“Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented so that the emotions, sounds, images, thoughts and physical sensations related to the trauma take on a life of their own. The sensory fragments of memory intrude into the present, where they are literally relived. As long as the trauma is not resolved, the stress hormones the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting played out.”
(Van der Kolk, 2014, p. 66)
“The concept of a single, unitary ‘self’ is as misleading as the concept of a single unitary ‘brain.’ The left and right hemispheres process information in their own unique fashion and represent a conscious left brain self system and an unconscious right brain self system.”
(Schore, A., 2011, p. 76)
In the 1950s, what was then called “multiple personality disorder” came to the attention of mental health professionals initially through books such as The Three Faces of Eve and Sybil. It was controversial and much disputed then, and today, dissociative disorders are still the subject of controversy. Even before therapists encounter a dissociative identity disorder (DID) client, they will have been affected by the anxiety and even hostility raised by any mention of the diagnosis among mental health professionals. The “countertransference” reaction to the idea that individuals can have multiple consciousness, parts with separate identities or separate lives often pits psychiatrists (least likely to believe such disorders exist) against psychologists and psychotherapists who have evidence that it does because they have encountered its distinctive symptoms and presentation. Since the 1950s, dissociative disorders have often been assumed to be “factitious disorders,” an assumption that is rarely questioned—and rarely documented. In the context of the institutional bias against it, the field has overlooked or ignored research that validates the reliability of the diagnosis of DID and demonstrates that it is much more common in the population than hitherto believed (Brand et al., 2012; 2016). Though there has been more published research on dissociative symptoms in borderline personality disorder and more establishing the under-diagnosing of dissociative disorders than on demonstrating that DID is a factitious disorder, the field of trauma and dissociation has never been able to shed that stereotype. Korzekwa et al. (2009) and Zanarini (1998), for example, have consistently found statistically significant rates of dissociative symptoms in borderline personality and strong correlations between severity of dissociative symptoms and severity of borderline symptoms, including rates of self-injury and suicidality, depression, global psychopathology, behavior problems, and use of psychiatric services. That strong evidence base is rarely mentioned in the literature on borderline personality disorder. Despite the need for better, more effective models for treating clients diagnosed as borderline, their dissociative symptoms are rarely noted or treated. When I was asked in 2008 to consult to a state hospital and provide training in “trauma-informed care,” I was told upfront, “We don’t have DID patients here. Our trauma patients are all borderlines.” I understood the message. It was clear: “Don’t come in here and start diagnosing our patients with DID. If you want to work with us, leave that particular diagnosis at the door.” I was untroubled, though. I was bringing to the hospital a training on trauma and a model for understanding unsafe behavior and suicidality, the Structural Dissociation model. To reassure the staff, I just kept saying, “This is a trauma model, not a dissociative disorders model. And it is the best approach to borderline personality that I have encountered in 25 years.” If that is not enough to allay anxiety, I say, “The parts language gives clients a way to externalize the problem so they can change their relationship to it—the same way eating disordered clients do better when they externalize their eating disorders as ‘Ed.’” All of these statements are true. Whether one believes that each part represents the implicit memories of a child or believes in using the language simply to externalize the behavior, the approach described in this book is helpful to the client. And that is what brings together the skeptics and the believers.
Since the statistical probability of therapists encountering a DID or DDNOS client is fairly high (especially for those who treat trauma, borderline, or suicidal clients), it behooves therapists to be familiar with the diagnostic and treatment challenges of treating dissociative disorders (Brand et al., 2016). In this chapter, we will describe the special challenges of working with clients whose parts are not only structurally dissociated but also function autonomously, often with little to no awareness of the others. Although the theoretical model and the treatment are almost the same as described in previous chapters, a dissociative disorder brings with it special complications for the therapist, not just for the client.
DSM-5 and ICD-9 diagnostic systems both have a “bottom line” criterion for a diagnosis of DID: making the diagnosis requires “evidence of losses of consciousness: two or more parts of the personality take control of the body and operate outside of conscious awareness” (DSM-IV-R, p. 2000).
Assigned to the inpatient unit during my predoctoral internship, my very first patient was a 40-year-old writer diagnosed as acutely psychotic. Caitlyn was besieged by scathing, humiliating voices telling her to kill herself. “You’re a cunt—a whore—you don’t deserve to live—make this world a better place.” Not knowing that clients with psychotic disorders are generally made worse when their delusions are questioned, I made the rookie mistake of suggesting that she take a stand: “Explain to the voices that they are not helping you get you discharged—you need them to back off a bit if they want you to get out of here.”
To the amazement of both of us, the voices responded: by the next day, they had quieted enough to win her a discharge. Two admissions later, the reason for my spectacular success became clear: Caitlyn had a dissociative disorder, not a psychotic disorder. Arriving at the hospital to meet with her, I found my stout 40-year-old patient wandering around the unit wearing a lace tutu and combat boots! “It’s been a strange day,” she said in a lost confused tone, “This morning, I couldn’t remember how to put my clothes on …” and her voice trailed off. As I opened the door to the meeting room, she froze on the doorstep and started screaming, “What are you doing to me?! Who are you? Where’s my mommy?!!!!”
When you’ve been a mother before becoming a therapist, you have certain instincts. One skill you never lose is the ability to know what to say when children are freaking out. “It’s OK,” I instinctively began speaking to her as if to a young child: “Your mom knows where you are. I talked to her today. [Which I had.] She knows you’re with me, and she said it was OK—do you want me to call her?” Calming down a little but keeping her distance from me, she began to wander around the bare hospital office like a child exploring the room while I made conversation with a child in an adult’s body: “Your mom didn’t tell me how old you are or if you go to school.”
CAITLYN: “I’m 6, and I’m in the red reading group!” [Smiles proudly] Everyone knows that’s the best one.” The big smile wasn’t the smile of a proud woman—I could see the grin of that 6-year-old. My heart ached for her: 6 was the year in which this innocent little girl in the red reading group had been raped by her older brother, bullied by neighborhood boys, and emotionally abandoned and unprotected by her alcoholic mother. Before she was used and abused, my client had once been this confident little girl who was proud of how smart she was and eager to learn.
Thanks to Caitlyn, I learned some important lessons very quickly: first, DID (or multiple personality disorder [MPD] as we called it in the early 1990s) really does exist; second, my previous “job experience” raising small children and working with families was going to make working with dissociative disorders remarkably easier—not easy but easier. What I did not know (but would soon learn) was that my success with the little 6-year-old part of Caitlyn would very shortly stand in stark contrast to my ability to enrage other parts of her! Yet another lesson useful for the novice therapist I was then: “You can’t please all the parts all of the time.”
Steinberg (2013) describes five symptom clusters characteristically found in dissociative disorders that facilitate making the diagnosis:
• Dissociative amnesia or “missing time” (i.e., amnesia for periods of time after the age of nine or gaps in daily memory not explicable by ordinary forgetfulness).
• Dissociative fugue: finding one’s self in an unfamiliar location with no memory of having planned to go there and no recognition of others around one. Sometimes, fugue episodes are accompanied by dissociative amnesia, the loss of memory for personal information, such as one’s name, address, age, and job or significant others.
• Depersonalization (feeling disconnected from one’s self or one’s experience)
• Derealization (experiencing other people or familiar surroundings as “unreal”)
• Identity confusion (“Who am I?”): Am I the person who functions? Or is that a false self? Am I needy and clingy? Or militantly independent? Do I want to live or do I want to die?
• Identity alteration: regression experiences, feelings or behavior that do not feel like “mine,” being known by different names, evidence of child parts (stuffed animals, sucking ones thumb, being afraid to be alone), or evidence of activities for which one has no memory.
Psychotic-like symptoms, such as hearing voices, internal dialogues, intrusive voices, thoughts, images, and visual “hallucinations” of the trauma, are also potential signs of a dissociative disorder. These symptoms all represent implicit memory and/or manifestations of parts but unfortunately tend to be diagnosed as symptoms of schizophrenia despite demonstrable differences between trauma-related voices and auditory hallucinations. Dorahy et al. (2009) compared the voices described by two groups of schizophrenic patients (one with histories of trauma and one with no reported trauma) with the voices reported by a group of patients diagnosed with DID. The researchers found that, in this sample, the DID subjects reported hearing voices at a more frequent rate than did the schizophrenic subjects. They also described the voices as having different genders and ages, and they summarized the content of the voices’ communications as generally negative and personally directed, focused on pointing out the individual’s inadequacies, lack of worth, and using these accusations to justify “why you deserve to die.” The voices reported by schizophrenic clients were fewer in number, did not have different ages or genders, and spoke from a more abstract spiritual or paranoid perspective, not a personal one, even if also encouraging self-destruction.
Making a DID diagnosis is not clinically essential if clients are already using trauma-informed treatment models in which the emphasis is on mindful awareness of the emotions, cognitions, body sensations, and action impulses of parts. The advantages or disadvantages of making a formal diagnosis should always be determined by the client’s clinical presentation and source of distress: if the symptoms are leading the client to feel crazy and afraid of being “locked up,” it may be reassuring to hear the diagnosis and learn that it is a treatable condition stemming from early traumatic experience. Annie illustrates a situation in which a diagnosis can be a supportive intervention:
Annie was increasingly troubled by the dissociative amnesia caused by parts switching frantically to gain control of the body and drive their survival strategies. After she sustained a bad fall with no recall of how it happened, and after her husband told their couples therapist “she” had repeatedly asked for a divorce that Annie did not want or recall, she was alarmed. And then, after weeks of being unable to leave the house, brush her teeth, take a shower, or eat regular meals, it became clear that she needed some explanatory system for understanding what was happening to her.
I greeted her at the next session with a big smile: “You know, Annie, I’ve been thinking about our last session and how you’ve been struggling to just do the simple things, and I’m excited to tell you I think I know why!” I always precede making the diagnosis with excitement or glee, as if I were about to tell my client he or she just won the lottery! Clients with child parts are often sensitive to adult mood changes: if I appear unusually serious or unsure of my words, their alarms will be triggered.
Annie was eager to hear “why” she couldn’t brush her teeth or eat breakfast or get through the day. After educating her about the structural dissociation model and sharing with her the diagnosis of DID, I explained: “Your parts developed a relay race system for surviving your childhood: one would grab the baton and run the next leg of the ‘race,’ while others were shielded from what was happening, and then another would grab the baton and run the next leg. It was automatic: the best ‘runner’ for a particular situation would be instinctively activated to run that leg, then the best runner for the next leg of the race would be triggered, and so on. No one was distracted by how the others were running because each was separate and had little to no awareness of the others. You should thank your parts! It’s thanks to them and the dissociative disorder that you and I are sitting here right now having this conversation!”
In contrast, there were many clinical disadvantages in making a formal diagnosis with Dustin: he had a lifelong phobia of being diagnosed psychotic after being raised by a schizophrenic mother and told by his father that he was “crazy—just like her.” He also wrestled with deeply painful beliefs that he was inadequate and “less than,” beliefs that could only be challenged by recalling his professional successes as an adult. Dustin had a very strong going on with normal life self, dating back to an early age, that was driven by the fear of being like his mother and fulfilling the negative expectations of his father. But he also had an intensely ashamed submit part that often took control of his body and led to acting out that part’s wish to be invisible and avoid other people, much to his girlfriend’s disappointment. She wanted him to be the dynamic professional man she had first dated, not the depressed, self-effacing, withdrawn little boy self he could become—especially in social situations. The little boy part just hoped that someone would be nice to him and not question his right to be there while his presence influenced Dustin to keep a distance from others under the belief that he was still “on the outside, looking in.” Though Dustin’s girlfriend frequently questioned this pattern, he never did; the physical action of anxious withdrawal to the periphery where he would not be noticed was all the evidence he needed to believe he was inadequate and unwelcome. The procedurally learned beliefs of childhood (“be seen and not heard,” “you don’t belong,” “there’s something wrong with you,” “no one wants you”) continued to condition his emotional and behavioral reactions to the social environment. To give him a diagnosis at this point in his therapy would only have given him ammunition with which to attack himself, rather than giving him hope and illuminating the path to recovery.
