Understanding and Treating Dissociative Identity Disorder (or Multiple Personality Disorder)

Jo L. Ringrose

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367101008
• eBook ISBN:
  9780429923487
• Topic: Psychologie
• Subtopic: Psychische Gesundheit in der Psychologie

This book provides all of the information a practitioner needs in order to begin work with clients with Dissociative Identity Disorder (DID). Drawing on experiences from her own practice and extensive research conducted with the help of internationally acclaimed experts in the field, the author describes the development of DID and the structure of the personality of these clients. The reader is guided through the assessment process, the main phases and components of treatment, and the issues and contentions that may arise in this work. Throughout the text there are case examples, practical exercises, techniques, and strategies that can be used in therapy sessions. The resources section includes screening and assessment instruments, as well as information on techniques for managing anxiety and self harm, both of which can be major problems when working with clients with DID.

CHAPTER ONE

The dissociative disorders and the presentation of Dissociative Identity Disorder (DID), or Multiple Personality Disorder (MPD)

The background of clients with Dissociative Identity Disorder

The vignettes I outline in this book have been based on an amalgamation of several clients’ experiences. They aim to depict the two main underlying issues, that of attachment problems and repeated trauma, which clients with DID have experienced. Any likeness to someone’s true life story is purely coincidental.

Vignette

Kerry is twenty-eight years old and currently lives alone. She lived with her mother and stepfather until she was fourteen when she ran away from home to escape sexual abuse by her stepfather and her uncle. In addition, her mother is an alcoholic and often got angry and violent with Kerry when drunk. The sexual abuse and violence had gone on for as long as Kerry can remember. Her biological father left the marital home when Kerry was two and had been out of contact since. Kerry had never got on well with her mother but the relationship broke down completely after she had told her about her stepfather’s abuse and her mum had not believed her.

At school, teachers reported that Kerry seemed a very bright and able pupil who had achieved some high grades on occasion but lacked concentration and consistently good results. She was also branded a troublemaker after apparently being the ringleader in a binge-drinking episode in the school. At twelve, she was found passed out in the school toilets, after she had cut both wrists having been raped by her stepfather the previous day. She was seen by a psychiatrist who asked about her family but she felt unable to tell anyone. She returned home after treatment having nowhere else to go and went back to school but from the age of thirteen missed more days than she attended.

Kerry left home at fourteen, slept rough, and prostituted herself in order to buy alcohol and food. She was picked up by social services who found her a place of safety with foster parents but unfortunately the foster father became ill and she had to be moved to a further home six months later. The relationship she had with the second foster parents had a bad start with Kerry’s drinking increasing at this time. After several months, they said they could not cope with her. At this point she was fifteen and decided she wanted to live alone. She was moved to temporary sheltered housing until she was considered able to live independently.

Currently Kerry is not working. She would like to go to college but states that there is too much getting in the way. She reports losing time and having no memory of what has gone on during these blank spells. She says she finds herself coming-to in strange places, not knowing how she got there, or why she is there. This frightens her because she was found wandering the streets in her nightdress one night at three in the morning and had to be taken home by the police. Her arms are filled with scars from cutting but she says that she does not cut herself. She states that she comes-to afterwards and it is like someone else has done it. When I ask if she has ever found anything that she does not recognise in her belongings she pulls out a small book with handwriting and pictures. She says that she does not know the artist or the one with the frilly handwriting. Neither, she says, are hers.

This is the typical background of someone with DID. These clients tend to have both attachment issues and repeated trauma, which is almost without exception sexual abuse; many are neglected in addition. The necessity of a good therapy relationship is paramount in all therapy work. However, with this client group, this point cannot be over emphasised. It is from this therapy relationship and the development of a safe base that the client learns she is valuable, worthy of love and care, and that relationships can be supportive. A strong therapy relationship challenges the client’s belief system that she is in some way deficient or not worthy of love, and this new knowledge and experience can be carried into further relationships outside of therapy. In addition, it is from this secure safe base that therapy can begin the process of fostering communication, collaboration, and co-operation between the identities and, where necessary, the trauma incidents can be worked through.

Definition of dissociation and the dissociative disorders

“The essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity and perception” (American Psychiatric Association, 2000, p. 519).

The five dissociative disorders, as outlined by the American Psychiatric Association (2000) are Dissociative Amnesia (DA), Dissociative Fugue (DF), Depersonalization Disorder (DP), Dissociative Disorder Not Otherwise Specified (DDNOS), and Dissociative Identity Disorder (DID) American Psychiatric Association, 2000; listed as “Multiple Personality Disorder” in the International Statistical Classification of Diseases and Related Problems, World Health Organization, 2007). This book contains information on working with DID and DDNOS—although, to avoid repetition, I have not written “and DDNOS” throughout the book. If you are a clinician working with a client with DDNOS the therapy that is advocated is sufficiently similar for it to apply.

