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Dissociative Identity Disorder: A Case Study
Braun, B. (1986) Treatment of multiple personality disorder. Washington D.C.: American Psychiatric Press.
Falvo, D. (2009) Medical and psychosocial aspects of chronic illness and disability. Sudbury MA: Jones and Bartlett Publishers.
International Society for the Study of Trauma and Dissociation (2005). Guidelines for treating dissociative identity disorder in adults. Journal of Trauma and Dissociation 64 (9), pp. 69-149. Retrieved July 31, 2009 from http://isst-d.org
Letch, N. (2004) The case of Billy Milligan. Retrieved July 31, 2009 from http://www.psychinaction.com/uimages//122.pdf
Ross, C. (1997) Dissociative identity disorder: diagnosis, clinical features, and treatment of multiple personality. New York: John Wiley & Sons.
“Dissociative identity disorder (formerly known as multiple personality disorder) is a condition in which at least two personalities exist within the same individual and control the individual’s behavior” (Falvo, 2009, p. 238). This is the only discussion of DID in Falvo’s text. This condition is highly complex; however, for the purposes of this paper, the author will focus on some of the main misconceptions about the condition. She will also discuss interventions and barriers to same, which in this case are directly related to the misconceptions—even, or perhaps most importantly, within the medical community itself. In addition to drawing on scholarly materials, the author has also conducted a face-to-face interview with an individual who was diagnosed with DID nineteen years ago, while pregnant with her second son. This woman has given numerous speeches on the subject of DID in her local area, and provided the author not only with scholarly references, but also with her own experiences as a DID system.
It’s Not What You See in the Movies
The last phrase in the previous sentence, “a DID system,” offers a perfect entrance point to this discussion. One of the most common misconceptions about DID is that, in her words, “Kathy is here. Kathy split into x number of people. Kathy will integrate and be one personality” (Boomgarden, K., interview, July 31, 2009). She goes on to explain: “We’re all here, maybe seven or so at once. It’s like one of those toys where you spin the wheel and you see an image, and if you stop it, nothing’s there. If I stop, nothing is here. There is no Kathy. In fact, I split so early in my life that there isn’t even what they call a ‘birth personality.’” There is a system of personalities or alters—in her case 45 discrete ones—who function as required by the lead personalities. This is discussed in detail in Ross (1997).
Another popular misconception is that DID systems—that is, the bodies they inhabit and the “person” they present to the world—are violent and psychotic. Films like “Primal Fear” feed this disinformation. While it is true that there is one very famous case of a DID system who did commit murder (Billy Milligan; see Letch, 2004), such is the rare exception and not the usual rule. “We are not devoid of moral compasses” (Boomgarden, 2009). There can be and usually are personalities who evince violence, but they are also usually kept in line by the executive identities.
A third misconception, most damagingly prevalent in the medical community itself, is that DID is not real. The use of hypnosis in the early 1980’s as part of the treatment for DID, in order to assist in recovering and working through the memories of the abuse that caused the personalities to appear, came under fire in the 1990’s by what the writer will call “the false-memory people.” Kathy herself was treated by one of the then-preeminent professionals in the DID field, Dr. Bennett Braun. He has since been “dethroned,” to use her term, by his staunch insistence that the memories his patients (Kathy included) recovered were indeed actual, not implanted. Braun (1986) says, “(A)lthough MPD [multiple personality disorder, the former name for DID] is not a by-product of hypnotic suggestion, some superficial symptoms of MPD can be elicited in highly hypnotizable subjects” (p. 4). Ross (1997) states that “(none) of the experiments with normal college students have resulted in the creation of anything even remotely approaching full clinical DID” (p. 77). Furthermore, he goes on to opine that the only reason DID, and not borderline personality disorder or panic disorder, is singled out “for the charge of iatrogenic artifact” is “ideology and bias, not because of data or science” (p. 78). He also states that, in his opinion, this charge is “a defense against dealing with the reality of child abuse in North America” (p. 80).
