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Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric

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Gabbard’s Treatments of Psychiatric Disorders > Part VI. Anxiety Disorders, Dissociative Disorders, and Adjustment

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Chapter 34. Dissociative Disorders and Depersonalization

INTRODUCTION

Dissociative amnesia, dissociative fugue, and dissociative identity disorder are characterized by

theoretically reversible lesions of autobiographic memory associated with overwhelming actual,

anticipated, or feared experiences. Characteristic subtypes of amnesia and the features of classic

versus nonclassical amnesia and fugue are found in Tables 34–1 and 34–2. Overwhelming

experiences associated with dissociative amnesia and dissociative fugue may relate to powerful and

intolerable affects, intense intrapsychic conflict, terrifying external circumstances, or explicit

traumatic events. Overwhelming experiences associated with dissociative identity disorder almost

invariably involve childhood traumatization, such as abuse, neglect, terrifying external

circumstances, or painful medical conditions and treatments. Confusion and/or alteration of

identity is associated with dissociative identity disorder and cases of dissociative fugue involving

the formation of an alternate identity. In dissociative amnesia and cases of dissociative fugue

without the formation of an alternate identity, identity is impacted because the individual’s sense of

himself or herself is distorted by the failure to integrate important information and/or intrapsychic

conflicts and/or powerful and intolerable affect.

Table 34–1. Types of dissociative amnesia

1. Localized amnesia Inability to recall events related to a circumscribed period of time.
2. Selective amnesia Ability to remember some, but not all, of the events during a circumscribed period of

time.

3. Generalized

amnesia

Failure to recall the whole life of the patient.

4. Continuous

amnesia

Failure to recall successive events as they occur.

5. Systematized

amnesia

Amnesia for certain categories of memory such as all memories relating to one’s

family or a particular person.

Source. Loewenstein 2001, p. 1624.

Understanding and treating dissociative amnesia, dissociative fugue, and dissociative identity

disorder require familiarity with dissociation; hypnosis; the interactions among trauma,

dissociation, and amnesia; and the study of memory and traumatic memory. However, a complete

exploration of these areas is beyond the scope of this communication. The authors recommend that

interested readers consult 1) Bremner and Marmar’s (1998) text, which includes many articles

examining dissociation and the relationships of dissociation to hypnosis, trauma, and amnesia; 2)

1. P. Brown, Scheflin, and Hammond’s (1998) masterful discussions of amnesia and memory

science; and 3) H. Spiegel and D. Spiegel (2004) for a straightforward introduction to hypnosis.

Table 34–2. Two syndromes of dissociative amnesia and fugue

“Classic” syndrome

1. An acute, overt, florid, dramatic dissociative disturbance.
2. Develops suddenly, usually in association with acute traumatic experiences such as combat and/or

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3. No predisposing personality disorder or usual comorbidity.
4. The patient may have a prior history of a dissociative disorder.
5. Amnesia is more common than fugue. Presentation most commonly is generalized, localized, or continuous

amnesia

6. Frequently is associated with psychological trauma and/or occurs in an individual with a prior history of

psychological trauma.

7. Possible association with head trauma in some cases.
8. Rapid response to treatment.

“Nonclassical” forms of dissociative amnesia

1. A “covert” dissociative disorder.
2. Characterized by chronic, recurrent, and/or persistent dissociative amnesia.
3. Dissociation is hidden, minimized, or rationalized.
4. Amnesia usually is a relatively circumscribed memory gap primarily for traumatic circumstances.
5. Clinical presentation usually is for other symptoms/syndromes.
6. Posttraumatic stress disorder or posttraumatic stress symptoms commonly present.
7. Amnesia is part of the trauma response.
8. Treatment is a long-term psychotherapy directed at the patient’s chronic dissociative and posttraumatic

disorders.

Source. Loewenstein 2001, p. 1625.

TREATMENT OF AMNESIA, FUGUE, AND DISSOCIATIVE IDENTITY

DISORDER

Overview of Treatment

Dissociative amnesia, dissociative fugue, and dissociative identity disorder are approached with a

three-phase model of trauma treatment. A phase of achieving safety is followed by a phase of

reviewing and processing traumatic memories and grieving their impacts, implications, and

attendant losses, after which a phase of reconnection develops the foundation for an integrated self

and a life relatively freed from domination by posttraumatic symptoms and concerns (Herman

1992).

Although these phases are conceptualized and described as sequential, they often overlap in clinical

practice, for the following reasons:

Intrusive trauma symptoms may need to be addressed before the goals of the phase of safety are

attained.

1.  

Work with patients who have suffered recurrent traumatization rarely allows all traumatic material to be

addressed simultaneously.

2.  

In dissociative identity disorder (DID) and allied forms of dissociative disorder not otherwise specified

(DDNOS), work with one or more personality states may be under way before other personality states

are even participating in treatment and while still others remain unknown both to the therapist and to

the alters cooperating with treatment.

3.  

In the phase of safety, the patient is given sanctuary and support; restabilized; strengthened by the

structure of the therapy, the development of the therapeutic alliance, and the relationship of

therapist and patient; helped to master more adaptive coping and self-regulation; afforded

symptomatic relief; and given psychoeducational interventions to facilitate understanding of the

trauma and the goals of treatment. In the phase of remembrance and mourning, the mind’s

representations of its traumatic experiences are explored, processed, and mastered, and the

consequences of traumatization are grieved. This includes efforts to overcome amnesia and addressPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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what is discovered as well as what was incompletely recalled and/or partially dissociated.

The phase of reconnection focuses on the reintegration of self and identity, with the resumption of

disrupted development; efforts to achieve competence in relationships, roles, and functions; and

the creation of a vigorous and renewed life no longer determined by the constraints imposed by

trauma-related symptoms and the domination of the psyche by trauma-related concerns.

A trauma therapy model is used because these patients have been so overwhelmed that they forfeit

continuity of their autobiographic memories and their identities. The experience of being

overwhelmed parallels the helplessness residing at the core of traumatic experience (Maldonado

and Spiegel 1998; D. Spiegel 1988, 1991) and constitutes a crucial factor in promoting dissociation

(Kluft 1984a).

These disorders occur in a wide range of individuals with diverse comorbidities. Treatments must

consider and respect the overall context of patients’ lives and circumstances. Therefore, the goals

of treatment may vary. Treatments of these disorders may need to be postponed while pressing life

circumstances and comorbid conditions are addressed.

Psychotherapy of Dissociative Amnesia and Dissociative Fugue

Loewenstein (1991a) reviewed general principles for treating dissociative amnesia and dissociative

fugue. He advised using a frame of reference that is adaptational rather than psychopathological in

the context of a triphasic model of trauma psychotherapy. Following D. Spiegel (1988), the

therapist should understand dissociation as a defense not only against traumatic memories and

unacceptable unconscious wishes but also against the trauma response itself. Amnesia becomes

understood as an adaptive safety valve or circuit breaker reflecting the patient’s inability to

tolerate full conscious awareness of the dissociated material—its narrative autobiographical

contents, its overwhelming affects, and the personal meanings of the traumatic events themselves

and one’s relationships with those who played a role in one’s being traumatized. Powerful and often

conflicting emotions (such as despair, guilt, shame, rage, self-hatred, helplessness, horror, and

terror) may be embedded within the traumatic material. The disavowed events may disrupt and

transform one’s view of self, significant others, the nature of the world, and human relationships in

general (Briere 1989; Freyd 1996; Janoff-Bullman 1985; D. Spiegel 1988; Terr 1991). The

underlying assumptions and cognitive models and representations of interactions that guide a

person’s understanding of and conduct in the world may be shrouded by amnesia. If these are not

identified or addressed, a person may remain permanently symptomatic (van der Hart and Brown

1992). Crucial historical and dynamic data that may explain central aspects of a patient’s character

and adaptations may be hidden by amnesia (Smith 1985; Terr 1991).

The patient’s relationship with the therapist is crucial. Facilitating the patient’s capacity to put his

or her trauma story into words, often for the first time, with a responsible, supportive,

nonjudgmental, and caring witness is essential in restructuring the meaning of the experience and

transforming disruptive, overwhelming traumatic memories into normal, albeit unpleasant,

memories. The therapist should be warm, expressive, and friendly. Failing this, traumatized

persons usually experience bland responses as indifference, if not rejection and shaming (Kluft et

1. 2000).

The patient must be helped to develop an organizing framework for understanding both his or her

condition and symptoms and the trajectory of the treatment process (Herman 1992; Kardiner and

Spiegel 1947). Amnestic patients should be educated about the adaptive nature of the amnesia and

the need to be respectful, careful, and deliberate in attempting to overcome it.

Safety considerations are both the most important and the most neglected aspects of trauma

treatment, especially when amnesia is present (Loewenstein 2001). Loewenstein (1991a), (2001)

and Kluft (1991) caution against yielding to pressures and impulses in either therapist or patient to

rush to pierce amnestic barriers. While it is generally true that the more acute the amnesia, the

shorter the period of treatment required, that does not obviate the necessity to carefully titrate

both the quantity and the intensity of dissociated material brought into awareness (W. Brown 1918;Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Fisher 1943; Kardiner and Spiegel 1947; Kluft 1991, 1996; Myers 1916). Treatment must be paced

and structured to make the retrieval of dissociated material tolerable. Patients working on the

recovery and/or processing of previously dissociated material require restabilization by session’s

end. Kluft’s (1991) rule of thirds holds that if either the retrieval or processing of traumatic

material is anticipated, it is best to begin such work in the first third of the session, complete that

work in the second third of the session, and reserve the last third of the session for reprocessing

and restabilization.

Patients suffering nonclassical forms of dissociative amnesia and dissociative fugue (see Table

34–2) have endured many episodes of trauma. Efforts to reverse amnesias before careful

stabilization and preparation are retraumatizing, commonly precipitating cascades of flashbacks of

additional traumatic events with intense and intrusive posttraumatic stress disorder (PTSD)

symptoms (Steele and Colrain 1990). Decompensation and self-destructive impulses may occur.

Acute amnesias and fugues often are psychological alternatives to suicide (Gudjonsson and Haward

1982) or interpersonal violence. If amnestic barriers are removed prior to strengthening and

stabilization, suicide is a risk (Kluft 1996; Takahashi 1988). Coons and Milstein (1992) observe that

dissociative fugue and dissociative amnesia may be stimulated by significant family, marital,

sexual, and/or relationship difficulties, making family and/or marital treatment advisable before

some dissociative patients can be returned to their customary interpersonal environments

(Takahashi 1988). Similar concerns apply to the workplace or school environment.

