Dissociative Identity Disorder

Gregory L. Nooney

doi:10.1093/acrefore/9780199975839.013.1633

Summary

Individuals with the diagnosis of dissociative identity disorder (DID) developed a myriad of methods, including the creation of an intricate inner world of alternate identities, or alters, to creatively survive the devastating effects of early childhood trauma and attachment wounds. Unfortunately, a belief in its rarity even by mental health professionals, the perceived difficulty in diagnosing and treating dissociation, and a fear of the unknown have resulted in DID’s being underdiagnosed. The result has been that many with this condition have been ineffectively treated for co-occurring disorders and have been inaccurately perceived as resistive to treatment. Detailed methods of diagnosing DID, specific steps to help stabilize clients with DID, and in-depth trauma-specific protocols are summarized, along with ways to minimize the elevated risks of compassion fatigue and countertransference in working with this population.

Types of Trauma

It is important to differentiate clients with single-incident trauma who meet the criteria for post-traumatic stress disorder (PTSD) and can be effectively treated utilizing a number of evidence-based treatment protocols from those who have experienced complex trauma and require additional consideration to be effectively treated (Kezelman & Stavropoulos, 2012). A subset of these complex trauma survivors will meet the criteria for DID. Owing to the prevalence of clients with early childhood trauma and insecure attachment histories, it is likely that social workers and other mental health professionals will encounter clients who meet the criteria for DID. These clients often live chaotic and distressing lives because of their propensity for experiencing profound amnesia while switching identity states. To make matters worse, most have debilitating co-occurring disorders which exacerbate their symptoms (Ross, 2007; Ross & Halpern, 2009). Unfortunately, this disorder is often underdiagnosed, and clients receive ineffective treatment as a result. Even though there are some important differences to take into consideration in the treatment of DID, many of the methods used in treating complex trauma can be utilized. If social workers and other front-line mental health workers are better informed of the symptomology and resilience of those with this disorder, false negatives can be reduced and more clients will have the opportunity to receive effective treatment.

Overview of DID

The diagnosis of DID was first listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association [APA], 1994). Prior to that, it was called multiple personality disorder, although, in spite of some common misunderstandings, it has always been defined as a dissociative disorder, never as a personality disorder.

By definition, clients with DID have “two or more distinct personality states” (APA, 2022, p. 330). A common term used to refer to these internal parts is “alters,” which is short for alternate personalities or alternate identities. Clients with DID often have their own unique way of referring to the parts, such as “friends, versions, other people,” and it is important to honor their terminology. One or more alters will be in charge of the body at any given time, which can be referred to as “fronting.” When there is one particular alter who appears to be primarily responsible for fronting, that alter will be referred to as the “primary.” It is important to note that the primary is not always the “original” and does not always refer to themselves with the name on their birth certificate.

Etiology

The APA published the third edition of the DSM (DSM-III) in 1980 and, for the first time, provided detailed diagnostic criteria for all mental disorders, opening the door to more consistency in diagnosis. As a result of conflicting theories about the causes of these disorders, the APA chose to mostly ignore etiology and defined the criteria on the basis of observable symptoms alone. One result of this decision is that early childhood trauma is listed as a risk factor rather than a cause of DID (APA, 2022, p. 333).

Several developmental models are used to explain the causes of DID. They all posit that the fragmented identities present in those diagnosed with DID were created as a result of childhood trauma and/or insecure attachment (International Society for the Study of Trauma and Dissociation [ISSTD], 2011, pp. 122–124), especially disorganized attachment (Liotti, 1992). Studies supporting the developmental model have shown that significant DID symptoms predate any interaction with clinicians and that clients with DID often present symptoms unique to DID that neither they nor their therapists were aware of at the time (ISSTD, 2011, pp. 122–124). Although such fragmentation creates significant difficulties later in life, it is clear that having alternate identities while growing up creates resilience to the chronic trauma and neglect that these individuals have experienced. Reinders and Veltman (2021) refer to these developmental models as “the trauma model,” point to neurobiological evidence, and define DID as closely related to PTSD, one of the few DSM diagnoses, along with reactive attachment disorder and adjustment disorders, that require a specific causal event in order to make the diagnosis.