Because DID is such a controversial diagnosis in both the professional and lay worlds, using standardized, validated assessment tools to support making a diagnosis can be very important to clients’ ability to accept it as true and useful information, rather than feeling shamed. Without the objectivity of a formal diagnostic instrument, they are likely to become suspicious of the therapist, anxious and defensive about the concept of parts, or apt to assume that it’s simply another black mark being imposed upon them. When the therapist uses formal assessment measures, there is a reassurance of objectivity: we are not assessing them but assessing for a condition common to trauma survivors. It can even lend a sense of reassurance that they are not alone with this complex, baffling array of symptoms and are being taken seriously by the therapist. But knowing that formal assessment can be threatening to some parts, it is important that the therapist exude curiosity and enthusiasm as if this endeavor will be interesting and maybe even fun!
The most well-known assessment tool, the Dissociative Experiences Scale (Carlson et al., 1993), a self-report instrument, is the easiest to administer but unfortunately is also the least reliable tool. Clinicians using it report a high rate of false negatives (very low scores in clients who later demonstrate very obvious DID symptoms, e.g., switching of parts during a therapy session). These false negatives can be dangerous if they give the therapist a green light to go ahead with therapeutic work (e.g., memory processing) that exceeds the client’s window of tolerance and activates the parts to act out self-destructively.
A more reliable measure is the Trauma Symptom Inventory (Briere et al., 1995), also a self-report instrument that elicits information about a range of symptoms from dissociation to intrusive images/sensations, anxiety and depression, and “tension-releasing” behaviors (e.g., self-harm, impulsive behavior, addictions). Although it does not explicitly diagnose DID, one of its measures is a severity of dissociation score and, when clients score high on that symptom cluster, the therapist has an objective statistic, usually along with other related scores, that provides a very natural entry point for a discussion of dissociation and dissociative disorders.
For making accurate and formal diagnoses of DID, there is no better assessment instrument than the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) (Steinberg, 1994). Most challenging to administer because of its long, very complex interview format (it usually takes 3 to 4 hours to complete in one sitting), it is nonetheless a valuable experience for client and therapist because of the detailed, non-pathologizing discussion of dissociative symptoms it encourages. Many of the SCID-D diagnostic questions can also be introduced separately to elicit information about dissociation bit by bit as the therapy proceeds, rather than the entire interview completed in a formal way.
Even when there is no immediate need for formal assessment and diagnosis, the therapist who is curious and concerned about a client’s dissociative symptoms can still benefit from utilizing portions of the SCID-D (Steinberg, 1994) as the work of information-gathering in therapy naturally proceeds. Many of the SCID-D questions can simply be incorporated into the therapeutic dialogue. For example, Will could not remember the names of a single one of his colleagues or coherently describe what he did every day at work, causing his therapist to become curious about the possible role of dissociation in his self-acknowledged “absent-mindedness.” When I suspect that the client may be experiencing transient time loss, I can ask some of the following SCID-D questions:
• Have you ever felt you had memory problems? Ever had gaps, small or large, in your remembering of things? For example, “I remember starting the project, but I don’t remember finishing it.”
• Is it ever hard to remember what you did yesterday or last week?
• Are there ever whole hours or days that seem to be missing or that you have difficulty accounting for?
• Have you ever found yourself having traveled somewhere without remembering how or why you went? (Steinberg, 1994)
Or for clients who frequently talk about being disconnected from themselves, questions eliciting information about depersonalization can be included into the discussion:
• Have you ever felt as if you were watching yourself from a point outside of your body, as if from a distance?
• Have you ever felt that you were going through the motions of living but the “real you” was far away?
• Have you ever felt like two different people? One going through the motions of living and the other just quietly observing?
• Have you ever heard yourself speaking and thought, “Is that me?”
• Have you ever felt that your words were out of your control? Your thoughts? Your actions? Your feelings? (Steinberg, 1994)
Questions about derealization often help detect parts that are disoriented in time and place. When they see the client’s current environment, it looks unreal to them and unfamiliar, causing the client to complain of experiencing things as “unreal.”
• Have you ever felt as if familiar surroundings or people seemed unfamiliar or unreal?
• Have you ever felt as if your surroundings were fading away?
• Have you ever had the experience of not recognizing close friends or relatives or even your own home? (Steinberg, 1994)
Eliciting information about internal struggles and conflicts always moves the therapy forward, regardless of diagnosis:
• Have you felt as if a struggle was going on inside you?
• Have you felt confused about who you really are?
• Have you ever felt as if there was a struggle going on about who really are, what you really want?
And if the answer to these questions is “yes,” the therapist might want to ask more direct identity alteration questions:
• Have you ever felt or been told that you were acting like a different person?
• Have you ever referred to yourself or been referred to by different names?
• Have you ever found possessions inexplicitly missing? Or inexplicably appearing?
• Have you ever experienced rapid changes in your ability to function? Or does your mood ever change rapidly without clear reason?
• Do you ever have internal dialogues? Are these dialogues more like thoughts or voices? Do they increase under stress? (Steinberg, 1994)
Because the SCID-D questions are meant to elicit discussion of the client’s day-to-day experience, rather than being primarily focused on obtaining a score, they facilitate gathering a detailed understanding of the client’s symptoms and struggles that can be invaluable in any trauma therapy, regardless of diagnosis. The SCID-D is a qualitative measure with all the advantages and disadvantages inherent therein: it is thorough, detailed, allows the therapist leeway to inquire further or even compose spontaneous follow-up questions, and it is not limited by standardized questions. Even if the therapist prefers not to make a formal diagnosis, the dialogue facilitated by the SCID-D will be valuable and elicit valuable information needed for the treatment.
Many therapists are intimidated by the challenge of taking on their first DID clients because they have received so little exposure to or training on the treatment of dissociation or dissociative disorders. In addition, they are often presented immediately with serious and complicated symptoms: regressive behavior, losses of functioning, suicidal or self-harming behavior, dissociative fugue states. Quite quickly, however, they discover the biggest challenge: there is no one “she” or “he” in the client’s chair. Though this client is a whole integrated physical being, he or she is not one integrated psychological being, and that proves to be not only confusing but also disturbing to even the most experienced of therapists.
The therapist is also hindered by the “information gap” inherent in the diagnosis. Clinicians are trained to rely on clients as the experts on their own internal states, to assume that they are the most credible source of information about both past history and moment-to-moment awareness. With DID clients, however, even very basic information can be inaccessible to the client or known to the client but censored by protector parts. Even more challenging is the unexpected, unrequested information the therapist is likely to receive from trauma-related parts seeking to promote their own agendas, usually either to push the therapist away or pull the therapist closer. Whereas adult clients infrequently use text and email as regular channels of communication, child parts driven to make contact with the therapist without the knowledge or consent of the normal life self regularly use these means of communication. When parts are free to act autonomously and secretly outside the awareness of the “observing ego” of the prefrontal cortex, when they are driven by primitive animal defense instincts in response to triggers associated with danger, there is often a loss of reality-testing, continuous consciousness, and behavioral control.
It is common for therapists working with DID clients to have secrets disclosed to them by individual parts communicating “behind the back of” (i.e., outside the consciousness of) the client’s normal life self. Young child parts who feel endangered by triggering of implicit memories often hijack the body and can end up dominating the therapy in an attempt to elicit protection from the therapist, usually through disclosures of abuse or by having flashbacks in therapy. Fight- and flight-driven aspects of the personality might attempt to control the therapy in a different way, either by pushing the therapist away (devaluing, “firing,” impulsively terminating) or punishing the young parts to prevent them from disclosing more secrets or becoming more dependent on the therapist. The therapist, confused by it all, can also inadvertently exacerbate the situation by unconsciously taking sides with young child parts that want a relationship or want to “tell what happened.” When therapists continue encouraging disclosure of memory despite evidence that protector parts are alarmed by it, the result is most often increased instability.
Sheila’s therapist approached the treatment of DID using a model first developed in the 1990s and then discontinued because of the risks of decompensation and regression inherent in that way of working. Founded on an assumption that the “talking cure” would also work for trauma, child parts of DID clients were encouraged to “come out” in therapy and “tell their stories” to the therapist, who in turn would inform the going on with normal life self as if reporting child abuse to a parent. When clients had a sufficient window of tolerance, this method was reasonably effective, but few DID clients had sufficient affect tolerance to manage the intensified trauma responses or increased tendencies to fragment.
Often, Sheila’s normal life self did not want to hear the disclosures, fearing being swept away by a “tsunami” of emotions. That rejection in turn triggered the child parts’ painful memories of not being heard or not being believed. The fight and flight parts became alarmed by the therapist’s knowledge of the secrets, believing that meant she or he would use them against the client. As they became agitated and desperate to take action, the result was increased addictive and self-injuring behavior. Child parts were being “punished” through self-harm by a fight part determined not to allow further regression or vulnerability.
The case of Sheila provides a good example of the risks of a memory disclosure approach to the treatment of DID. The history of the trauma treatment field reflects a series of paradigm shifts as leaders in the field were forced to give up the memory retrieval and disclosure approach of the 1980s and 1990s because clients so often got worse instead of better. In the last 15 years, guided by the neuroscience and attachment research, treatments have moved away from an emphasis on event memory retrieval to focus on the legacy of implicit memory, and on mindful witnessing in lieu of narrative expression. Nowhere is the new paradigm more necessary than in the treatment of DID. Mindful self-witnessing is an antidote to difficulties in maintaining continuity of consciousness. Understanding the parts as disconnected “containers” of implicit memory driven by instinctive subcortical animal defense responses reduces the degree to which they feel weird and crazy. I tell the client, “A part is the child you once were at a certain age or the child you had to be in certain situations. It’s the little you.” That rarely feels strange to anyone. In this model, the stories told by parts about the trauma reflect the meaning they have made of what happened and how the legacy of those events lives on in the client’s mind and body. The parts are not writing history. They are disclosing what they still dread, still feel, and the dangers they still watch out for.
Sheila was frightened by the child parts’ memories when they were disclosed to her by her therapist. She was very disturbed that she could go to therapy and not remember what happened after the first few minutes. When the therapist told her about parts that “came out” in therapy without her knowledge, she felt “possessed.” And the injuries she kept finding on her body were frightening to see: how could that have happened? She didn’t recall burning herself. Then, when the therapist disclosed that child parts were calling and emailing her between sessions, Sheila began to feel dangerously out of control. “I went to therapy to get better, but I feel like I’m getting worse!”
By developing an intense 1:1 relationship with the child parts and encouraging disclosure of memory, the therapist, Jennifer, had inadvertently dysregulated an already unstable system and triggered the attach part’s desperate need to make contact between sessions. Alarmed by the deterioration in Sheila’s condition, Jennifer assumed that what was needed was to meet more often so she could elicit more disclosure by the child parts and work on gaining acceptance of the memories by Sheila’s normal life self. They were caught in a vicious circle: Sheila thought about leaving the therapy to stabilize, but when she had those thoughts, the attach parts panicked, shutting down her prefrontal cortex so that she “forgot” or filling her with fearful beliefs that she couldn’t survive without Jennifer.
Although the treatment for DID clients should ideally be very much the same as that described earlier in this book, the therapist may have to be even more sensitive to the effects of disorganized attachment on the clients and parts. Because of the autonomous functioning of the parts, it is easier for the therapist to develop countertransferential relationships to each part as a separate “inner person”: to become intimidated by the anger and devaluing of the fight part, as if it could harm him or her, or to feeling intense protective impulses, “wanting to help” the child who feels so alone and in so much pain. The challenges of utilizing any treatment approach effectively become greater when amnesic barriers and/or intense conflicts between parts create an inability for the whole person or system to work with the therapist, much less work with itself.
