Therapy Treatment for complex Dissociative Disorders

Therapy and Medication

Therapy is the primary treatment; medication is neither a primary treatment for Dissociative Identity Disorder nor for Complex PTSD; typically resulting in only a partial improvement. Medication is commonly used to treat comorbidComorbid means the the presence of more than one psychiatric diagnosis at once, with substance use this is often referred to as "dual diagnosis" Also see [[Cormobid]]. conditions and for stabilization.^[1]

Therapy of dissociative disorders usually follows a phase-oriented approach (stabilization, processing trauma and integration). Studies show that treatment specifically designed for complex dissociative disorders improves a number of dissociative symptoms, while traditional trauma therapy has the risk of destabilizing or even decompensating the patient. ^[2]:xi-xiii The treatment of Complex PTSD also uses three phases: safety, processing unresolved trauma and consolidation of treatment gains. ^[3] The ISSTD has published treatment guidelines for adults, ^[4] as well as separate guidelines for children and adolescents. Movement through the phases is often non-linear; patients in the second or third phase of treatment may need to go back to a previous phase to maintain safety or to process previously unprocessed traumatic material.

Treatment Goals and Outcomes

Integrated functioning is a major treatment goal; this does not necessarily mean complete integration and loss of separateness between all alter identities/parts.^[4]:134 The term integration may refer to integrated functioning between altersAltered states of consciousnessExchangeable terms include parts, dissociative parts, personality states, self-states, states, identities, selves, or ego states. Alters are present only in those with dissociative identity disorder or similar presentations of other specified dissociative disorder, where the parts of the personality are highly dissociated and isolated. No alter, including the host alter, is a complete personality, even though an alter might feel as if they are. {{Rp|55-67}}Alters are psychodynamically interacting parts, each with their own separate centers of subjectivity, identity, autonomy, and sense of personal history. {{Rp|55}}An individual with dissociative identity disorder may have few or many |alters, which include a variety of ages, cross gender, animal or objects, with coconsciousness (see coconsciousness) at varying degrees, and [[communication]] can be limited to one direction. (one way amnesia) {{Rp|301}}/dissociated parts, integrating traumatic memories, the fusion of two or more alters, or final fusionIntegration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." {{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. {{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." {{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. {{Rp|143}} (known as unificationAlso known as final fusion. See 'integration'.Integration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." {{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. {{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." {{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. {{Rp|143}}, or complete integration). Ringrose (2011)^:24 states that people with complex dissociative disorders should discuss the decision about whether to remain multiple or fully complete integration with their therapist, in order to judge which route to follow in treatment. Ringrose cautions that discussing whether this should be a treatment goal at the start of therapy may not be useful; it is better to discuss this once dissociative parts (alters) have a greater awareness of each other and their common goals.

The ISSTD treatment guidelines state:

A desirable treatment outcome is a workable form of integration or harmony among alternate identities... IntegrationIntegration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." {{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. {{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." {{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. {{Rp|143}} is a broad, longitudinal process referring to all work on dissociated mental processes throughout treatment."^[4]:134

Cooperative Arrangement

All alters/parts remain separate but work together, communicate and agree shared goals. This outcome is the less stable because later stresses can lead to floridAn organization that has been voted down by other experts, because it mixes many disorders together. {{Rp|419}} dissociative identity disorder and/or PTSD.^[4]:134 Many people with dissociative identity disorder choose not to aim for final fusion, or are unable to fully achieve it.^[4]:133

Fusion plus Cooperative functioning

Some alters/parts fuse together, with a cooperative arrangement being reached between remaining alters/parts. This is less stable that final fusion.^[4]:134 During treatment the increased communication and cooperation between alters may lead to less fear of fusion or final fusion.

Final Fusion

If a person no longer wants to have a sense of having multiple identities then all alters/parts within that person will need to fuse together for this to happen. All alters/parts will need to cooperate and communicate before this is possible. Final fusion is when a patient’s sense of self shifts from multiple identities to a unified self.^[4]:134

The same three phases are used for all these treatment goals, with some differences occurring during the second and third phases of treatment.

Equality among alters / dissociated parts

The treatment guidelines state that alters in a system should be treated equally. A therapist should not pick favorites and no alter should be treated as more important than another. Although it is sometimes necessary to exclude certain alters from therapy to improve stability and safety, this should only be used temporarily and only when there are no other options. Again, all alters should be treated equally. ^[4]:132-133 It is countertherapeutic to tell alters to go "back inside" and ignoring alternate identities is not appropriate. ^[4]:140

Some alters may be unlikable, disruptive or engage in certain (destructive) behaviors; repeated suicide attempts and self-harm are very common.^[4]:137 It is certainly untherapeutic to try to "get rid" of any alters or even suggest this,^[4]:133 but a therapistPyschotherapists are often called a 'therapists'. These professionals may be a psychiatrist, psychologist or other mental health professional who have specialist training in psychotherapy. They are qualified to work with patients in a clinical setting. can "provide strategies for the patient to resist the influence of destructive identities, or to help control the emergence of certain identities at inappropriate circumstances or times)"^[4]:133.