Another theory, the sociocognitive model, also referred to as the iatrogenic model, rejects DID as a real psychiatric diagnosis (ISSTD, 2011). The theory posits that DID is an artifact of clinicians who have a strong attraction to, and interest in, treating the condition. As a result of this preoccupation, they influence their suggestible patients to exhibit the symptoms of DID. Research demonstrating that the complexity of symptoms exhibited by those with DID can be created and sustained over time as a result of therapist influence is lacking (ISSTD, 2011, p. 123). Putnam (1991) cited multiple sources demonstrating the validity of the DID diagnosis. Ross (1999) pointed out that advocates of the sociocognitive model have only a vague notion of the treatment approach for such clients and have offered no data to support their position (p. 185). Brand and Loewenstein (2014) studied the iatrogenic hypothesis that focusing on direct interaction with alters harms patients with DID, and the authors concluded that it did not, and that it was more likely that depriving patients of such intervention caused harm.

Adherents of the sociocognitive theory also note media influences and argue that clinicians and their patients are overly affected by such presentations and work hard to reproduce alternate personalities (ISSTD, 2011). Watters (2022) emphasized the negative effects of the recovered memory movement of the 1980s and early 1990s and concluded that repressed memories should not be trusted and the fragmentation reported by clients diagnosed with DID and their therapists was suspect. The fact that false memories can be created does not negate the reality that repressed memories do, in fact, exist. Van der Kolk (2014, pp. 192–194) pointed out that even though false memories can be produced in the laboratory, the terror and helplessness associated with PTSD cannot be artificially reproduced. It is these sources of suffering that therapists must deal with in working with clients who have suffered early childhood trauma.

Prevalence

Although multiplicity had long been treated in psychology and psychiatry, the first edition of the DSM (APA Mental Hospital Service, 1952) did not list multiple personality disorder as a recognized diagnosis. The closest it came was a listing of “dissociative reaction” under the heading of “psychoneurotic disorders” and indicating dissociated personality as one aspect of this disorder (p. 32). The second edition of the DSM provided a diagnosis of hysterical neurosis, dissociative type, under the neuroses category, “equating symptoms of multiple identities as due to hysteria” (APA, 1968, p. 9).

The DSM-III included a section titled “Dissociative Disorders,” which provided for a separate diagnosis called “multiple personality,” listing it as “apparently extremely rare” (APA, 1980, pp. 257–258). The revised third edition, published by the APA (1987), altered this estimate: “Recent reports suggest that this disorder is not nearly so rare as it has commonly been thought to be” (p. 271). Fortunately, the decades that followed have seen a dramatically increased understanding of the powerful effects of adverse childhood experiences (Felitti et al., 1998) and of insecure attachment on brain development as well as on the development of emotional, psychological, medical, and behavioral problems throughout the life cycle. A fragmentation of identity is one of the most severe of these effects.

In the fourth edition and fourth edition, text revision, of the DSM (DSM-IV and DSM-IV-TR, respectively), the name of the disorder was changed from multiple personality disorder to DID. The DSM-5-TR provides two estimates: a lifetime prevalence in a Turkey study at 1.1% and 12-month prevalence at 1.5% in a small U.S. community, which is identical to their estimate of the 12-month prevalence of bipolar I disorder and higher than that of schizophrenia at 0.3%–0.7% (APA, 2022, pp. 116, 146, 333). Yet it is not uncommon to hear psychiatrists, psychologists, social workers, chemical dependency counselors, and other practitioners who work with individuals with severe mental illness to hold onto the belief that DID is a rare disorder and consequently not important enough to learn how to diagnose and treat.

It is possible that the actual prevalence of DID is much higher. Some studies estimate that 3% of the population meet criteria for DID (ISSTD, 2011, p. 117). Ross and Halpern (2009) estimate that 20% of psychiatric inpatients have a dissociative disorder and that 7% of those involved in chemical dependency treatment meet criteria for DID. Ross (2015) reported six studies in 10 countries that show that 3.9% of 1,529 psychiatric inpatients met criteria for DID but were not so diagnosed.

Clients with DID are commonly misdiagnosed with bipolar II disorder (APA, 2022, p. 335). A high percentage of clients with DID have been misdiagnosed with schizophrenia. Ross (1999, p. 184) estimates 25%–50%, and Kluft (2009) estimates 26.5%–40.8%, the result of which is ineffective treatment or treatment that makes the client worse. Equally concerning is the frequency of clients with DID being misdiagnosed with borderline personality disorder (BPD).