The inner worlds or systems of most DID clients reflect the environments in which they were raised: harsh, secretive, critical, punitive, neglectful, intimidating, and/or terrorizing. To the extent that the client’s parts survived by creating “smoke and mirrors” to hide secrets from each other as well as from family, neighbors, and teachers, the client will struggle to find stability. Each step forward addresses one layer of secrecy, followed by exposure of another layer—often maintained by saboteur parts that operate outside of consciousness to keep other parts intimidated, shamed, or invisible. As one such part told me, “It’s easier to protect them if they’re too afraid or ashamed to leave the house.” To the extent that the individual and his or her parts survived by suppressing vulnerability or fighting for control, the inner world will be characterized by parts that fight to prevent vulnerability, for example, hurt, dependency, rejection. To the extent that the early environment was harsh, punitive, and neglectful, that world will be reflected in clients’ habitual ways of treating themselves and their parts.
Annie’s inability to manage basic activities of daily living (grooming, showering, eating three meals a day, following a routine that included self-care) reflected the powerful influence of neglected child parts who longed to be taken care of and had no idea how (or were too ashamed) to take care of themselves. They had learned early in life to take care of others but associated self-care with the pain of being uncared for and unwanted. Annie learned from observing other children in school to wash her hair and to match tops and bottoms when she picked her clothing out of a pile of unwashed, ill-fitting dirty clothes all over the floor. No one made sure they were clean or ironed or free from stains and rips. Four children shared one toothbrush, two pairs of boots, and one umbrella. The only item of which there was always plenty in the house was alcohol.
Decades later, Annie’s system of parts continued to recreate the hostile environment of her childhood: her attempts to get up in the morning, brush her teeth, eat breakfast, and plan her days were interrupted by the parts’ “safety concerns.” Depressed parts would feel too tired to get up and beg her to stay in bed. A part that used caretaking to elicit safety and connection, the Little Saint, would get anxious about who needed to be cared for. Although caretaking inflamed other parts to anger and feelings of oppression, it was associated with safety for the Little Saint. Annie’s flight parts had yet another agenda: what was she going to do today that was meaningful and important enough to prove her worth in the world? Every day, they drove her to frantic activity, not stopping until her body ached and her limbs couldn’t move anymore. The fight part’s hypervigilant eye was on each part’s performance, followed by a relentless negative critique of each and every activity, just as her mother had, triggering fear and shame in the little parts. At that point, her 16-year-old part would suggest a beer to anaesthetize them. Several cans of beer later, the little parts would quiet, as they had years ago when Annie’s mother would feed the children beer because there was no food in the house. Because the parts were still defending against the old dangers, it still didn’t feel safe inside.
“Restoring order” to the inner world and thus to the client’s life circumstances begins with increasing the ability of the normal life self to observe the way the system of parts operates, including its struggles and conflicts. Brain scan research with DID subjects (Reinders et al., 2006) has demonstrated an association between the normal life self and the prefrontal cortex, while none of the trauma-related parts’ brain scans showed cortical activity. This finding suggests that the therapist can make use of the prefrontal cortex as a way to connect to the normal life self. To facilitate unblending and manage the intense reactivity and emotional volatility of the trauma-related parts, the normal life self has to cultivate dual awareness.
In addition, to learn new models and new skills requires cortical activity. Because the prefrontal cortex is connected to the abilities to be mindful and curious, retrieve and manipulate already learned information, and to integrate new information, only the normal life part has the potential to learn new concepts or skills and bring that new learning to the parts. By engaging the prefrontal cortex, the normal life self can have access to information about both past and present, imagine parts he or she has never met, connect them to other information (such as childhood photographs), and even visualize them.
As described in Chapters 4 and 5, the client is asked to make the assumption that all instincts, emotions, bodily reactions, and thoughts reflect communications from parts, even if they can only be “heard” retrospectively because of dissociation-related amnesia. Next, the client’s normal life self is taught to observe these signs, to name each feeling state or belief as that of a part, and to validate the part’s experience.
Particularly when safety is an issue, events in present time for which the normal life self has no memory must be “decoded”: what triggered the intense emotions? Or the depressed part’s hopelessness? When that hopeless feeling came up, what happened next? If the client has amnesia for what happened next, are there clues that fill in the gaps? For example, movie tickets, receipts, emails, Internet activity histories. Or if there is no memory and no clues, how does the therapist help the client gather more information?
With the use of structural dissociation model and some creative thinking about parts and animal defenses, therapist and client can also make educated guesses. Which part would have gone to the cemetery in the middle of the night? (It had to have been a part that could drive—i.e., an adolescent part.) Which part would have allowed itself to be picked up at the bar near the cemetery and taken to a seedy motel? (Probably not the part that went to the cemetery, but an attach part might have.) Which part would have been too afraid to ask the therapist for help? (Submit? Freeze? Not the attach part certainly!) And which part would have refused any offer of help? (Flight and fight would never yield their self-reliant, counterdependent stances to ask for help.) The simple act of naming overwhelming emotions as the feelings of a part usually decreases some of the client’s emotional intensity. Developing the ability to observe, “A part of me is feeling this way” or “a part of me was desperate not to be alone” seems to have the same effect as a parent has in noticing a child’s mood and naming it: there is relief in being seen by a compassionate “other.” Being able to identify “who” is feeling that emotion, having that reaction, or about to act on a desperate impulse helps clients unblend, making easier the task of managing internal unrest.
To understand themselves and to make conscious decisions and choices, rather than be hijacked by their parts, DID clients will also need to learn to notice the comings and goings of different parts and to observe what triggers control each part’s mysterious appearance and disappearance—even in therapy. Often, early in treatment, therapist and client can use the structural dissociation model as a guide: “Was that fight or flight that didn’t want to come today? Was it submit or attach that came because they wanted to please?”
Because of the “information gap” inherent in the diagnosis, it is crucial to develop internal communication skills early in DID treatment, as well as the ability to observe intrusive feelings and physical phenomena and interpret these as communications from parts, rather than be frightened or ashamed of them. A sudden feeling of fear in response to thinking about the client’s job must be reframed by the therapist as, “There seems to be a part of you that’s anxious about your job,” and then the client must be encouraged to obtain more information about this anxiety: “What could that part be feeling worried about? What triggers are you aware of in the workplace that would alarm a child?” In non-DID clients with structural dissociation, information-gathering will be much easier because the dissociative barriers between parts are not as impermeable. With DID clients, it is more difficult to know if a part is worried or lonely or ashamed because other parts may not be aware, and the normal life self has little access to inside information.
Although “switching” so that individual parts can “come out” and interact with others is more typical of DID, blending also takes place in DID clients. The normal life self might feel the intrusion of parts’ feelings and thoughts but tend to interpret these as “my feelings.” Feelings of depression, critical thoughts, or ruminations may not be experienced as parts but should always be attributed to them. With DID clients, just as with any traumatized client, the practice of noticing moments of being blended and then unblending is a crucial skill. For example, in response to the client’s perseverating on “his” hopelessness, the therapist reflects, “It seems there’s a part that believes he’s worth nothing—a part that feels there’s no hope for him, no way to belong or be accepted by others. Is that right? Do you notice him?” Feelings of anger, especially if they frighten the client or frighten others in the client’s life, need to be named as indicators of a fight response: “Perhaps this reaction is coming from a very angry fight part determined to defend you verbally and physically … it would make sense that you would have needed a strong bodyguard. We all need a protector.”
In DID clients, not only do parts communicate their presence by intruding thoughts, feelings, images, body tension and sensations—they also “speak” through actions outside the awareness of the normal life adult. Finding evidence of actions one does recall is unsettling and often humiliating for clients, yet it is important that the disturbing feelings not interfere with curiosity, creativity, and therapeutic detective work. Curiosity is cultivated when the therapist repeatedly asks, “If this pattern of finding yourself in the kitchen late at night, __________ were a communication from a part of you, what would that part be telling you?” “If what you find yourself eating told you something more about this part, what would that be?” The “decoding” of parts activity outside the normal life self’s consciousness is an extremely important focus of DID treatment that should never be conducted judgmentally, without empathy for the parts in question. And it helps the client become familiar with his or her own system—as important as meeting one’s family for the first time.
Helping DID clients “unblend” from their parts also increases in importance when those parts have the ability to take over the body and take action independently outside of consciousness. The depressed, hopeless part is at risk to sacrifice her- or himself for others she perceives as more deserving despite the normal life self’s determination to have healthy boundaries. The anxious part might inadvertently sabotage the client’s first day at his or her new job by asking too many self-doubting questions. When those parts blend with the client’s normal life self, it is crucial that the client not identify with them but instead differentiate them as child selves worried about “their” ability to cope with the demands of adult life or driven by triggered memories of being young, inadequate to grownup tasks, and in mortal danger.
In therapy, Annie learned to language these phenomena in ways that helped her be more aware of how the parts affected her feelings, perspective, and abilities moment by moment. Initially, she and I worked simply on reframing distressing feelings as communications from parts and trying to respond to them with reassurance that they were safe now. But her parts interpreted blanket reassurances as if they were the manipulative words of childhood perpetrators: they didn’t trust words of comfort. Only when she validated why they were so distressed by acknowledging their traumatic experiences did they seem to relax a little bit as if to say, “If you really know what I’m afraid of and why I’m afraid of it, then I can believe you when you tell me I’m safe now.” I reminded her, “You wouldn’t have trusted what I said if you hadn’t felt I understood, would you? Would the kids you’ve helped all these years have trusted you if you didn’t ‘get’ what they were struggling with?”
At first, Annie’s normal life self was resistant to even indirectly referencing the experiences of her childhood: “I don’t want to remember all the terrible things that happened—I don’t want to see those images and feel those feelings.”
ME: “It’s not required that you remember the details of what happened. It is only necessary to demonstrate that you ‘get it’—they just need to know you know what happened. Because if you know what happened, it becomes credible when you say, ‘I won’t let that happen again—not in my world.’ They really need help to see what’s different about your world versus the world they still are stuck in. What shall we call their world? Where did you live growing up?”
ANNIE: “I grew up in New Jersey—they’re afraid of those New Jersey people, of my mother and my father and Father O’Malley.” [All of these individuals were deceased, but since their fears were implicit memories of the past, the parts were indifferent or resistant to thinking of them as dead.]
ME: “OK, that’s wonderful that they can be so clear: they don’t want to be in New Jersey, and they definitely don’t want to be afraid of getting killed every day! Or scared of being abandoned or assaulted or used in some way. Of course, they don’t—who would? And what shall we call where you live now? What shall we call the world you deliberately created as an adult?”
ANNIE: “Let’s call my world ‘Maine’ because it’s where I live, where my house and family are. It’s a whole different culture in Maine—I made sure of that.”
This example illustrates another related challenge facing DID clients and their therapists: the loss of time orientation, the confusion of past and present. With traumatized parts that are driven by animal defense survival responses, dissociatively disconnected from one another, and hypervigilantly alert for signs of the dangers each faced “then,” it is not surprising that time orientation becomes distorted. The client might be engaging in the simplest of normal life tasks (getting out of bed in the morning, helping children get ready for school, washing the dishes, making a meal, driving a car) when that activity suddenly becomes triggering: driving activates implicit memories of being taken somewhere dangerous; washing dishes or cooking a meal triggers the shame and loneliness connected to being a Cinderella child, treated like a slave or expected to be the family drudge. In one moment, the body tenses in response to those triggering activities: the heart rate increases, legs begin to shake; stomach knots up; and shame washes over the client. Without a visual image to orient us to where we are in time and space, most individuals and most parts assume that something or someone just “made” them feel that way: right now, they must be in danger—about to be humiliated at best, killed at worst.
