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Guidelines for Treating Dissociative Identity Disorder in Adults (2005)


Treatment Considerations

Clinicians treating DID may be faced with both sides of the medical/somatization problem. DID patients may seek out medical care for some of their problems, but ignore many other serious medical issues. On the one hand, DID patients may utilize health resources at a higher rate than the general population, yet other patients may be phobic of seeking any medical care at all. Somatoform elaboration may be superimposed on medical illness. DID patients may have an uncanny ability to produce realistic conversion symptoms that mimic serious medical problems including seizures, severe headaches, neurological problems, breathing difficulties, etc. Occasionally, family practice or internal medicine physicians may ask mental health professionals for consultation because a DID patient presents with extensive somatization, or problems such as widely fluctuating blood pressure or glucose intolerance, apparently related to switching among alters with different physiological profiles.

DID patients may be preoccupied with somatoform pain syndromes and take high doses of narcotic analgesics with limited response. On the other hand, other DID patients may be able to dissociate pain for long periods of time, thus delaying seeking medical care until severe complications have occurred, even metastatic cancer that might have been prevented if medical care had been sought earlier.

These Guidelines cannot explicate all the complex issues that need to be addressed in evaluating and treating the somatic problems of the DID patient (see Goodwin and Attias, 1999). In brief, the treating clinician must educate the patient about reasonable health care and be an advocate for the patient to seek out appropriate medical care. The treating psychiatrist often has a role in the interface with the medical care community to help the patient get needed services but to help rein in the pressure for more and more tests or interventions when there is no clear-cut major new problem.

Education about somatoform symptoms in a supportive and respectful way, emphasizing the impact of trauma on the perception of the body, may help the patient more readily accept the idea of somatization, rather than eliciting the response, “You say it’s all in my mind!” This can help reduce unnecessary health care utilization and encourage appropriate utilization. The treating clinician and the patient must both respect the ambiguity of the mind/body situation in attempting to evaluate bodily symptoms.

Education about medical care, work on cognitive distortions, and PTSD related to medical care may be helpful in the patient being able to tolerate necessary medical procedures and to follow medical recommendations. The therapist also may need to educate medical personnel about dissociation and help them anticipate any difficulties that might occur during the procedure or treatment. Careful preparation is especially important for any intervention that is intrusive, especially interventions involving anesthesia and/or surgery. The therapist may need to work with alternate identities who deny “the body,” or who state they live in a different body, or that their body is a different chronological age, etc., in order to help the patient accept appropriate care. Assistance to alternate identities’ severe somatoform flashbacks (“body memories”) can reduce inappropriate treatment for somatoform symptoms.

G. Hypnosis as a Facilitator of Psychotherapy

Hypnosis has been used to assist the treatment of DID since the early 19 th century (Ellenberger, 1970). There is a wide literature concerning the use of hypnosis and DID (cf. Kluft, 1982, 1989; Ross & Norton, 1989b). Hypnosis is a facilitator of treatment, not a treatment in and of itself. Clinicians should always be adequately trained in any adjunctive modalities – especially hypnosis – that they are using in the treatment of a particular patient. Further, clinicians using hypnosis in the treatment of trauma and dissociation should receive specialized training in using hypnotic interventions with this patient population. In addition, clinicians should be aware of current controversies concerning the use of hypnosis in trauma treatment, memory recall during trauma treatment, and in the etiology of DID (Brown, Scheflin, & Hammond, 1998).

It has been shown repeatedly in both clinical studies and studies using standardized measures that DID patients consistently show the highest hypnotizability when compared with all other clinical groups (schizophrenics, bulimics, borderline personality disorder patients, PTSD patients, and others) as well as normal controls (Frischholz, Lipman, Braun, & Sachs , 1992). Accordingly, many hypnotic techniques have been developed to assist with DID treatment. DID experts generally agree that hypnotic techniques can be useful both in session and between sessions if patients are taught autohypnosis.

Since, as a group, DID patients are highly hypnotizable, many techniques developed for use with hypnosis can be used without the formal induction of trance utilizing patients’ autohypnotic abilities. Hypnotic techniques can be used for ego-strengthening, symptom exploration and relief, anxiety relief, accessing alternate identities and restoring adult identities when immature or dysfunctional identities are in control at a session’s end, containment of flashbacks, containment and control of both spontaneous and facilitated expressions of strong feelings and abreactions, stabilizing the patient or particular identities between sessions, exploration and relief of painful somatic expressions of traumatic materials, restabilizing and restoring mastery, cognitive rehearsal and skill building, facilitating communication within the alternate identity system, and in fusion rituals.

