. It speaks to the grass roots of why we do therapy, and resonates with the (albeit unique) stories of clients and the heart of what it is they truly need.
I used to freak out inside when I started seeing my first complex trauma client in an impatient setting. But, I never showed the freak out on the outside. Instead I would calmly ask “and what happened next.” I knew she needed calm because she was pretty freaked out. I had to find ways to help calm. I had to find ways to get her to question for herself what she had been taught to believe. I won’t write about the things she shared out confidentiality, but also to prevent triggering anyone else reading this. I learned to believe the unbelievable. Thought each day I had heard the absolute worst that anyone could go through only to find I was wrong. I tired denying that what I heard was real, but the abreactions I saw were too real. The words, the story, emotions, the behaviors all fit together. I couldn’t deny the truths I was seeing. That was in the fall of 1982, just after graduate school. Then I recognized the symptoms in others. Things they said or behaviors they had that pointed to abuse. I saw the micro-regressions. Heard the slight voice changes. Asked questions about did they remember their childhood? Did their handwriting change? Did they find notes they didn’t recall writing? Did they find clothes in their closet they did not remember buying and were not their taste? Did they ever think I need to go do X, only to find it done, but they did not recall doing it? Did people come up and seem to know you, but you did not know them? I looked for signs of disremembering as I was initially working on a diagnosis. I pushed another therapist to open his eyes and see what he wasn’t seeing, after he told me to stay away from his clients. I found a way to challenge him and things to look for and questions to ask, and I would not interfere with his clients if he honestly approached them with an open mind. Then we had another clinician join the practice who immediately started seeing dissociation in some of his clients. I stumbled into this. I went to ISSD conferences in Chicago for several years. I met Cornelia Wilbur, Richard Kluft, Catherine Fine, and many others. Dr Wilbur assured me I could help dissociative folks and cure them in ways we can’t with genetic mental illnesss. assured me I Trained in hypnosis and read about dissociation seen by Milton Ericksen in his monographs. My colleague and I obtained supervision with George Greaves PhD in Atlanta. He helped quiet some of the freak out I was having when a client shared she had over a thousand parts. His calm response and suggestion that they would coalesce around the traumatic events that they shared. I leaned to calm myself when I saw polyfragmented clients who had been through repetitive catastrophic trauma. I went through the anxiety produced by the “false memory” factions abs clinicians being sued. My saving Grace was that I never led clients and never asked if this trauma or that trauma happened. In fact I would do the opposite and ask, “ they let you leave before anything else happened.” Never did anyone confirm my suggestion…. I thought when I moved to Key West, FL that somehow I magically would never see dissociation again….my attempt at denial did not work! That was 2001 and within 6 months I began seeing clients with dissociation again. I’ve seen probably more than a hundred dissociative clients over the years. For 16 years I averaged a caseload of 10 clients per week. I see fewer now, but I also live in a small town now.