For years, Annie woke up each morning to a feeling of dread, sick to her stomach as she faced another day. As she began her biological children’s morning routine, the dread was replaced by intense anxiety. As she made their school lunches, the shaking and fear would intensify, so much so that she could barely make their sandwiches. She made meaning of the feelings in the same way she had as a child: “I’m going to fail again today—I still won’t amount to anything—no one will want to be my friend—they’ll think something is wrong with me.” It was an automatic assumption that still operated as a “default setting.” Without acknowledging where it came from, the belief felt just as true now as it had when she was a child: because she was a failure, something bad was going to happen.
I asked her: “What was scary about going to school as a kid?” Immediately, Annie knew: “Because my father could get at us—the principal was his buddy who ignored the restraining order—he could just take us out of school and do what he wanted as long as we were back by the end of the school day.”
ME: “Can you see why the parts are afraid in the morning? Why it’s scary to make ‘school’ lunches?”
ANNIE: “Yes! And I had to make our school lunches every morning—I wanted to throw up!”
Most clients “get it” when therapists remind them to think, “Why might that have been frightening about that ______ when you were young?” or “What was special about that kind of situation or that time of day/day of the week/month/year when you were young?” Note that these questions do not require a detailed narrative of past events for an answer: they promote awareness of the links between past and present by acknowledging what happened. Validating the feeling and body memories as normal responses to trauma (“Of course, that’s scary,” “Of course, that’s extremely triggering!”) is reassuring for clients, and few need “proof” to believe that they are triggered and their bodies are remembering.
Because of the denser dissociative barriers within, it is more challenging for DID clients to learn to recognize the shifts in mood, belief, and behavior that occur under the influence of their parts. It is challenging for them to accept that, unless they exhibit curiosity and interest in their inner worlds, a willingness to care about and care for their parts, they may be susceptible to “hijacking.” “Hijacking” is a term developed by Pat Ogden (Ogden et al., 2006) to describe what happens when traumatized clients are exposed to triggers: the body mobilizes an emergency stress response, which “turns on” the sympathetic nervous system, stimulating a release of adrenaline and inhibition of the prefrontal cortex. As the parts are activated by the trigger, they can also stimulate the emergency stress response and animal defense responses. With the prefrontal cortex inhibited, the normal life self loses conscious awareness of the parts’ actions and reactions, much less the ability to control or manage their behavior. When the normal life self loses all ability to keep normal life functioning intact, it is a clear sign that the client has been hijacked by parts. By reframing “I’m having a nervous breakdown” or “I’m falling apart” as “No, what you are feeling reflects the fact that your parts have staged a ‘coup d’etat’ and taken over,” the therapist externalizes the crisis and empowers the normal life self. Most clients respond: “Well, I want my life back!” Especially with clients who are intimidated by their parts or ashamed of “how far I’ve fallen,” it is important to evoke the drive to reclaim one’s life, to take it back. I ask them: “Do you want a life determined by your parts and the trauma? Or do you want a life after trauma? A life you get to choose?”
Implicit reactions to triggers reflect conditioned or procedural learning to experiences that subjectively feel life-threatening. As a colleague once reminded me, “Trauma is the only single-incident conditioner of human behavior we know. Even one experience leaves indelible traces.” These conditioned responses are very challenging to shift or alter. It is as if the body and nervous system are loathe to “give up” the automatic responses that ensured safety for another day. In addition, as a result of chronic dysregulation, made worse by repeated shutting down of the prefrontal cortex, the majority of trauma clients have difficulty retaining new information. They find it difficult to remember and utilize the same steps or skills that brought relief yesterday without being reminded or cued by others. It is as if the repeated inhibition of left brain activity makes encoding and retrieval of new information more difficult and also more unstable.
To add to their challenges, DID clients often have “eraser” parts, “thought-stopping” parts, or “information extractor” parts that actively interfere with encoding of new present-day-oriented information. It feels dangerous to trust it. In the dangerous world of their implicit memories, the parts fear that changing assumptions associated with survival will be foolhardy at best. In order to reduce fear and increase retention, DID clients need help practicing their observational and unblending skills in therapy. They benefit from and rarely complain about repetitive instructions to notice feelings and thoughts, make the assumption that the feeling belongs to a part, evoke curiosity about the part, name the feeling or thought as “his” or “her” thought/feeling, and increase dual awareness. And, if the parts take over control of the body, causing time loss and dissociative fugues, the therapist and client must also repetitively practice curiosity, asking over and over again: which part might have been triggered by what stimulus? And which part impulsively took the troubling action?
Although more clearly fragmented and less in control of their responses, DID clients still present in one body with a narrative that is usually preceded by the word, “I.” It is easier and more comfortable for any therapist to conceptualize this new kind of client in the same way that other clients are understood: as a “she” or a “he,” rather than as “they.” But for DID clients to stabilize and recover requires that both client and therapist stay focused on the ultimate goal of dissociative disorders treatment: the ability to have “continuous consciousness” with fewer breaks in time orientation, fewer instances of parts operating behind the backs of both therapist and client. Continuous consciousness can only be developed through repetition of new practices: focused concentration, awareness of being present in the body or “right here, right now,” and habits of inner communication with parts so that information can be shared even if in fragmented pieces contributed by different parts.
Once DID clients have greater access to “continuous consciousness,” when their parts are less activated and more willing to collaborate, they can stabilize. They can learn to know “who” they are moment to moment and make increasingly sound life decisions that are sensitive to their parts’ feelings, likes, and dislikes but not constricted by post-traumatic paranoia. With increased ability for internal dialogue, it also becomes possible to bring switching under voluntary control. With the ability for inner communication, the normal life self can negotiate with parts who switch at problematic times to “let me do that job—that’s not a job for kids.” When dissociation is involuntary and unconscious, traumatic triggers determine “who” is out or, as I say to my clients, “who is driving the bus.” Then I add: “Unless you want your life run by a 7-year-old or a 16-year-old, you might rather drive the bus yourself.”
As dual awareness and inner communication allow for internal trust and understanding to grow, involuntary switching tends to decrease or come under better control. Once DID clients realize that they have the ability to inhibit parts from switching, they understand that they can also choose to switch to summon “the right part for the right job.” When DID clients begin to experience dissociative compartmentalization as a potential asset, not just a liability, the client’s confidence grows. When the prospect of giving the toast at a best friend’s wedding triggers terror among the parts, for example, the normal life self might ask inside: “Who would be willing to give the toast?” And a part unafraid of public speaking can be asked to take over that function. Often there is a feeling of triumph when the client and parts together feel the confidence of the “public speaking part” as he stands up in front of the group, poised and articulate, able to evoke a laugh. The normal life self might learn to enlist the fight part to support her in setting boundaries with others in the client’s life who intentionally or unconsciously take advantage of her inability to say no. Sometimes, these “victories” trigger other parts: an ashamed part who feels undeserving: “I have no right to set boundaries.” Or parts who are afraid to be seen and feel exposed by the public displays of mastery and confidence. With repeated experiences of mastery the conscious use of dissociation enables, the parts can feel something is different. At these points, it is very important for the therapist to remember that opaque dissociative boundaries between parts interfere with taking in new information: the normal life self must always be asked to “show the parts what happened just now. You promised them that you could say No, and nothing bad would happen. Ask them to notice: did they see you setting the boundary?? And is there anything bad happening now?”
Trust begins to build with increased internal communication and experiences of mastery and competence. All their lives, the young parts have longed for someone who would hear, believe, and protect them—someone strong enough to keep the “bad people” away. The teenage parts have been waiting for someone strong enough to protect not only the younger parts but the adolescents, too. As the younger parts develop confidence in the normal life self, fight and flight’s hypervigilance can relax a bit; their muscular tension loosens; they can “sit back” more easily. As the parts build increasing trust in an older and wiser grownup self, they can more easily believe the normal life part’s reassurances and perspective. “It’s not an emergency—nothing bad is happening” feels like reliable information, not a manipulative ploy. Healing their attachment wounds requires “basic trust” in a normal life self that is more palpable, who doesn’t disappear each time the going gets tough, facilitating the ability of older parts to threaten the little ones. Trust is a prerequisite to being able to offer reparative experiences to young parts that transform or resolve their implicit and explicit memories and that offer them a felt sense of safety and welcome.
To feel safely welcomed, however, child parts have to experience the palpable sense of “who” is welcoming them. The parts have to be able to feel emotionally and physically that there really is an “other” who smiles at their entrance, who is glad to see them, who is tender where the child is wounded, and unafraid when he or she is angry and hostile.
When Annie thought about the parts’ world as “New Jersey,” it reminded her why they were so hypervigilant and easily alarmed but without triggering the flashbacks she tried so hard always to avoid. She could more easily see, at first with my help, how they projected their New Jersey experience onto her environment in Maine. When the parts were in distress, she worked on remembering to ask herself, “Why would they have been worried about this in New Jersey? Why would it have been dangerous there?” As she did so, she discovered all kinds of connections her parts were making between her old world and the safe environment she had created for herself after fleeing New Jersey at the age of 19. Ironically, although she had created a life that soon became a refuge of safety for friends and family, she and her parts did not feel safe in it—because she was so often blended and identified with them. Sometimes she blended with their hopelessness and shame, sometimes with their fears and longing, and sometimes with their distrust.
Even more troubling were the parts that operated in secrecy, “behind her back.” Following her curiosity about why she seemed unable to remember her therapy sessions almost as soon as she left my office, she heard other parts talking about the “eraser part.” Then images and more internal conversation with the parts revealed the presence of a part who erased the blackboard of memory immediately when ever Annie had positive or empowering experiences so that she never remembered them again. It also erased information: her diagnosis of DID, the fact of her trauma history, her repertoire of skills, and her resources. She would learn a skill, only to find it had disappeared, and then relearn it again. Asking inside, she inquired, “What is the eraser part worried about if she lets what we talked about today stay up on the blackboard?” “It’s different,” said the eraser part. “And what are you worried about if the information is different or new?” “We know we can survive this way—but we don’t know if we can survive this new way … It might not be safe.” “Thank you for telling me,” Annie responded. “All this time, I thought I was getting dementia, and it was just you trying to protect everyone!” From that day on, Annie and I tried to remember to contact the eraser part at the end of each session to ask: “Would you be willing to leave what we talked about today up on the blackboard? Do you have any concerns about it that we should know about?” And then Annie would ask the part, “What do you need from me—right here, right now—to feel safe leaving this information up?” We also developed some techniques for ensuring she could revisit ideas, skills, or insights that felt important: I might write on an index card a list of all the things she reported wanting to remember so she could take it with her. (I knew her attach parts wouldn’t let it get thrown out!) Or I might ask her to send me an email after the session sharing what she wanted to take away from it. Or at times, I asked her to journal about the day’s session or about particular parts and what they needed or what triggered them. I sometimes sent her emails summarizing what I had learned and thought might be useful to her. Earlier in the therapy, she and I used to wonder why those kinds of emails always disappeared from her email box! Then, at a session, I suggested to Annie, “Ask the eraser part if she would be willing to do two jobs?” “She says ‘maybe, depending on the job.’” Annie reported.
ME: “Tell the eraser part that we appreciate her working with us so nothing valuable gets erased. But her first job is still to erase anything ‘bad.’ (Maybe she could help erase some of the hurtful beliefs the little parts have about themselves.) But we also need someone who can help you [normal life self] save important information and store it in a safe place. That’s hard for you to do when you’re being overwhelmed by so many voices and so many feelings. So often, important moments and empowering experiences have gotten erased that might have been saved if we’d had her help.”