In the hospital, staff can be trained to assist with an agitated, overwhelmed, self-destructive, and/or violent DID patient by means of “temporizing techniques” such as imagery for calming, grounding, and/or containment of symptoms. However, staff members should not use formal hypnosis per se unless credentialed to do so by the hospital (Kluft, 1992). When these techniques are employed, the patient is generally informed beforehand and the intervention becomes part of the nursing treatment plan.

There is a range of opinions concerning the role of hypnosis in the ongoing psychotherapy of DID. Some clinicians discourage its use because they prefer alternative techniques, and others are concerned that the use of hypnosis may encourage the patient to report material consistent with perceived suggestions that may not be consistent with historical reality. Some experts point to the long history of the success of DID treatments that have employed interventions facilitated with hypnosis. They maintain that some form of hypnosis inevitably takes place in therapeutic work with this highly hypnotizable group of patients.

There is little controversy about the use of hypnosis for supportive and ego strengthening interventions, resolving crisis, stabilization, and promoting integration. Hypnosis may also be used to provide a relaxed state and to better facilitate modulation and titration of affect while working on already recalled traumatic memories in Phase 2 therapy (e.g., placing traumatic images on a mental “screen” to see them at more of a distance, etc.). The impact of using these techniques on memory material itself has not been studied and it is unclear to what extent, if any, these hypnotic techniques influence the patient’s recall (Brown, Scheflin, & Hammond, 1998).

Some consider the use of hypnosis to access alternate identities controversial (e.g., requesting identities to make themselves available, promoting inner dialogues, the use of Fraser’s [2003] “Dissociative Table” and allied techniques). More controversy surrounds the use of hypnotically facilitated techniques to explore areas of amnesia, or to further explore fragmentary images or recollections. Some authorities who support hypnosis for these indications point to the recovery of material that has been confirmed at a later date or to the therapeutic progress often achieved irrespective of the veracity of what is found. Others believe that use of these methods carries the risk that hypnotically facilitated memory processing will increase the patient’s chances of mislabeling fantasy as real memory. They believe that these are strong disincentives to this use of hypnotic exploration.

In addition to being highly hypnotizable, some DID patients may be highly “fantasy-prone” (Lynn, Rhue, & Green , 1988), although preliminary studies suggest that most DID patients are only moderately fantasy prone (Williams, Loewenstein, & Gleaves , 2004). Nonetheless, there is concern that some DID patients are vulnerable to confuse fantasy and authentic memory whether or not hypnosis is induced. Thus, therapists who do use hypnosis in an exploratory manner should minimize the use of leading questions and avoid hints and pressures that may, in some cases, alter the details of what is recalled in hypnosis. Hypnosis may also leave patients with an unwarranted level of confidence in what has been recalled in hypnotic states. However, there is evidence that specific informed consent concerning this latter issue may result in the patient not showing this undue confidence in memories newly retrieved under hypnotic conditions (see Cardeña et al., 2000). Brown, Scheflin & Hammond (1998) provide an extensive discussion of indications, contraindications and the potential risks and benefits of increasingly intrusive methods, ranging from free recall to hypnotically facilitated interventions, for overcoming amnesia in traumatized patients.

As with any other specialized technique, the therapeutic use of hypnosis should be conducted with appropriate informed consent provided to the patient concerning its possible benefits, risks, limitations, and current controversies concerning hypnosis and delayed recall of trauma as well as for the use of hypnosis for the diagnosis and treatment of DID and other trauma disorders. Informed consent should include possible limitations on the permissibility of testimony in legal settings concerning recollections obtained under hypnosis based on the statutes and judicial rulings of the jurisdiction in which the therapist practices (American Society of Clinical Hypnosis, 1994).

H. Eye Movement Desensitization and Reprocessing (EMDR)

Controversy exists concerning the application of EMDR to the treatment of DID. There is empirical support for EMDR as an efficacious treatment for single-event PTSD, but there are little data on the efficacy of EMDR for complex PTSD and dissociative disorders. Both proponents and critics of EMDR agree that additional research is needed to resolve questions about EMDR’s mechanism of action (Chemtob, Tolin, Van der Kolk, & Pitman, 2000). Based on research studies, some Task Force members have suggested that the beneficial effects of EMDR may come from the more careful attention to treatment structure, cognitive-behavioral interventions, and phase oriented planning for work on trauma as part of EMDR protocols, not the eye movements and related techniques.

Major clinical problems have occurred when EMDR has been used without modification with DID patients, or when DID has emerged unexpectedly during EMDR treatment. These have included florid decompensation with self-destructive behavior, marked increases in intrusive PTSD symptoms, and emotional flooding, sometimes resulting in hospitalization.

