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... completely cured, and he / she will be able to lead healthy and normal life. There are four goals of therapy which interweave with each other. They are to stabilize symptoms of DID, to control dysfunctional behavior, to restore normal, everyday functioning, and to improve relationships.
Proper conduct of a therapist for a DID patient is especially crucial, because DID patients are extremely vulnerable. Physical contact between the therapist and the patient is not recommended because it can be misinterpreted. However, holding a patients hand during an abreaction may help ease the pain. The therapist must discuss with the patient if he / she wishes to seek out massage / bodily therapy. Sexual contact between a therapist and a patient is never appropriate. The frequency of therapy sessions depends on the particular therapist and the particular patient.
The number of sessions per week should reflect how stable the patient is and how well he / she is able to function on his / her own. However, for an average therapist who is treating the average DID patient, two sessions of therapy per week is recommended. The therapist may consider it necessary to hold marathon sessions, and in this case they should be pre-scheduled as such and should have a pre-determined structure and schedule. Although extra sessions are sometimes needed, if a patient schedules a particularly large number, the therapist needs to reexamine the regularly scheduled amount of sessions and verify that that number is sufficient for the particular patient.
The therapist should also ensure that the increased amount of sessions is not detracting from the patients ability to return to normal functioning and living. Three to five years is accepted as the minimum length of treatment for a DID patient, although more complex cases may sometimes take six years. There are four phases of therapy. The initial phase of therapy is the assessment and planning phase. This phase involves contacting the alter personalities and developing a plan of treatment.
The middle phase is the working phase. It involves establishing communication between the alters, breaking down amnesic barriers, sharing memories, and abreaction. The late phase involves the evaluation of progress made in the middle phase of therapy. There is also a further reworking of memories and preparation for and integration of alter personalities. The post integration phase involves resolution of major abuse issues and memories. The patient must learn to develop and apply new coping skills and adjust to new feelings and memories (from the alter personalities).
This phase also involves grieving the loss of the alter personalities. In the initial phase of therapy, the therapist must help the patient to contact the alter personalities and develop a plan of treatment. To do so, the therapist must establish safety and trust with the patient. The therapist must develop a treatment alliance, and ensure that the patient agrees on the goals and will make a commitment to the treatment. The therapist must discuss the diagnosis with the patient, explaining his / her dissociative process.
He / she must also explain all dissociative disorders to the patient and provide reading materials or resources. He / she must map the patients personality system, and ensure that the patient understands that the goal of the treatment is direct contact with and integration of the alters. The last part of this stage is to develop an agreement between the therapist and patient regarding the length of treatment, consequences of self-destructive or violent behavior, and any other treatment expectations. The middle phase of therapy is the working phase. The patient must establish communication between the alter personalities break down amnesic barriers (allowing the host personality to remember when other alters in control). He / she must reveal abuse and traumatic memories that were dissociated with alter personalities.
This results in arresting the abuse memories, a physical and emotional re-experiencing of the abusive events. The patient must also explore and cope with thoughts, memories, and feelings regarding the abuse. The therapist must ensure that he / she adjusts the treatment approaches when working with a younger alter personality or when working with particularly aggressive alters. To aid in this particularly difficult middle phase, therapist may choose to use a number of techniques with the patient to aid in therapy. For example, to encourage integration among the alters, he / she may choose take a vote among all the alters regarding some aspect of the hosts life. He / she may choose to use creative elements (metaphors, rituals, imagery, dreams) to recover memories in a safer way.
Hypnosis can also be used to contact alters, integrate personalities, recover memories, or reduce symptoms. Age progression or regression can be used to increase or decrease the age of an alter personality. Writing exercises can be used to encourage communication between alters, audiovisual recordings of sessions can be used to convince a patient of the existence of other alters. It can also serve to allow alters to become better acquainted. Expressive arts (music, drawing, movement) and medications can be used to relieve depression or anxiety. If therapy is not progressing well, the therapist may choose to use physical restraint against the patient in order to avoid injury to him / herself or anyone else.
The therapist may also choose to hospitalize the patient to allow him / her to safely work through a crisis. Group therapy, social services, AA groups, vocational counselors, and social support groups may also be called in. Sometimes spouses, friends, and relatives of the patient are asked to become involved in the patients life and treatment. The late phase of treatment involves evaluating the progress made in the middle phase of therapy and final integration of the alters. The therapist must set limits on the pace of therapy, the behavior of the patient, and the rate at which painful memories are uncovered. Finally, the alters must be joined into a single personality.
This is usually done by hypnosis. The post integration phase involves coping with major abuse memories, new feelings and memories, and grieving the loss of alter personalities. The patient must learn to deal with conflict without dissociating. He / she must increase his / her confidence and self esteem and explore his / her future plans for life.
Although there are alternative treatments for DID, they generally have not proved successful when used alone. Some of these treatments have proved detrimental even when used in conjunction with outpatient therapy sessions. These treatments include inpatient treatment, group therapy, therapist telephone availability, physical restraint, and hypnotherapy. Inpatient therapy should be used only when the specific goal is returning the patient to a functional state. The therapist must be able to determine which factors have destabilized or threaten to destabilize the patient, what must be done to alleviate these factors, and should help the patient attempt to acquire skills to cope with destabilizing factors.
Inpatient therapy should not be used in place of outpatient therapy sessions. Group therapy is generally not advised as a treatment for DID, even in conjunction with outpatient therapy sessions. However, the patient may need to be assured that he / she is not coping with the disorder alone. The patient may feel positive results when the leader sets clear expectations within the group. However, patients usually tend to act out during these sessions, and there are not enough therapists to help each patient cope with his / her abreaction. This usually has a negative impact on the rest of the group.
Although limited telephone availability access from the patient to the therapist is advisable for emergencies, providing unlimited telephone access has not proved beneficial. Regular calls by the therapist to check up on the patient are not advised either. Some therapists may feel that physical restraint is necessary when violent alter personalities become physically aggressive or self-destructive and it becomes impossible for the therapist to work with all the personalities in therapy. However, other therapists feel that resolving issues verbally with the alter is more beneficial, and allows all the alters to be contacted during therapy. The amount of physical restraint used hinges on the discretion of each particular therapist.
Hypnotherapy is generally a positive tool. It helps patients manage crisis by overcoming sudden flashbacks and reorienting themselves to actual reality. It helps to strengthen the ego, helps patients remain stable between sessions, serves as a safe outlet for expressing feelings, and aids in skill building. It also relieves traumatic memories, helps to increase communication between alters and between alters and the therapist, and aids in memory retrieval. However, hypnotherapy should be used in conjunction with other approaches in treating DID.
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