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A Survey of Practices and Recommended Treatment Interventions Among Expert Therapists Treating Patients With Dissociative Identity Disorder and Dissociative Disorder Not Otherwise Specified

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Little empirical evidence exists about the treatment of dissociative identity disorder and dissociative disorder not otherwise specified. Thus, we must rely on the clinical literature, which advocates a staged course of treatment. A survey of 36 international experts in the treatment of dissociative disorder (DD) was conducted to learn what treatment interventions they recommended at each stage of treatment. These highly experienced therapists recommended a carefully staged treatment consisting of three phases. In the initial phase, they advocated emphasizing skill building in development and maintenance of safety from dangerousness to self or others and other high-risk behaviors, as well as emotion regulation, impulse control, interpersonal effectiveness, grounding, and containment of intrusive material. In addition, they recommended specific trauma-focused cognitive therapy to address trauma-based cognitive distortions. They uniformly recommended identifying and working with dissociated self states beginning early in treatment. They advised the use of exposure or abreaction techniques—albeit modified to not overwhelm these complex dissociative patients—balanced with core, foundational interventions for the middle stage. The last stage of treatment is less clearly delineated and more individualized. Unification of self states appears to occur in only a minority of patients with DD. This study provides directions to pursue for future training and research on DD.
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Psychological Trauma: Theory, Research,
Practice, and Policy
A Survey of Practices and Recommended Treatment
Interventions Among Expert Therapists Treating Patients
With Dissociative Identity Disorder and Dissociative
Disorder Not Otherwise Specified
Bethany L. Brand, Amie C. Myrick, Richard J. Loewenstein, Catherine C. Classen, Ruth Lanius,
Scot W. McNary, Clare Pain, and Frank W. Putnam
Online First Publication, December 5, 2011. doi: 10.1037/a0026487
CITATION
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., Pain,
C., & Putnam, F. W. (2011, December 5). A Survey of Practices and Recommended
Treatment Interventions Among Expert Therapists Treating Patients With Dissociative
Identity Disorder and Dissociative Disorder Not Otherwise Specified. Psychological Trauma:
Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0026487
A Survey of Practices and Recommended Treatment Interventions Among
Expert Therapists Treating Patients With Dissociative Identity Disorder and
Dissociative Disorder Not Otherwise Specified
Bethany L. Brand
Towson University Amie C. Myrick
Family & Children’s Services of Central Maryland
Richard J. Loewenstein
Sheppard Pratt Health System, Baltimore, MD Catherine C. Classen
University of Toronto
Ruth Lanius
University of Western Ontario Scot W. McNary
Towson University
Clare Pain
University of Toronto Frank W. Putnam
Cincinnati Children’s Hospital Medical Center and University of
North Carolina School of Medicine
Little empirical evidence exists about the treatment of dissociative identity disorder and dissociative
disorder not otherwise specified. Thus, we must rely on the clinical literature, which advocates a staged
course of treatment. A survey of 36 international experts in the treatment of dissociative disorder (DD)
was conducted to learn what treatment interventions they recommended at each stage of treatment. These
highly experienced therapists recommended a carefully staged treatment consisting of three phases. In the
initial phase, they advocated emphasizing skill building in development and maintenance of safety from
dangerousness to self or others and other high-risk behaviors, as well as emotion regulation, impulse
control, interpersonal effectiveness, grounding, and containment of intrusive material. In addition, they
recommended specific trauma-focused cognitive therapy to address trauma-based cognitive distortions.
They uniformly recommended identifying and working with dissociated self states beginning early
in treatment. They advised the use of exposure or abreaction techniques—albeit modified to not
overwhelm these complex dissociative patients—balanced with core, foundational interventions for the
middle stage. The last stage of treatment is less clearly delineated and more individualized. Unification
of self states appears to occur in only a minority of patients with DD. This study provides directions to
pursue for future training and research on DD.