Some Task Force members are more supportive of EMDR. They note that there are clinical reports that modified EMDR can be helpful as a limited adjunctive technique in the treatment of DID (Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995; Shapiro, 1995, 2001; Twombly, 2000). Gelinas (2003) has written the most comprehensive review suggesting an integrated approach combining modified EMDR with phase oriented trauma treatment in complex PTSD. Gelinas notes that combining EMDR with the treatment of DID requires a solid understanding of phase oriented trauma treatment as well as a good understanding of DID treatment and work with alternate identities. EMDR proponents also insist that practitioners treating DID patients must take both parts of the EMDR training course, and obtain subsequent consultation regarding its use in complex PTSD and DID until they are experienced in utilizing EMDR with these populations.

The use of modified EMDR in a phase-oriented trauma treatment for DID implies an understanding of how to structure the treatment to protect the patient’s overall stability while doing specific work on particular traumata, an approach described by Fine (1991, 1993) who was chair of an ISSD work group on the use of EMDR for DID.

In addition, practitioners wishing to use EMDR with DID should be well acquainted with current controversies about its use, and give appropriate education and informed consent to patients concerning potential risks and benefits of this modality of treatment.

I. Expressive and Rehabilitation Adjunctive Treatments

Expressive and rehabilitation therapies may be very helpful to DID patients, as they are often uniquely responsive to nonverbal approaches. Modalities such as art therapy, music therapy, movement therapy, psychodrama, occupational therapy, recreational therapy, and horticultural therapy provide the patient with an alternative expressive format through which they may safely communicate underlying thoughts and feelings. The nonverbal process and products (artwork, musical expression, movement sequence etc.) can serve as a visual record of the experiences of the internal system of alternate identities, and may be examined at any point in treatment. They can provide vital information about past traumatic experiences, current triggers and stressors, safety issues, and coping strategies. At times, this information can be provided nonverbally at a point in treatment long before it can be verbally accessed. In addition, verbal discussion of the nonverbal work can facilitate a variety of treatment goals. In conjunction with verbal associations, nonverbal psychotherapy approaches bridge the gap between the patient’s inner and outer worlds.

Nonverbal therapeutic techniques may improve concentration, reality based thinking, internal organization, problem solving skills, and use of grounding and containment techniques. Additional goals may include improving internal communication and cooperation amongst alternate identities, fostering insight, sublimating rage, working through traumatic experiences, and assisting with fusion and integration. Expressive therapies can be used to facilitate goals of all three phases of trauma treatment. Many psychotherapists find the productions of nonverbal modalities (such as patients’ drawings and journals) useful as part of ongoing psychotherapy.

Through the provision of structured, reality based activities and interactive experiences, the patient’s level of functioning can be assessed, including the ability to execute tasks in a consistent and age appropriate manner. Occupational therapy assessments may help acquire data about how daily living is impaired by symptoms. Personal hygiene, meal preparation, money management, work, school, leisure/unstructured time, and social life all may be affected adversely by DID and PTSD.

Individual art therapy may be helpful for inpatients and outpatients at various points in treatment. Studies of art therapy in DID have led to the development of the Diagnostic Drawing Series (DDS), a standardized art assessment method that can be helpful in the differential diagnosis of DID ( Cohen, Mills, & Kijak, 1994).

The lack of availability and cost of adjunctive therapies may make it difficult to provide many of these treatments outside of a hospital setting. However, art, movement, and occupational therapy in a group format have been conducted successfully in outpatient settings and may be a cost-effective alternative to individual expressive therapy.

Expressive/Rehabilitation therapists are typically licensed masters or doctoral level clinicians, and are board certified in their respective fields. Although clinicians occasionally may ask DID patients to create artwork as part of therapy assignments, the formal use of expressive/rehabilitation therapies must only be practiced by clinicians with appropriate training and certification.

The primary clinician of the DID patient has primary responsibility for the treatment and should work closely with all adjunctive therapists to assure coordination of care. Open releases of information should be maintained in order to allow ongoing communication and coordination on an as-needed basis.

J. Electroconvulsive Therapy

ECT has not been shown to be an effective or appropriate treatment for dissociative disorders, but it may be important in relieving an associated refractory depression. Only one case series involving ECT with dissociative disorder patients has been reported (Bowman & Coons, 1992). Three patients with Dissociative Disorder, NOS and severe treatment-resistant resistant depression were successfully treated with ECT with marked improvement in depressive symptoms and minimal side effects. Dissociative symptoms as measured by the DES were not changed. The patients in this study were more able to use psychotherapy for their dissociative disorder after ECT.