Issues of safety and containment often respond to hypnotic or related techniques. When

overwhelming material has emerged, suggestions for permissive amnesia and suggestions for

imagery to contain the memories and strong affects in a vault or other stronghold are useful.

Split-screen techniques help to contain material and strong affect between sessions (H. Spiegel and

Spiegel 2004). The patient is taught to visualize the traumatic material on one side of the screen

and a safe/pleasant situation on the other. Next, the patient is taught to switch attention to the

safe/pleasant scene when he or she needs respite from the trauma, and/or to allow either side to

expand and cover the other completely should this be advisable or likely to enhance either

processing or safety.

Treatment will work to restore knowledge of personal identity, life circumstances, and recent

history if the patient suffers amnesia in these areas. The dissociated material will be processed

repeatedly to restructure the meaning of dissociated experiences, and the treatment will focus on

achieving resolution and reintegration. Adjunctive psychopharmacology, family therapy, marital

therapy, and group therapy may play valuable roles.

Phases of Treatment

Establishing physical safety is essential. The patient should be removed from any traumatizing

environment (e.g., direct combat, scene of civilian violence, disaster zone); receive appropriate

medical evaluation and treatment (with special attention to possible head injury and sexual

assault); and provided with shelter, food, and rest. Sedatives may be necessary for sleep. In cases

involving social dislocation (disaster, war, political upheaval), efforts to provide a safe environment

will coincide with overall efforts to provide basic safety and services.

Patients with global amnesia or dissociative fugue may suffer a generalized amnesia with

unawareness of customary personal identity and events antecedent to and during their amnesia or

fugue (Fisher 1945; Gill and Brenman 1959). Assessment (as noted above) should be considered.

Both disorders may be prompted by rape or sexual assault (Kaszniak et al. 1988).

Spontaneous recovery of memory may follow removal from the situation that generated the

amnesia and placement in safe surroundings (Abeles and Schilder 1935; Grinker and Spiegel 1945;

Kennedy and Neville 1957; Sargent and Slater 1941). This plus food and sleep suffices to cure many

combat-related cases. When symptoms fail to resolve, more definitive treatment follows, usually

after removing the soldier from the front (W. Brown 1918; Kardiner and Spiegel 1947; Kubie 1943).

Most combat-related fugue cases had wandered away from the front, did not remit spontaneously,Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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and required sustained treatments (Grinker and Spiegel 1945). In civilian settings, Abeles and

Schilder (1935) noted rapid spontaneous remission of amnesia in 75% of patients once they were

safe in a medical setting.

Patients who have not spontaneously recovered their memories often do so while giving their

psychiatric histories or when a clinician offers reassurance memory will return and/or suggests its

return (Tureen and Stein 1949). The patient is reassured that he or she will remember when he or

she is ready to do so, can remember at his or her own pace, and need not recall everything or every

detail all at once. The patient is told that the clinician has the skills required to help the patient

manage the dissociated material. The literature emphasizes the importance of permissive

suggestions for recall. Patients with amnesia usually have profound concerns about matters of

control and trust. Permissive approaches enable patients to have a sense of control over the pace of

recollection of the dissociated material, allowing them a sense of mastery and self-efficacy during

the treatment process. Patients with covert nonclassical presentations will require a more

extensive psychotherapy that attempts to resolve the complex psychological sequelae of the events

and address the antecedent circumstances that generated the amnesia, usually recurrent

traumatizations (Brende 1985; Briere 1993; D. Spiegel 1988; van der Kolk 1986).

Active interventions may be required if the patient is acutely dangerous to self or others or is

involved in severe substance abuse. Typical difficulties include suicide attempts; self-mutilation;

alcohol and/or substance abuse; eating disorders; involvement in abusive or destructive

relationships; episodes of rage or violence; abuse of one’s own children, spouse, or other family

members; and lack of adequate food, clothing, or shelter (Turkus 1991). Hospitalization and/or

special programs for alcohol/substance abuse or eating disorders may be useful.

Many patients will have severe intrusive PTSD symptoms as well (criterion A events may be known

or remain obscure). These usually will be contained rather than explored or processed in the safety

and stabilization stage. This may be done with dynamic, hypnotic, supportive, cognitive-behavioral,

and psychopharmacological interventions, alone or in combination (Colrain and Steele 1992; Fine

1990; Friedman 1990; D. Spiegel 1989; Steele and Colrain 1990). No medication specifically

addresses the symptoms of dissociative amnesia or fugue, but treating comorbid conditions or

co-occurring but subdiagnostic threshold symptom complexes may prepare a firmer foundation for

treating the amnesia (Friedman 1987, 1990; Loewenstein 1991b; Saporta and Case 1993).

Many amnestic patients, especially those with histories of recurrent trauma, do not know how to

prioritize their own safety and contain potentially self-endangering behaviors. Vulnerable to

revictimization (“the sitting duck syndrome” [Kluft 1989a]), they must learn to value the safety of

themselves and others, a concept that may feel unfamiliar and suspect. Protective limit setting may

be perceived as hurtful.

Amnestic patients with comorbid chronic PTSD often utilize self-injury and/or substance abuse as

state-altering agents to manage painful intrusive symptoms and to support amnesia, keeping

painful material at a distance. Van der Kolk (1987), (1993) argued that self-injurious behaviors

may be an attempt to enlist the endogenous opiate neurotransmitter system in the service of

self-regulation. It is often important to acknowledge the subjective, apparently powerful,

short-term efficacy of such methods but to identify their long-term self-destructive consequences.

Studying the state-altering and addictive aspects of these activities often leads the patient to

become interested in alternative means of self-regulation, such as self-hypnosis.

Both the dissociation and the dysfunctional efforts at self-regulation should be identified as active

efforts at adaptation rather than bad behaviors that must be ablated. This communicates that the

patient is active, resourceful, and driven to master his or her traumatic experiences, even if those

efforts are maladaptive. The pursuit of alternatives encourages the creation of genuine safety in the

patient’s life.

Direct Treatment of Amnesia

Dissociated memories are usually associated with overwhelming dysphoric affects andPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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self-undermining cognitions. The patient should be strengthened and stabilized and the therapeutic

alliance established before direct efforts are made to access dissociated material. Occasionally a

patient cannot achieve the goals of the early stages of treatment because intrusive painful

memories are too disruptive. In such cases, it may be necessary to accept the risks of processing

traumatic material before stabilization and strengthening have occurred. Once this material is

processed or contained, treatment should return to stabilization and strengthening rather than

continue trauma work (Kluft 1996, 1997a).

Several issues should be considered in determining whether it is reasonable to proceed to work

with traumatic material (Colrain and Steele 1992; Kluft 1991, 1997a):

1. Is the patient a voluntary and cooperative participant who has given informed consent to the process?

Is the patient’s motivation rational, or are toxic agendas at play that may obstruct the process or exert

a distorting influence upon or actually create what is discovered?

2.  

Are the patient’s life circumstances so stressful or so lacking in supports that engaging in trauma

processing or undoing dissociative amnesias may prove destabilizing? Sometimes minimal supports are

available; the patient and therapist must plan how the patient will cope with the impact of trauma work.

3.  

Have comorbid conditions, medical and psychiatric, been addressed adequately, so that the patient can

participate in a demanding process without unnecessary risk?

4.  
5. Does the patient have sufficient ego strength to withstand this work without risking decompensation?
6. Has the patient achieved the goals of the earlier stages of the treatment?

Is the therapist prepared, in terms of both skills and emotional stability, to carry out the treatment and

tolerate the impact of the traumatic material?

7.  

Are the logistics adequate to the proposed work? Additional sessions, intersession telephone contacts,

and prn medications may prove necessary. Such work should not be scheduled if interruptions of

treatment are anticipated or if the patient is facing unalterable important academic or vocational

deadlines.

8.  

In a flashback, revivification, or dissociated state, the patient may become highly agitated and

disorganized, mistake the present for the past, and even experience the therapist as someone who

is abusive or unknown to the patient. Reliving a trauma may prove so compelling that the patient

actually believes he or she is in the past and may lose contact with contemporary reality. Patients

may age-regress or (in DID) switch to a personality that does not know the therapist.

The therapist must help reorient the patient and/or terminate or otherwise contain reexperiencing

gone out of control. Grounding techniques help the patient reconnect to the present situation and

diminish the disruptive intensity of the past experience. Therapists may need to begin by

specifically identifying themselves because patients engaged in full revivifications may lose duality

(the capacity to retain contemporary orientation while vividly reliving a past experience) and

experience the clinician as a figure from the traumatic event being relived.

Grounding maneuvers include requesting that the patient 1) open his or her eyes (if the patient’s

eyes were closed) or redirect his or her gaze (if the patient appears to be visualizing and

interacting with those in the past experience); 2) look around and recognize familiar “landmarks”

in the office or treatment room; 3) feel his or her feet on the floor and/or hands on the chair; or 4)

breathe deeply. There are many other interventions unique to particular situations. With DID

patients, personalities not involved in what is being accessed or processed may be asked to help

reorient the involved alters. Clinicians trained in hypnosis have additional options, including (with

or without formal induction) inducing a visualization to override the traumatic scenario; suggesting

a split screen in which the trauma is on one side and the contemporary situation is on the other,

and inviting the patient to focus increasingly on the contemporary situation; suggesting

interventions that “turn down” the distress (“You will notice a dial that controls the discomfort. .

.”); suggesting age progression from the age of the episode being relived back to the present; and

the like. It is often helpful to remind the patient that the event from the past is over and that he or

she has survived it and is in the “here and now” of the psychiatrist’s office.Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Containment efforts may involve the use of images, with or without a formal induction. Common

images involve placing the traumatic material on a mental television set that can be turned off, or

envisioning the material/memories as placed in safe vaults, rooms, files, books, and so forth

(Colrain and Steele 1992; Kluft 1982, 1983, 1988, 1989b; D. Spiegel 1989; Steele and Colrain

1990). One should develop images congenial to the patient prior to doing trauma work or undoing

dissociation and teach the patient to use them to contain distress in daily life and to control

spontaneous intrusive images.

Patients with dissociative fugue (or global amnesia) may present complex problems in stabilization.

