Holistic Therapy for People with Dissociative Identity Disorder

Patricia Frankish, Valerie Sinason, Patricia Frankish, Valerie Sinason

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429914553
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book puts forward a model of therapy and support for people with DID that provides individual therapy, staff support, and a safe place to live. It relies upon the ideas of Bowlby by providing a secure base and this recognises the attachment needs. It also includes staff who are trained to provide a therapeutic environment and also receive support to do their work. The fourth element after the base, the staff, and the training, is the individual therapy. Together it has been possible to adopt a holistic approach which leads to a significant improvement in quality of life for individuals with DID, and confidence for commissioners and teams in the approach. By including the perspective of all the players and presenting a practical model for successful working, the book will be invaluable to anyone looking to commission or provide services for this client group.

Chapter One
Starting out

We need your help, we need your aid
Because we are so much afraid
The bad ones talk and hurt us so
We have no safe place to be and go
We’re wanted dead we’re wanted gone
The road is wearisome and long
We need to find a strengthened place
An open and a friendly space.

We need you to hear what we say
And help us find a better way
The dark ones always in a crowd
Follow us and they are proud
To hurt and maim and poison too
Like we’re the dog dirt off their shoe
They never care about us so
Do you know somewhere safe to go?

The information in this chapter is relevant to a number of people with DID and will be presented in such a composite way as to enable the maintenance of confidentiality for the individuals concerned. Safety is always an issue for people with DID, who have survived abuse and trauma, often in a family context, and usually with some continued threat. The stories and the information informing the plans are those found most often with the client group.

The assessments by tertiary centres specialising in DID are usually the starting point for planning a support package. They highlight the level of trauma and complexity of the client and there is an immediate realisation of how carefully a plan would have to be made if it were to be effective. The level of self-harm and “calling out” to attend rituals for some people is a significant concern such that only a twenty-four-hour package of support has any chance of success. The attachment to dangerous groups can lead to people being called out to attend ritualistic events of an abusive kind. Hospital stays, although twenty-four hours, have often not proved to be useful or helpful. Supervision and support in hospital is not twenty-four hours and people can still be taken to rituals. There is also an impersonality in hospital that can fail to meet any attachment needs. Trust is difficult and can be absent.

Consequently, the basic requirements are just not there. Many people have tried, over many years, to diagnose and provide a suitable treatment but none has been fully successful. The people who have benefitted most from interventions are those who have had access to individual intensive psychotherapy and are living in a relatively safe environment.

An example of a plan follows (see Chapter Six for more details). Initially, Carly (an amalgam name to protect confidentiality) was seen for outpatient therapy in a local health centre. These were two-hour sessions once a week. After a period of time in hospital and respite care, it was decided that she could have a care worker at home all the time. This helped but it was difficult to maintain workers who were aware of the difficulties and able to provide the right level of support. They needed to be the same workers and this proved too hard. They also needed to be trusted and this proved too much for Carly and her other parts. Eventually the CEO of the Trust that was supporting her agreed to a specialist provision that would meet all her needs. This was a 24/7 supported living package with therapy twice a week. This was innovative and very brave of the CEO, who was known for her ability to think creatively to solve a difficulty and to make it person-centred.

Supported living packages are more usual with the learning disability population than they are for people in the mental health services, so it was helpful to reframe DID as a potentially chronic disability. Carly also has a physical disability, which helped in the establishment and recognition of her needs. Big questions were about the level of support needed and who could provide it, along with suitable therapy, psychiatric support, GP support, and care management.

It is important to recognise the difference between supported living and a residential placement. Although the plan is for twenty-four-hour support, it does not have the restrictions and shared space elements of residential care. It also allows the individual to keep their benefits and pay their own bills, hence keeping a level of responsibility and a sense of an ordinary life. The authorities then only pay for the staff support element and the therapy. Everything else is covered by rent allowance, disability benefits, and income support. The legal regulations are different too, as well as staffing levels. In residential care there are requirements that can be restrictive. Staff support is often at the level of two staff to a room of twenty people. This can’t provide the consistent message that is required for the treatment of someone with DID.

Once it was decided that the best option for Carly was to provide a supported living environment that kept her safe, the plans could be put into operation. There are four elements to the trauma-informed care (TIC) model and all needed equal attention if the plan was to have a chance of succeeding.

Trauma-informed care

The first element is a safe place to live. We decided in our “amalgam” to provide an example of someone with a physical disability to do justice to the environmental adjustments needed, and, of course, many people with intellectual disabilities also have extra physical needs. Carly is a wheelchair user so suitable housing was needed, in the right place, with the right space, and where it was possible to recruit enough staff. A bungalow was identified that looked appropriate. It belonged to the family of an elderly person who had passed away and was available for a long-term tenancy. The bungalow has since changed ownership but the tenancy has continued and is safe for as long as it is needed. Whatever the disability or needs, it is important that suitable property is found, in a safe place, and feeling right for the person involved. There will always be traumatic triggers to be considered, even to things like gardens and trees, so these must be taken into account. There needs to be a short-term tenancy at first, to ensure that the place will feel right, but with the option for it to be long term when the individual is settled. If it doesn’t feel right it won’t fulfil the need to be a secure base (Bowlby, 1979). You can see that it is very different from the usual housing provision.