On the other hand, many DID patients have had ECT before the diagnosis of DID while being unsuccessfully treated for apparent refractory mood disorders, and before the posttraumatic nature of the mood problems was recognized. In these cases, the ECT was almost always reported to be unhelpful, often resulting in memory loss and other disturbing side effects without clinical benefit. A small, severely ill subgroup of DID patients actually will seek out ECT because of its propensity to wipe out memories for a period of time.

However, a sub-group of DID patients in appropriately structured treatment for DID, with a distinct, persistent worsening of mood symptoms accompanied by significant psychomotor retardation and other vegetative symptoms different from the patient’s usual baseline, may respond to ECT after other antidepressant strategies have failed.

Patients should be carefully prepared prior to ECT as should be done in the case of any interventions requiring anesthesia and/or surgery. Specific informed consent for ECT should be obtained by the treating psychiatrist.

K. Pharmacologically-Facilitated Interviews

Before the development of clinical and psychometric assessment tools, hypnotic and/or pharmacologically-facilitated interviews – most commonly using amobarbital (Amytal) – were used to aid in diagnosis of DID. Due to the current academic and forensic controversies surrounding dissociative disorders and trauma memory, it is prudent to reserve these interventions for emergency situations when other methods of assessment have failed, e.g., in a hospitalized patient who is engaging in high risk behavior in dissociated states, but who has been refractory to other methods of inquiry, including hypnosis. These interventions should optimally be conducted by a clinician experienced in their use and in the differential diagnosis of dissociative disorders. Clear informed consent should be obtained for use of these interventions for the diagnosis of DID and recall of traumatic experiences.

Occasionally, pharmacologically facilitated interviews have been used to assist DID patients in accessing to alternate identities or to allow emergence of traumatic material that otherwise cannot be recalled. No systematic modern data exists on the fallibility or accuracy of what is recalled in such interviews, although amobarbital was widely used in World War II to facilitate recall of traumatic memories in soldiers with combat-related amnesia. Studies from the 1940s and 1950s showed that patients can dissemble and confabulate while under the influence of amobarbital and similar agents (Henderson & Moore, 1944; Redlich, Ravitz, & Dession, 1951). Given the current controversies, the clinician should give a similar informed consent regarding the nature of memory to the patient contemplating a drug-facilitated interview for amnesia symptoms as is given to the patient considering hypnosis. The clinician should emphasize that these drugs are not a “truth serum,” and that whatever apparently new information emerges under the drug condition should be regarded no differently with respect to accuracy than any other material that emerges in the course of treatment.

Side effects of amobarbital and similar drugs can include respiratory depression, sedation, hypotension, incoordination, and allergic reactions. Accordingly, these procedures should only be done in a medical facility where monitoring and resuscitation equipment is available. Due to the many complexities and problems associated with these procedures, they are currently rarely performed in the diagnosis and treatment of DID.

L. Psychosurgery

There is no evidence to support the use of psychosurgery in the treatment of DID.

V. SPECIAL TREATMENT ISSUES

A. Informed Consent

Clinicians should be aware of the general issues of informed consent for psychological and psychiatric treatment and for DID treatment in particular. Therapists should obtain informed consent in a manner consistent with prevailing standards of care (Brown et al., 1997; Courtois, 1999; Gutheil & Applebaum, 2000), and should consider specific additional informed consent procedures for adjunctive treatment modalities such as hypnosis or EMDR.

Further, clinicians should educate themselves about the specific issues that have become of heightened concern due to recent controversies around trauma treatment. In particular, these relate to several areas: the traumatic versus “sociocognitive” etiology of DID, the debate over the existence of delayed recall for traumatic experiences, the possibility that therapy can produce confabulated “memories” of events that have not occurred, and regression in treatment. Even properly conducted treatment of DID can cause temporary regressions while patients are adjusting to recollections of trauma and the accompanying emotions. Experienced therapists attempt to limit the duration and severity of these temporary regressions and inform patients of this possibility before addressing recollected trauma. Clinicians should acquaint themselves with the issues and controversies about these matters and give a balanced view of them to patients initiating treatment for DID. There is some evidence that this sort of informed consent and education of patients can help patients evaluate memories that emerge during treatment (Cardeña et al., 2000). Each state, province, or nation has its own definitions and criteria for the adequacy of informed consent, and clinicians must inform themselves about the conditions in their locality.