While most fugues are relatively brief and without extensive travel, some are prolonged for months

or more (Fisher 1945) and may involve considerable travel. Ready access to air transportation

makes world travel possible in even a brief fugue. Fuguers manifest a range of amnestic symptoms,

including complete generalized amnesia with loss of memory for personal identity, amnesia for the

entire fugue episode, and localized amnesia for recent times (remaining themselves but living in an

earlier time of their lives) or with a change in personal identity (Fisher 1945; Gill and Brenman

1959; Loewenstein 1991a). It might be argued that the retention of identity but dislocation in time

is better considered an age regression and classified with DDNOS.

Some fuguers resist even hypnotic and drug-facilitated efforts to uncover their original identities.

Family, sexual, occupational, and/or legal problems that played a role in generating the fugue

episode may be exacerbated by the time the patient’s identity and life situation are clarified. Family

treatment, marital treatment, legal involvements, and social services interventions may prove

necessary.

Rarely, a new identity develops occupational and social relationships in another location (Hilgard

1986). When the original identity is discovered, often by accident, predicaments may ensue. The

patient may become confused, overwhelmed, or even suicidal. Further dissociative symptoms may

develop, including additional fugues and Ganser’s syndrome.

The patient may have to grapple with responsibility for illegal acts that may have prompted the

fugue or that were committed in the new identity (e.g., bigamy). Differential diagnostic dilemmas

are posed. What are the primary and secondary gains? Can one distinguish among factitious

disorder, malingering, and a legitimate dissociative disorder? Indeed, these phenomena are not

wholly mutually exclusive and may coexist, further complicating the situation (Kluft 1995a, 1997b;

Loewenstein 2001). Forensic aspects of such cases are beyond the scope of this chapter. Having a

dissociative disorder is not by itself an adequate foundation for an insanity defense. However, some

dissociators will qualify due to unique aspects of their particular conditions or by virtue of a

comorbid disorder.

With safety ensured and a therapeutic alliance formed, treatment endeavors to help the patient

regain awareness of his or her identity and general personal situation. Many patients arrive with

identification or concerned others able to provide information. However, patients with global

amnesia with or without fugue may be encountered for whom neither legal nor media appeals bring

identification, who fail to respond to or actually resist clinicians’ efforts, and who are inaccessible

to hypnosis or drug-facilitated interviews.

When this occurs, evaluators study the patient’s showing implicit knowledge for information that is

dissociated. Psychological tests, free recall, formal word-association tests, random generation of

words, drawings, or motor behavior may reveal implicit autobiographical information not

consciously available to the patient (Kaszniak et al. 1988). Clinicians should attend carefully to

such information and provide patients with refractory amnesia opportunities for this kind of

self-expression.

Often amnestic patients will describe recurrent thoughts, dreams, images, or sensory phenomena

for which they have no explanation. Exploring these may begin to retrieve dissociated information,

as may classic free association. The patient is asked to reflect inwardly and report all thoughts,

images, and sensations that come to mind, holding back nothing, no matter how irrelevant orPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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inconsequential the information may seem. The patient may be asked to associate further to

elements of what has been said. This may gradually permit the assembling of autobiographical

information. Hypnosis may facilitate understanding these recurrent phenomena.

The therapist may make the return of dissociated material more tolerable by using language that

implicitly enables the patient to maintain some distance from its full affective intensity. The patient

may be encouraged to discuss what he or she can without feeling obligated to provide every detail.

An overview is needed first; details and feelings can be addressed gradually over time. The patient

may be asked to offer only his or her thoughts about the material, avoiding the language of feeling

and affect.

Abreaction

Abreaction is an “emotional release or discharge after recalling a painful experience that has been

repressed because it was consciously intolerable. A therapeutic effect sometimes occurs through

partial discharge or desensitization of the painful emotions and increased insight” (American

Psychiatric Association 1980, p. 201). Curative factors in dissociative amnesia are debated, with

some maintaining that the intense emotional release is a key therapeutic agent and others insisting

that the integration of dissociated affects, cognitions, and self-perceptions is essential to the

amnesia’s resolution. Proponents of the latter view argue that bringing dissociated affect into

awareness may lead to chronic decompensation rather than resolution, while proponents of the

former maintain the emotional release is essential for optimal therapeutic results.

A single release of strong emotion rarely offers definitive relief. Full resolution of dissociated

material is a complex process that usually occurs over an extended number of sessions. No single

extraordinary effort (that may prove retraumatizing) need be made to resolve matters. However, if

abreactive work is thoughtfully planned, is paced carefully, employs newer techniques for

containment and titration, and is restricted to patients with the strength and stability to manage it,

adverse reactions are infrequent and transient. If full resolution of dissociated material occurs

without abreactive work (and it often can), then there is no need to initiate abreactions. However,

if the material remains disruptive and unsettling after being processed without abreaction,

abreaction may resolve residual difficulties successfully (Kluft 1996, 1997a).

Transference Phenomena

Traumatic transferences (a set of unconscious perceptions and expectations of the clinician based

on relationships formed in traumatic circumstances) are often significant early in treatment of

traumatized populations (Lindy 1989; Loewenstein 1993; D. Spiegel 1986). The therapist may be

experienced as a buddy killed in battle, an incompetent officer who unnecessarily sent his men into

harm’s way, the patient as victim, an abuser, or a person who failed to help the patient (e.g., a

parent turning a blind eye toward the patient’s abuse by the other parent or sibling). Davies and

Frawley (1995) noted characteristic patterns: The therapist may be seen as an abuser, a victim, a

rescuer, or a failed protector. In patients with amnesia, the therapist’s recognition of characteristic

trauma transferences may prove a route to undoing the amnesia. Discussion of these patterns may

result in recall of the events that gave rise to them.

In severely traumatized patients with dense dissociative amnesia, episodes of

transference/countertransference difficulties, enactments, and apparent impasses are common.

The patient’s interactions with the therapist will stimulate traumatic transference reactivity

repeatedly, and the therapist’s compassionate confrontation of these transferences, candid

exploration of enactments, and judicious sharing of countertransference responses may enhance

the patient’s ability to acknowledge and address the many ways in which dissociated experiences

from the past determine contemporary behaviors and attitudes.

Psychotherapeutic Issues Concerning Memory

The treatment of dissociative amnesia, dissociative fugue, and dissociative identity disorder

involves efforts to lift amnesia for events absent from memory. Considerable controversy hasPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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developed over whether such once-unavailable memories are accurate, and even over whether they

can ever be accurate. Concerns have been expressed that such memories are confabulations or

pseudomemories created by therapists’ interventions, attitudes, and subtle cues. While this debate

continues, polarized stances advocating that such memories be accepted as accurate or that such

memories be regarded as inaccurate a priori are untenable. The recovery of accurate but previously

inaccessible memories has been demonstrated, and the inaccuracy of some recovered memories

has been demonstrated. D. P. Brown et al. (1998) concluded that whether a memory has always

been in awareness or whether it has emerged after years of inaccessibility is not relevant in

determining its accuracy. Dahlenberg (1996) studied and tried to confirm or disconfirm both always

available and recovered memories. She found that 74% of the always available memories could be

confirmed, and that 74% of the recovered memories could be confirmed as well.

“Notwithstanding controversies associated with autobiographic memory, especially when elements

of memory are recovered, most authorities concur that unless memories are processed it is difficult

to bring about a full recovery in which continuity of personal identity is restored and the patient is

able to make sense out of what has befallen him or her” (Kluft et al. 2000, p. 90). Exposure is a

crucial factor in treating the traumatized. Memories that generate disruptive, affectively intense

and painful symptoms, regardless of their veracity, generally require therapeutic interventions that

transform them from sources of disruptive distress into simply bad memories.

Patients’ accounts should be heard with empathy and respect, appreciating that their historical

accuracy may never be confirmed or disconfirmed. Empathy rather than skepticism is essential to

create a safe and effective holding environment and therapeutic alliance. It is inappropriate to

begin therapy by trying to document or disconfirm memories. Neither a patient’s account nor

reports from sources appearing to invalidate a patient’s account should be assumed to be correct.

Firm confrontations and critical observations are less productive than calling the patient’s attention

to discrepancies that have been noted and expressing confusion or puzzlement about how to

understand them.

The importance of work with autobiographical memories of trauma should be acknowledged and

discussed with the patient; difficulties associated with memory and its vicissitudes should be

reviewed. Memory should be explored under the aegis of informed consent, requirements for which

vary widely from state to state. Practitioners should inform themselves of what is required in their

practice locations.

The informed consent process should include discussion of any techniques that might be used to

explore the patient’s past (e.g., hypnosis, drug-facilitated interviews, guided imagery) and to

review proposed benefits and possible drawbacks to their use. Patients must be informed that

materials elicited with such techniques may be of uncertain veracity and may prove to be more

“grist for the mill” of therapy than grounds for drawing firm conclusions about the events and

persons in question. Such memories may not be accorded credibility in forensic situations; it is

premature to contemplate taking actions that might disrupt the lives of patients or others on their

basis. Patients should be helped to appreciate that psychotherapy is more potent as an instrument

of healing than as a search for historical truth. Helping the patient struggle through how to

understand and what to do about such recollections is a major aspect of the treatment of anyone

who suffers amnesia and may dominate some psychotherapies.

The urge to confront individuals who are identified as alleged abusers in recollections long absent

from memory is a Siren’s song, tempting patients and therapists alike to wreck themselves on

dangerous psychological and medicolegal shoals. The risks of such confrontations almost always

outweigh their potential benefits.

Treatment Modalities

Cognitive therapy may have specific benefits for the traumatized (Solomon et al. 1992). Identifying

the specific cognitive distortions based on trauma may also provide an entrée into areas of

autobiographic memory shrouded in amnesia.Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Hypnosis is not a treatment in itself. It is a catalyst that can facilitate many therapeutic processes.

Although many argue that posttraumatic and dissociative disorders can be treated without formal

heterohypnosis (e.g., Futterman and Pumpian-Mindlin 1951), certain groups of dissociative disorder

patients appear to be characterized by high hypnotizability, and the clinician cannot contain or

prohibit patients’ spontaneous trances or autohypnosis. Hypnotic techniques, with or without

formal induction of heterohypnosis, can be used to contain, modulate, and titrate the intensity of

hyperarousal symptoms; to facilitate memory recovery or abreaction; to contain abreactions and

flashbacks; to provide ego strengthening and support; and to promote the working through and

integration of dissociated material (D. P. Brown and Fromm 1986). The patient can be taught

self-hypnosis to apply containment and calming techniques in daily life, which enhances the

patient’s sense that he or she can move toward more successful control of distressing symptoms.

