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Dear Lost in Florida,
You have asked several perceptive and challenging questions about “integration” for people with D.I.D. I will try to answer a few of these and then provide you with a few references for further thought.
You ask when is integration the right step, but integration is far more than a step, it is a complex process that extends over a time period that may stretch out over years. The consensus of therapists writing about doing integration work is that it usually takes up the last quarter of a multi-year course of therapy, often 1-2 years or more. Integration should be considered when there is already a significant sense of connection and relatedness among the parts of a person’s system, i.e. they accept that they are part of a totality and are working together, and the total person has made progress in replacing maladaptive behaviors with more adaptive ones, tolerating feelings, and generally getting on with the business of living.
The “Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults (1997)” published by the International Society for the Study of Dissociation http://www.issd.org/indexpage/treatguide1.htm states that integration is an overall treatment goal:
The DID patient is a single person who experiences himself/herself as having separate parts of the mind that function with some autonomy. The patient is not a collection of separate people sharing the same body. The terms personality and alter (short for alternate personality) refer to dissociated parts of the mind that alternately influence behavior in DID patients. Some clinicians prefer terms such as disaggregate self state, part of the mind, or part of the self. Wherever possible, treatment should move the patient toward a sense of integrated functioning. Although the therapist often addresses the parts of the mind as if they were separate, the therapeutic work needs to bring about an increased sense of connectedness or relatedness among the different alternate personalities.
In her essay “Understanding Integration As A Natural Part Of Trauma Recovery” Rachel Downing, L.C.S.W.-C., quotes Frank Putnam on this topic:
Although there is a general consensus among experienced therapists that integration of the alter personalities is a desirable goal, this simply may be unrealistic with many patients. Kluft (1985d) is the first to acknowledge, “In a given case, it is hard to argue with Caul’s pragmatism: `It seems to me that after treatment you want a functional unit, be it a corporation, a partnership, or a one-owner business'” (p.3) It is a mistake to make integration the focus of therapy. Treatment should be aimed at replacing maladaptive behaviors and responses with more appropriate forms of coping. Ideally, integration of the alters will emerge from this process, but even if it does not, the therapy may well be termed a success if the patient has achieved a significant improvement in his or her level of functioning (p.301).” (Diagnosis and Treatment of Multiple Personality Disorder, Frank W. Putnam M.D. 1989)
Both of these excerpts highlight that the goal of therapy is to improve how the alters function together so that the person-as-a-whole can function more effectively with less stress and emotional pain. But I would add that in my opinion it is important to note that integration cannot be imposed on a patient, and it is not a matter of “should.” Integration can only proceed successfully if it is perceived by the system of alters as a choice. I think this is important because abuse survivors know all too well what it means to be coerced, to be required or forced to act in ways that hurt them. Thus, abuse survivors are extremely sensitive to feeling pressured or controlled by people in authority positions, including therapists (and sometimes peers). Therapy will rapidly reach an impasse if the therapist does not respect the person’s right to make choices.
Much of the therapy for people with dissociative identity disorder involves promoting negotiation and cooperation among the alters in the system. The same principles apply to integration: it requires a lot of negotiation and working together inside, and there must be at least a strong consensus that integration is a desirable goal. Alters can slow or interrupt the process of integration if they are uncomfortable with it, but, in my opinion, as long as they maintain enough autonomy and separateness to be able to walk out, full integration cannot be said to have occurred.
However, integration is not an all-or-nothing phenomena: it is approached in steps of greater cooperation and increasing co-consciousness (at least for some), and can potentially be undone by a very serious trauma occurring after integration. I have worked with patients who state they had achieved integration for years, but re-experienced dissociation and the re-emergence of their alters after suffering very traumatic experiences that had some similarities to their early-life traumas. Perhaps this is a semantic argument (about whether integration can be undone), and some might argue that if it can be undone, then it wasn’t real integration. The capacity for dissociation as a defense mechanism against overwhelming anxiety and terror persists, at least for some people, after integration and the working-through of older traumas, but only the most severe trauma can cause the re-emergence of alters as a way to deal with the overwhelming emotional pain.
Some people do experience loss and mourning after integration, or when some alters seem no longer to be present, such as when all of the memories they have held have been recovered and their positive attributes and roles are taken up by other parts of the system. I have heard several people I have worked with talk about how they miss alters that they had in the past, but who no longer seem to be present (whether due to integration or hiding inside). I have also heard people talk about feeling a strange sense of loneliness or emptiness in their heads when they no longer hear their alters, particularly if they had worked toward cooperative relationships with their alters and were able to converse with them in a friendly manner.
With regard to your question about dealing with issues after integration, I would say that when a person (system) has integrated, this includes having all of the abilities and skills to respond to issues and stresses that were formerly held by more distinct parts of the system. Thus, the development of these coping skills in therapy is a necessary pre-condition for integration.
To return to your initial question about knowing whether integration is the right step, if several alters in your system picture the process of integration as “waiting on death row” to be sacrificed, I do not see this as indicating readiness (at least on the part of those alters) to participate in integration. Let me put this another way: integration needs to be your (the system’s) goal and agenda to occur. It might be useful to talk to someone who has gone through the process and have them describe their experience of it.
As a final note, the ISSD International Fall Conference in November of this year is titled: The New Mainstream of Psychotherapy for the Dissociative Disorders: Theory, Practice and Research” and may lead to updated treatment guidelines. See: www.issd.org
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