B. Boundary Issues in the Psychotherapy of DID

Victims of child abuse or neglect – such as persons with DID – have often grown up in situations where personal boundaries were not established and were invaded. In the therapy of such persons, there is a significant potential for reenactments of boundary violations. Accordingly, therapists must be very prudent, cautious, and thoughtful about the issue of boundaries. The therapist must foster a therapeutic relationship with clear boundaries. The therapist is responsible for clearly defining such a therapeutic relationship. Transference and countertransference responses with trauma patients, especially those with DID, are complex and must be meticulously managed. In general, sudden or impulsive changes in boundaries or treatment frame should be avoided in DID treatment. Consultation can often be helpful in managing clinical dilemmas concerning boundaries. A fuller discussion of these issues can be found elsewhere (see Dalenberg, 2000; Davies & Frawley, 1994; Loewenstein, 1993; Pearlman & Saakvitne, 1995; Wilson & Lindy, 1994).

Boundary issues arise throughout treatment of DID, with negotiation and discussion of these issues occurring as needed. Requests from DID patients to extend or alter the boundaries in therapy are very common. Therapists need to carefully evaluate such requests before making any changes to the usual and customary boundaries of treatment. Most experts agree that the patient needs a clear statement near the beginning of treatment concerning therapeutic boundaries. This statement may not always be understood immediately by the patient, may take several sessions to convey, and frequently may require repetition at various points in the therapy. The discussion concerning therapeutic boundaries might include some or all of the following issues: length and time of sessions, fee and payment arrangements, the use of health insurance, confidentiality and its limits, therapist availability between sessions, procedure if hospitalization is necessary, patient charts and who has access to them, the use (or nonuse) of physical contact with the therapist, involvement of the patient’s family or significant others in the treatment, discussion of the therapist’s expectations concerning management by the patient of self-destructive behavior, legal ramifications of the use of hypnosis as part of the treatment (i.e., persons who have been hypnotized may be deemed to have an entirely contaminated memory and unable to testify on their own behalf), among others. A fuller discussion of these issues can be found elsewhere (Chu, 1998; Courtois, 1999).

The subsequent sections describe specific areas related to the boundaries of treatment of the DID patient. Although some of the discussion of therapist practices may seem bizarre or absurd, experienced clinicians have found many cases where the kinds of boundary problems described in the subsequent sections have occurred. The DID patient may experience an intense pressure for certain changes in the boundaries or treatment frame, and repeatedly request them from the therapist or indirectly pressure the therapist to make these changes . Experienced clinicians often use these situations as opportunities to explore important clinical material without altering the treatment structure. These may include unconscious urges to reenact earlier boundary violations with significant others, conflicts among alternate identities wishing to “test” the therapist, and a cognitive mind set that everyone is untrustworthy about boundaries in some way, so it is best to “get it over with” quickly (i.e., the betrayal of the patient by the therapist), among others. However, clinicians new to DID treatment may find themselves changing the boundaries in a misguided attempt to repair the woes of the DID patient that seem difficult to help with more usual therapeutic approaches.

Treatment should ordinarily take place in the therapist’s office. It is not appropriate for a patient to stay in the therapist’s home or for members of the therapist’s family to have ongoing relationships with the patient. Treatment usually occurs face to face instead of on the analytic couch, though the latter is also acceptable in selected patients for therapists with psychoanalytic training. Treatment should ordinarily take place at predictable times, with a predetermined session length under most circumstances. Clinicians should generally strive to end each session at the planned time. Therapists need to follow relevant legal and ethical codes with respect to gifts exchanged between therapists and patients, dual relationships, and informed consent for treatment.Further, clinicians should rigorously follow relevant legal and ethical guidelines concerning disclosure of fees, payment arrangements, barter, and collections procedures.

A personal relationship of any kind with the DID patient some time after the conclusion of treatment is not recommended, even if this is allowed by the ethical codes of the professional organization of which the therapist is a member and not prohibited by local laws.

Crisis Management

Because many DID patients are prone to crises at certain points in treatment, patients need a clear statement about the therapists’ or other clinicians’ (such as crisis intervention workers) availability in emergencies. Generally, offering regular, unlimited telephone contact is not helpful – and may even be regressive. However, providing limited availability to the patient on a predefined basis at times may be essential. Except under unusual or emergency circumstances, calls from the therapist that are not either in response to a patient request or preplanned interventions are not recommended. The payment policy for telephone contact should be discussed with the patient in advance wherever possible. Although extra sessions are sometimes needed, when the patient frequently requests or requires the scheduling of extra sessions because of crises, the therapist needs to evaluate the structure of treatment to assess the patient’s stability and whether the patient perceives the scheduled frequency of sessions to be adequate for his/her needs. DID patients frequently have the belief that they must show the therapist in actions how distressed and overwhelmed they are, lest the therapist not believe or understand them. This can lead to a state of almost continual crisis until this issue is better clarified. At other times the patient may be unconsciously seeking to avoid taking responsibility for symptom management or life changes. In other DID patients, more classical dependent transference needs are being expressed. Repeated crises may also reflect the patient’s inability at a given time to function outside a more restrictive level of care such as an inpatient, residential or partial hospital setting. As in most predicaments in DID treatment, the therapist should discuss the issues in depth with the patient, using the framework of the patient’s alternate identity system in order to carefully assess the situation and make appropriate treatment decisions.