In DID clients, the autonomous functioning of the parts causes problems with reality-testing, relationships, safety, and judgment, and the crises that result generally become the focus of therapy. The lack of conscious awareness of the parts’ feelings, thoughts, bodily responses, and actions interferes with opportunities to get to know them in the way discussed in Chapters 4 and 5. With less severe compartmentalization, we can “know” a part by its feelings (“so sad”), its wishes (“it just wants someone to care”), its beliefs (“it’s not safe to be alone”), and its body language and facial expression (a sad face, a child’s shy body language). In a DID client, the manifestations of that part might be felt when the “client” has trouble leaving the office at the end of sessions or texts and calls repeatedly between sessions.
When she was not blended with them and instead was consciously centered in her normal life self, she could perceive the differences between her perspective and that of the parts; she could feel the safe reality of her current life in her body—her heart rate slowed; her breathing was easier; she felt solid but not tense. It was a good feeling, even though the parts had always urged her not to trust it and for many years, she had accepted their reality: she believed their projection that she lived in a dirty, depressing, impoverished home with people who used and abused her and never tried to meet her needs. For many months, she and I worked on “orienting” (Ogden & Fisher, 2015) the parts: first asking them to show her images of “where” they were scared or paralyzed with dread or ashamed and humiliated. (Always, images of New Jersey would come to mind.) Then Annie would ask, “Would you like to see where I live?” and then she would bring up images of her home and neighborhood now: an image of the fenced-in yard, the back door she had painted red, her flower garden, the river where she loved to swim and canoe in the summer. As the images associated with the traumatic past arose, she could feel the activation in her body, the shaking and trembling, tightening in her stomach, and feelings of wanting to run. As she oriented the parts to the details of her present environment (Ogden & Fisher, 2016), she could feel her autonomic arousal settle, the trembling lessen, and curiosity increase. As she repeatedly reoriented “them,” she was less blended and better able to see her present objectively. By helping the parts to see where they were, she could finally appreciate where she was. Annie could now see the old rambling farmhouse in which she and her husband have lived for years as “quaint,” instead of a “slum.” Always in need of one repair or another because of its age, the parts had viewed the house as a blatant symbol of their neglect and lesser worth, like the torn and dirty clothes she wore to school as a child. Annie could now recognize its contents, the antiques and “found” objects she and her husband had refinished, as reflecting something about the person she became in the life she had created beyond trauma. She could even see the personal touches that reflected who she is as a person: a bright red back door to welcome her extended family of choice, a kitchen that is the center and heart of their home, colors and decorative touches that reflect her aesthetic sense. “I never knew this before,” she said as she showed her parts images of “then” and “now”: “Right here, I have what I always wanted—what I always dreamed of as a child …, but I didn’t know I had it.” As long as the parts dominated her perceptions, she could not correctly identify what was before her very eyes—nor could they. Until Annie deliberately and consciously drew their attention to the details of the environment, the parts could not perceive, much less integrate, that they were no longer in New Jersey.
Annie is an example of how dissociative compartmentalization interferes with information flow even within one life and one body: while Annie’s normal life part was creating a home with her husband, raising their children, and offering a safe haven for family members in distress, her parts believed that she was trapped in a hell-hole with a coercively controlling man forcing her every move. Their perceptions, biased by expectations of danger and chronically activated survival defenses, saw only what they expected to see: the same environment in which Annie had been raised.
Because a diagnosis of DID implies a loss of memory for personal information (especially for information about the autonomous activity of self-destructive parts), clients must learn to “fill in the blanks,” to consciously gather evidence of what their bodies may have done outside of their awareness even if it is retrospective. Gazzaniga (1985) writes about the propensity as observed in “split brain” patients whose right and left hemispheres have been surgically separated by removal of the corpus callosum: the right brain might take action on impulse for which the left hemisphere would have no memory, but nonetheless, the left brain would construct a narrative to provide a rationale for the missing time or consequences of the action. The researchers were struck by the left brain’s persistence in establishing a motive and meaning-making even when disconnected from the right hemisphere’s actions and reactions.
A related challenge for clients with DID is the problem of what to do when parts are engaging in self-destructive or self-sabotaging behavior outside the awareness of the left brain normal life self. Gazzaniga (1985; 2015) emphasizes that the left brain’s ability to use language to rationalize the actions of the right brain increases the chances of the behavior happening again, a potential risk to life in DID clients. Therapists working with such clients must be unafraid to ask directly, “Do you remember the details of what happened? Or just the outcome?” It is important for the treatment to distinguish: was the normal life self blended with the part that acted out last night? Or did the acting out part hijack the body and act outside of consciousness? If the answer is, “I guess I was blended with the suicidal part,” therapist and client can begin to work on recognizing when the client is blended and practicing unblending strategies. If the part acts outside of left brain consciousness, then the work will have to focus on internal communication and increased ability to negotiate with the acting out part.
Therapists can also help their DID clients reconstruct what occurred either through diagramming (see Chapter 5) or by asking them to go “back in time” imaginatively to just before the crisis, identify the trigger, then move forward, frame by frame, with the therapist asking, “And what happened next?” Often, clients find gaps in the “video” for which they have no memory of what was happening. Then, the therapist’s task is to remind them to ask inside, “Does anyone know what happened after that?” Being able to use internal communication to establish what triggered the parts, which ones responded and how, and why fight or flight parts “came to the rescue” is essential for establishing safety.
Underlying the instability in the client’s life is the capacity of each part for independent action and the lack of shared consciousness and memory. Without meta-awareness, without an observer keeping track of moment to moment experience, it is no wonder that trauma-related parts can inadvertently and unconsciously sabotage the client’s normal life, believing that they are just trying to save their lives. Early in treatment, it is important to begin building the skills that clients will need to develop a continuous, unbroken consciousness for their daily experience. To restate Chapter 2, there is no focus at the stabilization phase of treatment on the client’s consciousness of traumatic memory. The focus is on “now”: the losses of conscious awareness in the past served the client’s survival; the losses of consciousness now are destabilizing and sometimes unsafe.
Gaby provides a good example: as she began to stabilize her life after years of drug addiction and high-risk behavior, she initially felt proud and energized. It felt like a vindication of what she had been through, not only in the childhood past but as an adult trying to survive after trauma. She was going to graduate school, in a stable relationship, shared a home with her partner, and even had just gotten a part-time job. It was then that she started to feel increasingly depressed. Many days, she could not get out of bed, missing classes and falling behind on her schoolwork. When she began to skip work, her partner became frustrated and critical: “Don’t you know how much we need that income?” As she retreated under the covers in her bed (as she had as a child), memories began coming up: memories of the losses, the abuse, the loneliness, and the pain of having no one to care or comfort her. After several months of hopelessness and despair, Gaby’s partner came home from work one day to find her unconscious. She had taken an overdose. Without having had a moment of conscious thought about suicide, Gaby had overdosed. Unbeknownst to her, the suicidal part had acted to end the suffering of the depressed part. She, of course, was too blended to even consider that her depression might belong to a part of her threatened by Gaby’s successful going on with her life. Afraid of being left behind, the depressed part had come forward to let her know how badly she needed help.
Gaby’s experience underscores the importance of building skills that increase conscious awareness across time. Had she been aware in advance of the suicidal part’s intentions, her normal life self would have sought help. The first skill I teach clients with DID is to keep track of their daily activities by recording what they are doing or whatever is happening every hour on the hour on an hourly time schedule. If they encounter a gap in time (e.g., “I looked at the clock at 2 when I came back to work after lunch, and then the next thing I knew, it was 5 and the end of the day”), they are asked to look for clues to fill in the blanks. (For example, “I looked around to see what I had done from 2 to 5pm, and I could see I returned several emails, wrote a letter for my boss, and finished a report due tomorrow.”) Simply the instruction to concentrate on what they are doing throughout the day and record it often by itself decreases the likelihood of switching. Clients learn a great deal from this assignment. They are often surprised how much focused concentration on tracking their activities helps to challenge automatic habits of switching or spacing out. Sometimes they are surprised by the activities they see written on the schedule: “I didn’t think I spent that much time in bed …”
Another skill I often assign to DID clients who report missing time or frequent switching is learning to notice “who you are” moment by moment. In sessions, they are asked to observe the signs of blending with different parts, to notice the words, themes, emotions, and beliefs they verbalize, and to be curious about “which part is talking,” “What part believes that?” or “What part is nervous that I won’t like her?” As discussed in earlier chapters, a sentence preceded by the word “I” does not signify that the normal life is speaking or that all the parts feel exactly the same way. To know “who” is talking or feeling an emotion or believing a thought requires curiosity and at least brief exposure to the structural dissociation model to help foster the ability to recognize different parts. With clients who have issues with missing time or hijacking by parts, practicing this skill for one or two hours a week in psychotherapy is not nearly enough, especially when unsafe behavior is an issue. To reduce the memory and time gaps and to increase awareness of blending and switching, I often ask clients to purchase an inexpensive watch with an alarm function that can be set to automatically go off each hour. Each time the alarm rings, the client is instructed to pause and notice “who I am” or “who’s here?” To make the task more structured, I often provide clients with a Dissociative Experiences Log to record what they observe. (See Appendix E.) When dissociative fugues occur during the night (i.e., the client discovers evidence that some part engaged in unsafe or unwanted behavior while he or she “slept”), the normal life self can be taught to set the car’s trip odometers at the end of each day and then check in the morning to see if there has been any travel without his or her knowledge.
Some DID clients with parts that hold specialized abilities valuable for functioning can recruit a scheduling part to keep track of whatever they and other parts do in the course of the day or night. Or, when there is evidence that some activity must have occurred outside conscious awareness, clients can learn to ask inside, “Does anyone know why ______ happened? Who is responsible?” They are also taught to add, “And how was that part trying to help?”
By framing the dialogue around the expectation that each part is motivated by the instinct to protect and help, the client and therapist communicate that no one will be blamed or penalized for having tried to “help” in his or her own way. Such language communicates, too, that this is a different environment and a different kind of grownup, one that is not punitive or shaming but instead wants to help all parts to feel safer and better appreciated. If the goal is to increase communication and develop trusting relationships, there can be no “bad guys.” Parts can be asked to be sensitive or thoughtful of one another, but even parts that harm the body cannot be vilified. When parts are labeled as dangerous or abusive, no one can feel safe. If self-injuring parts are understood as trying to help bring relief to parts with overwhelming emotions or trying to numb the body or trying to teach everyone to “toughen up,” they are framed as having inherently good intentions. If there is no judgment of their behavior or attempt to suppress or marginalize them, they and other parts are likely to share more and allow more to be shared. Most importantly, when treated as inherently collaborative in nature, the chances of their learning to become collaborators increases. For that reason, I am very adamant that there is no such entity as an “internalized perpetrator.” Clients cannot “internalize” their abusers, though it might feel as if they have. The parts who can sound and act just like the perpetrator are reframed as protector or fight parts that “learned their ways” by modeling the perpetrator but whose intentions are always to protect the client and/or the little parts.