Many clinicians make tapes for their patients to use between sessions. Clinicians who work with

posttraumatic and dissociative patients should obtain training in hypnosis and the use of hypnosis

with these patient populations. Clinicians should master some basic induction techniques and

containment imagery. However, it is always best to help patients work toward imagery that feels

right to them. D. P. Brown and Fromm (1986), Hammond (1990), and H. Spiegel and Spiegel (2004)

are useful resources for approaching hypnosis. Hypnosis for DID is discussed below.

Safe place imagery involves the creation of an image associated with calmness, serenity, and safety

to which the patient can “go” to be at peace and to distance him- or herself from trauma and stress.

Patients can be taught to distort time, so that the subjective experience of comfort can be

prolonged and the perceived duration of distress abbreviated. Containment imagery was discussed

earlier.

Once the patient has been stabilized, a working alliance has been established, and distancing,

calming, and containment strategies have been learned, it becomes possible to consider resolving

the dissociative amnesia. It is useful to plan for such sessions, identifying the dates for the sessions

and discussing how the sessions will be structured. Planning may include deciding what material

will be approached, which techniques and images may be used, and how emotional intensity will be

titrated. Potential difficulties may be anticipated, and plans for their management developed.

Postsession concerns, such as residual emotional reactivity and the breakthrough of additional

material, should be addressed, and coping strategies and potential supports should be discussed.

The session should be conducted in a carefully structured manner, with attention both to allowing

adequate time (possibly longer sessions) and to ensuring that the “rule of thirds” (Kluft 1991) be

respected (i.e., exploratory or abreactive work should get under way in the first third of the session

and continue for the second third, but the last third should be reserved to restabilize the patient

and help the patient come to grips with the material, or to sequester it anew with permissive

amnesia).

Generally, patients must process dissociated material repeatedly, often at different levels of

intensity, to complete its detoxification and integration (Kluft 1996, 1997a; van der Hart and Brown

1992). It is usually wise to begin in a more cognitive manner and get an outline of what had been

unavailable to memory. Subsequently, the material can be addressed more intensely and

thoroughly. Some patients who are stabilized in ongoing treatment and have demonstrated their

capacity to resolve trauma material in planned sessions can address traumatic material when it

intrudes into a session. However, usually material will be contained and processed later.

Many try to account for the BASK (behavior, affect, sensation, and knowledge) (Braun 1988)

dimensions of dissociated experiences (see Fine [1991, 1993] for such efforts with DID) and track

which dysphoric affects (e.g., despair, sorrow, grief, horror, shame, helplessness, rage, guilt,

confusion, anguish) are most and least available to the patient. Inquiry about affects that have not

been prominently displayed or discussed may help to resolve amnesia. Shame is particularly

important because it severs connectedness (Nathanson 1992) and has many intriguing

relationships with dissociation. Shame script work is discussed under DID (Kluft, in press).

Often some aspect of the traumatic event, its meaning, or the patient’s response is central toPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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resolving the amnesia yet is withheld despite the processing of other aspects. Clinicians must be

ready to wonder, “What may be missing?” Often either intolerable shame or heartbreaking betrayal

proves crucial. Many a patient who has worked on memories of father–daughter incestuous assaults

without the material losing its disruptive force ultimately learns that her mother had walked in on

an assault only to turn and walk away. Likewise, many rape traumas remain unresolved until the

victim shares her mortification and horror over experiencing sexual arousal during the assault. Only

when these “unspeakable details” are shared and processed do the intrusive symptoms begin to

diminish. “Unspeakable details” may be redissociated several times before they are retained in

awareness and processed.

Hypnotic age regression or Watkins’ (1971) affect bridge facilitates recall of information hidden by

amnesia. Many techniques are described in Hammond (1990).

While these techniques can be powerful agents for healing, cautions about the potential inaccuracy

of retrieved material must be respected. Their healing potential should not seduce the clinician into

using them in patients unable to tolerate them (D. P. Brown et al. 1998; Hammond 1990; Kluft

1996, 1997a).

Some dissociative amnesia and dissociative fugue patients’ conditions were generated by

intrapsychic conflict, notwithstanding earlier traumatic experiences. Their wishes or their behaviors

are in conflict with deeply held moral values and behavioral standards (Coons and Milstein 1992).

Indiscretions or powerful urges to commit indiscretions (e.g., personal, sexual, financial) may

trigger dissociative episodes. In other cases, conflict concerns behavior that is not morally

problematic in itself (e.g., entering the military to follow in the footsteps of an abusive parent) but

conflicts with other strongly held convictions or values (e.g., building a family life by remaining at

home). Irresolvable shame, painful conflict, or uncontainable desperation may trigger acute

amnesia or fugue.

Patients are helped to tolerate these affects or conflicts without resort to dissociative defenses.

Often from homes in which moral codes were rigid and physical discipline harsh, patients may have

difficulty tolerating anger or violent impulses because these trigger recall of earlier experiences

with physical abuse or other traumas, often as flashbacks. Therapeutic efforts are directed in part

toward reducing patients’ brutally unreasonable and often conflicting expectations for themselves,

as well as the guilt and shame that accompany and/or play an etiological role in the dissociation

(Kluft, in press). Therapy not only addresses the acute dissociation—it endeavors to explicate, work

through, and restructure the patient’s thoughts, feelings, self-perceptions, and character issues

related to the antecedent traumata.

In fugues with assumption of a new identity, the new identity embodies unacceptable experiences,

memories, cognitions, identifications, emotions, strivings, and self-perceptions that were too

conflicted to be acknowledged yet too peremptory to be successfully suppressed. Often their

expression in the alter identity is so sublimated and oblique that it is hard to infer their original

power and force. When such alter identities can be accessed, the most desirable outcome is to

facilitate their integration and the resolution of the issues that generated them. Techniques

applicable to DID are utilized.

In generalized amnesia or severe localized amnesia (e.g., missing the past 20 years), rapid

resolution is virtually unknown; a chronic course with slow and partial recovery is likely. Some such

cases are DID presenting in a newly formed alter created in the context of adolescent/adult

trauma, without established connections to other alters.

Supportive structured groups designed to promote functioning and prevent chronic disability

(Grinker and Spiegel 1945; Kardiner and Spiegel 1947) may be adjuncts to hypnotherapy (Kardiner

1941). Some groups provide a context in which memories are recovered and processed (Goodwin

and Talwar 1989), but in general, dissociative patients often are disrupted by groups’ focusing on

or addressing trauma. Most concur that groups for dissociative patients should be structured and

preserve a here-and-now focus with clear rules (Coons and Bradley 1985).Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Ideally, during the final phases of treatment the patient should be able to experience the

information that had been dissociated as autobiographic memory, which is capable of being

recollected or put aside. There should be no intrusive images, affects, or sensations, and memory

gaps should not remain. Conflicts or issues once fraught with conflict, guilt, or shame should be

tolerated in consciousness. Responsibility for shortcomings, failings, and lapses should be accepted

without paralyzing shame or guilt. What previously seemed overwhelming and disruptive should be

experienced with a sense of perspective. Energy is available for life tasks and avocations. Hypnotic

imagery for integration and mastery may facilitate further mastery, images associated with healing,

wholeness, calm, mature reflection, peace, quietude, and serenity. Hypnotic imagery for letting go

of the past, turning to the present and future, and reuniting traumatically dissociated aspects of

self may be helpful (Brende 1985).

Somatic Therapies

There is no known pharmacotherapy for dissociative amnesia and fugue. Drug-facilitated interviews

(Kolb 1985; Patrick and Howells 1990; Perry and Jacobs 1982; Ruedrich et al. 1985) have a

venerable history in trauma treatment, notwithstanding Patrick and Howells’ (1990) report that

sodium amytal did not surpass saline placebo in generating clinically useful information.

Narcosynthesis (Grinker and Spiegel 1945) involves the processing of material uncovered in a

drug-facilitated interview in a normal alert state. Sometimes hypnosis is used in the drug-facilitated

state.

Interviews must be performed where resuscitation equipment and medical backup are available in

case of respiratory arrest, a rare complication, and should be audiotaped or videotaped. Some cases

require repeated procedures (de Vito 1993; Fackler et al. 1997). Information retrieved is subject to

cautions noted above.

Outcome data

Kardiner (1941) stated that 63% of World War II combat amnesia and fugue cases were

ameliorated by rest, sedatives, and hypnosis. Lambert and Rees (1944) cited in Perry and Jacobs

(1982) reported complete resolution of symptoms in 82% of their World War II amnesia cases

treated with drug-facilitated interviews.

TREATMENT OF DISSOCIATIVE IDENTITY DISORDER

This treatment section primarily addresses work with the identities or personality states (i.e.,

alters). Work with amnesia has been discussed above. Treatment of DID will be presented as it is

conceptualized in the mainstream dissociative disorders literature. Those skeptical about the

dissociative disorders advocate very different approaches (e.g., Brenneis 1997; Fahy 1988; McHugh

1992; Merskey 1992; Piper 1997; Spanos 1996).

Stages of Dissociative Identity Disorder Treatment

DID treatment is consistent with the three-stage model (Herman 1992) discussed earlier. Table

34–3 lists the stages of trauma and DID treatment. In the definitive treatment of DID, the first

three stages of Kluft’s (1991) model correspond to Herman’s first stage. In the supportive

treatment of DID, however, the third stage of DID treatment would not be part of the stage of

safety, lest these explorations prove overwhelming. Herman’s second stage corresponds to stage 4

in Kluft’s model, and Herman’s third stage, reconnection, encompasses Kluft’s stages 5 through 9.

Table 34–3. Stages of treatment for traumatized individuals and for dissociative identity disorder

Treatment of traumatized individual Treatment of dissociative identity disorder

1. Safety
2. Establishing the psychotherapy
3. Preliminary interventions
4. History gathering and mappingPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Treatment of traumatized individual Treatment of dissociative identity disorder

2. Remembrance and mourning 4. Metabolism of the trauma
3. Reconnection
4. Moving toward integration/resolution
5. Integration/resolution
6. Learning of new coping skills
7. Solidification of gains and working through
8. Follow-up

Source. Herman 1992; Kluft 1991.

