Understanding and Treating Dissociative Identity Disorder

A Relational Approach

Elizabeth F. Howell

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781135845827
• Edition: 1
• Topic: Psicología
• Subtopic: Psicoanálisis

Building on the comprehensive theoretical model of dissociation elegantly developed in The Dissociative Mind, Elizabeth Howell makes another invaluable contribution to the clinical understanding of dissociative states with Understanding and Treating Dissociative Identity Disorder. Howell, working within the realm of relational psychoanalysis, explicates a multifaceted approach to the treatment of this fascinating yet often misunderstood condition, which involves the partitioning of the personality into part-selves that remain unaware of one another, usually the result of severely traumatic experiences.

Howell begins with an explication of dissociation theory and research that includes the dynamic unconscious, trauma theory, attachment, and neuroscience. She then discusses the identification and diagnosis of Dissociative Identity Disorder (DID) before moving on to outline a phase-oriented treatment plan, which includes facilitating a multileveled co-constructed therapeutic relationship, emphasizing the multiplicity of transferences, countertransferences, and kinds of potential enactments. She then expands the treatment possibilities to include dreamwork, before moving on to discuss the risks involved in the treatment of DID and how to mitigate them. All concepts and technical approaches are permeated with rich clinical examples.

Part 1

Understanding Dissociative Identity Disorder

Chapter 1

The Lives and Psychotherapy of Three People With DID

Introduction

I have enormous respect and admiration for the courage, endurance, and capacity to love that these individuals with dissociative identity disorder (DID) have, and I am grateful to them for their consent for me to use incidents from their lives as they reported them to me and from their treatment to illustrate what it is like for a person to have DID and what it is like for a therapist to work with a person who has DID. Although identifying information has been changed, these are not composites. Before I begin to tell of their stories, I want to remind the reader that life can be stranger than fiction. These are horrifying stories. I refer to work with three patients (Janice, Dennis, and Margaret) at various points throughout this book. The work with them is not the only discussion of case examples, but these individuals offer anchoring cases.

Janice

Janice is a 43-year-old woman, recently remarried, who has two teenage daughters. Although an accomplished painter, she is just beginning to show her work. An extremely caring person who is kind and sensitive to the feelings of others, she generally presents as upbeat, cheerful, optimistic, and highly energetic. Yet, there have been many times when she has privately experienced overwhelming depression and suicidality. Especially as a child, Janice got through life by pleasing others. She developed a pleasing face and a funny face, among others—faces that hid her immense grief. Luckily, she is extremely intelligent, and this helped her to figure out and adaptively adjust to many unbearably difficult situations as she was growing up.

Janice came into treatment with me almost 4 years ago to work on her newly discovered DID. She has been in therapy with a number of different therapists for most of her adult life, but her DID was never diagnosed until a recent 2-month hospitalization in a trauma program. During this time, she did much work on herself. She did time lines of her history, drawings, and some of her alters were identified. In our early work, her awareness that she has DID emerged gradually, like an increasingly flickering lightbulb that finally comes on. This began with an examination of her need to rescue stray, needy, damaged people, people who could in fact sometimes be dangerous. When the rescuer part was contacted, a very sad child of about 6 emerged who described the most recent rescue operation in detail, as well as others. She finally admitted with great sadness and pain that she rescued others because she could not rescue Janice. The enormous sadness of this part was partially communicated to Janice. She was amazed to know about this part of herself and to know the sadness of this part. Following this session, other parts emerged, each time with Janice experiencing some of their sadness, an experience often upsetting and sometimes overwhelming to her. As a result, this initial work with parts was carefully titrated. She recently reported that she realized that she had always thought of herself as The “We” of Me, but that she had never before now put together its meaning.

All Janice remembers about the development of her multiplicity is that by the time she was in middle childhood, she would privately refer to herself as The We of Me. Janice’s “we” is a polyfragmented multiple. She has at least a hundred parts, many of them for particular purposes or roles, existing in many clusters and layers, parts behind other parts. Most of the parts do not have names, although I recognize many of them by their behavior. There is a little 4-year-old who speaks with a lisp and with a 4-year-old’s language structure. There are many young children who go by “Janey,” some adolescent ones, and several adult ones. Of those who have specific names, there is Tomboy, who is a cheerful, enthusiastic, happy tomboy companion to her father. There is The Little Girl in the Torn Dirty Slip, who was sexually abused and has always felt tortured and ashamed. There is The Mother, who takes care of her children when Janice, as the host, is too exhausted. There is The Driver, who takes care of safe driving when other parts have become too upset. There is The One Who Knows How to Get Things Done. There is The Sexy One. Then, there are many prison guards and gatekeepers who have functioned to keep parts with overwhelmingly scary, shameful, angry, and painful memories and feelings locked up, and there is a hierarchy among these guards and gatekeepers. There is the seemingly suicidal, but actually internally homicidal, Ereshkigal, who wants to kill the host, Janice. Then, there are The Suicides, who become activated when things begin to feel hopeless. They have provided hope to the system with their prospective solution of ending pain by ending life. However, in our work together, they have continued to expand the realm of their subjectivity to include connections with other parts. They have also gained awareness that as an adult Janice has much more power than she did as a child, that in current reality, pain is not forever, and that if she did murder herself, her children would suffer immeasurably. (See Chapter 14 for more discussion of suicidality.) Then, there are many other parts who come and go. In response to my asking their identity, they often say, “Oh, I’m just one of them.”