It is important to note that clients diagnosed with BPD and DID share histories of childhood trauma and attachment wounds. Ross and Halpern (2009) consider DID to be a more complex form of BPD. A diagnosis of BPD requires “a pervasive pattern or instability of interpersonal relationships, self-image, and affects, and marked impulsivity” (APA, 2022, p. 752). Owing to the tendency for clients with DID to switch alters during situations of stress or when triggered, they can easily meet these criteria. According to the DSM, there are several criteria that must be met in order to diagnose any personality disorder. Category E states: “The enduring pattern is not better explained as a manifestation or consequence of another mental disorder” (APA, 2022, p. 735). Consequently, if a client meets criteria for both BPD and DID, and the symptoms present can be explained by the DID diagnosis, then BPD need not be diagnosed.

Diagnostic Process

One of the reasons that DID is underdiagnosed is that, in doing initial assessments, clinicians do not routinely ask the right kinds of questions to determine whether dissociation is present and, if so, how extreme it is (Ross & Halpern, 2009, p. 36). One way to bridge this gap is, when asking about memory problems, to enquire whether the client has ever lost time. In asking this question, the therapist should be prepared to explain what that means. The experience of getting immersed in a television program and then realizing that a couple of hours have passed is different from waking up on Monday morning and not remembering anything about what one did over the weekend. Sometimes it is helpful to introduce a dissociation continuum in which normal dissociation (such as highway hypnosis) is at one end and having alternate identities take over the body without the client’s knowledge is at the other end (Nooney, 2022, p. 56).

There are easy-to-use instruments that can help with the diagnosis. The Dissociative Experiences Scale II (DES-II) is an open-sourced and easy-to-use screening tool. It consists of 28 questions, and the client indicates the percentage of time from 0% to 100% in which they experience each symptom. Scoring is simple (one adds the totals and divides by 28), and if the client scores 30 or higher, there is a high probability of significant dissociation and further enquires can be made (Carlson & Putnam, 1993). If the clinician goes over each question that the client rated high, useful information can be gleaned about the extent of dissociation. Additional detailed instruments are available through the International Society for the Study of Trauma and Dissociation website.

According to Kluft (2009), only 6% of adults who meet the criteria of DID will make their dissociation obvious on an ongoing basis. Even when the clinician asks the right questions, clients are unlikely to reveal the extent of their dissociation until a trusting therapeutic relationship is established. Clients who may ultimately be diagnosed with DID will almost always meet criteria for other disorders such as depression, anxiety, obsessive-compulsive disorder, and PTSD, and these conditions can be diagnosed. Once a definitive DID diagnosis can be made, it can be added to the list (Nooney, 2022).

False Positives

False positives and false negatives clearly exist in the diagnosis of DID as in all diagnostic categories. False positives can occur when the client has a strong motivation to simulate an illness because of, for example, pending legal charges (ISSTD, 2011, p. 129). These individuals tend to engage in dramatic switching of alters and overreport dissociative amnesia and offer their symptoms as an excuse for their criminal behavior. In these cases, the correct diagnosis would be malingering or factitious disorder (APA, 2022, p. 337).

Pietkiewicz and colleagues (2021) noted that the frequency of DID presentations in social media creates a risk of individuals imitating the symptoms of DID which could result in a false positive. The authors noted several ways of identifying clients who are motivated to imitate DID, including becoming upset if the diagnosis is not confirmed; involvement with support groups for dissociative patients; self-diagnosing DID; an absence of avoidance behaviors; eagerly reporting dissociative symptoms, including dramatic switching prior to developing a trusting relationship with the clinician; and attributing unacceptable behavior to the emergence of an alter. It is important for therapists to be aware of these red flags in order to reduce the chances of a false positive.

False Negatives

Brand and colleagues (2015, p. 257) examine six myths about DID and show evidence that believing these myths leads to false negatives: belief that DID is a fad; belief that DID is prominently diagnosed in North America by DID experts who overdiagnose the disorder; belief that DID is rare; belief that DID is an iatrogenic rather than a trauma-based disorder; belief that DID is the same as BPD; and belief that DID is harmful to patients.

Reinders and Veltman (2021) noted other factors contributing to false negatives, including inadequate and misleading information about trauma in undergraduate and graduate programs and a general reluctance to believe the horrendous stories of abuse and neglect that clients with DID reveal. False negatives are especially problematic. “If not assessed and treated specifically for the dissociative disorder, these individuals often receive prolonged treatment for the comorbid diagnosis only, with limited overall treatment response and resultant demoralization, and disability” (APA, 2013, p. 297).