Moving day for Carly was hard work and helped by everyone working together to achieve the goal. It was possible to arrange for one of the new support workers to be there to help pack and to travel with Carly to the new home, then to help unpack and settle in. The chaotic lifestyle that Carly was used to meant that there were lots of things that were in varying states of mix-up so it took a little while to achieve some order. The previous owner of the new house had left some pieces of furniture which were good quality and useful, so they were brought into use and helped with storage space for books and suchlike. The house was fully carpeted and curtained so that was not a problem. It had a conservatory that was quickly brought into use as a safe place for the younger alters and this was fitted out with toys, craft materials, and drawers for each alter’s belongings. The availability of space for the young alters to be in and feel seen and valued is an essential part for many people with DID. Some do not have child alters, or can’t access them, but most have, and, as they are the ones who were traumatised initially, it is necessary for them to have space within which to process that trauma. It has been my experience that this space is used well, when it is needed, and generally looked after by the adult alters, as they respect what their young alters need.

The second component of a therapeutic package is enough staff to establish a safe team. It was important for Carly and others that these were people who were already employed by the support provider, so as to ensure that no potential abusers applied for the jobs. Individuals were identified from the existing workforces and transferred to work in this specific service. They need to be selected for their ability to be calm and accepting, not domineering but able to make decisions and be reassuring that they are competent to keep everyone safe. The shift pattern was afternoon, sleepover, and morning shift for most of the time. Sometimes there would be a change in the morning or a new person would come for the sleepover and morning. It was arranged to allow for the maximum involvement with the community, allowing time to use public transport for shopping trips and other outings. There were considerations about transport generally as public transport was not ideal, so some staff needed to be drivers and able to put the wheelchair, where relevant, in and out of the car. It has been found helpful to use a conflict management scale at interview in order to identify staff who are neither too timid, nor too authoritarian. If they are too timid they will potentially be bullied by hostile alters who may identify with the perpetrators; and, if too dominant, they may activate memories of abuse and past trauma.

The third component is staff training and support. All staff are provided with an opportunity to attend a support group on a weekly basis. They need to be able to do this in work time or be paid if they come in on non-work days. In addition they need access to the level two training in trauma-informed care (www.frankishtraining.co.uk) and are encouraged to complete this. This course helps them to understand the processes involved in the development of a sense of self, enabling them to explore the issues of multiple selves. Later on there can be some specific training sessions around the specific needs of the individual. For this later training it is very helpful if the client themself can contribute as this brings the issues alive for the staff, enabling them to reach a deeper understanding. There will always be the potential for some tension but, if the staff are recruited for their suitability, trained, and supported, the potential for a successful living plan and treatment is there. Over time it may be possible to reduce the staffing component and this can be an aim. If it isn’t possible, it is still better to have a settled life with staff support, than a chaotic and dangerous life, maybe short, without adequate support.

The fourth, and final, piece of the puzzle is individual therapy. This is usually provided twice a week for a long time (years). During the sessions it is possible for all of the alters to have an opportunity to speak and be listened to. Over the years in excess of thirty alters can make themselves known, and some stay as host for weeks or months or years. In addition to the face-to-face contact there can be text and email contact. These afford another channel for use between sessions. Of special importance can be a goodnight text from the therapist to a younger alter, which is reassuring and confirming. The therapy aim is to help the person with DID to become able to live comfortably with who they are. There may be a wish to integrate, there may not. Facing the traumatic memories and living with them is a primary aim. Valuing all the selves is another, with acceptance of the need to have them there to fulfil their function in the maintenance of the whole. This happens in the context of a safe attachment figure in the therapist.

The TIC model is based on an acceptance that trauma experienced early in life, and compounded later in life, interferes with the development of a stable sense of self. At its most extreme the personality development splinters into many selves and DID is the result. The presentation varies according to the earliest trauma, with those traumatised before the age of three or four being the most distressed and disturbed.

Early emotional development

The model used is based on the work of Margaret Mahler and her book, with colleagues, The Psychological Birth of the Human Infant (2000). This work has been extended by Frankish (2013) to arrive at a model for understanding, and measuring, delayed or arrested emotional development in adults. Most of this work has been with people with learning disabilities, but it has relevance for anyone suffering trauma in the early stages of life, between biological birth and psychological birth. Frankish has developed a tool for measuring the stage of emotional development. In individuals with DID, there will be some alters who have reached a higher level of development than others, but the condition itself, of multiple selves, indicates a failure of the individuation process, so it is a useful theory to consider.

The first stage to look at is called symbiosis and indicates a very close relationship between the parent and child. This is the first building block and my experience of people with DID would suggest that this one is probably traversed adequately. People who don’t even have this would potentially be seriously sociopathic which we don’t see in DID. If they didn’t care they wouldn’t hurt.