Some patients will paradoxically attempt to avoid treatment during crises, or avoid obviously needed emergency contact with the clinician, usually on a posttraumatic or traumatic transference basis (e.g., refusing to make an emergency call when acutely preoccupied with a sudden increase in suicidal ideation after a major loss). At these, and at other times when the patient is acutely dangerous to self or others and refusing appropriate increased levels of care, emergency interventions involving the police, the patient’s family, or others may be necessary to involuntarily hospitalize the patient, following local laws. In addition, the clinician should psychotherapeutically address the patient’s difficulties in seeking appropriate help at times of crisis and at other times.

Physical Contact with the Patient

Physical contact with a patient is generally not recommended as a treatment “technique.” Therapists generally need to explore the meanings of a patient’s requests for hugs or hand holding, for example, rather than reflexively fulfilling these requests. “Reparenting” techniques such as sustained holding, simulated breast feeding or bottle feeding, etc. are clinically inappropriate and unduly regressive behaviors that have no role in the psychotherapy of DID. Some therapists feel that limited physical contact may be appropriate when a patient is feeling highly distressed or is overwhelmed, such as when the patient is intensely re-living a very disturbing traumatic experience as part of Phase 2 therapy. If previously and specifically discussed with the patient – that is, by full exploration with the whole alternate identity system – limited physical contact, such as briefly holding the patient’s hand or resting a hand on the patient’s arm, may help the patient stay connected to present-day reality. However, other therapists feel that such contact should be avoided because patients may misinterpret its intent or meaning based on intense posttraumatic reactivity.

Some patients may seek out massage therapy or other types of “body work”; the risks and timing of such treatments should be carefully discussed with the patient and the adjunctive therapist. Some DID patients have found these interventions helpful, generally when the massage therapist is knowledgeable about trauma issues and careful about personal boundaries. Others have experienced severe intrusive PTSD symptoms, switching, and disorientation when being touched during massage or physical therapy. Because of this, before the patient undertakes massage or related therapies, full discussion of the risks and benefits should be undertaken considering the impact on the entire alternate identity system. The primary therapist may need to coordinate directly with the massage therapist to assure that the proposed treatment is appropriate and safe for the DID patient.

Sexual contact with a current patient is never appropriate or ethical. Laws and ethical standards of the various healthcare disciplines regulate such contact with a past patient. Because DID patients have a relatively high vulnerability to exploitation and because of the intensity of the therapeutic interactions in DID treatment, any sexual contact by a therapist with his or her former DID patient is exploitive and inappropriate.

C. Validity of Patients’ Memories of Child Abuse

Frequently, DID patients describe a history of abuse, often including sexual abuse, beginning in childhood. Many DID patients enter therapy having continuous memory for some abusive experiences in childhood. In addition, most also recover memories of additional previously unrecalled abusive events and/or additional details of partially recalled memories, with recovery of material occurring both inside and outside of therapy sessions. Frequently, delayed recall of trauma precedes or precipitates the patient’s entry into psychotherapy (Chu, Frey, Ganzel, & Matthews, 1999). Delayed memories can often be corroborated and are no more likely to be confabulated than memories always recalled (Dalenberg, 1996; Kluft, 1995, 1997; Lewis, Yeager, Swica, Pincus, & Lewis, 1997). Discussion of this material and its relationship to present beliefs and behaviors is a central aspect of the treatment of DID.

A number of professional societies have issued statements concerning recovered memories of abuse (American Psychiatric Association, 1993, 2000b; Australian Psychological Association, 1994; British Psychological Society, 1995). These statements all concluded that it is possible for accurate memories of abuse to have been forgotten for a long time, only to be remembered much later in life. They also indicate that it is possible that some people may construct pseudomemories of abuse and that therapists cannot know the extent to which someone’s memories are accurate in the absence of external corroboration, notwithstanding how difficult it may be to obtain any type of corroboration for a specific traumatic memory from childhood . DID patients’ recall of child abuse experiences, as well as their recall of other experiences, may at times mix recollections of actual events with fantasy, confabulated details, or condensations of several events. Comprehensive discussion about the controversy around these issues can be found elsewhere (Brown, Scheflin, & Hammond, 1998; Courtois, 1999; Dallam, 2002; Freyd, 1996; Pope, 1996).