The need for collaboration and community is exponentially more important for DID clients than other structurally dissociated clients because there is no other way to create lasting safety and stability. With autonomous, disconnected parts that may not know each other, even the normal life part cannot enforce new rules—because he or she may not be present when they are broken. The therapist often needs to take on the role of a coach with a nearly impossible task: helping a chaotic conflicted “team” of individual parts, all unknowingly reacting to triggers of past experiences rather than to present moment threats. Each is perceptually biased by the legacy of traumatic experiences. Each is instinctively prepared to act according to automatic impulses and underlying animal defense. None of them is accustomed to collaboration, and none has had a coach before. Some parts will see the therapist not as a coach but as a godlike rescuer or protector; some will assume the therapist has nefarious ulterior motives; and only the normal life self or selves will be able to accurately understand the therapist’s role, motivations, and even interventions. Because the normal life self can be more autonomous in DID clients and has greater access to prefrontal processing and learning, therapeutic “work” can most effectively be done when the normal life part is present in session. The therapist must create a therapeutic alliance based on here-and-now goals: teaching the going on with normal life part self-regulation skills, skill-building, offering psychoeducation that increases the client’s ability to work with the system, to unblend, and to soothe or regulate vulnerable parts before their intense emotions drive fight and flight parts to act impulsively. Often, in the treatment of DID clients, the therapist is faced with what I call the “revolving door” of parts: he or she does not have one client who can be counted upon to predictably appear for the appointment. Many “clients” come, each of which has their own agenda: to elicit help and protection (attach), to please (submit), to fight for control (fight), to keep a safe distance or not come at all (flight), and to remain invisible (freeze). To prevent chaos in the therapy mirroring the chaos in the client’s life, the therapist needs to balance welcoming whichever parts appear in the therapy hour with the therapeutic goal of empowering the normal life self and increasing his or her ability to form trusting relationships with the parts and eventually to help them become a team. Since one of the core issues in DID is hijacking by parts who act outside the normal life part’s consciousness, the therapist must attempt to discourage the “revolving door” approach to therapy. There are several ways of accomplishing this goal without empathically failing the parts:
• Despite the absence of the normal life part during some or all of a session, the therapist can reference the client’s adult self in conversations with each part: “Do you know Felicia? Oh, you’d like her! She’s smart and funny, and she likes kids.” “How can you say you don’t trust Felicia if you don’t talk to her? That doesn’t make sense—you two have to get to know each other.” “Does Felicia know how scared you are at night?”
• The therapist can insist on the normal life self or “wise resourceful adult self” being present in the therapy hour: “I really think Felicia should know how lonely and scared you feel,” “It’s really important for Felicia to know you’re offering to kill the body to make the pain go away—maybe she could help the little parts with their pain so you wouldn’t have to use your ‘bail-out plan.’ She would at least want to thank you for offering such a big thing.” When parts resist, I emphasize that I myself need to talk to the normal life self because I want their concerns to be addressed: “How is she going to change this situation if she doesn’t know it’s a problem for you?”
• Creating a structure for each session that balances the needs of the parts with those of the normal life self: for example, the parts can be assigned the first 10 minutes of the session, the middle 20 minutes, or the last 15 minutes. (I prefer to have the younger parts present earlier in the session so the normal life self and I can work during the latter half.) The key is that the structure or norms for therapy are not couched in authoritarian terms: they are framed as concerns about the parts. “I know you want to tell me everything that’s bothering you, but I also need time to talk to Felicia about how to help you with those things.” Or, “I need time to teach Felicia how to help you.” Notice that only the normal life self is acknowledged by using the given name of the client or the word “you.”
Because the dissociative barriers are more impermeable in DID clients, it is even easier for clients to disown some parts and over-identify with others. It is also easier for parts to be unaware of each other, hypervigilantly aware, or even to disown other parts that threaten them.
It can be particularly challenging for DID clients to believe they have a normal life self, much less to feel connected to its strengths and competencies. The parts may remember a normal life child equally powerless to protect herself whose role was foreign to them. While they prepared to fight, flee, freeze, submit, or cry for help, the normal life child kept moving forward along a normal developmental path, more focused on the multiplication tables or playing baseball or taking care of younger siblings. If the client has been more identified with younger parts (e.g., the attach part’s loneliness and distress, the submit part’s shame and depression), it may feel ego-dystonic to think of the normal life self as “me.” Many clients have become so accustomed to feeling overwhelmed, shaky, crazy, or defective (the outcome of being blended with or hijacked by their parts) that any positive qualities or skills they possess have been thrown into doubt. It would be challenging for any human being to hold on to feelings of being normal or successful or competent when one is flooded with panic, shame, despair, rageful feelings, and impulses to harm—all at the same time. It would be difficult for anyone to maintain accurate self-esteem with judgmental parts communicating day after day that one is stupid, worthless, disgusting, or undeserving. Often, the therapist, too, is hard-pressed to remember that the client cannot lack a normal life part as long as he or she has an intact prefrontal cortex, areas of daily functioning, or even the wish or vision for a normal life. The example of Cecilia illustrates how therapists can work to strengthen the capacity of the normal life even when competency and executive functioning are limited:
Cecilia had never experienced “normal life.” From the day of her birth, to two drug-addicted parents, there was nothing safe or normal in her life experience. She was in foster care by age 5, identified as “disturbed” by her teachers by the 3rd grade; and, by the age of 12, she had her first hospitalization. She had rarely been out of residential environments since. But as her therapist explained the structural dissociation model, she had a flash of excited recognition. “I do have a going on with normal life part! That’s the part of me that’s always wanted to have a normal family, to live in a home instead of a hospital—that’s the part that wants to go to college! I remember that part from my first foster home—that’s the part that kept telling me that someday I wouldn’t have to live under the thumb of crazy people—I could make my own life if I could just live long enough.” Inspired by feeling emotionally connected to her desire to be whole and healthy and have a normal life, Cecilia immediately knew she wanted to help her trauma-related parts learn to feel safer and stable. She felt a physical determination and drive she had never consciously felt before. For the first time that she could recall, she asked her therapist, “What do I have to do to have a normal life?”
The therapist’s job is to hold the belief that human beings have an instinct to “keep on going,” to keep the home fires burning, even to self-actualize—even if it is hard to believe or hard to convince the client to believe. Cecilia’s treaters were understandably skeptical when she presented them with her question: they were aware that, before she could live a normal life, she would have to resolve her eating disorder, refrain from self-injury and suicidal threat, and get “clean and sober.” As the supervising therapist, I was confident. “Tell her that her first task is to begin noticing each part separately and naming them according to what they do or feel, like ‘the shame part,’ the ‘sad part,’ ‘the little girl part,’ ‘the suicidal part.’ She can use the structural dissociation model diagram to remind her of what kinds of parts to look for.”
Even in the face of the client’s adamancy that there is no adult self or normal life part, the therapist must remain a believer. As long as the client’s prefrontal cortex is intact, he or she is capable of curiosity, mindful awareness, compassion, creativity, confidence, courage, and commitment (Schwartz, 2001). If there is normal functioning in any arena of the client’s life, some aspect of self must be responsible for it. Which part of the client takes the car to be serviced? Who takes care of the children? Who goes to parent-teacher conferences at school? Who walks the dog? Who pays the bills? Can he remember even one time when he had patience? Or one time she was curious or creative? Or one time she extended compassion to another human being? Or were sought out by others for support or advice?
Maggie suffered painful bouts of self-doubt, shame, and aloneness related to the belief, “I don’t belong.” The feeling memory of a frightening childhood in a family that made her feel as if she wasn’t wanted pervaded her consciousness, interfering with incoming data that might have told her parts that, in her adult world, she was welcomed warmly. I asked her if she would be willing to do some research as a homework project for the following week: would she be willing to look for any and all evidence that might maybe, possibly mean that she did belong? And as an addendum: would she be willing not to critique her list or to question the evidence she found? She came back for her next appointment with a list and lots of questions: “Does having friends and family calling you up to ask for advice count as ‘belonging’?” she asked. “Absolutely!” I said. “How about being asked to represent your school at a teachers’ conference?” “Wow! That would be evidence of belonging and being seen as valuable,” I clarified. “And how about being asked to become a deacon in my church? I guess that counts, too. How could they ask me to take such an important role if they didn’t think I belonged?” “So, Maggie, we’ve learned something important,” I said. “You now have hard evidence that you do belong here—in the world you made for yourself and the life in which you choose to participate—now it’s a question of conveying that to the parts: pointing out to them each and every time one of these moments occurs that you do belong. Could you bring their attention to the moment you see the evidence and share it with them? Otherwise, they will continue to feel that painful sense of being on the outside, looking in.”
When amnestic barriers around dissociated self-states prevent communication from part to part, information about current life experience cannot be integrated. The attach part feels a longing to be important to friends, spouse, or children, causing the normal life part to prioritize relationships in her life that evoke feelings of being cared about. But the news that there are now caring people in the client’s life never reaches the attach part, much less the fight and flight parts or the depressed submit part. The attach part still feels little and vulnerable to abandonment, never having gotten the news that she is part of a body that is now 43, not 5 years old. The normal life part may not be aware that the suicidal fight part, triggered by the submit part’s shame, is planning to take an overdose. Other parts feel nervous, sensing that something bad is about to happen but unaware of what exactly will unfold. The normal life plans a summer vacation and makes reservations, unbeknownst to the suicidal part. Had the suicidal part known the depression was a memory, not evidence of all hope lost, the suicidal impulses might have subsided. As one client put it, “So much in my life has changed, but obviously there has been no trickle-down effect—the news hasn’t yet reached the parts.”
Annie provides us with an example of how to help clients work on “the trickle-down effect,” on techniques that can help provide information about present time to parts lost in the traumatic past.
Annie found herself wandering around her backyard with blood oozing from a cut on her leg after “coming to” after dark one night. The last thing she recalled was an afternoon conversation with her therapist about the latter’s upcoming vacation/absence. As they talked, she had felt a rush of anxiety; her back tightened up; and she felt a sense of dread. “How are the parts feeling about this?” I asked. “They’re scared,” Annie said. “If you’re around, they feel there’s some protection against danger—if you’re not here, anyone could hurt them.” “Annie, where do they think they are? Ask them to show you a picture of where they are right now.”
ANNIE: “A picture of my childhood home comes up.”
ME: “That makes sense. They’re afraid the bad people will hurt them again. Who would I have been back in New Jersey in those days? What would my absence have meant to them?”
ANNIE: “They think you’re Wonder Woman—or some combination of the school guidance counselor who kept asking me if I was OK and Wonder Woman.”
ME: “So, in their eyes, I’m the person with the power to rescue them if the bad guys come for them? Didn’t anyone ever tell them that you rescued them a long, long time ago? Don’t tell me no one has ever brought them up to date! Annie, you never told them?! All this time, they’ve been safe, but no one told them!” [I deliberately speak with a slightly horrified tone, as if appalled by this oversight.]
ANNIE: “That’s right—but I never told the parts because I didn’t know they were there.”
ME: “Annie, it’s so important to tell them now. Could I talk to them? Maybe they’ll believe me. Could you ask if everyone can hear me? [Pauses while Annie attunes inside to make sure all parts are listening.] There is something very, very, very important that I think you all should know—some good news! Great news! A long, long time ago, almost 20 years ago, Annie left that scary house in New Jersey where so many bad things happened and went far, far away to Maine, so far away that your mother was really mad and told her she could never come back to that house! Does anyone remember when your mother did that?” [Waits for parts to respond to the question and gets a nod. She goes on.]
“Once she was far away from New Jersey, Annie realized that the bad people who hurt all of you couldn’t do that anymore if they didn’t know where you were, so she decided not to tell anyone where she was. It was a secret to protect you and her, and it’s never been broken. The bad people have never known where you all are, and now they are all too old to hurt you as long as Annie is here—she has a tall strong body now, much taller and stronger than they have. Annie, what’s it like for the parts to hear me give them this news?”
ANNIE: “There’s a kind of stunned silence inside—they’re taking it in … It’s hard to believe, but they want to.”
ME: “Show them a picture of your home today. Explain that it’s where you live. Ask them to look around each room very slowly and notice if your house is like New Jersey or different.”
ANNIE: “Oh no, they think it’s very different—it’s clean and pretty and homey. Just what they always wanted … But the little ones want to know if they have to be alone in this house because they don’t like being alone—it’s scary.”
ME: “Tell them who lives in this house and why you allow your husband, son, and Ethan to live there …”
Annie brings up images of her husband, son, and nephew and invites the parts to share their reactions: “They like the idea that there are strong men who want to protect me in this house …”
ME: “Of course they do! It’s good to have strong men who want to protect you, who would fight for you—your sons would; your nephew Ethan would; your husband would.”