The stages of treatment for DID reflect the need to address the alters and their issues, and the

processes of resolution and/or integration, problems not encountered in more typical trauma

treatments:

Establishing the psychotherapy involves creating an atmosphere of safety in which evaluation can be

completed, the security of the treatment frame can be ensured, and the therapeutic alliance begins.

1.  

Preliminary interventions involve gaining access to alters, contracting for safety and cooperation,

fostering cooperation and communication among the alters, offering symptomatic relief, and teaching

techniques for coping, grounding, self-soothing, and containment.

2.  

History gathering and mapping involve learning more about the alter system, the world of the

personalities (the “third reality”), and the alters’ histories and concerns.

3.  

Metabolism of the trauma involves processing the overwhelming experiences reported as

autobiographical memory. The patient’s sense of the reality of his or her autobiographical memories may

oscillate repeatedly between belief and disbelief. The historical veracity of most material will be neither

confirmed nor disconfirmed, so tact and discretion are advisable.

4.  

Moving toward integration/resolution involves working through material across alters and facilitating

increasing cooperation, communication, and mutual awareness, with enhanced mutual identification and

empathy.

5.  

Integration–resolution consists of the patient’s coming to a new and more solid stance toward him- or

herself and the world.

6.  

Learning new coping skills is crucial. The patient will require assistance in working out alternatives to

dissociative functioning. Issues deferred or left unaddressed in earlier stages may require attention.

7.  

Solidification of gains and working through involve the DID patient’s continuing to process what has

been learned while mastering how to live in the world without the use of pathological dissociative

defenses. Work in the transference is crucial. Supportive coaching on the management of relationships,

intercurrent stressors, and traumata is often required.

8.  

Follow-up is preferable to termination. Stability of the outcome should be monitored, and additional

layers of alters may be encountered. Attachment and loss issues are so painful for many DID patients

that the prospects of formal termination may cause stalemates or regressions to preserve connection

with the therapist. Treatment is tapered as tolerated until visits occur at several-month intervals.

9.  

Principles of Successful Treatment of Dissociative Identity Disorder

The psychotherapy of DID requires “the respectful treatment of the personalities and their

difficulties while discouraging their irresponsible autonomy and always indicating that they are

parts or aspects of a single human being” (Kluft 1991, p. 177). This entails engaging the alters

directly in the service of the psychotherapy. Although some recommend against dealing with the

alters on the assumption that they are no more than artifacts that will be reinforced, and others

maintain that while the alters are naturalistic phenomena, treatment can be conducted through the

host without directly addressing or accessing the alters, no body of clinical reports has developed

that documents the effectiveness of such stances. Kluft (1985), (1993a) found that only 3% of DID

patients in therapies that did not directly address the alters reached integration. Most clinicians

who are experienced with DID have treated many patients who had failed to improve in prior

psychotherapies that did not work directly with the alters.Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Summarizing reasons for working directly with alters, Kluft (2006) reported that engaging the

alters makes them stakeholders in the therapy, reduces opposition, and helps put the host, which is

simply another alter, in perspective. It is important to discuss with the alters their reluctance to

participate, withholding of information, participation in rationalized avoidance of crucial material,

and sabotage of therapeutic efforts. Accessing alters often allows working directly to alleviate

symptoms and erode amnesia without using intrusive and/or suggestive techniques. Empathy,

support, and efforts at shame reduction are much more effective when offered in direct contact

with alters. Working directly with alters avoids inflicting the narcissistic injuries experienced when

alters feel treated as insignificant, and it is helpful in preventing reenactments of experiences of

rejection and neglect. Finally, the shared experiences and bonds created by working directly with

the therapist prepare the alters for integration work. This stance also conveys in the process of the

psychotherapy the reality that the alters are components of one overall personality structure.

Because DID is usually covert and alters often exert their influences from behind the scenes, the

psychiatrist is well advised to develop a searching image for their manifestations based on subtle

indicators of their activities. This hiddenness helps explain the delayed recognition of this

condition, averaging 6.8 years in the mental health care delivery system prior to accurate diagnosis

(Putnam et al. 1986). Loewenstein et al. 1987) demonstrated that most switches and shifts of

executive control are neither reported by the patient nor noticed by observers. The “dissociative

surface” concept (Kluft 2005, 2006) describes the phenomena and processes associated with the

covert interactions and intrusions of the alters and lists observable minor disturbances that indicate

the activity of these phenomena and processes. The clinician must learn to appreciate how alters

pass for the host, are often present in combination rather than “one at a time,” intrude into one

another, and instruct or threaten an alter in apparent control in ways that influence that alter’s

behavior. This awareness allows the clinician to identify alters’ interactions (which may convey

valuable dynamic and historical material) in the here and now of therapy (Kluft 2006).

Certain precepts characterize successful treatments and usually have been violated when therapies

progress poorly or fail (Kluft 1991, 1993b). Because the etiology of DID involves broken

boundaries, its treatment requires a secure frame and firm, consistent boundaries. Because DID

patients experience subjective dyscontrol and have helplessly endured overwhelming

circumstances, therapy must prioritize mastery and enlist the patients’ active participation. The

therapeutic alliance must give the patient some sense of participation in controlling the treatment.

DID involves sequestering overwhelming experiences and affects, so what has been hidden away

must be addressed and processed, even if it seems unlikely to have historical validity. Inaccurate

memories are often metaphors or screens for important incidents or conflicts. Because DID involves

the experience of separateness and conflict among the alters, treatment must emphasize their

cooperation, collaboration, empathy, and identification with one another to alleviate their conflicts

and render separateness redundant.

Because DID is the delivery and maintenance system for multiple reality disorder, involving

autohypnotically and fantasy-driven alternative constructs of reality to escape intolerable life

circumstances, therapists’ communications must be straightforward, and material must be

approached gradually and gently. Because DID patients often have experienced inconsistency in

important others, the successful therapist must be evenhanded to all alters. The therapist’s

consistency across all alters (avoiding “multiple therapist disorder”) is a powerful assault upon

dissociative defenses. Because DID involves the shattering of security, self-esteem, and future

orientation, DID patients rarely are able to accept general supportive comments or

encouragements. Morale and hope are better inculcated by referring to specific accomplishments

within treatment.

DID patients have endured overwhelming experiences with insufficient supports. Their treatments

must be paced, respecting their limitations in tolerating the material and its affective load,

preventing memory processing from becoming retraumatization. More gentle and controlled

fractionated abreaction techniques (Fine 1991, 1993; Kluft 1988, 1990) may be useful. DID patients

usually have experienced important others’ failing to be responsible. The therapist must behavePrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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responsibly and convey an expectation of responsibility to the patient across all alters. DID often

occurs because those who might have protected the patient as a child failed to do so. The therapist

must be warm and engaged. Remoteness and passivity will be experienced as rejection. DID

patients develop many cognitive errors in adapting to irrational and abnormal circumstances (Fine

1988). These must be addressed and corrected. Encouraging an experimental data-gathering and

hypothesis-testing attitude in the therapy and gently creating cognitive dissonance about irrational

beliefs are helpful (Fine 1991).

Heterogeneity of Dissociative Identity Disorder

In the modern era of DID treatment, initial optimism faded as clinicians found themselves unable to

duplicate the accomplishments of pioneers and encountered patients who appeared untreatable.

Investigators found an unexpected heterogeneity in DID; three subgroups could be identified (Caul

1988; Fraser and Raine 1992; Horevitz and Loewenstein 1994; Kluft 1984a, 1986, 1994a, 1994b;

Ross and Dua 1993).

A first group suffered primarily dissociative and posttraumatic symptoms and had periods of

relatively good and stable function. Comorbid conditions, if present, were treatment responsive.

These patients had considerable ego strengths and psychological assets. Hospitalizations, if any,

were infrequent. They generally integrated and completed treatment in 2–7 years. Most did well

even with neophyte therapists. Generally, they had smaller personality systems than those in other

groups.

The second group had fewer psychological resources and more formidable comorbidity. They were

less completely medication responsive. Alter systems were generally more complex and difficult to

contain. Borderline features, usually present, were often intermittent rather than entrenched.

Affective disorders, eating disorders, and histories of substance abuse were common. These

patients’ functioning and their relationships were less stable, with prominent dependency and

attachment concerns. While many came to integrations or satisfactory resolutions in treatment,

their therapy careers were often stormy and crisis ridden, and their progress slower and either

irregular or intermittent. Treatments of 5–12 years were not uncommon. Many had long periods of

instability and several hospitalizations, and they required considerable supportive work to maintain

their safety and function. At such times they were unable to engage in definitive treatments. This

group did far better with therapists who had extensive experience with DID and who intervened

more actively in their alter systems to contain crises and problematic behaviors.

A third group suffered more severe comorbidity and often had very complex alter systems. They

were likely to be enmeshed in exploitive relationships, chronically self-destructive, entrenched in

their character pathology, and quite identified with a dissociative lifestyle (their DID was

ego-syntonic and/or they were unwilling to consider undertaking crucial aspects of DID treatment).

Features associated with psychotic disorders or refractory affective disorders might occur on an

intermittent or ongoing basis. Supportive treatment was required for prolonged periods of time;

many therapies never transitioned from supportive to definitive. A minority made their way to

integration or stable resolution after very prolonged treatments (generally over 10 years), but most

slowly became more resilient and less chaotic over time.

Matching DID Patients With Appropriate Treatments and Therapeutic

Stances

Given the heterogeneity of DID, it becomes important to individualize treatments. Caul (1988) and

Boon (1997) listed findings that suggest considering supportive treatment. Boon (1997)

recommended assessing five areas: 1) the patient’s current personal and professional functioning,

2) the presence of an Axis II disorder, 3) the patient’s life-cycle phase and/or external life crises,

4) the presence of substance abuse, and 5) the presence of ongoing abuse. Problems in any of

these areas contraindicate moving beyond supportive treatment into definitive psychotherapy.

Current functioning is emphasized, suggesting that definitive treatment cannot occur without

adequate functioning.Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Conversely, Kluft (1994a), (1994b) argued that assessment of potential to progress should be made

on the basis of demonstration of an ability to change relative to baseline assessment. His treatment

outcome research (Kluft 1984a, 1986, 1993a, 1994a, 1994b) showed that once DID patients had

settled into a treatment that actually addressed their DID, many who initially appeared to be poor

candidates for treatment did very well. He developed an instrument to quantify DID patients’

change along several dimensions. Patients who improved their scores and/or who maintained high

scores progressed well.