Challenges

There are many challenges facing social workers and other professionals in working with clients with childhood trauma, including the establishment of trust and attunement, unreliable memory, decompensation when uncovering trauma memories, suicidality, and the provider risk of compassion fatigue. For those clients with DID, additional risks include rapid switching and the risk of breaking down dissociative barriers too quickly (Nooney, 2022).

Attunement

Disorganized attachment in childhood is a precursor of the development of dissociation in later life (Liotti, 2009; Sroufe & Siegel, 2011). When attunement can be established between a therapist and a client in the context of a positive therapeutic relationship, clients with disorganized attachment histories can alter traumatic patterns of interaction and develop a secure state of mind (Sroufe & Siegel, 2011). This occurs because of brain plasticity and long-term potentiation (Montgomery, 2020). The requisite attunement is difficult to achieve with survivors of early childhood trauma and attachment wounds but is especially challenging with clients with DID since it is not enough to establish a sense of trust with the primary alter. Clients with DID often have multiple alters, each with their own experiences and memories of abuse and neglect. Unless they agree to engage in the therapeutic process or at least agree not to disrupt the process, protective alters can disrupt the development of trust and attunement. Another challenge is the possibility of additional alters, not yet identified, who may emerge during the course of therapy to disrupt this process.

Compassion Fatigue

Listening to accounts of abuse and neglect can have a negative effect on therapists working with clients with DID. Therapists must be diligent in coming to terms with any instances of countertransference. Paying careful attention to setting clear boundaries at the beginning of therapy and seeking expert consultation when needed will help mitigate problems developing in the therapeutic relationship (ISSTD, 2011, p. 164). Periodically revisiting those parameters when additional alters are identified is also important. Therapists must also attend to any unresolved issues in their own lives, such as their own trauma histories, and seek therapy intervention for themselves if needed. Smullens (2015, p. 42) pointed out the important connection between compassion fatigue on the one hand and burnout resulting from countertransference and vicarious trauma on the other. Unless successfully dealt with through increased awareness, transparency, and self-care, compassion fatigue will become another barrier to creating sufficient trust and attunement.

Unreliable Memory

Ross (2007, p. 51) noted that there are no clinical criteria whereby a memory, whether recovered or continuous, can be definitively determined to be true or false. O’Keane (2021, p. 208) noted that owing to the imperative of change, all biographical memory is suspect because it is false to some degree. For these reasons, it can be dangerous for therapists to take at face value the details of memories as reported by clients. This is especially important with clients with DID because an alter who tried in the past to tell someone about the abuse they suffered and was not believed might plead with the therapist to believe their memory. If the therapist agrees, there is the possibility that a another alter will remember the incident differently, and this puts the therapist in a posiiton of having to choose whom to believe. Psychoeducation with clients early in the therapy around the unreliability of memory can mitigate these risks.

Decompensation

In work with clients with DID, decompensation can take on many forms, including suicidality, rapid switching, and the risk of breaking down dissociative barriers too quickly.

Suicidality

The risk of a client with DID completing suicide is high. About 70% of clients with DID have attempted it, and many have done so multiple times (APA, 2022, p. 334). Attending to suicidal risk, the risk of self-harm, and other safety issues in the therapy process is essential in order for other treatment interventions to be effective (ISSTD, 2011).

Ross (2007, p. 241), in discussing suicide attempts, describes three processes occurring simultaneously. The first process is the obvious one: the client attempting to kill themself. The other two processes are metaphorical: the “other” killing the self and the self killing the “other.” The “other” refers to those who have harmed the client, whether in the past or the present.

With clients with DID, the situation becomes more complicated because it is possible for different alters to take on the role of each of these “murders.” There can be a suicidal alter who is determined to die by suicide. A protective alter may take on the role of the perpetrator and join with the suicidal alter, and a homicidal-leaning alter seeking revenge from past abuse can be prepared to kill the actual perpetrator. If the clinician gets to know these particular alters, provides psychoeducation, and encourages other alters in the system to meet the needs of these alters, many more options open up for creating an effective crisis plan to mitigate the risk that the client will act on suicidal or homicidal urges (Nooney, 2022, pp. 125–126).