Definition of Dissociative Identity Disorder

“Dissociative Identity Disorder (or Multiple Personality Disorder) is characterized by the presence of two or more distinct identities or personality states that recurrently take control of the individual’s behaviour, accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. It is a disorder characterized by identity fragmentation, rather than proliferation of separate personalities” (American Psychiatric Association, 2000, p. 519).

Practitioners sometimes refer to clients with DID as having one or more host identities, one of whom tends to be the part who presented to therapy initially and one or more alter identities (see below). At present, treatment focuses on fostering communication and cooperation amongst the host(s) and alter(s), understanding and processing the trauma each identity has carried and sometimes, towards the end of therapy, there may be integration of the different identities.

Demographics of Dissociative Identity Disorder

Dissociative identity disorder has for many years been seen as a rare disorder and in ICD-10 is still classified as such. However, as awareness of the disorder and diagnostic instruments have improved, newer versions of DSM-IV have dropped the term rare in its descriptions. Steinberg (1994) wrote “in the past ten years studies have estimated the prevalence of DID to range from 1% and 10% in the psychiatric community”.

Rifkin et al. (1998) found that one per cent of randomly selected women aged between 16 and 50 years old, who had recently been admitted to an acute psychiatric hospital, were found to have DID using the Structured Clinical Interview for DSM-IV Dissociative Disorders.

The vast majority of these are female. For example, a study of 50 consecutive patients with Dissociative Identity Disorder found that 88 per cent were female (Coon et al., 1988). The average age at diagnosis is between twenty-nine and thirty-five years (Allison, 1978 cited in Putnam, 1989; Coons et al., 1988).

The development of Dissociative Identity Disorder

A vignette

At five years old Kerry was molested by her stepfather. During the molestation she got through it by imagining it was happening to someone else. Kerry imagined this sufficiently strongly for her to separate herself from the part of her that was abused, creating an alter personality—“someone else”. The next time Kerry was abused by her stepfather “someone else” just came and took the abuse which meant that Kerry could get on with her life. After a while Kerry forgot about “someone else” but when Kerry was alone with her stepfather she would become scared but did not know why, although “someone else” knew.

When Kerry was eleven, her uncle raped her. Kerry pretended it was happening to “anyone but her”. Kerry saw “anyone but her” from the ceiling of her bedroom. Kerry believed “anyone but her” looked nothing like herself. Kerry left for a while and “anyone but her” took her place.

“Anyone but her” began drinking and smoking cannabis. “Anyone but her” was not like Kerry: Kerry let her curly hair run loose and liked pretty dresses; “anyone but her” wore her hair tied back, always wore jeans, and let no-one come close. Other people viewed “anyone but her” as a bully. “Anyone but her” knew about “someone else” and berated her for whingeing and getting upset. “Anyone but her” called “someone else” a baby and told her to shut up whenever “someone else” spoke.

At thirteen Kerry returned, causing “anyone but her” to retreat into the background for a while. Kerry was invited to a friend’s party. She had to buy a dress, since all she could find in the wardrobe were jeans and T-shirts. Unbeknown to Kerry these had been chosen and worn by “anyone but her”. Kerry put on her new dress, wore her hair loose, and said goodbye to her mother. Her mother said she had the old Kerry back. Kerry did not know what she meant. At the party, one minute Kerry was talking with friends; the next thing she remembered she was coming-to, slumped in her friend’s hall with her friend’s parents shouting at her. She could not understand it. She never got drunk. She did not even like drink. She said her drink must have been spiked, but her friend said she had left soon after arriving and returned with a bottle of vodka. Unbeknown to Kerry “anyone but her” had returned part way through the party, bought the drink, got drunk, and had now left, leaving Kerry to pick up the pieces.

On the way home, when Kerry was trying to explain things to her mother, “anyone but her” told Kerry to shut up, called her “a useless bag of shit”, and told her that she would shut her up if she did not shut up of her own accord. Kerry went quiet.

Kerry began to lose time, with no memory of what happened for long spells during the day. On one occasion, Kerry found herself coming-to following an overdose of sleeping pills. Kerry had no memory at all of taking the pills. When Kerry’s stepfather picked her up from the hospital he told her that she was a liar and of course she must know what had happened. Being called a liar and making excuses for behaviour she had no recollection of performing were becoming commonplace. Other strange things happened too. She had kept a diary for years and one day when she went to write in it, she found that it was full of a child’s handwriting. Kerry did not know it but the handwriting belonged to “someone else”.

The structure of the personality

The host

Frequently, initial contact in therapy is made by a host (sometimes referred to as the “Apparently Normal Personality” (ANP)) (Van der Hart et al., 2006: 5) as opposed to an alter identity. In the vignette, for simplicity’s sake, the client had one host, Kerry. Where there is only one host, it is she who clients typically identify with as being “me”. The host tends to be the part who has executive control of the body most of the time. However, often there are two or even several hosts (Van der Hart et al., 2006). As a general rule, the more identities there are, the longer that therapy will take, particularly if there are multiple hosts. Also, occasionally, the host may not be a single personality. Putnam (1989, p. 107) writes: “In some cases, the host is a social façade created by a more or less cooperative effort of several alters agreeing to pass as one.” These alters may share the outside role and have similar but slightly different names.