The process of treatments that follow the three-stage model of contemporary trauma treatment

(Herman 1992) or the more elaborate DID-specific models of Braun (1986), Kluft (1991), and

Putnam (1989) helps to define their own course and nature (Kluft 1999a). All start with attempts to

stabilize and strengthen the patient prior to approaching trauma work or considering integration.

Therapists who appreciate that their patients have not mastered the tasks of the stages preliminary

to trauma work will, with rare exceptions (Kluft 1997a), defer trauma work. If patients who appear

to have mastered preliminary tasks prove unable to manage trauma work, it will be essential to

assess what has gone wrong and redirect the treatment back to the concerns of the earlier stages.

Patients who repeatedly either cannot master the tasks of the early stages of therapy or cannot

apply what has been learned to make trauma work safe are candidates for supportive therapy. The

rare exceptions occur when the clinician determines that a particular piece of trauma work must be

addressed in order to enable the patient to move forward with the earlier stages of therapy (Kluft

1997a).

Pragmatic Considerations in Treatment of Dissociative Identity Disorder

The definitive treatment of DID requires intensive individual therapy (Putnam and Loewenstein

1993). For the patient, this may be experienced as an exhausting, painful, and humiliating ordeal

that feels interminable. Although some highly functional, mildly afflicted, or supportively treated

patients may do well with a single session a week, and some experienced therapists are able to

manage patients in a single weekly session, the consensus in the field (International Society for the

Study of Dissociation 2005) is that two sessions per week or a single session of double length

constitutes the minimal treatment in which good results can be achieved in a reasonable period of

time. Some favor two single sessions, and others one double session. Putnam (1989) observed that

90-minute sessions allow time to do difficult work and restabilize the patient; others hold that two

individual sessions offer more structure and support. Some treatment modalities, such as eye

movement desensitization and reprocessing (EMDR) (Shapiro 1995), routinely use 90-minute

sessions. Theories and models aside, some patients cannot complete a piece of trauma work and

restabilize in a 45- to 50-minute session. Patients who travel considerable distances to work with a

therapist with dissociative disorder expertise may be seen in prolonged sessions on one or a series

of days.

The authors’ experience indicates that more intense treatments are often desirable, especially in

psychodynamic psychotherapy, and would prefer three sessions per week when possible. Others

fear such treatments lead to regressive dependency. Consensus exists that some patients, while in

crisis, may need extra sessions, sessions of extended length, or even daily meetings.

Although very simple cases may resolve completely in a matter of months (Kluft 1984a, 1986),

most DID patients are more complex and suffer considerable comorbidity. Motivated patients in the

best prognosis group treated by therapists experienced with DID in therapies of adequate intensity

still require 2–7 years of treatment before sessions are tapered off.

The intensity of treatment recommended here is often challenged by managed care organizations.

Some patients seen less frequently never experience the therapy as sufficiently protective and

structuring to create an environment in which they feel safe enough to do the work of the therapy,

resulting in prolonged, incomplete, or stalemated treatments. Recommendations for less intense

treatments may situate DID patients in therapies that are known to be ineffective, suboptimal,

unproven, or experimental.Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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As a group, DID patients are vulnerable due to their instability, sensitivity to any hint of rejection or

disapproval, stressful lives and relationships, and the demanding nature of their treatment. Crises

and destabilizations are common even in carefully conducted treatments. Emergencies (real and

catastrophized) and telephone contacts between sessions are common, especially in treatments of

inadequate intensity. Therapists who are accessible but insist that their accessibility be respected

and not abused usually create atmospheres in which such occasions diminish. Often crises among

alters or over intrusive material can be negotiated rapidly over the telephone if a firm agreement is

made to address relevant concerns in the next session (Kluft 1991). The frequency of problematic

events and contacts is often inversely related to the success with which the tasks of the first two

stages of DID treatment are accomplished (Kluft 1993a, 1993b, 1993c).

Trauma Work

Traumatic materials must be transformed from powerful entities capable of creating a wide range

of disruptive symptoms into bad memories that, although unpleasant, are no longer disruptive.

Trauma work has been described previously under the treatment of dissociative amnesia and

dissociative fugue. However, certain considerations are unique to DID.

In DID, autobiographical memory is distributed across the alters. Traumatic experiences and their

associated affects, cognitions, and understandings were too overwhelming to be held in available

memory. What is not consciously available to some alters may be known to others, and may be

reenacted in an inner world. For some alters, these memories are experienced as new; for others,

they are relived recurrently in a terrible perpetual present.

Some therapists try to bring dissociated traumatic experiences directly into the awareness of the

alters that function in daily life and may encourage all or as many as possible to “listen in” while

traumatic material is recovered and processed For many DID patients, this is intolerably disruptive.

Most clinicians appreciate that functioning and safety are better preserved if such material is

recovered and/or processed with one or a small group of alters, shielding the rest from its impact

in the short term and making that awareness more available when it can be tolerated. Hypnotic

techniques can be useful in such efforts (Kluft 1982, 1988, 1989b, 1994c).

Fine (1991), (1993) described a model in which, after mapping, work is done in clusters of similar

alters while hypnotic interventions shield the others from the main impact of the trauma work. The

impact on those alters that function in daily life is deferred until the trauma has been processed to

the point of being a less powerful disruptive force and until the alters that function in daily life are

prepared to contend with the traumatic material.

If trauma work is begun without mapping, without knowing the structure of the personality system,

work on one trauma may activate many unsuspected alters who have suffered analogous traumas,

overwhelming the patient. Mapping is rarely complete, but it usually offers the therapist a “gist”

impression of what the treatment will encounter.

Fine (1991), (1993) invites the patient to write his or her name in the center of a piece of paper.

Alters are invited to write (or dictate to the alter that is “out”) their names on the sheet where they

feel their names belong and near to those alters to which they feel most close. Alters who have no

names or will not reveal their names are invited to make a mark, such as a dash, a check mark, or

an “X.”

Commonly there will be clusters of alters that have had similar experiences, have similar functions,

or were active at a similar time in the patient’s life. Names or marks interposed between

traumatized parts and the host, or between parts based on abusers and traumatized parts,

respectively suggest that some alters perceive a need or duty to prevent memories of abuse being

known by the host and that others perceive a need or duty to protect vulnerable parts from parts

based on traumatizers. Usually the number of alters on the map exceeds the number that the

patient can enumerate during an interview. Alters who come out and pass for the host are identified

as quite near the host and may represent themselves as sharing the host’s name andPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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characteristics.

Follow-up questions can further characterize the identified alters. This process may reduce the

chance of triggering an abreaction, flashback, or reliving while taking a history. Alters near a

traumatized cluster often can give the history of those in that cluster in a relatively detached and

cognitive manner.

Mapping allows the therapist to more easily address the personality system, gain cooperation with

exploration of memories, negotiate how best to shield the vast majority of the alters from the

trauma work, and address the concerns of alters who usually express their apprehensions or

opposition by obstructing and sabotaging treatment. Shielding may involve putting alters that are

not doing the trauma work into a hypnotic sleep, sending them to a protected part of the inner

world, and using similar strategies. Then work proceeds with the alters in the like cluster, usually

one at a time. They generally integrate more easily with one another than with dissimilar alters,

because they have had similar experiences and can easily empathize with one another. By the time

work in a like cluster is completed, most of its trauma has been processed and those functioning in

daily life are strong enough to gradually assimilate and process traumatic material without

derailing their function or endangering safety. Regardless of how the trauma is processed, those

alters who become aware of experiences for which they had been amnestic commonly develop a

spectrum of posttraumatic symptoms and may have to reprocess traumas experienced by other

alters.

Supportive Psychotherapy for Dissociative Identity Disorder

Some DID patients are unwilling or unable to undertake definitive treatment. External

circumstances may preclude definitive treatment. In such situations supportive treatment may be

indicated. The strategies and interventions associated with the early stages of DID treatment

remain predominant components of the therapy (Boon 1997; Kluft 1993c, 1997a; van der Hart et al.

1998). Boon (1997) described eight components of this work:

1. General supportive interventions useful with most patient groups are advocated.

Psychoeducational efforts to help the patient better understand dissociation, DID, and posttraumatic

stress enhance the patient’s sense of control and reduce shame, guilt, and anxiety. In addition, the

patient is educated about attachment issues and traumatic bonding.

2.  

Enhanced coping skills are taught, and the patient is shown how to use dissociative and autohypnotic

talents to contain traumatic memories and flashbacks.

3.  

Alters are taught to interact more cooperatively, especially with those that function in daily life and may

be largely unaware of the traumatic past.

4.  

The therapist makes active efforts to develop a constructive relationship with those alters that are

aggressive against self and/or others and uses this relationship to build better relationships between

those and other alters.

5.  
6. Cognitive therapy is used to correct alters’ faulty cognitions and basic assumptions.

Marital and family therapy is used with the patient and his or her current significant others and current

family (not with the family of origin).

7.  

Individualized protocols are developed for crisis intervention, including plans for short-term inpatient

treatment.

8.  

Patients gradually master and internalize more productive ways of functioning in both the inner

worlds of their alters and the external world as well. They become more adept and confident in

managing difficulties in their daily lives, gradually becoming more productive and resilient. Some

become strong enough for definitive treatment.

Pathways to Integration

Integration is a major goal in the treatment of DID, but many contemporary therapists and DID

patients are reluctant to pursue it. Their concerns stem from three primary sources: 1) patients’

reluctance; 2) theoretical considerations; and 3) the intensity, duration, and expense of workingPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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toward integration.

Many patients are simply unwilling to undertake the discovery, exploration, and processing of their

painful experiences. Their reasons may include fear of the pain associated with trauma work, fear

of punishment for making forbidden revelations, fear of disrupting their lives, fear of learning

information that might disrupt certain relationships, fear of making false accusations, alters’

persistent perception of integration as death, fear of the consequences of abandoning dissociation

and switching as defenses, and alters’ unwillingness to give up one another’s companionship.