Therapy does not benefit either from clinicians automatically telling patients that their memories must be false or that they are accurate and must be believed. The therapist is not an investigator, and should not become involved in attempting to prove or disprove the patient’s trauma history. A respectful neutral stance on the therapist’s part, combined with great care to avoid suggestive and leading interview techniques, along with ongoing discussion about the nature of memory seems to allow patients the greatest freedom to evaluate the veracity of their own memories.

Although therapists are not responsible for determining the veracity of patients’ memories, it may be therapeutic, at times, to communicate their professional opinion (Van der Hart & Nijenhuis, 1999). For example, if a patient has developed a well-considered belief that his or her memories are authentic, the therapist can support this belief if it appears credible and consistent with the patient’s history and clinical presentation. Conversely, if the therapist has developed a well-considered and strong belief that the patient’s memories are false, it may be important to voice this stance, and to provide education to the patient, e.g., concerning the vagaries of memory and recall, the presence of delusional thinking, etc. Discussion of therapists’ beliefs should take into consideration the phase of therapy and the rapport with the patient. The therapists’ beliefs should not be shared with patients in a manner or at a time that forecloses discussion, and does not respect the patient’s potentially differing belief.

In general, DID patients often are conflicted and unsure about their memories, with different alternate identities taking different points of view. Accordingly, it is most helpful for the therapist to help the alternate identities explore these conflicts and differing viewpoints rather than side with any one of them. The therapist can help educate the patient about the nature of autobiographical memory (e.g., that it is generally considered reconstructive, not photographic), and about factors that can confuse memory and how these might impact a given memory report. The therapist should foster a therapeutic atmosphere that enjoins premature closure about the memory material, assuring that it can always be reviewed again at a later time, for example, after a number of fusions have changed the patient’s level of dissociative symptoms and orientation to reality.

D. “Ritual” Abuse

There is divergence of opinion in the field concerning the origins of patients’ reports of seemingly bizarre abuse experiences such as involvement in organized occultist “ritual” abuse and covert government sponsored mind control experiments. Some clinicians believe that patients’ reports of such occurrences can be rooted in extremely sadistic events of organized abuse experienced by these patients in childhood and/or later in life. They believe that such abuse experiences may be part of a larger pattern of organized crime that sometimes includes child pornography, child and adult prostitution, and trafficking in women and drugs. These clinicians have sometimes observed that some of these patients are still enmeshed in such networks at the beginning of therapy, and the alternate identities that present for treatment may have total amnesia for the fact that the abuse is still continuing. Although these clinicians accept the possibility that these reports can be accurate, they also acknowledge that some accounts may contain inaccuracies, and that other accounts may be entirely rooted in fantasy.

Other clinicians believe that patients’ experiences of extremely sadistic events in childhood can be misremembered as “ritual” abuse and covert government sponsored mind control experiments. They believe that the actual events are distorted or amplified by the patient’s age and traumatized state at the time of the abuse, and sometimes by deliberate attempts by perpetrators of abuse to deceive, intimidate or overwhelm their victims.

Yet other clinicians believe that alternate explanations – such as contagion, unconscious defensive elaborations, false memory, delusion, or deliberate confabulation – may suffice to explain these patients’ reports. Therapists who automatically regard all such reports invariably as historically true or historically false in the therapy setting may diminish the likelihood of timely progress toward the patient’s clarification of the historical accuracy of such memories. As patients become more integrated and less dissociative, they may become more able to clarify for themselves the relative accuracy of their memories. See Fraser (1997), for a balanced series of presentations on the issue of ritual abuse.

 

VI. OTHER ISSUES

A. Publications and Interactions with the Media

The media and the public have a long fascination with DID, going back to the 19 th century. Also, when doing a story, media reporters commonly want an individual to be the focus of the “human interest” aspect of the story. Thus, clinicians working with DID may find themselves targeted by the media asking to do a story on DID, usually with the request that the clinician provide a patient to be the story’s focus.

In all interactions with the media concerning DID, the therapist’s primary responsibility remains the welfare of his/her patients. Thus, the therapist must maintain the highest ethical and legal standards of confidentiality with respect to clinical material.

Appearances by patients in public settings with or without their therapists, especially when patients are encouraged to demonstrate DID phenomena such as switching, may consciously or unconsciously exploit the patient and can interfere with ongoing therapy. Therefore, it is generally not appropriate for a therapist actively to encourage patients to “go public” with their condition or history. Patients who ignore this advice rarely have a positive experience and often wind up feeling violated and traumatized.