ANNIE: “That’s true—I have bodyguards!” Laughs delightedly. “Can you imagine? I have all these males around me who are over 6 feet tall who all depend on me. Imagine that?!”
ME: “Now, the challenge is going to be this: helping the parts take this news in. Each time they automatically react to your home and neighborhood as if they’re still in New Jersey, ask them to pause, open their eyes, look around, and focus very carefully so they can see where they are. Ask them: is this New Jersey or Maine? How can you tell? Yes, the red door tells you you’re in Maine—the white paint on the house, the smells of cooking coming from the kitchen, the quiet, the sound of laughter—that’s not New Jersey. That has to be Maine.” And each time Annie asked her parts to look around the room or around the house, she could feel a calming of her body as the parts recognized the signs of where they were now and breathed a sigh of relief.
Survival behavior, learned in the context of life threat, is often difficult to change: the body resists relaxing patterns of clenching, bracing, increases in heart rate and respiration, impulses to punch or kick or claw (Ogden et al., 2006). Lowering one’s guard, softening tension, opening the heart can all feel threatening, thanks to the implicit memories connected to the threats of the past. As soon as the client’s body relaxes, anxiety escalates. Without the ability to modify those automatic, instinctive threat responses, trauma survivors cannot feel safe, can’t feel a sense that “it’s over” (Ogden & Fisher, 2015; Ogden et al., 2006). These challenges are compounded when the client is dissociatively compartmentalized, especially when there are parts amnestic for each other’s behavior and/or engaged in a life-or-death internal struggle. Even the most basic skills of trauma recovery are difficult to remember, much less utilize, under these circumstances. If we want to help clients with dissociative disorders, the best approach is to rely on:
• Increasing conscious mindful awareness of parts, as discussed in Chapter 4, and of the signs of triggering, switching, and blending.
• Psychoeducation.
• Helping clients learn to speak the “language of parts.”
• Piecing together a continuous sense of consciousness, challenging the client to observe the emotional, cognitive, and action patterns connected to different parts.
• Emphasizing practice and repetition of new patterns or actions until they become familiar.
• Renegotiating internal relationships: using internal communication to develop greater trust and collaboration among the parts.
Typically, with a client presenting with multiple serious symptoms and issues, therapists often try to address the problems causing the highest risk first. In DID clients, that means addressing the amnesia, the internal conflicts, problems with self-regulation, and the attachment issues of the fight and attach parts that can fuel self-injurious behavior—all complex and multifaceted challenges that cannot be effectively met at first—not until the client has developed dual awareness, the ability to unblend, at least rudimentary inner communication skills, and a capacity to convey empathy to the parts. (See Chapters 4 and 5.)
To renegotiate the role of a fight part from that of suicide threat to one of stabilizing protector requires that the client learn to differentiate the suicidal part from the normal life self who “keeps on keeping on” in spite of everything, and then to unblend from the suicidal part, learn how to manage the conscious impulses of that part (as well as any pulls to switch), to communicate a respect for and a wish to build relationships with both the angry or suicidal part and the wounded child selves it protects, find ways of comforting and bonding with the attach parts to reduce their vulnerability to painful emotion, and then to build up the somatic sense of protection connected to the fight response (aligned energized spine, readiness for action, muscular strength, movement impulses to punch, push away or block in the arms and shoulders) (Ogden & Fisher, 2015).
The most sophisticated interventions depend for their success on the building blocks of DID treatment: awareness of shifts in emotion and sensation connected to parts, mindful naming of each part’s function or attributes, unblending from parts’ impulses and emotions, “befriending each part,” developing interest in and compassion for them, learning through inner dialogue to decipher their intentions and motivations, allying with the “best self” of each part, and then negotiating new resolutions to old issues. Annie gives us an example of how much patience and repetition is necessary for DID clients to become proficient in these skills—and the way in which layers of parts defending other parts result in patterns of stuckness.
Annie found that, even after what felt like years of practicing the basic skills of working with her parts, she kept encountering new road blocks: first, she discovered teenage parts who distrusted my every word or piece of advice, believing I would ultimately use or abuse them. Once they were reassured that, even if she listened to me, Annie was strong enough to hold her own opinion, no matter how much the young parts wanted to please me, the protectors relented and allowed her to keep growing. A year later, she encountered a part that fought to deny the trauma and abuse she had suffered, a part responsible for her “forgetting” that she had parts and therefore forgetting to unblend. Most recently, she identified the “eraser part,” the part that deliberately caused amnesia for new ideas, skills, information, and especially for any positive change in her life, in order to protect her from changing the status quo that had allowed her to survive not only familial abuse but also ritual abuse. By erasing the memories of all positive change and even positive experiences, this part reinforced the feelings of hopelessness, shame and guilt, avoidance of being seen, and a sense of isolation and not belonging—all of which had kept the traumatic secrets “locked down” for so many years that Annie only learned what had happened to her in her 30s.
In DID, amnestic barriers between parts interfere with the client’s ability to know his or her own inner world and the parts that make it up, creating ripe opportunities for guerilla warfare or sabotage by parts of whom even the normal life is often unaware. In addition, the amnesia helps ensure that the trauma-related parts are equally unaware of the safety, stability, and comfort of the normal life part’s consciously constructed adult life.
Two of the strongest drives in any human being are the attachment drive and the fight response. Both are crucial to survival. Proximity-seeking as an attachment drive and its corollary, the cling for survival response, are necessary for the protection of the young. Fight is the animal defense that gives us the strength to protect ourselves as well as others. Both of these drives tend to be dramatically intensified in DID clients, a diagnosis that is statistically associated with disorganized or traumatic attachment in childhood (Lyons-Ruth et al., 2006). With an attach for survival part dissociatively encapsulated and forever a tiny child, unaware that he or she is protected by a grownup body or has interpersonal power in relationships, fear of rejection and abandonment are easily activated and feel “present now,” not a memory of the past. The emotional pain or anxiety associated with loss of proximity in turn triggers the fight part to anger, hypervigilance, mistrust, even paranoia. Disoriented in time, the fight part comes to the defense of the attach part, both parts assuming that the therapist, friend, or significant other is the cause of these feelings of hurt and anger. This “other” is rejected as “cold and uncaring,” “insensitive,” or “condescending,” with the implied demand to remediate these failings because they are “wrong.” Or the opposite may occur: the client may come to therapy blended with the attach part, shy and mute or highly distressed and agitated. In either case, the therapist will feel a pull or yearning to help when faced with the neediness and “littleness” of the attach part or, conversely, may feel pushed back or defensive in the face of the fight part’s accusations. Some therapists draw their boundaries more clearly in the face of the regressive or aggressive behavior, while other therapists try to prove their trustworthiness and caring by giving and doing more for the client. Both extremes tend to intensify the traumatic transference: the setting of boundaries inflames the fight part as a challenge for control and triggers feelings of rejection in the attach part. Giving and doing more is also threatening because it inflames the attach parts’ longing and fear of loss, a red flag to the fight part. In many trauma therapies, these issues complicate the treatment but, in therapy with DID clients, they can more dramatically intensify because of the greater autonomy of the parts. When the neediness and fear of abandonment are held by a young part unintegrated with competent, protective, or nurturing parts, the communication of need and vulnerability is palpable and hard for the therapist to resist without feeling guilty and abandoning. When anger and outrage are held by an unintegrated fight part, the anger is more intimidating and unleavened by perspective, empathy, or gratitude. Some therapists have trouble holding the boundaries in the face of the onslaught; some rigidify the boundaries and tighten the treatment frame. Either extreme tends to be triggering to the parts. The challenge in both cases is that of holding in mind a paradox: each part is separate in its perspective, its sensitivities, and its defenses; each can take over the body and drive action as if it were a separate person, yet each is part of a whole, a whole that is fully able to function and care for itself. The therapist must try to hold onto this double perspective in order to avoid treating the child parts as if the whole client were young and unable to function on his or her own—or, even worse, treat the whole client as if she or he were only angry, accusatory, and devaluing.
To treat the paradox, rather than treating each part separately, requires that the therapist be able to resonate with the young part and communicate at his or her developmental level and also be able to resonate with the angry part as if it were an individuating adolescent, in need of respect for its insight and sense of fairness as well as its courage. The angry part’s positive intentions, the wish to protect the child, must be acknowledged. Most of all, working with disorganized attachment in DID clients requires restraint on the part of the therapist: a holding back of the impulse to soothe the child, to offer the reassurance requested, to become a go-between for the normal life self and the angry part. If we as therapists can restrain ourselves from over-reacting to either regression or aggression, then we can facilitate a growing relationship and dialogue between the normal life aspect of the client and his or her traumatized younger selves. If the normal life self learns to soothe the child and provide the feeling of specialness so necessary in secure attachment, then the fight part will not have to be the only protector. If the normal life part is able to negotiate with the fight part and take over the protector function, then fight’s aggressive behavior will not be activated so automatically by the sense of threat to the child. If therapists substitute themselves for the normal life part, then the system becomes dependent upon the therapist—which fuels the disorganized attachment. The fight part’s sense that the therapist is a threat intensifies when the client as a whole becomes more dependent on us; the attach part’s fear of abandonment also intensifies. The parts are then caught in a vicious circle, and so is the therapist. Without restraint and repeated self-reassurance that the client knows how to survive (is an expert at it, in fact) and we need only to teach him or her how to manage the internal forces triggered by relationships, we cannot help clients weather the storms caused by trauma-related disorganized attachment.
If we as therapists exercise the appropriate restraint of both nurturing and self-protective impulses, it means that we don’t become responsible for the parts that want to live, the parts that want someone to whom they can attach or tell their stories or feel special. We don’t “take on” the angry protectors on behalf of the normal life self or on behalf of the child parts. If we are exercising the kind of “economy” that communicates our commitment, care, and compassion while avoiding induction into the system or taking on the roles of rescuer, victimizer, or victim, all the parts will feel safer. The normal life self can more easily shoulder the responsibility of caring for the young parts if the therapist is not competing for that job. If the therapist can hold warmth in the heart for the little attach part, respect for the fight part and admiration for its courage, and can see the signs of a normal life self with the potential to become a healer and comforter, then it becomes easier not to feel pressure to “fix” the problems and crises. This requires patience on the part of the therapist, persistence, and holding on tight as the system tests our consistency in being caring and compassionate but not caretaking—even when the suicidal part is threatening, the child feels lost and alone, the normal life part is so blended that it can’t be mindful, engaged with the parts, or able to prevent switching and acting out.
Clients and their fight or attach parts sometimes take issue with my emphasis on the client’s normal life part working directly with the parts, while my role, as I describe it to the parts, is to “teach the grownup how to take care of you.” I am the coach for this team, the parent educator. All involved would much rather that I help each and every part myself. An understandable wish, of course, but one that is challenged by the necessity for mindfulness as an antidote to trauma. Without an observing witness that resides in the client’s body, a “part that can see all the parts,” the child and adolescent selves will still be “home alone.” The parts’ locus of control will still be external. The loss of control associated with trauma will persist as a need for an external resource to regulate the nervous system and transform negative feelings into positive.