Janice is a middle child in a family of four, with two older brothers and a younger sister. She grew up as a kind of real-life Cinderella, but without the unqualified happy ending. From her infancy until she was about 5, she was sickly: As a baby and young child, she could not hold food down and frequently had a fever, facts of life that made her mother angry. If Janice had a temperature in the morning before kindergarten and first grade, the school would not take her. Janice described how this infuriated her mother because it interfered with her daily bridge game. When it was finally discovered that she was allergic to milk, Janice began to thrive physically.

Janice remembers that she was frequently punished, but she rarely understood the reasons for her punishments. Her mother often spanked her with a hairbrush on many parts of her body, including her chest and back, arms, and hands as well as her butt. When Janice tried to defend herself by putting her hands in front of her chest or behind her back, her mother would strike her hands with the brush.

Janice’s mother did not intervene when her father heaped strange and sometimes violent punishments on her. Although he also spanked her with a belt, his most notable punishment was his placing her in a certain chair, where she would have to sit and listen to him excoriate her verbally for what he saw as her misdeeds and inadequacies. There were many times when she was forced to sit in this chair for hours while he stood over her telling her what a terrible person she was. In particular, he would demand that she repeat after him that she was “a liar, a thief, and a cheater.” Janice knows the phrase by heart by virtue of being forced to repeat it so many times. Despite this maltreatment, Janice also found ways to please her father. This included singing songs to him while still a child, such as “I’m a little teapot, short and stout; sock to me baby, let it all hang out.” She recalled that her father and his friends thought it was hilarious.

Janice soon learned to keep her mouth shut and put on a happy face. She developed the art of servicing the different members of her family in different ways. For her father, she was hostess and maid for his many cocktail parties. She also developed an alter, Tomboy, who was her father’s sidekick in his hunting expeditions with his cronies. Tomboy knew just when to get down when the rifles would go off. Unlike other children and her siblings, Janice had to be home from school by 4 p.m. to attend to household chores. Janice brought tea to her mother on a tray every day when she came home from school. She also massaged her mother’s back often because her mother was frequently bedridden with what she described as back pain. By the time she was a young adolescent, Janice cooked many family meals. She poignantly remembers baking her father’s birthday cake when she was about 10 years old—only to have him become furious with her because the candles on the cake had melted by the time she was able to carry the cake to him. She made a birthday party for her sister, also only to be rebuffed. On her mother’s instruction, she sewed her sister’s wedding dress and two bridesmaid’s gowns. In contrast to the way she treated Janice’s siblings, whom she showered with expensive clothing, Janice’s mother refused to buy all but the bare necessities for Janice. (It should be borne in mind that Janice’s desperate need to please—as well as her ability to do so—might have contributed to the way that her family came to rely on her.)

Considering that Janice’s parents seem to have had a great need to control her and to keep her at home, it seems strange that she seemed as a young child to be wandering around a great deal on her own, with no one noticing. When Janice was about 5, some friends of one of her brothers enticed her into the basement of an abandoned house. This was her “torture room.” They would force her to lie down. Then, they would fill her vagina with muddy sand. Next, they would place a board on her and walk on her pelvis. They told her that they would kill her if she told, and she never did. Her mother never seemed to be curious about her frequent urinary tract infections. Even today, since she has remembered these times, she has tortured herself with wondering why she went back, and the complete answer to this is still not clear. Most likely, she was terrified to refuse, and possibly, even though it was bad attention, it was some attention. In addition, her body was aroused—just as are the bodies of children who voluntarily engage in sex play. Because of the terror and shame, these awful experiences were dissociated as The Little Girl in the Torn Dirty Slip until recently. There was so much shame about these instances that The Little Girl in the Torn Dirty Slip was isolated, “locked up,” by other parts, who believed that she was dirty and bad and should not be allowed to come out. Gradually, in therapy this part found the courage (and was allowed out by the rest of the system) to come out and to talk about these harrowing times, including the physical pain, terror, and shame. It is because she came out to talk to me that this paragraph could be written in a coherent narrative sequence. Before that, it was a bad feeling that would come over her, but it was also what she called a “butterfly” memory. She would at times have a fleeting memory of this or other harrowing times, but then it would disappear, and all she would remember is the image of a butterfly.

As a child, she would often wander into the woods for long periods of time, often taking off her clothes, and dancing around, pretending that she was a fairy. On one occasion, two wild boars came by. She quickly climbed a tree and was completely still and quiet in utter terror for a long time. As soon as they left, she ran home. She told no one because she did not want anyone to know that she had been out, and she did not want the privilege taken away from her. In her later, early adult years, she often traveled in third-world countries, alone, in third-class transport and not wearing a bra. Now, in the present, she remembers the driver looking at her breasts and realizes that she could have been raped, killed, and disappeared. She has had many close calls in her life and has, indeed, cheated death many times. For example, she was attacked by a widely feared and dangerous rapist and was raped and nearly murdered in her apartment.