Therapists oriented toward ego-state therapy and certain models of relational analysis believe that

the mind naturally consists of multiple ego states or multiple selves, making integration an

outmoded and conceptually impossible therapeutic goal. However, although all alters are ego

states, not all ego states are alters. Alters (with their own identities, self-representations,

autobiographical memories, and sense of ownership of their thoughts, feelings, and actions [Kluft

1991]), not the phenomena of ego states or multiple selves, are the subjects of integration efforts.

The definitive treatment of DID may require intensive work over a long period of time. Some who

do not contest the legitimacy of DID nonetheless raise concern about whether in an era of “Get the

target symptoms, make the DSM diagnosis, write the prescription—and on to the next

patient . . . we can no longer afford to diagnose and treat complex dissociative disorders” (Fawcett

2005, p. 618). When economic considerations, long considered anathema to the practice of good

medicine, are elevated to the status of moral imperatives, it becomes acceptable to many to

relegate a treatable group of trauma victims to inexpensive treatments unlikely to ameliorate their

conditions.

Alters generally move or can be moved toward coming together when their reasons for remaining

separate lose their relevance. However, some alters’ narcissistic investments in their separateness

and some patients’ unwillingness to “lose” particular alters may cause separateness to persist

(Kluft 1993d). The alters’ coming together is called integration, fusion, or unification. In contrast,

resolution denotes the outcome of functioning well while all or some of the alters remain separate.

More specifically, integration signifies transformation through a process of structural and functional

change, an ongoing process of undoing dissociative dividedness that begins long before any

reduction in the number or distinctness of the personalities occurs, persists through the time of

fusion, and continues at a deeper level even after the personalities have blended. In contrast,

fusion refers to the moment in time at which an alter or the whole alter system appears to have

ceased to be separate (“apparent fusion”) (Kluft 1984a, 1993d).

In a follow-up study of DID patients in treatment, Kluft (1982, 1984a, 1986, 1993a, in preparation)

observed that many apparent fusions do not hold. Rapid relapses are frequent until all issues

related to an alter that had apparently fused are worked through. He suggested that the term

fusion be used only after certain criteria had remained fulfilled for 3 months, and that stable fusion

be used only when these criteria remained fulfilled 2 years after the original 3 months. Less than

1% of alters absent over 27 months after fusion reappeared, even on follow-ups of more than a

decade. Patients with stable integrations were less likely to relapse into dysfunctional dividedness

than those with resolutions.

Pressing for integration early in treatment is always an error. Patients must have completed

particular alters’ portions of trauma work before their integration is feasible. Integration

suggestions merely formalize work already done; they are not helpful when applied out of context.

Even when some alters have done their work and are ready to join, other alters may oppose

integration for a variety of reasons. Sometimes such impasses are negotiated easily, but these

impasses may signify that additional work will be required before moving toward unification.

Alters come together in many different sequences and patterns. No particular protocol is superior,

but some may prove more congenial to individual DID patients, who may harbor unique fantasies or

personal myths about how their unifications should proceed. Whenever possible, these preferences

should be honored and should be modified in collaboration with the patient if they provePrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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unworkable. In most DID patients, alters integrate individually or in small groups, whether the

process is spontaneous or must be facilitated. Most commonly, similar alters will integrate with

similar alters before integrating with alters more different from themselves or an alter regarded as

either the original personality or the one that will form the basis of an integrated identity, or with

the system as a whole. Sometimes many or even all alters will wait to integrate at once; at times

alters will wait until another alter with which they are closely affiliated is ready to integrate or to

accept their integration into that other alter. Alters may grieve the integrations of other alters.

Kluft (1993d) described six pathways to integration. Most common is gradual merger or blending.

The involved alter reports and is reported by others to be fading gradually and becoming less

distinct or slowly blending into or joining another alter or alters. This most commonly occurs in

treatments prioritizing process over techniques. The second, involving ceremonies of joining or

fusion rituals, is more common in treatments facilitated by therapist-directed interventions such as

hypnosis or EMDR. They evoke imagery and suggestions in conjunction with either formal hypnosis

or EMDR, or they rely on the patient’s autohypnotic capacities. It is crucial to find images congenial

to the patient. Images that suggest merger, union, or rebirth, accompanied by suggestions that all

aspects of all alters will be part of the unification, are associated with success; verbalizations

suggesting elimination, subtraction, death, or going away are not helpful and may cause

complications and resistance.

Spontaneous cessation of separateness after sharing what an alter had encapsulated is a third

pathway, usually occurring in conjunction with abreactions (spontaneous or facilitated by hypnosis

or EMDR). A fourth occurs when alters decide to cease being separate. Often alters feel that they

are dying or going away. Such reports are often false, made to avoid painful material or integration.

Fifth is the brokered departure, in which an alter’s ceasing to be separate is negotiated within the

alter system, usually to achieve a particular goal (e.g., a strong personality’s joining a scared child

to prevent the child part’s being alone and overwhelmed when it has to deal with its traumatic

material). The sixth occurs in the context of a series of temporary blendings (Fine 1991). In some

DID treatments, alters are asked to blend temporarily to achieve a therapeutic objective. When

they are permitted to separate, their separation is rarely complete. After several such exercises, the

involved alters generally blend or request help to do so.

Modalities, Techniques, and Approaches

Psychodynamic and psychodynamically informed psychotherapy was the most frequently utilized

therapeutic approach to DID in Putnam and Loewenstein’s 1993 survey, and it was the major

treatment in the series of follow-up studies that integrated 89% of its subjects (Kluft 1999b). It

was often facilitated by other modalities. It is adaptable to work with DID, especially if all of the

alters are invited to share their associations and remarks on various subjects. Its strengths are its

careful study of the transference-countertransference matrix, the appreciation and interpretation of

enactments, and the impact of therapist and patient on one another (Brenner 2001, 2004;

Bromberg 1998; Chefetz 1997; Howell 2005; Kluft 1991, 1995b, 2000; Marmer 1980; Schwartz

1994; Stern 1997).

Hypnotically facilitated interventions often prove useful. Hypnosis may be used to offer ego

support, give anxiety relief, treat sleep disruption, and provide intercurrent pain relief, especially

for the headaches (tension and migraine) and other somatoform distresses (often “body

memories”) so common in DID patients. In addition, many hypnotic interventions have been

developed particularly for the treatment of DID. Most may be used either with or without the use of

formal inductions. They are listed in Table 34–4 and described in detail by Kluft (1982, 1992a,

1992b, 1994c) and by Phillips and Frederick (1995). It is often useful to record hypnotic

interventions designed to offer support, symptom relief, and restabilization. Patients may use these

recordings to interdict incipient panic or regression.

Table 34–4. Hypnotic interventions useful in the treatment of dissociative identity disorderPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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1. Accessing personalities
2. Alter substitutions
3. Reconfiguring the alter system
4. Ideomotor questioning
5. Providing sanctuary
6. Bypassing or attenuating intense affect
7. Slow leak suggestions
8. Curtailing abreactions
9. Fractionated abreactions
10. Facilitating abreactions
11. Gathering historical information
12. Time sense alterations
13. Distancing maneuvers
14. Facilitating integration
15. Temporary blendings
16. Integration rituals
17. Recheck protocols
18. Symptom relief and symptom substitution
19. Teaching autohypnosis
20. Suppressive measures
21. Trance ratification
22. Relapse prevention

Ego-state therapy (Watkins and Watkins 1997) involves working with the alters in a manner

reminiscent of family therapy. The alters are helped to communicate and cooperate more

effectively. With negotiation and diplomacy across the alters, improved function and safety are

prioritized. The ego-state therapy paradigm is implicit in virtually all other definitive approaches to

the treatment of DID.

Cognitive and cognitive-behavioral therapy may be extremely useful in helping DID patients modify

dysfunctional interpersonal and tension-modulating practices and may help develop more

functional behaviors than the patient was able to acquire in a dysfunctional childhood environment.

This is especially important before the DID patient is prepared to address the determinants of these

problems. Cognitive interventions are useful in helping DID patients cope with their distorted

patterns of thinking, the impact of trance logic, affect management, and ego strengthening (Fine

1988, 1992, 1993). Many clinicians have applied ideas derived from Linehan’s (1993) dialectic

behavior therapy to this patient population.

Drug-facilitated interviews may diminish resistance to accessing alters and making revelations and

may facilitate recall. Cautions and concerns about such practices were reviewed previously. The

modern literature is cautious about the use of drug-facilitated interviews, but these procedures

have a long history in psychiatry and continue to be useful on selected occasions. They are a

valuable adjunct when a clinician is not proficient with hypnosis, when a DID patient objects to

hypnosis on either personal or religious grounds, when an examination must be done before a

relationship has been established, or when a patient is too terrified to cooperate with hypnosis.

Patients who are paranoid or “too eager” for this modality are considered poor candidates. On

occasion hypnosis induced during drug-facilitated interviews allows access to material inaccessiblePrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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to either technique alone.

EMDR (Shapiro 1995) has been used with DID patients (Brenner 2004; Fine and Berkowitz 2001;

Lazrove and Fine 1996; Paulsen 1995; Shapiro 1995). Several cautions are in order. There is no

evidence that the use of structured eye movements during the treatment has any specific effect on

outcome, making the treatment more a kind of structured review and abreaction of traumatic

experiences. EMDR alone is not a sufficient treatment for DID. EMDR must be used in the context of

an ongoing psychotherapy that is more conversational and interactive. EMDR can evoke strong

responses. EMDR work with one alter may evoke responses from many others as well,

overwhelming the patient. Many clinicians defer the use of EMDR until the therapy is well

established, the personality system is reasonably well mapped and understood, and the therapeutic

alliance with major known alters is strong (Fine and Berkowitz 2001). Protecting the alter system is

advisable, in the manner described by Fine (1991) and discussed above with hypnosis. Standard

EMDR protocols may not be optimal for DID patients because most demoralized DID patients cannot

accept the installation of positive cognitions until late in the treatment (Fine and Berkowitz 2001).

Hypnosis and EMDR can be combined (Fine and Berkowitz 2001).

Contextual therapy (Gold 2000) endeavors to instill resources essential for normal functioning that

had not been developed during childhood. It addresses the interpersonal context (developing

capacities for cooperation and collaboration), the cognitive or conceptual context (promoting the

development of a cognitive understanding of self, others, and current difficulties as reflections of

the patient’s trauma history, family background, and socio-cultural-political context), and the

practical context (teaching skills needed to overcome the impact of trauma and for effective daily

functioning).