The second stage is called differentiation and relates to the age from a few weeks to about ten months in traditional development. It is characterised by self-referenced behaviours, lack of seeking interaction with others, but responsive to contact from others. We all have some differentiation behaviours like hair twiddling, nail biting, and suchlike. People with DID will potentially have some alters at this stage, who have been traumatised in the first year of life, either by neglect or fear.

The third stage is practising and relates to the age range of approximately ten months to fifteen months. The relevant behaviours are repetitive and can look obsessional. They are based on competence. The person does what they know they can do and repeats this behaviour until another behaviour is learned or becomes available. There are lots of repetitive behaviours seen carried out by different alters. It is clear that some alters can do some things and other alters can’t do them, but can do other things. One alter may be an obsessional cleaner, another may be a repeat self-harmer and so on. People traumatised at this age will have alters who are associated with the skills that were available to them at that time, and the behaviour of each alter will be stuck with the patterns that felt safe, or was a response to feeling unsafe. This stage is still relatively self-referenced and not very interactive, so the individual alters who are at the practising stage will not have skills to negotiate or choose, but will be stuck in patterns that are an end in themselves.

The fourth stage is early rapprochement and marks the beginning of an interactive style. Another person is needed for the give and take behaviours that are prominent at this stage, which is mostly pleasant and fun. The alters from this stage will be happy to play games, do things together, be guided in activities, and express their own wishes. They are also likely to react badly to being left, as they have just begun to value the presence of another. People who have been abandoned, neglected, or tortured at this chronological age will be very traumatised and this will show in alters who need to always know who is looking after them, whether they can be trusted not to abandon them, and won’t hurt them or pass them on to abusers.

The late rapprochement stage follows and is a continuation of the move to independence. There is an increase in decision making with the necessary reasoning and weighing up of alternatives. There is development of the ability to think about consequences and the “if-then” phenomenon. At this stage individual alters may be happy to be, and enjoy being, alone for periods of time, able to hold on to feeling safe for progressively longer periods. Support staff may find themselves rejected and will need to learn to accommodate the changing demands, not expecting too much, but not being overprotective. If an alter at this stage is threatened in some way, or begins to feel insecure, they are likely to switch to a younger alter who will feel able to ask for help or support. It becomes an adaptive way of functioning, even though there is not total integration. Between them the alters manage to have their needs met so long as support staff recognise them. The problems come if the person with DID is apparently coping, then switches, and the other people around don’t recognise it for what it is. This can lead to a major breakdown of trust and is probably the most common situation around admissions to hospital as the presentation will be of someone becoming irrational, whereas what has really happened, is that they have used the dissociative defence that they learned to use as a small child in order to survive.

The final stage, individuation, is only possible if the person with DID reaches a state of integration. This can happen and be held for periods of time, but may be lost at times of increased stress. It requires the ability to trust the self to be competent and able to trust, so a big ask for someone who has experienced serious traumatic abuse in early childhood. Many people without DID may struggle to stay fully adult all the time, secure in their identity and place in the world. Someone with many alters will have even more difficulty, but can reach an understanding of when they are able to do it, and what the triggers will be that challenge the more mature state. They can then use their cognitive ability to make plans and ensure that they stay within their comfort zone.

Summary and implications

So, to summarise, someone with many alters will have some alters at all of these developmental stages. These will relate to the trauma they experienced at the relevant chronological age of the developmental stage, bearing in mind that the earlier the trauma, the more interference there will be with the overall process, so there could be an overall delay in development. Support staff and therapists will need to learn which alters are at which stage and respond appropriately to that person, as well as help them to work out what it was in the environment that activated that alter. For example, a more adult alter may suddenly feel that no one is there and switch to a young alter who can more easily ask for help. Alert staff will recognise what caused that to happen, and while welcoming the child alter, will gradually help the building up of a picture that is comprehensive and has the opportunity to lead to integration. Some will be afraid that the younger ones are killed off in some way, so gentle support to recognise that we all have integrated child selves that we need to look after, and have the ability to warn us of danger, so they are not lost.

The implications for support staff of the emotional developmental model of understanding are significant. The recognition of the emotional needs of the alters helps with day-to-day behaviour and support, as well as enabling the integration process. As each frightened part is enabled to live in the world and experience positive support and no punishment, there is potential for them to grow individually through the stages, although some will stay stuck, carrying the trauma that they carry, which is too much for others to even look at.

It is clear that the process is very complex and there will be lots of false starts, times when it looks like progress is being made, for it all to come crashing down with a very young or withdrawn alter taking over as host for quite long periods. This can be very hard for support staff and others to work with but, if it can be understood as a reaction to a triggering event, it can be faced up to and the pain shared, which...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• ABOUT THE EDITORS
• INTRODUCTION
• CHAPTER ONE Starting out
• CHAPTER TWO A usual bumpy road to treatment
• CHAPTER THREE Life—what's that?
• CHAPTER FOUR Setting up a service
• CHAPTER FIVE Making progress
• CHAPTER SIX Being support staff
• CHAPTER SEVEN A client's voice
• CHAPTER EIGHT A new therapist
• CHAPTER NINE Conclusion
• REFERENCES
• FURTHER READING
• INDEX