It is important for a therapist to explain the idea that the alternate identities represent adaptive attempts to cope or to master problems that the patient has faced. ^[4]:133

Phase-oriented Treatment

The consensus is that a phase-oriented approach to treating dissociative disorders is the most favorable and has the most chance of success. The most common phases are these:

1. Establishing safety and stability and help cope with the (often very destabilizing) symptoms of dissociation.
2. Working through and processing the traumatic memories
3. Identity integration, better overall life adaption and rehabilitation

These phases are not set in stone. For example, working through traumatic memories is often destabilizing and needs to be accompanied by phase 1 treatment. And while integrating the various identities, new traumatic material may be found which needs to be processed (and may even require stabilizing in phase 1). Phase 3 improving life may be needed throughout the whole therapeutic process. ^[4]:135-136

Phase 1: Stabilization and Symptom Reduction

Patients with Dissociative Identity Disorder often start in a crisis situation. ^{(citation needed)} The first step is then to regain safety. This may include: ^[4]:136-137

• identification of possible harmful alternate identities and finding ways to make sure nothing harmful will happen. This is very important, especially considering 67% of Dissociative Identity Disorder patients have a history of repeated suicide attempts. Safety agreements or "contracts" can be part of this (but should not be relied upon).
• learning how to cope with PTSD and dissociative symptoms (for example, grounding techniques).
• medication and/or crisis planning.
• managing addictions (and eating disorders). This may require referral to other therapists who are specialized in that.

Part of phase 1 treatment is to gain better communication and cooperation between parts of personality, needed for more internal support and to help them feel more validated and heard. This almost always involves that the therapist talks directly with alternate identities (although more experienced therapists will find more subtle ways of communication).

It is important to view the system of alters as just that: a system, a cooperation. This can be hard because some alters may consider themselves as not part of the same body or may feel like they are the 'coreThe terms "core" and "original" were used back in history to mean the part that body was born with, but today we know there is no such part. Many also incorrectly assume the host or ANP is what they call the core. {{Rp|59}} {{Rp|80, 87-88}} (see personality and alters) (see personality)Note: Outside of the dissociative disorders the term core is used by some to mean an individuals "suchness;" a part that is "beneath narrative and memory, emotional reactivity and habit." {{Rp|208-209}}' or most important part. ^[4]:139-140

People with dissociative identity disorder function at many different levels, the treatment of people who remain chronically low-functioning should focus on stabilization, crisis management, and symptom reduction. ^[4]:141 This is because they may not be able to manage the intensity of the processing of trauma memories, or the fusion that may occur after this. This means some people may not progress beyond this phase or may continue in Phase 1 for long periods of time. However, these patients may still make considerable improvements in safety and overall functioning.^[4]:141

Phase 2: Working through and Processing Traumatic Memories

In this phase, memories that were long repressed, will be walked through and processed, possibly using abreaction. ^[4]:142

Because this has the potential to destabilize again, it is important not to proceed too fast with this. ^[4]:143-144 If it gets out of hand, it may be necessary to go back to phase 1 (stabilization). ^[4]:142 This is also needed if when resistance happens to integrate memories. ^[4]:143-144 It is also important that the patients learns beforehand what this all means and what will happen. And it is also important for the patient and therapist to plan ahead together for what memories will be processed, when they will be processed, how they will be processed and who (which alters) will participate. ^[4]:142

Part of phase 2 is also the integration of traumatic memories across the whole system. This is called synthesis in structural dissociation. Synthesis should also be followed by realization and personification (full realization of what happened in the past and that the past is just a memory - at that stage). Sometimes, this process may be the most fearful. ^[4]:143

Integration of identities can also happen in this phase, but may also happen in phase 3. Integration can happen spontaneously because traumatic memories are integrated and alternate identities feel less and less separate and distinct. However, fusion should not be pressed: alters may 'disappear' in order to please the therapist. ^[4]:144

Phase 3: integration and rehabilitation

In phase 3, major trauma memory work has finished and most people feel a greater sense of calm, resilience, and internal peace.^[4]:144-145 In this phase many tasks are similar to those needed for non-traumatized patients who "function well but experience emotional, social, or vocational problems".^[4]:145

Other things that are done in phase 3 treatment:

• internal cooperation improves and functioning becomes more coordinated and integrated^[4]:144
• people usually "begin to achieve a more solid and stable sense of self and sense of how they relate to others and to the outside world."^[4]:144
• Further fusion of identities (if the person sees this as a desirable treatment goal) See also Integration '
• Reconstructing and reviewing autobiographic memory, either as a single, unified person (in the case of final fusion) or with the different perspective gained from processing the major traumas
• a more coherent sense of the past and the person's personal history may develop
• Leaning to cope with day-to-day problems in nondissociative ways

In this phase, patients will be able to use their energy more productively, not just to cope with past trauma. They will also be able to have more perspective on life and be able to set life goals. ^[4]:144-145

Types and Costs of Treatment

Standard forms of treatment that have not been specifically designed for dissociative disorders have been tried (including cognitive behavioral therapy, but these have shown to be less effective for those with significant dissociative symptoms, and clients have been less responsive to treatment. Stage-oriented treatment designed for dissociative disorders has been shown to be the most cost-effective treatment, and less clients drop out of treatment. ^[5]:390

Treatment of Dissociative Identity Disorder is very costly in the United States, with clients needing more treatment sessions than for other diagnoses.^[5] However, the cost and distress caused by avoiding treatment is even greater.^[5]:390 One study on data from Medicaid patients from 1993 to 1996 showed that treatment of Dissociative Identity Disorder accounted for one-third (33.5%) of all inpatient treatment costs, while those patients made up only 2.6% of the sample of patients. This shows that funding for longer term research, with larger numbers of clients and in more locations, is badly needed to make it clear which treatment techniques are the most beneficial. Brand (2012)^:393 also states:

In view of the high cost associated with DD patients, it is particularly noteworthy that treatment is associated with improved social and occupational functioning as well as decreases in self-destructive behaviors and suicide attempts."

Even the most severely traumatized individuals improve with proper treatment, adapted to address the complex trauma these patients suffer from. ^[5]:16 The treatment guidelines for dissociative identity disorder use the same three-phase approach used for the treatment of complex posttraumatic stress disorder; which is normally a comorbid diagnosis.

Effectiveness of Treatment

Severe dissociative disorders are associated with high levels of treatment, and high levels of impairment according to Brand et al. (2013). The same research commented on the high social, psychological and occupational cost to patients, and the fact that accurate diagnosis and treatment can reduce these costs as well as the financial burden to society and the individual. People with untreated dissociative identity disorder may continue to be involved in "abusive relationships or violent of violent subcultures", putting both themselves and their children at risk of future traumatization which may result in children developing DID. Sadock (2011)^:674 reports that many authorities believe people with undiagnosed or untreated DID die of suicide or risk-taking behaviors; repeated suicide attempts and self-harm are known to be common in people with DID.^[4]

Cloitre et al. (2010) conducted a randomized, controlled trial of people being treated for PTSD as a result of childhood abuse, and Brand et al. (2009) studied out-patient treatment for Dissociative Identity Disorder and Other Specified Dissociative Disorder (DDNOS), both findings showed that phased-based treatment had better outcomes for dissociative forms of PTSD and severe dissociative disorders.

Brand et al. (2009) analysed a 280 patient reports and 292 therapist reports, finding that those in the later stages of treatment "engaged in fewer self-injurious behaviors, had fewer hospitalizations, and showed higher levels of various measures of adaptive functioning" compared to those in the first stage of treatment. Those in the later stages of treatment also reported lower symptoms of dissociation, posttraumatic stress disorder, and distress than patients in the initial stage of treatment, finding the results similar to those for research on chronic PTSD which was related to childhood trauma and depression, and comorbid with borderline personality disorder.

References

1. ^ Brand, BL; Loewenstein, RJ (2010). Dissociative Disorders: An Overview of Assessment, Phenomenology and Treatment. Psychiatric Times, volume 27, issue 10, page 62-69.
2. ^ Hart, Suzette Boon, Kathy Steele, Onno van der (2011). Coping with trauma-related dissociation : skills training for patients and their therapists. New York:W. W. Norton.468.
3. ^ Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L., Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A., Van der Hart, O.. The ISTSS Expert Consensus Treatment Guidelines For Complex PTSD In Adults. Journal of Traumatic Stress, volume 24, issue 6, 5 November 2012, page 615-627.
4. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae International Society for the Study. Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, volume 12, issue 2, 28 February 2011, page 115–187. (doi:10.1080/152947)
5. ^ a b c d Brand, BL; Lanius, R; Vermetten, E; Loewenstein, RJ; Spiegel, D (2012). Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move toward the DSM-5.. Journal of trauma & dissociation : the official journal of the International Society for the Study of Dissociation (ISSD), volume 13, issue 1, 1 January 2012, page 9-31. (doi:10.1080/152987)

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