Keywords: dissociation, treatment, dissociative identity disorder, trauma, posttraumatic stress disorder,
exposure
There has been a significant increase in research involving
dissociation over the last two decades (Dalenberg et al., 2007),
including a clinical literature describing assessment of patients
with dissociative disorders (DD; Brand, Armstrong, Loewenstein,
& McNary, 2009a; International Society for the Study of Disso-
ciation [ISSD], 2006) and an emerging literature that suggests an
underlying neurobiological basis for dissociation (e.g., Lanius et
al., 2010; Vermetten, Dorahy, & Spiegel, 2007). However, sys-
tematic research on treatment outcome for dissociative disorder
patients is in its infancy. Case studies, case series, and uncontrolled
inpatient studies of patients diagnosed with dissociative identity
disorder (DID) and/or dissociative disorder not otherwise specified
(DDNOS) have emerged from North America, Europe, and Puerto
Rico (e.g., Ellason & Ross, 1997; Coons & Bowman, 2001; Coons
& Sterne, 1986; Kluft, 1984; S¸ar & Tutkun, 1997; S¸ar, Öztu¨rk, &
Kundakc¸ii, 2002; van der Hart & Boon, 1997). These studies show
that DID and DDNOS are complex trauma-based disorders (Her-
man,1992; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola,
2005). A systematic review of the treatment literature on a variety
of DD (Brand, Classen, McNary, & Zaveri, 2009b) found that
Bethany L. Brand, Psychology Department, Towson University; Amie
C. Myrick, Family & Children’s Services of Central Maryland; Richard J.
Loewenstein, The Trauma Disorders Program, Sheppard Pratt Health Sys-
tem; Catherine C. Classen and Clare Pain, Department of Psychiatry,
University of Toronto; Ruth Lanius, Department of Psychiatry, University
of Western Ontario; Scot W. McNary, Department of Educational Tech-
nology and Literacy, Towson University; and Frank W. Putnam, Mayerson
Center for Safe and Healthy Children, Cincinnati Children’s Hospital
Medical Center and University of North Carolina School of Medicine.
Correspondence concerning this article should be addressed to Bethany
L. Brand, Psychology Department, Towson University, 8000 York Road,
Towson, MD 21252. E-mail: bbrand@towson.edu
Psychological Trauma: Theory, Research, Practice, and Policy © 2011 American Psychological Association
2011, Vol. ●●, No. , 000– 000 1942-9681/11/$12.00 DOI: 10.1037/a0026487
1
treatment was associated with significant improvement, with effect
sizes ranging from 0.36 to 1.82 (M0.71) using either posttreat-
ment or follow-up data. Cross-sectional and longitudinal data from
a large, observational international sample of DID and DDNOS
patients indicated decreased symptoms of dissociation, posttrau-
matic stress, depression and general distress, reductions in rates of
self-injury, suicide attempts, and hospitalization, and improve-
ments in adaptive functioning over 30 months of treatment (Brand
et al., 2009c; Brand, et al., 2011). Together, these studies provide
preliminary evidence that treatment is effective in reducing a range
of Figure 1 symptoms associated with DD.
The primary goal of this study is to systematically investigate
the structure and techniques of treatment that DD experts be-
lieve are important at various treatment stages. Although gen-
eral treatment guidelines have been developed by a consensus
of experts (ISSD, 2006; International Society for the Study of
Trauma and Dissociation [ISSTD], 2011) and suggest a phasic,
multimodal, trauma-focused psychotherapy, the trauma field
has yet to develop an empirically supported, criterion standard
set of interventions that are effective at the various stages of
treatment for DD (Chu, 1998; 2011; Courtois & Ford, 2009;
Herman, 1992; ISSD, 2006; ISSTD, 2011; Kluft, 1994a, 1999).
Figure 1. Top 10 interventions by stage.
2BRAND ET AL.
Three overarching phases of treatment are described for com-
plex posttraumatic stress disorder (PTSD; Courtois, 1997; Her-
man, 1992; Kluft, 1993a). First, treatment focuses on symptom
stabilization and safety with a focus on enhancing symptom con-
trol, education about trauma treatment and complex trauma disor-
ders, and the establishment of a collaborative working relationship
(Chu, 2011; Courtois, 1997; Gold, 2000; Herman, 1992; Kluft,
1993a). Patients begin to understand that self-injurious behaviors,
suicide attempts, substance abuse, aggression toward others, and
current abusive relationships are reenactments of trauma and dis-
rupted attachments (Brand, 2001; ISSTD, 2011; Foote, Smolin,
Neft, & Lipschitz, 2008). Patients with DD are taught affect and
impulse regulation skills as well as internal communication with
dissociated self states.