I realized one day while working with Annie why this issue felt so important to me beyond an intellectual commitment to self-regulation and mindfulness-based treatment. Her little parts were begging me to “say something nice,” interrupting the work Annie and I were doing to address the parts responsible for her inability to have daily structure. I asked Annie if she would be willing to say something nice to the child parts so we could go back to the structure issue. “But they want you to say something nice—they need a good feeling today.” These little parts communicated an important message: “Our feelings are not our own. Other people make us feel bad, and only other people can make us feel good.” This is one of the lessons taught by trauma. Thanks to those child parts, I have been committed to ensuring that my clients would leave therapy with the ability to manage bad feelings and evoke good feelings—without having to depend upon others to “make” them feel good or bad. If I work using primarily “direct access” (the IFS term for 1:1 work with the parts), then client and parts will learn that they can depend on me to feel good feelings. But if I am away on a speaking trip or between sessions, the parts have no resource for good feelings unless I provide outside-of-therapy contact—thereby risking exacerbated disorganized attachment. The unrelenting fears of abandonment of the attach part are heightened: without “her,” they believe, there is no source of good feelings. But if, on the other hand, the work of building relationships with the parts, earning their trust, and developing warm attachment bonds is an internal experience, then control rests with the client. The attach parts do not have to worry about abandonment because the wise, caring normal life self of the client is always there. He or she becomes the source of the warm, pleasurable safe feelings. Dependency is safe when child parts depend upon a caring adult self available in the same body.
It can be hard for therapists accustomed to working with the relationship between client and clinician to take the more “backseat” role of family therapist. But although it can be very effective to use the relationship as the vehicle for healing with one individual client, there is no “one” therapeutic relationship with fragmented or DID clients. We are dealing with many “clients,” all of whom are part of a family system that must heal itself to be free of the past, just as a biological family must do. This value is also central to the work of Sensorimotor Psychotherapy as the principle of “organicity” (Ogden & Fisher, 2015), referring to the body’s innate drive toward healing and growth, toward “righting itself” when off-balance, growing new skin cells after a cut, or automatically compensating when there is an injury to some part of the body. In Internal Family Systems, the same principle is called “self-leadership”: the belief that we heal ourselves through access to the innate capacities for compassion, curiosity, clarity, creativity, courage, calm, confidence, and commitment to all of our selves. Young, traumatized parts impacted by trauma and neglect have long been deprived of the compassion and calm they deserved; they have needed someone to courageously protect them, and they have suffered from the failure of adults to make a deeply felt commitment to them. On top of that rejection, their banishment as “not me” parts by the normal life self has re-enacted the failure of commitment day after day ever since.
What both Sensorimotor Psychotherapy and IFS teach is that the therapist must provide a “container” or “growth-facilitating” environment that evokes these natural tendencies necessary for healing. In IFS, the therapist’s own use of the qualities of self (Schwartz, 2001) is meant to stimulate the client’s natural access to states of curiosity or commitment or compassion. In Sensorimotor Psychotherapy, these same qualities are not specifically named, but they are cultivated. The therapist’s commitment to staying embodied and mindful and his or her palpable curiosity has a contagion effect, spontaneously engaging the client’s curiosity and attentional focus, facilitating organic change (Ogden & Fisher, 2015).
Even without taking over the role of healer, the therapist nonetheless contributes to the sense of safety in the therapy via the social engagement system (Porges, 2011). The social engagement system is a neural system connected to the ventral vagus or ventral portion of the vagus nerve, controlling the movements of the eyes and eyelids, the muscles governing facial expression, the larynx, middle ear, and the tilting and turning movements of the head and neck. These are the channels of communication between babies and parents: a mother holds the baby’s gaze, smiles and laughs, her eyes sparkling. Then the baby coos, and the mother imitates his vocalizations, and the baby echoes hers. She tilts her head and smiles again; the baby smiles back. The child feels safe and warm.
By using the social engagement system to communicate welcome, warmth, and understanding to every part, particularly to those parts with whom the client is uncomfortable, the therapist creates a felt sense of safety. Not only can the child part can hear the caring tone of voice but also sees a softness in the therapist’s eyes or face, automatically returns the smile, and is soothed by the soft tone of voice. If the therapist says with warmth and sadness, “Of course the little part is scared in an empty house—how could she not be? With no one taking care of her and so many people who were mean to her, it must be terrifying to be by herself,” the child is reassured not just by the words but by the tone of voice, the normal life self is educated, and there is modeling of how to attune to a child. If therapists use a tone of respect or even delight when referring to the fight part, rather than a tone of concern or authority, they will communicate that they are not scared away by the threats of the fight part but admire that part’s adversarial protectiveness or willingness to fall on its own sword if the battle is lost. “Wow! The angry part really shut me down and put me right in my place—and that’s not easy to do. That part definitely has your back!” “Could you thank the suicidal part for its generous offer? Maybe that part believes that you’re not strong enough to handle all the feelings and memories, so it has to intervene, but you could explain that you’d like to be strong enough to tolerate them, and you can’t learn to do that if the fight part is always bailing you out.”
In the role of family therapist or coach, the therapist can contribute to strengthening the connection between the normal life self and both attach and fight. Therapists can urge clients to make a special place in their lives or hearts for the littlest self, the part that is innocent, trusting, and the most vulnerable. Use of facial expression, tone of voice, and softening of gaze can all support the communication of empathy or evoke it in the client.
Because the prefrontal cortex is associated with neutrality, observing presence, and access to compassion, I can be confident that, if I am talking to the normal life part, I will hear more integrated responses: “I’m a little ambivalent about dealing with these little parts. I’m afraid of them, I guess.” When I hear, “I wish they’d go away and never come back,” I can be sure that exposure to the vulnerability of attach has triggered a distancing or gatekeeper part that “hates the other parts.” Hostile, punitive remarks can only mean one thing: an intrusion by a part that is phobic of the traumatized parts. In those moments, I know the wise, compassionate “best self” of the client is not speaking. And I feel confident challenging the “I” as unrepresentative of the client, as I did in the following example with Tom. Because my belief in his “best self” is a compliment, it is hard for him to argue with my remarks and even harder to take offense.
Tom was adamant: “I never asked for these parts to help me survive, and I don’t want them now. I wish they were dead!”
ME: “Why do you wish they were dead, Tom?” I asked.
CLIENT: “Because they embarrass me—they look sad; they’re scared of their own shadows; they want me to depend on people. I did that once before, and look how that turned out!”
ME: “Tom, I know you. And I know that you would never, ever turn your back on a child who was hurting! I refuse to believe that you of all people would make fun of a child who was crying or looked sad. You always try to help everyone! Imagine for a moment that there is a little boy standing right here in front of you [I point to a spot on the floor]. He’s looking lost and he’s crying and looking around [I imitate the same movements as if I were scared]—what’s your impulse? To say ‘Shut up, kid’ and just walk on by? Or is there another impulse?”
TOM: “No, my impulse is to stop and ask him, ‘What’s wrong?’”
ME: “Of course it is! I knew it—you’d never turn your back on a child in need! What is he saying?”
TOM: “He’s saying that he ran away from home because bad things were happening, but now he’s lost, and he’s scared.”
ME: “That was very brave of him to run away—for such a little guy, too. What’s your impulse? What are your body and your feelings telling you?”
TOM: “I want to say, ‘Come with me—I’ll take care of you—no one gets hurt at my house …’”
ME: “And what goes with those words? Do you want to take his hand? Pick him up? Or ask him to follow you?”
TOM: “I feel like I want to pick him up …”
ME: “Then follow that instinct—just reach out to him and see if he’d like that.”
TOM: “He’s already jumped into my arms—as soon as I said I wanted to pick him up!”
ME: “Then just feel him in your arms—feel the warmth of his little body—see if he likes that feeling of being held …”
TOM: “I can feel him relaxing—like he knows I’m safe—I won’t hurt him.”
ME: “Feel his knowing that … Yes, he can relax—he’s in good hands now—is that a pleasurable feeling?”
TOM: “It’s the best—it feels so good to hold him.”
ME: “Well, I’m glad it feels so good because he really needs to be held—it’s been a long time coming. He needs someone to hold him, to notice when he feels bad, to greet him every morning with a big smile and hugs and kisses.”
TOM: [tearing up] “Yeah, no one ever looked happy to see me every morning …”
ME: “That was his experience and yours, wasn’t it? And what’s it like to see him and feel him with you right now?
TOM: [through his tears] “He’s asking if it’s OK to cry—he doesn’t know why he’s crying, so he’s saying ‘sorry.’ That’s so sad. I told him it’s OK—I’m crying, too, because I’m happy.”
ME: “It’s the grief of relief. He’s finally getting what every baby and every little kid wants: for someone’s eyes to light up when they see him coming—to feel so very special to someone. And just feel it in your body … you are giving him something he’s always wanted, and it feels just as good to you as it does to him!”
American Psychiatric Association (2000). Diagnostic and statistical handbook of mental disorders-TR. Washington, D.C.: American Psychiatric Association.
Brand, B.L., Lanius, R. Loewenstein, R.J., Vermetten, E., & Spiegel, D. (2012). Where are we going? An update on assessment, treatment, and neurobiological research in dissociative disorders as we move towards the DSM-5. Journal of Trauma & Dissociation, 13, 9–31.
Brand, B.L., Sar, V., Stavropoulos, P., Kruger, C., Korzekwa, M., Martinez-Taboas, A., & Middleton, W. (2016). Separating fact from fiction: an empirical examination of six myths about dissociative identity disorder. Harvard Review of Psychiatry, 24(4), 257–270.
Briere, J., Elliott, D.M., Harris, K., & Cotman, A. (1995). Trauma Symptom Inventory: psychometrics and association with childhood and adult trauma in clinical samples. Journal of Interpersonal Violence, 10, 387–401.
Carlson, E.B., Putnam, F.W., Ross, C.A., & Torem, M. (1993). Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: a multicenter study. American Journal of Psychiatry, 150, 1030–1036.
Dorahy, M.J., Shannon, C., Seager, L., Corr, M., Stewart, K., Hanna, D., Mulholland, C., & Middleton, W. (2009). Auditory hallucinations in dissociative identity disorder and schizophrenia with and without a childhood trauma history. Journal of Nervous and Mental Disease, 197, 892–898.
Gazzaniga, M. S. (1985). The social brain: discovering the networks of the mind. New York: Basic Books.
Gazzaniga, M. S. (2015). Tales from both sides of the brain: a life of neuroscience. New York: Harper-Collins.
Korzekwa, M., Dell, P.F., Links, P.S., Thabane, L., & Fougere, P. (2009). Dissociation in borderline personality disorder: a detailed look. Journal of Trauma and Dissociation, 10(3), 346–367.
LeDoux, J. (2002). The synaptic self: how our brains become who we are. New York: Guilford Press.
Lyons-Ruth, K. et al. (2006). From infant attachment disorganization to adult dissociation: relational adaptations or traumatic experiences? Psychiatric Clinics of North America, 29(1).
Ogden, P. & Fisher, J. (2015). Sensorimotor Psychotherapy: interventions for trauma and attachment. New York: W.W. Norton.
Ogden, P., Minton, K. & Pain, C. (2006). Trauma and the body: a sensorimotor approach to psychotherapy. New York: W.W. Norton.
Reinders, A.T.T.S., Nijenhuis, E.R.S., Quak, J., Korp, J., Haaksma, J. Paans, M.J., Willemsen, A.T.M., & den Boer, J.A. (2006). Psychobiological characteristics of dissociative identity disorder: a symptom provocation study. Biological Psychiatry, 60, 730–740.
Schwartz, R. (2001). Introduction to the internal family systems model. Oak Park, IL: Trailheads Publications.
Steinberg M. (1994). The structured clinical interview for DSM-IV dissociative disorders-revised (SCID-D). Washington, D.C.: American Psychiatric Press.
Steinberg, M. (2013). In-depth: understanding dissociative disorders. Psych Central. Retrieved on September 13, 2015 from http://psychcentral.com/lib/in-depth-understanding-dissociative-disorders/.
Zanarini, M.C., Frankenberg, F.R., Dubo, E.D., Sickel, A.E., Trikha, A., Levin, A., & Reynolds, V. (1998). Axis I co-morbidity of borderline personality disorder. American Journal of Psychiatry, 155, 1733–1739.