B. Patients’ Spiritual and Philosophical Issues

Like other victims of trauma by human agency, DID patients may struggle with questions of moral responsibility, the meaning of their pain, the duality of good and evil, the need for justice, and basic trust in the benevolence of the universe. When patients bring these issues into treatment, ethical standards for the various professional disciplines specify the need to conduct treatment without imposing one’s own values on patients, e.g., that “forgiveness” of perpetrators is mandated by God, that an appropriate treatment outcome will result in the patient believing or disbelieving in God, etc. Indeed, when carefully explored, there may be a range of spiritual and religious beliefs among DID alternate identities. Exploration of these spiritual and existential issues can be very fruitful in DID therapy and may result in a deepening of the therapeutic work. Education and coordination between therapist and clergy can be helpful in ensuring that patients’ religious and spiritual needs are addressed.

Although patients may experience certain alternate identities as demons and as not-self, DID experts regard these entities as additional alternate identities, not supernatural beings. Accordingly, therapists should approach with extreme caution the wish of the DID patients or their concerned others for an exorcism ritual. Names of alternate identities such as “Devil,” “Satan,” or “Lucifer” may likely reflect the patients’ concrete culture-bound stereotyping of their self aspects using religious terminology. The name given to an alternate identity can express many different subjective, symbolic, and/or interactive meanings and purposes, such as power and sense of personal badness. It also may reflect specific spiritual and/or religious abuse such as abuse by clergy and/or being told in the course of abuse that the patient “is filled with the devil,” etc. The name given to an alternate identity should not be taken as prima facie evidence that there is a demonic presence in the person.

Indeed, exorcism rituals have not been shown to be an effective treatment for DID, have not been shown to be effective for “removing” alternate identities, and have been found to have deleterious effects in two samples of DID patients that experienced exorcisms outside of psychotherapy. Some Guidelines Task Force members have noted that, in rare cases , exorcism rituals may provide a way for some patients to rearrange images of their identity systems in a culturally syntonic manner (Bowman, 1993; Fraser, 1993; Rosik, 2004). Other Task Force members do not believe that exorcism is ever an appropriate intervention for DID patients.

C. DID Patients as Parents

DID patients have been shown to have a wide range of competence as parents – from exemplary to abusive (Kluft, 1987b). However, because many DID patients may have difficulty in parenting and a minority admit to being abusive toward their children, and also because DID may involve a heritable biological predisposition to dissociate, some experts have recommended that the children of all DID patients be assessed by a therapist familiar with dissociative disorders and indicators of child abuse. Other family interventions, such as couple’s therapy and family therapy sessions including the patient’s children may be indicated. However, caution should be exercised in what information is shared with minor children concerning the patient’s DID diagnosis, depending on the age of the children, and their cognitive and emotional development.

Clinicians should have an index of suspicion that the DID parent may be abusive and that this may occur in dissociative states. However, when a DID patient is dysfunctional in parenting, the dysfunction is often not abuse, but the result of the symptoms of DID (e.g., amnesia) and the life problems associated with this disorder (e.g., depression, fear of being assertive). This dysfunction can include neglect of the children, allowing the children to be exposed to reportedly abusive members of the DID patient’s family of origin, exposure to the abusive significant others of the patient, witnessing the patient being subjected to domestic violence, allowing the children to witness the patient switching among alternate identities, committing acts of self-harm in front of the children, etc.

The therapist should actively assess these issues and assist the DID patient with appropriate parenting behavior. The patient may need extensive education and assistance in learning how to behave as an appropriate parent. Work on safety of the patient’s children should be an absolute priority in the adult patient’s treatment. This may include specific work with alternate identities who deny that they are the parent of the patient’s children and/or refuse to acknowledge the needs of the children in a variety of ways. In addition, patients should be strongly enjoined to behave as an adult with their children, to not switch openly in front of children, and to not regress into child identity states with the children in the belief that this is a better way to behave with children. DID patients may have particular difficulties with specific developmental phases in their children or with particular child temperaments. This may relate to specific traumatic events or specific developmental disturbances experienced by the DID parent. Due to the many life difficulties in which the DID patient’s children may be enmeshed, referral to and formal treatment of the children by a specialist in child psychiatry and/or child psychotherapy may be indicated no matter what diagnoses the children receive.

CONCLUSIONS

These Guidelines present current accepted principles that reflect current scientific knowledge and the clinical experience of the past 25 years related to the diagnosis and treatment of Dissociative Identity Disorder. However, the Guidelines are not intended as the final word, as the field of dissociation is still in development . The field is in need of additional systematic research – including treatment outcomes research – in addition to the collection of more case material. Given that ongoing research on the diagnosis and treatment of dissociative disorders, and other related conditions such as Posttraumatic Stress Disorder (PTSD), will undoubtedly lead to further developments in the field, clinicians are advised to consult the published literature to keep up with important new information.

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