Interventions: Three-Phase Treatment
According to the Guidelines for Treating Dissociative Identity Disorder in Adults (International Society for Study of Trauma and Dissociation, Chu, et al., 2005), over the last 20 years the medical community working with “complex trauma-related disorders” has settled on a three-phase treatment plan: “safety, stabilization, and symptom-reduction,” followed by memory work with regard to the trauma-inducing experiences, and ending with “identity integration and rehabilitation” (p. 89). That being said, it is important to understand that not all DID systems desire to fully integrate. “Lack of ‘integration’ is not an indication of dangerousness. Not all persons with a dissociative disorder choose integration as an end point for their treatment. In many treatments, the focus is on function, living a life” (isst-d.org, http://www.isst-d.org/education/faq-dissociation.htm, “My (spouse, sibling, employee, child care worker) has a dissociative disorder,” paragraph 3).
The first portion, regarding safety, stabilization, and reduction of symptoms, involves setting up agreements with the DID system much as is done within the AA framework for alcoholics. The professional must elicit agreement from all alters within the system (not individually, but through speaking with those in charge and gaining assurance from them that “everyone heard it and agrees”) that they will not knowingly and willingly cause harm to themselves or others. This also may involve suicide watch/prevention, depending on the individual case. The stabilization process may include cognitive therapy, PTSD medications, and affirmations (ISSTD, 2005, pgs. 93-6), among many other options.
The second stage, working with memories, has a specific purpose. “Specific interventions for DID patients involve working with alternate identities that experience themselves as holding the traumatic memories. These interventions help broaden the patient’s range of emotions and affects across alternate identities, and assist the patient as a whole with tolerating the affects associated with the trauma such as shame, horror, terror, rage, helplessness, confusion, anger and grief” (ISSTD, 2005, p. 100). It is in this phase that hypnosis is most often employed, if indeed the clinician treating the patient incorporates such into the plan. “The process of Phase 2 work allows the patient to gain a sense of control over the experiences and their reactions to them, and to build a better understanding of his/her personal history and sense of self. In addition, DID patients become able to recall the traumatic experiences across alternate identities, especially those who were amnestic or without emotional response to them” (p.101).
During the final phase of treatment, “patients make additional gains in internal coordination and integration, and usually begin to achieve a more solid and stable sense of who they are and how they relate to others and to the outside world” (ISSTD, 2005, p. 103). It bears repeating here that not all patients will want to achieve full integration. It may be sufficient for them to acquire a working system of identities, with agreement between them of who is in charge of what situations or issues at what times. “It’s not true that people with DID have trouble holding a job. In fact, they’re really very good at functioning in the real world. It’s what they do” (Boomgarden, 2009).
Why Not Seek Treatment?
Restraining forces, those that can prevent the DID system from seeking or receiving proper care, are mainly the aforementioned misconceptions within the medical community. The initial diagnosis itself may be years in coming; often DID systems are misdiagnosed as psychotics of various types, and spend years in and out of institutions and/or being adversely medicated (Ross, 1997, p.128). Kathy explained it this way: “If you give someone who’s DID haldol, for instance, which is great for psychotics, that can limit the ability to maintain the structure” (Boomgarden, 2009). “If you mess with the workings of their frontal cerebral cortex, where all that happens, the structure falls apart.”
Even if the DID system does find a psychiatrist who is accepting and understanding of the DID diagnosis, and is able to work with the system toward maintaining a functional life, there remains the issue of other medical professionals who may need to see the system for other reasons. The problem then becomes whether the DID system tells these other professionals about the DID, or not. Kathy again: “If the doctor doesn’t believe in DID, or won’t accept the diagnosis, you will lose their respect for you, causing problems when you relate your reactions, your symptoms—your whole experience is marginalized” (Boomgarden, 2009). She herself has resorted to telling doctors she suffers from PTSD instead of DID, because that is a diagnosis they will readily accept. “I have to lie and say I’m PTSD to get help, but I don’t have those issues any more” (Boomgarden, 2009).
In the End . . .
DID is not as rare a condition as one would first believe. As with so many other diseases and chronic conditions, its existence has become more noticed—and therefore it has been reported to be more prevalent—within the last thirty years or so. While patients with DID can and do greatly benefit from treatment, the rampant misconceptions extant within the population at large, and more damagingly, within the medical profession present definite barriers to seeking treatment initially, and to successfully completing the treatment once it has begun. Those same misconceptions further complicate the patient’s interactions with other medical professionals she may need to see for other needs (surgery, for instance). Education, both of the general populace and of the medical community, would benefit everyone concerned.