With sufficient stabilization patients may move into the second
phase of treatment, which involves processing of traumatic mate-
rial and associated intense affects. As these traumatic memories
are explored, trauma-related cognitive distortions and reenact-
ments can be resolved, and previously avoided emotions such as
grief, betrayal, terror, helplessness, rage, and shame expressed.
Patients develop a narrative of their nontraumatic as well as
traumatic experiences, a sense of mastery over their memories, and
a sense of themselves as being worthwhile and strong (Courtois &
Ford, 2009). The third phase entails “reconnection” in which all
disowned aspects of self are fused together so that no dissociated
self states are present; alternatively, some patients achieve a state
of “resolution” where self states remain unfused in a cooperative
system (Kluft & Loewenstein, 2007). Also in the third phase,
clinical attention focuses increasingly on current and future life
issues and goals such as developing a sense of purpose in life
supported by healthy relationships and engagement in meaningful
activities (Courtois, 1989; Herman, 1992; Kluft, 1984).
In this article, we use unification to describe the process of a
person’s sense of self shifting from that of having multiple self
states to that of a unified self (Kluft, 1993b; ISSTD, 2011). Many
patients achieve some fusions yet they do not become fully unified.
Clarity about the terms is important because different terms have
been used to mean different processes in the treating DD (Kluft,
1993b; ISSTD, 2011).
Although there is a general consensus among experts about the
overall structure of treatment for DID, there are differences of
opinion about several treatment issues. A secondary goal of this
study is to document the treatment recommendations of experts in
the field of DD on three such issues: (a) the extent to which full
reexperiencing of emotion during traumatic memory processing is
necessary; (b) the degree to which dissociated self states should be
worked with directly in treatment; and (c) whether physical touch
(such as shaking hands or hugging) should ever be used when
treating patients with DD. The use of emotional reliving of trau-
matic experiences, called exposure therapy in cognitive behavior
therapy and abreaction in psychodynamic therapy, is an interven-
tion that sometimes receives a mixed response. A discussion of the
necessity of using full, emotive abreaction or exposure in DD
treatment parallels a similar ongoing debate in the field of simple
PTSD (Jaycox & Foa, 1996; Lauterbach & Rieland, 2007; Rosen
et al., 2004), although no research has been conducted on this issue
in patients with DD. Some practitioners do not utilize exposure-
based techniques or do so infrequently, believing that exposure
evokes too much distress (e.g., reviewed in Chefetz, 1997; Gold,
2000, 2009; Gold et al., 2001; Feeney, Hembree, & Zoellner,
2003; Becker, Zayfert, & Anderson, 2004; Lanius et al., 2010).
Only one study has systematically investigated the impact of
dissociation on the efficacy of exposure therapy (Hagenaars, Min-
nen, & Hoogduin, 2010). The authors concluded that dissociation
did not interfere with response to exposure therapy. However,
study subjects had primarily experienced single episodes of adult
traumatization and individuals with current suicidality, ongoing
traumatization, or substance dependence were excluded, making it
unlikely that participants were suffering from DD or complex
PTSD (Courtois & Ford, 2009; Herman, 1992). Nonetheless, 69%
of the study participants who scored high on a measure of disso-
ciation still met criteria for PTSD at follow-up, compared to only
10% of low dissociators still meeting PTSD criteria after exposure
therapy. A couple of case reports detail successful treatment of
DID patients to the point of unification without doing any abre-
active work (Gold et al., 2001; S¸ar et al., 2002). However, neither
Gold’s team or S¸ar’s team did not define specific criteria for
assessment of initial or maintained unification.