Rapid Switching and Breaking Down Dissociative Barriers Too Quickly

It is important to remember how instrumental early childhood trauma and attachment wounds were in the resulting fragmentation of identity for clients with DID. It is dangerous, however, to elicit details of those experiences too soon in the therapy process, as it can easily result in a “florid decompensation” (ISSTD, 2011, p. 125). Even when the therapist is careful and takes things slow, the willingness of the client to engage in therapy tends to open up internal doors, and the dissociative barriers between alters can start to break down. Alters who have been in the background or pushed down by more powerful alters may find it easier to take over the body, and this can result in increased dissociative experiences and rapid switching. If the clinician continues to encourage inner communication and cooperation, these risks can be reduced and the client can move toward a greater degree of stability (Nooney, 2022, pp. 85–86, 118–121).

Treatment

If the clinician understands the etiology of DID as a combination of early complex childhood trauma and attachment disruption, it may be possible to borrow from well-established forms of trauma treatment.

Evidence-Based Practice

However, owing to the existence of semiautonomous alters who can take over control of the body and amnesia caused by dissociative barriers, the treatment of DID is more complicated than the treatment of trauma survivors who do not suffer from DID. Additional factors make it difficult to do the research necessary to develop an effective evidence-based treatment. The best designs for treatment outcome studies involve a “randomized prospective double-blind placebo-controlled trial.” Additionally, restrictive inclusion and exclusion criteria are necessary in order to ensure the participants in the study are well defined diagnostically. (Ross & Halpern, 2009, p. 63). There are numerous factors that make it difficult to construct such a study for clients with DID: Most clients with DID have co-occurring disorders which would result in their exclusion from the study; the length of treatment for DID can be measured in years and, owing to cost constraints, most studies last a few weeks; it would be easy for clients with DID to figure out whether they were receiving the treatment or a placebo; and there would be ethical problems with withholding a real treatment from clients with DID.

Consequently, there are no recognized evidence-based practices designed specifically for treating DID. Miller (2013) argued that instead of attempting to design a particular protocol for treatment and insistence on following its fidelity, clinicians should consider the best evidence available in combination with clinical expertise and patient values and expectations. The ISSTD’s (2011) recommendation that a phase-based form of treatment for those suffering from complex trauma-related disorders, including DID, appears to meet this standard, Phase 1 involves establishing safety. Phase 2 is when intensive trauma-specific work is carried out, and the third phase involves identity integration and rehabilitation (ISSTD, 2011, p. 135). Debra Korn (2009) and Gelinas (2003) recommend that eye movement, desensitization, and reprocessing (EMDR) practitioners adopt a similar phase-oriented treatment for complex trauma. Joanne H. Twombly outlines a phase-based treatment protocol when using Internal Family Systems (IFS) (Sweezy & Ziskind, 2013). Although Schwarz and colleagues (2017) specifically reject the need for stages of treatment in implementing her comprehensive resource model in treating complex trauma, including DID, the ISSTD reports that the consensus of experts is that sequenced stages for the treatment of DID are indicated (ISSTD, 2011, p. 135).

Phase 1: Stabilization

Clinical judgment is important in determining at what stage of the treatment a particular modality be implemented. Since the disruption of dissociative barriers that exist between the alters in a DID system can lead to profound decompensation, intensive trauma-specific treatment processes are counterindicated until the client is ready for the second-stage work (i.e., has established both internal and external stabilization and is able to handle any disruption which might occur when processing trauma content) (Nooney, 2022, p. 137).

In this first phase of treatment, interaction with the inner parts or alters of the client system takes prominence, but parts work is not confined to DID. Ross (1999) argues that all humans have inner parts which he refers to as “polypsychism,” but those parts are more separate and discrete with a person with DID (p. 193). Carl Jung (1964, pp. 24–26) wrote about a universal fragmentation of identity. Watkins (1993), from a psychodynamic perspective, referred to inner parts as ego states and described methods to work with them. Stone and Stone (1989) developed a therapeutic voice dialogue process to communicate with inner parts. Schmidt (2020) recommended ego-state work as a method to resolve attachment wounds in preparation for EMDR’s trauma-specific work. In the IFS model, all humans have multiple subpersonalities called “parts,” which can be directly engaged in the therapeutic process (Schwartz, 1999).