Janice’s parents did not want to be disturbed after Janice’s bedtime. Because she was so terrified of her parents and of disturbing them, and because she symbolized them as monsters at the doorway of her bedroom who would kill her if she exited, she was afraid to get up from bed and go to the bathroom at night. As a result, she often wet the bed. This continued until she was 8 years old. Her mother’s solution to this was to refuse to wash the sheets, to make Janice sleep in them, and when she did have them washed, to hang them out in the yard for everyone to see and to know that Janice had again wet the bed. Furthering this humiliation, her brothers would then ride their bikes through the neighborhood, informing the neighbors that Janice had wet the bed. Needless to say, Janice’s sister followed suit and treated her in the same humiliating manner as did her parents.

Despite continuous, flagrant, serious maltreatment, Janice focused her life on pleasing her mother, and this most likely did establish the kind of inverted caretaking bond that her mother apparently needed as well as palliate her mother’s ire at her. She became a little soldier (or many such) with respect to herself, containing her pain, fury, terror, and longings. Not surprisingly, Janice attempted to hang herself with her mother’s stockings when she was 8 years old.

Odd attitudes about sexuality were enacted by both of her parents and an uncle and aunt toward the child, Janice. When she was 12, Janice had sewed her own Easter dress, but before she could wear it to church, she remembers that her mother suddenly flew into a rage and ripped out the hem, insisting that Janice had made it an inch shorter than what she thought she had marked. Her father often told her, but not her sister, that girls and women could only be wives, secretaries, or prostitutes. However, neither she nor any of her parts have reported physical incest with her father.

By the time Janice was a preadolescent and an adolescent, she began to spend summer months and many weekends with some friends of her parents, whom she addressed as uncle and aunt. The “uncle” was, in fact, her father’s boss. Until she was in the postpartum period of the birth of her first child, she had always remembered these times as idyllic. These people were kind to her, did things with her, and showered positive attention on her. In contrast to how she was treated at home, they thought well of her and praised her. They did not demand that she perform such chores as cooking and sewing. She idealized them and thought of them as her saviors.

While she was recuperating from the birth of her first child, she was plunged into severe depression by the onset of a different sort of memories of the time she spent with the uncle and aunt. She became largely unable to function or to paint for about 13 years. She remembered that the uncle would come into her room at night and fondle her. In addition, to “Uncle’s” nightly fondlings, she remembered sudden gushings of vaginal blood that alarmed no one. Both the uncle and his wife stated to Janice that she should support herself through college by prostitution, with no embarrassment or reflection on what they were saying. The uncle planned to continue his sexual exploitation of her beyond her childhood by suggesting to her that she should support herself through college by going to the environs of the Alaska pipeline and setting up shop as a prostitute. He told her that he would help her get set up in this work, and that he would visit her. At the time, it did not occur to her that this might be objectionable. It was not until her mid-20s that Janice began to feel weird about having sex with him and stopped it. She did not formulate the experience: She did not think about or remember any precursors to this behavior. It was just something she did.

In the home of her nuclear family, there also were strange issues with sexuality and control in which it seemed that Janice was the recipient of much projection about sexuality. She was also frequently “locked up,” confined to her room for long periods of time or to the home for months at a time in the summer, as if she were promiscuous, which she was not.

About a year ago, Janice received some elucidating information: The situation of her birth was highly unusual. Janice’s mother was having an affair about 9 to 12 months before her birth and mistakenly believed that Janice was the biological offspring of the man with whom she had been consorting. When Janice was a baby, her mother told her father of the affair. It is only recently that Janice recovered this memory from her mother, on a special trip that she had arranged both to comfort and to become closer to her mother. This information was the explanatory key that had been missing from so much of her story of brutal sadistic abuse and extreme exploitation on the part of her parents and her “uncle.” Since her sister and brothers had not been treated as she was, it was always curious to her (and to me) why she had been singled out for such treatment. The pattern of triangulation (in Murray Bowen’s terms; both parents made her a scapegoat to protect the harmony of their own relationship) had always been apparent, but there had been no obvious explanation regarding why. For instance, while her siblings were sent to college by her parents, Janice put herself through college. The implication that she was a “whore” that was attributed to her in late childhood and adolescence becomes her parents’ projection regarding her mother’s extra-marital affair. Following her mother’s revelation, Janice requested genetic testing. This testing revealed that her father was indeed her biological father.

Dennis

Dennis, who has DID, is a personable, extremely intelligent, 32-year-old man. He works in finance and owns a motorcycle repair shop on the side. Clearly, he is a man of many talents. Yet, he suffers an inner chaos and immense psychic pain. He finds some surcease from his suffering in focused work and in the joy of being in the presence of true friends. He came into treatment with me after finding my earlier publications on the Internet. At that time, he stated that he was aware that he had some dissociative problems and was interested in dissociation but did not “believe in” DID. We have been working together for about 3 years, but not continuously, as he has had to take some breaks for financial reasons. Much of this work has been painful for him...