NAVIGATING LIFE WITH DID: Understanding Treatment Expectations

Sometimes living with DID may feel like multiple people inhabiting the body. This impression comes from the subjective experience of alternate identities and how each may come across. The identity or the state that's in control of the executive function most of the time, may feel helpless, intruded, has no control, as if another entity or person took over the body. Some may experience time lapses, which they have little to no recollection of what took place. Some may find evidence they don't remember, evidence such as a piece of art or creative writing they don't remember doing, but have all the reasons to believe they must've done it. Some may miss or lose something important while in a different state and could not locate or find the item in another state which may become alarming for most people and enough a reason to seek treatment.

The attribution of DID experience as taken over by "an entity" or attribution to multiple people inhabiting the body may be more prevalent in some cultures than others. But the overall subjective experience may feel like multiple people inhabiting the body than a whole person with alternate states. In this case, it's important for clinicians, practitioners and other support system to realize and be pragmatic about the fact that a person with DID is a whole person with distinctive states taking on different roles and responsibilities.

One person with DID may have a different treatment goal than another. The gold standard of treatment expectation is a "more integrated functioning" in a day to day experience. For that reason, some seasoned clinicians aim at bringing the whole person towards a more integrated state of functioning as much as possible.

Treatment on average may take two years or more depending on the etiology, work associated with the etiology, and the complexity at hand. Treatment is usually divided by phases. During the gradual integration process of the treatment phase, the therapist may from time to time use the individual's description of the alternate states in service of the treatment. But at the end of the day the core value of treating DID entails bringing about increased degree of awareness into the different states and functional coordination of alternate states.

In the majority of DID experiences each alternate state appears to have its own first person perspective and feeling of its own self as well as a view of other parts as not Self. The alternate state that is taking charge of the executive control at any given time typically talks in the first person and may disavow or be entirely oblivious of the other identity states.

The shift or switch from one identity state into another is usually precipitated by stressful situations that typically surpass the capacity of the identity state that's in charge of the executive control at the time. Put it another way, the transition between states takes place in reaction to changes in emotional state or environmental demands leading to the emergence of another identity state to assume executive control. It's important to note that these different identities may have different emotions, memories, beliefs, and opposing point of view about a situation or experience which may become a challenge for clinicians with limited experience with DID.

The Guidelines for DID, 2nd Edition, published by ISSTD suggests:

"Helping the identities to be aware of one another as legitimate parts of the self and to negotiate and resolve their conflicts is at the very core of the therapeutic process. It is counter therapeutic for the therapist to treat any alternate identity as if it were more “real” or more important than any other. The therapist should not “play favorites” among the alternate identities or exclude apparently unlikable or disruptive ones from the therapy (although such steps may be necessary for a limited period of time at some stages in the treatment of some patients to provide for the safety and stability of the patient or the safety of others). The therapist should foster the idea that all alternate identities represent adaptive attempts to cope or to master problems that the patient has faced. Thus, it is counter therapeutic to tell patients to ignore or “get rid” of identities (although it is acceptable to 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)."Journal of Trauma & Dissociation, 12:115–187, 2011 133

Clinicians and other providers have to be very mindful of how they address alternate identity states. Some individuals with DID may already have names, gender, age and other distinct identity attributes associated with each alternate identity state they're aware of. This may not be the case for many individuals with DID. In these situations, it is counter therapeutic for clinicians to suggest that the person with DID to name identities when in fact they have no names, or to suggest that identities function in a more elaborated and autonomous way than they already are.

During the last stages of treatment, most individuals with DID may appreciate and benefit from the increased awareness into the alternate identity states and functional collaboration between and among alternate identity states. The idea of complete integration may not be feasible in some cases, but also it may not be desirable in some other. Ultimately, after considering all options and practical needs of the situation, the therapist and the person living with DID have to decide what the best desirable outcome or stage of progress would be. Following a successful progress or completion of a treatment, it's beneficial to do some maintenance work and follow up as appropriate.