Psychoeducation is important in this first stage of treatment. Ross (2007) recommends that therapists be aware of seminal constructs in treating trauma and teach them to their clients. These include (a) the locus of control shift and attachment to the perpetrator whereby the child being abused blames themself and (b) the victim–rescuer–perpetrator triangle where clients frequently get stuck switching from one point of the triangle to another. There is a significant risk of the therapist getting caught on the triangle, which can lead to countertransference and boundary violations.

During this first stage of treatment, a number of well-known therapeutic modalities, some of which have been recognized as evidence-based, can be used. Kezelman and Stavropoulos (2012) refer to these forms of therapy as “top-down.” Some examples—and these are not exhaustive—include motivational interviewing, cognitive behavior therapy (CBT), dialectical behavioral therapy, and acceptance and commitment therapy. Fortunately, many clinical social workers and other front-line mental health workers are trained in some or all of these modalities.

In order to be successful in using these methods, Kezelman and Stavropoulos (2012, p. 272) emphasize the importance of helping the client establish a balance between hyper-arousal (agitation) and hypo-arousal (shut-down) through resourcing techniques. Van der Kolk (2014) refers to this as “limbic system therapy” (pp. 207–208), which reflects his understanding of the ways in which the brains of clients with complex trauma histories are too easily activated because of an oversensitive limbic system. Siegel (2010, pp. 50–53) describes how resourcing techniques can widen the “window of tolerance” within which therapeutic work is possible without slipping into the extremes of rigidity or chaos. This mirrors the goal of helping clients step away from the extremes of chaos and rigidity and find the “middle way” of integration (Siegel, 2011, pp. 69–71). Various resourcing techniques, if properly utilized with the client’s approval and consent, can help the client stay in this window where therapeutic work can be carried out most effectively.

It would be impossible for therapists to have expertise in every possible form of resourcing, but it is worthwhile to learn a few methods and offer them to their clients. Nooney (2022) suggests dividing the kinds of resourcing into three sections: mindfulness, somatic, and cognitive-imaginative (p. 101). Schwarz and colleagues (2017) divide them into breathing, imagery, attachment, somatic, or spiritual (p. 225). Regardless of how one organizes the different forms of resourcing, it is important to check in with whichever alter the therapist is working with and invite them to choose the type of resourcing that works best for them.

The ISSTD recommends helping clients “respect the adaptive role and validity of all identities” in this first stage of treatment (p. 139). This involves a process of getting to know the alters, and there are many methods of achieving this. Nooney (2022) suggests specific questions that can be asked and describes common types of alters, including responsible adults, protectors, adolescents, and children. He emphasizes the importance of the alters in the system developing their own methods of coping through learning to communication and cooperate (pp. 104–121). Ross and Halpern (2009) outline methods of normalizing and working with defenses, talking through to the voices, developing internal safe places, orienting parts of the system to the body and the present, forming a working alliance with persecutor parts of the system, increasing internal communication and cooperation, and focusing on adaptation in the present (pp. 123–164).

When the client has made progress in developing skills in managing their internal system, it becomes easier for the therapist to assist them in managing the kinds of day-to-day challenges faced by many clients with trauma histories whether diagnosed with DID or not. They include staying the course of therapy, safety issues in their relationships with others, building a support system, and handling day-to-day crises and triggering events (Nooney, 2022, pp. 122–132).

Phase 2: Trauma-Specific Therapy

When the client has achieved enough stability through the work in phase 1, it is time to consider doing some trauma-specific work. Phase 1 primarily used top-down therapy techniques, and phase 2 will use what Corrigan and Hull (2018) refer to as “transformational trauma approaches” which can be called “bottom-up” therapies, some of which have been designated as evidence-based methods for the treatment of PTSD but not necessarily studied for the treatment of DID. They include cognitive processing therapy, prolonged exposure therapy, EMDR, CBT for PTSD, narrative exposure therapy, and written exposure (Schrader & Ross, 2021). Other methods include brainspotting (Grand, 2013), comprehensive resource model (Schwarz et al., 2017), somatic archaeology (Gibson, 2008), and IFS (Sweezy & Ziskind, 2013).

Twombly (2000) emphasizes the importance of therapists being trained in both DID treatment and EMDR prior to using EMDR to treat clients who have been diagnosed with DID. Similarly, it would be important for therapists, prior to beginning phase 2 work with clients with DID, to have specific expertise in the particular trauma-specific method they choose to utilize. Fine and Berkowitz (2001) outline some of the dangers of using EMDR in the treatment of clients with DID and offer specific suggestions on how to incorporate hypnosis through a particular wreathing protocol to mitigate those dangers.