The alter personalities

Kluft (1984) defines an alter personality (sometimes referred to as an Emotional Part (EP) (Van der Hart et al., 2006)) as:

An entity with a firm, persistent and well-founded sense of self and a characteristic and consistent pattern of behaviour and feelings in response to given stimuli. It must have a range of functions, a range of emotional responses and a significant life history (of its own existence).

(Kluft, 1984, p. 23)

The alters view themselves as separate people and do not understand that they share the same body and that all of them together constitute a whole person. It is important that therapists do not go along with this belief and that they inform all identities that there is only one body and that harm by one identity harms all of the other identities, although as a therapist you can empathize with each identity’s desire for separateness.

Child alters

In the vignette of Kerry above, “someone else” is one of Kerry’s child alters. Child and infant alters are very common and are locked in the timeframe within which they were created. They often present as small, fragile-looking souls, frequently frightened, and need to be addressed in a manner appropriate to their age. These child alters are often crying out for attachment and pull on the heart strings of therapists, making it difficult for therapists to keep strict boundaries. Therapists can become drawn into mothering scared, sad, and lonely alters because they find it difficult to ignore their pleas. However, the host(s) and where appropriate, older alters, need to be encouraged to parent the child alters as much as possible, as it is this that will help them to grow up.

Persecutor and violent alters

As is often the case, Kerry also has an alter who persecutes the other identities: “anyone but her”. In this instance, she wants to silence Kerry when she, or one of the other alters, tries to speak in therapy, or at other times. It is important for therapists to explain to all of the identities any consequences there may be if someone talks about their life story, particularly abuse or torture incidents, in therapy. Persecutor alters often function to silence the other identities because they fear bad consequences if a part talks about the perpetrators of trauma. Hence, they often want to kill off the host or another alter in order to silence them, but do not understand that this means that they will die too. Talking indirectly through the host, or where necessary, directly to the persecutory alter(s) early on in the process of meeting the alters, is vital. It can prevent suicide attempts and self-mutilation as these are less likely to occur once you have persecutory alters on board. Even if I do not know whether there is a persecutory alter or not, I will ask if anyone has any objections to anybody talking in therapy. If there are concerns, I will explore these and answer them as far as I can. This can also bring a sense of relief for therapist, host(s), and alter(s) alike. Occasionally it may be necessary to put a ban on talking about a particular event until all are satisfied with disclosure. In addition, it is important to find out from angry, aggressive, or persecutory alters what their rules are and to respect the boundaries of these alters. I explain that I do not wish to remove their authority but that I want to try to help them work through their problems (Ringrose, 2010).

Whilst I have never been confronted with a violent alter in private practice, bear in mind that they exist. I would advocate you take steps to manage the risks that these clients can pose. I choose not to work with clients from my own home, do not have my home telephone number listed in the telephone directory, and do not give details of my home address and home number to clients. One of my clients came to me after her previous therapist said she could no longer work with her. This was because the client would stand for hours outside her house. Also, some child alters are prone to texting and telephoning when they feel scared and if this were on your home telephone it could become a nuisance. More seriously, violent alters are capable of killing and may do so in response to child alters feeling vulnerable (Ringrose, 2010). Whilst working in forensic services, I worked with a woman who was incarcerated because of the actions of her scared persecutory alter. Also bear in mind, even if these alters are not physically hurting the host or other alters, they may control and persecute them, often leaving them frightened. Respect violent or persecutory alters and negotiate with them as much as possible. Find out what function they perform and why they were created. This is usually to protect the host. A goal for therapy is for all the identities to eventually get along; for example, explaining that the persecutory or violent alter(s) arose as a means of protecting them all, can help with this. Do all that you can to promote an ethos of pulling together in the fight against the aftermath of trauma and encourage all identities to be on the same side in this respect. Typically the host(s) or outside alter(s) just wish that the other identities would go away. This is even stronger where there are persecutory or violent alter(s). One of the most important tasks of the therapist is to encourage the identities to work together.

Helper alters

In addition to child and persecutor alters, there may be one or several helper alters. Initia...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• PREFACE
• CHAPTER ONE The dissociative disorders and the presentation of Dissociative Identity Disorder (DID), or Multiple Personality Disorder (MPD)
• CHAPTER TWO Assessment and diagnosis
• CHAPTER THREE Beginning stage of psychotherapy
• CHAPTER FOUR Middle stage of psychotherapy
• CHAPTER FIVE Final stages and integration
• CHAPTER SIX Considerations for psychotherapy
• CHAPTER SEVEN Problems and issues
• RESOURCES
• REFERENCES
• INDEX