What is the recommended treatment approach for therapy for dissociative identity disorder?
WHAT CONCLUSIONS DOES TREATMENT FOR DISSOCIATIVE IDENTITY DISORDER DRAW?
There is growing evidence that the appropriate therapy for dissociative identity disorder does yield positive results. There is a large international study currently taking place which is following nearly 300 therapists from around the world along with their DID or DDNOS patients (Brand et al, 2009a). The data so far suggests that appropriate treatment leads to fewer dissociative, post-
DISSOCIATIVE IDENTITY DISORDER – STAGES OF TREATMENT
The consensus of experts is that phase-
- Establishing safety, stabilisation and symptom reduction.
- Working through and integrating traumatic memories.
- Integration and rehabilitation.
In reality, there is unlikely to be a linear progression through these three stages: more commonly the work will spiral through each phase, with a frequent need to return to stabilisation work during the middle and later stages. As well as addressing dissociative symptoms, and working through and integrating the underlying trauma, a third area of treatment is that of ‘attachment’, with the vast majority of dissociative identity disorder clients presenting with disorganised attachment patterns.
Phase 1 focuses on establishing safety and stabilisation and reducing symptoms. People with dissociative disorders often enter therapy in a very dysregulated, chaotic state and it is important to bring some balance and safety back to their lives before working on traumatic material. The focus during Phase 1 work is on:
- establishing a therapeutic alliance
- educating patients about their diagnosis and symptoms
- explaining the process of treatment.
- The goals of Phase 1 work include:
- maintaining personal safety
- controlling symptoms
- modulating affect (managing emotions)
- building stress tolerance
- enhancing basic life functioning
- building or improving relational capacities.
The ISSTD Guidelines (2011) stress the importance of establishing a sound treatment frame during Phase 1 work so that there is sufficient stability to be able to manage the later, more challenging work of confronting and integrating traumatic memories.
Phase 2 work is by its very nature difficult: for many years, traumatic memories have been ‘dissociated’, ie cut off from conscious awareness, and bringing them back into consciousness in order to integrate them into an autobiographical life narrative can be harrowing. As Kluft warns, “The patient often experiences therapy as a guided tour of his or her personal hell without anaesthesia. When a therapist fails to pace the treatment to the tolerance of the patient, the patient may become overwhelmed over and over” (Kluft, as cited in Chu, 2011, p.212) It is important to focus again on safety and stabilisation whenever this occurs: dissociative identity disorder therapy should not destroy the person in the process.
The quality of the relationship between therapist and client is the best predictor of therapeutic success, and so a warm, empathic, consistent, engaged therapist who is willing to be flexible and work long-
A variety of adjunctive therapies or techniques can be used alongside traditional talking therapies, including cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT), eye movement desensitisation and reprocessing (EMDR), and Sensorimotor Psychotherapy, amongst others. Some of these, such as EMDR, need to be modified in order to be safely used with dissociative clients. Many people in the field of dissociative disorders highly recommend Sensorimotor Psychotherapy: for more information go to www.sensorimotorpsychotherapy.org.
James Chu quotes Dr David Caul who once observed:
Therapists should always remember that good basic psychotherapy is the first order of treatment regardless of any specific diagnosis.
(Chu, 2011, p.227).