It is beyond the scope of this article to describe all the different ways in which trauma-specific treatment methods can be adapted to treat clients with DID in this second phase. Whatever treatment model is chosen, both safety and efficacy must be considered. The following 10 steps are adapted from Nooney (2022, pp. 137–149) and address these concerns. Therapists must decide whether these suggestions are consistent with the fidelity of the model being used, and if not, whether they should be ignored or adapted to fit

The planning needs to take place prior to the actual day of the therapy session. If possible, 90 minutes should be scheduled for the session.

A specific traumatic event needs to be chosen.

The particular alters involved in that event need to provide informed consent to do the trauma-specific work. All other known alters must agree for the work to proceed.

Unless child alters are directly involved in the traumatic event, they should be encouraged to go to their safe place, and at least one adolescent or adult alter needs to stay with them to help protect them from being retraumatized by the work being done.

Other alters not involved in the traumatic event can elect to watch or to go to their own safe places away from the work.

Alter volunteers need to be found to support the alters doing the work and to be available for support after the session.

Sufficient resourcing needs to occur for all of the alters involved in the work.

The work will proceed using the therapist’s preferred trauma-specific modality.

At the conclusion of the session, time needs to be spent to ensure the safety of the client, including validation that a responsible adult will take charge of the body in order to ensure the client arrives home safely.

10.

Time should be spent in the next session to discuss the work and whether processing had continued in the time between sessions.

Phase 3: Identity Integration and Rehabilitation

While admitting that full integration is not up to the therapist but must be left to the client to choose or not, Ross and Halpern (2009) insist that a stable integration where “fragmented identities gradually blend together into an ever more unified whole” (p. 72) should be the goal of therapy with DID. They describe this last stage of therapy as “life after trauma” and emphasize that it is as important as the other stages (pp. 220–221). According to the Guidelines for Treating DID in Adults, the fusing of alters in this final phase is either completed or slowly evolves, and the client develops a more solid sense of self. The treatment in this phase resembles treatment of nontraumatized clients who struggle with day-to-day conflicts and problem-solving (ISSD, 2011, pp. 144–145).

Schwartz and colleagues (2017, p. 224) do not set integration as the ultimate goal of therapy. Instead, they emphasize that integration will happen when the client is ready. Nooney (2022) has concerns that having a goal or expectation of integration or fusion can be terrifying to alters who have already lived through devastating experiences of abandonment and who may see such a goal as a loss of identity or a death sentence. He considers the first two phases sufficient with an understanding that achieving a unified whole is not necessary to define treatment success.

Conclusion

This article provided an overview of the often-misunderstood diagnosis of DID, including its etiology in complex childhood trauma and insecure attachment, especially disorganized attachment, and its prevalence. Challenges in the diagnosis and treatment of clients with this disorder were explored. Social workers and other front-line mental health clinicians who encounter clients who meet the criteria for this disorder will need to consider whether their knowledge and expertise are sufficient to diagnose and treat these clients. There are times when referring to another clinician with more expertise in treating DID may be indicated. However, the intensity of the therapeutic work with clients with DID often results in a paucity of suitable referral options. This is especially true for social workers working in community mental health centers where clients with DID may have limited financial resources and access to transportation to transfer to a clinician in private practice. If a clinical social worker is competent in treating complex trauma, they should be able to diagnose DID and proceed with at least the first phase of treatment. Since engaging with internal alters is crucial in this first stage, training in doing parts work with non-DID clients, such as IFS, or other forms of ego-state work such as inner child work, can also be helpful. Additional training in the treatment of DID and in trauma-specific interventions would then be important, in addition to accessing supervision from another clinician with more experience in treating this disorder.

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Article contents

Dissociative Identity Disorder

Dissociative Identity Disorder

Summary

Keywords

Subjects

Types of Trauma

Overview of DID

Etiology

Prevalence

Diagnostic Process

False Positives

False Negatives

Challenges

Attunement

Compassion Fatigue

Unreliable Memory

Decompensation

Suicidality

Rapid Switching and Breaking Down Dissociative Barriers Too Quickly

Treatment

Evidence-Based Practice

Phase 1: Stabilization

Phase 2: Trauma-Specific Therapy

Phase 3: Identity Integration and Rehabilitation

Conclusion

Further Reading

Seminal Books on Trauma and Dissociation

Treatment Models

References