Structural dissociation (van der Hart et al. 1998, 2004) has recently emerged as a theoretical and

treatment paradigm popular among European clinicians.

Adjunctive and Ancillary Therapeutic Modalities

Treatment may be facilitated by shame script work, interventions informed by Nathanson’s (1992)

formulation of the compass of shame, derived from Sylvan Tomkins’ (1962), (1963) basic affect

theory. To avoid enduring shame, an individual may deploy one or more of four shame scripts:

withdraw and evade being seen, engage in activities or take substances that deny his or her

humiliation, attack self, or attack others. Many traumatic memories thought inaccessible are

consciously available to alters that deny knowing about them, refuse to share them, and engage in

shame script–driven behavior to avoid mortification (Kluft, in press). Avoidance frustrates trauma

treatments, which require a component of exposure. Alters helped to understand their shame

script–driven behavior often become willing to share what had been withheld. This approach may

be helpful when using hypnosis or when drug-facilitated interviews are problematic.

Therapists may encourage patients to participate in journaling for 20–30 minutes per day; the

writing can be reviewed in session. More extensive journaling risks becoming obsessive and is

difficult to review. Often DID patients can be more open in their writing because of shame or

prohibitions against “telling,” which they may construe concretely to mean speaking aloud. Alters

that are mute, unwilling, or unable to come out in session may express themselves in this format.

Also, alters suppressed in session may use this modality to give warnings about materials withheld

in session, such as suicide plans, unacknowledged self-injury, and inappropriate behaviors.

Audiotaping and videotaping sessions are considered for confronting and piercing amnestic

barriers, offering the patient feedback about the condition and the alters and eroding amnesia for

sessions (e.g., Orne and Dinges 1989). It is rarely used. This technology lacks curative power and

may seriously disrupt the patient (Caul 1984). Peremptory penetration of amnestic barriers may be

experienced as overwhelming and/or assaultive; material played back to the patient may be

disavowed or redissociated. This approach violates many of the most well-established

recommendations for the resolution of amnesia (discussed earlier in this chapter). There appears to

be no royal road to the dissolution of dissociative barriers.Print: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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Group therapy for dissociative disorder patients (excluding depersonalization disorder) has been

discussed earlier. DID patients usually do not fare well in self-help groups, mixed groups, or DID

groups with a focus on the traumatic past. Boundary issues, contamination of one patient’s

autobiographical memory by another person’s narratives, decompensating in response to others’

accounts of their trauma, and implicit reinforcement of apparent memories by peers’ uncritical

acceptance of one another’s accounts render such situations chaotic. Individual therapy may be

derailed by patients’ preoccupation with experiences and relationships in such groups.

Homogeneous DID groups led by skilled professionals that are structured, maintain a here-and-now

focus, and prohibit trauma and abreactive work in group can be helpful (Caul et al. 1986; Coons and

Bradley 1985; Fine and Madden 2000). There are some exceptions to the general rules offered

above. DID patients who can participate without switching or whose alters remain co-conscious and

consistent in their level of function, and DID patients who share much in common with those in a

specialized group such as Alcoholics Anonymous or a dialectic behavior therapy group (Linehan

1993), may both tolerate such groups and benefit from them.

DID patients generally do well in the more structured formats of both individual and group art,

movement, music, and occupational therapies (see E. Kluft 1992). Family therapy with DID

patients’ families of origin usually miscarries (Kluft et al. 1984). Usually the DID patient is

repudiated and/or shunned rather than accepted, the therapist is attacked for disrupting the family,

and the family members feel attacked. Supportive family work with current significant others can

be valuable if the relationships are essentially solid (Benjamin and Benjamin 1992, 1993; Kluft et

1. 1984; Sachs et al. 1988). Relationships with partners may be strained or dysfunctional; partners

may require considerable education and support (Sachs et al. 1988). Specialized groups for the

significant others of DID patients can prove valuable (Benjamin and Benjamin 1992, 1993).

Psychopharmacology

No medication has been shown to resolve the symptoms of DID. Medications are used to treat

coexisting conditions, palliate intense dysphoria, and reduce particular target symptoms (Barkin et

1. 1986; Kluft 1984b; Loewenstein 1991b, 2005; Putnam 1989; Ross 1997; Torem 1996). Such

interventions may indirectly reduce the prominence of dissociative psychopathology.

DID patients may complain vociferously about side effects, tend to have brief placebo responses,

and occasionally demonstrate different drug responses across the alter personalities. Eating

disorders and body image disturbances are common among DID patients, many of whom will refuse

any medication they associate with a risk of weight gain, creating thorny problems in managing

comorbid affective disorders.

Anxiolytics and sedatives are useful palliatives but rarely offer complete relief and are prone to

misuse by overwrought DID patients. The effects of selective serotonin reuptake inhibitors on the

symptoms of depression, anxiety, panic, and PTSD in DID patients are often helpful but are partial.

Selective serotonin reuptake inhibitors appear to be helpful to many DID patients, even those

without classic diagnosable comorbid disorders. Antidepressants of all classes are often effective

for a coexisting depression or symptomatic depression experienced across all, many, or an

increasing number of alters. They rarely have a predictable or sustained effect on so-called

depressed personalities.

No firm role has been established for major tranquilizers, atypical antipsychotics, mood stabilizers,

or anticonvulsants although they may prove useful in selected patients. Loewenstein et al. (1988)

reported clonazepam alleviated PTSD symptoms in the majority of the DID patients in a small open

clinical trial. Anecdotal reports indicate that atypical antipsychotics, especially olanzapine, may

reduce chaos in some DID patients. Ross’ (1989), (1997) observation that every prescription for a

DID patient is a clinical experiment remains painfully astute. Therefore nonpharmacological

interventions, especially hypnosis and reconfiguring the alter system, should be considered (Kluft

1984b, 1994c; Loewenstein 1991b, 2005).

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Wilbur (1986) described multiple transferences from the several alters and noted that their rapid

fluctuations and/or abrupt incongruities could be vexing. Brenner (2001) reformulated this as the

“mosaic” transference. In the traumatic transference (D. Spiegel 1988; Loewenstein 1993; Kluft

1994d), the therapist is perceived as an abuser from the past and reacted to with great

apprehension and defensiveness. Loewenstein (1993) and Kluft (1994d), both deriving their

formulations from Blank (1985), described the flashback or scenario-based transference. The

therapist is seen as if he or she were a participant in a particular event that is being reenacted

without conscious awareness. The patient may reenact any role in the prior situation and attribute

any role, including that of the patient, to the therapist. When traumatic, scenario-based, or

flashback transferences emerge abruptly, the patient may appear transiently borderline or

psychotic.

In the dissociative or hypnotic transference (Loewenstein 1993), the patient’s high hypnotizability

and/or dissociativity impacts the transference field. Phenomena such as absorption, focused

attention, and amnesia; altered perceptions; and cognitive distortions such as literalness and

tolerance and rationalization of illogic and contradiction (Loewenstein 1993) must be addressed.

In the quasi-positive submissive transference (Kluft 1994d), the patient responds to the therapist

with positive affect and compliance, and the treatment appears to be going well. However, what is

being reenacted is a unique negative transference in which the therapist is perceived as a past

abuser who insisted on being told he or she was loved and that the patient enjoyed what was done

to him or her. It is often recognized in consultations as a cause of stalemate. Often such patients

seem pleased and serene in the therapy session but are doing things outside that involve risk or

self-harm.

First encounters with DID patients often elicit fascination and overinvestment (Wilbur and Kluft

1989). Therapists often then react in one of four common patterns (Kluft 1991; Wilbur and Kluft

1989). In the first, the therapist reacts to the intense and intolerable nature of the patient’s

accounts of trauma by withdrawing into a detached, skeptical, and detective-like stance in which

empathy is forfeited and the patient is pressed to prove whatever has been alleged or it will be

discounted. In the second, the therapist concludes that the patient has suffered so horribly that

therapy within normal limits cannot relieve the hurt. Normal boundaries are abandoned in an

attempt to love the patient into health. In the third, the therapist decides that treatment alone will

not suffice to address the wrongs allegedly done to the patient and becomes an advocate, urging or

supporting the patient’s efforts to pursue redress through legal measures. In the fourth, the

transient trial identification of empathy is overwhelmed, and counteridentification occurs.

Immersed in the patient’s pain, the therapist develops vicarious or secondary posttraumatic stress

symptoms.

Initial enthusiasm usually gives way to exasperation and frustration (Coons 1986). Kluft (1994d)

outlined eight chronic countertransference themes:

1. Frustration/exasperation with the world of multiple reality disorder
2. Frustration/exasperation with the patient’s preoccupation with pain evasion
3. Frustration/exasperation with the patient’s preoccupation with controlling the therapist
4. The price of empathizing with trauma
5. The rebuffing of the healer
6. The loss of a sense of efficacy and the pressure to misguided repair
7. The frequent absence of collegial appreciation for or validation of the therapist’s efforts
8. Discounting/invalidation of the therapist’s contemporary personal identity and sense of reality

Obtaining consultation or supervision may be very helpful when these reactions prove difficult to

contain.

Outcome Studies

Major questions remain unanswered. Kluft (1982, 1984a, 1986, 1993a) followed 123 patients in anPrint: Chapter 34. Dissociative Disorders and Depersonalization http://www.psychiatryonline.com/popup.aspx?aID=259199&print=yes…

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open-ended project; 89% ultimately achieved integration, 2% achieved resolution, 5% interrupted

treatment, 2% died, and 2% remained in active treatment. Relatively healthy patients were

overrepresented, and the therapists were very experienced. Coons (1986) studied 20 state hospital

clinic patients (averaging 39 months follow-up). Nineteen were treated by supervised neophytes.

On follow-up, 25% were integrated and 67% considerably improved. Ellason and Ross (1998)

found that 23% of the DID patients hospitalized on their unit were reported integrated 2 years

after discharge. Many DID patients can and do recover. Experienced DID therapists using

approaches tailored to DID can achieve success with most DID patients in the best and

intermediate prognosis groups; neophytes supervised by experienced DID therapists help the

majority of DID patients improve.

CONCLUSION

Most dissociative patients ultimately respond reasonably well to psychotherapies that acknowledge

and address their unique psychopathologies. However, intense and often prolonged individual

psychotherapies may be required.

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