Another area of debate is the extent to which dissociated self
states need to be targeted directly in therapy. The clinical literature
on DID encourages therapists to work with self states, as well as
to talk openly to increase internal awareness and cooperation
among them (e.g., Kluft, 1994a, 1994b; Putnam, 1998). However,
some clinicians support a more indirect approach and rarely, if
ever, attempt to work with self states other than those spontane-
ously presenting in therapy sessions. The Guidelines for Treating
Dissociative Identity Disorder in Adults (ISSTD, 2011) state that
while clinicians may talk to alternate identities as if they were
separate, this is to be done with the goal of decreasing all aspects
of dissociative dividedness and encouraging the patient to increas-
ingly see him- or herself in more unified terms. The Guidelines
discourage contributing to self states’ functioning more autono-
mously than they already are as well as ignoring self states. Some
researchers have expressed concern that working directly with self
states will reinforce or further develop them, thereby hypotheti-
cally making the patient more dissociative (Lilienfeld et al., 1999).
There exists no published, empirical data demonstrating that direct
intervention with self states worsens DID, although there is a
clinical literature that describes negative outcomes of inappropri-
ate interventions with self states (Kluft, 1989a).
Discussion of the use of touch during general psychotherapy is
controversial and it is even more controversial when considering
treatment of trauma survivors. A subset of clinicians support the
use of touch with general psychiatric patients as a means of
conveying genuineness and support or of correcting problematic
childhood experiences by teaching patients that safe touch is
possible in relationships with healthy boundaries (see Hethering-
ton, 1998; Kertay & Reviere, 1993; Zur, 2007). However, trauma
survivors may experience touch as confusing, overwhelming, and
intrusive, particularly when further complicated by the power
differential between patient and therapist (Ogden, Minton, & Pain,
2006; Rothschild, 2002).
A third goal of this study is to explore therapist and treatment
characteristics related to the reported number of patients clinicians
treated to unification as well as to characterize training and prac-
tice patterns among DID experts. It seems likely that years of
experience and the number of patients successfully treated to
unification might be associated with differences in treatment in-
3
SURVEY OF PRACTICES FOR DISSOCIATIVE PATIENTS
terventions. A final objective of this study is to describe the
training and current caseloads of the experienced therapists.
Method
Participants
Clinicians well known for their expertise in treating DD were
contacted by email and asked to participate in an online survey
about interventions utilized in the treatment of DD. Inclusion
criteria were having treated patients with DD for at least 9
years, having coauthored the updated ISSTD Guidelines
(ISSTD, 2011), or having been highly recommended by one of
the Guidelines’ coauthors because of expertise and success
treating patients with DD. Sixty-six therapists were invited to
participate and 38 (57.6%) completed the survey; 12 partici-
pants were coauthors of the Guidelines. Data for two therapists
were excluded because the therapists had not been treating
patients with DD for 9 years. Thus, 36 uncompensated partic-
ipants completed the survey.
Therapists were from several countries and the majority was
psychologists in independent practice in the United States (see
Table 1). None of the participants were from Asia, Africa, or
South America. Participants reported an average of 25 years
(SD 7.98) of experience treating traumatized patients and
over 22 years (SD 8.39) of experience treating patients with
DD across a variety of treatment settings (see Table 2). The
majority of the participants reported a psychodynamic theoret-
ical orientation (77.78%) and had published articles or books
about trauma and/or dissociation. Some had specialized training
in trauma and DD (33%, n12; 31%, n11, respectively),
although the majority had developed their skills by working
directly with patients in trauma-focused inpatient and/or outpa-
tient settings (56%, n20), consulting with specialists (75%,
n27), attending workshops and lectures (83%, n30), and
reading books about DD (86%, n31). Five of the clinicians
(13.8%) completed the ISSTD’s Dissociative Disorders Psycho-
therapy Training Program courses.
Procedure
Participants were provided with a link to an online survey,
which was adapted from the Treatment Outcome for Patients with
Dissociative Disorders study (Brand et al., 2009c). After questions
about training and experience, participants completed the Treat-
ment Activities with Dissociative Disorders (TADD; available
from coauthor Bethany Brand), a measure of 28 treatment activi-
ties based on those discussed in the second edition of the ISSD
Guidelines for Treating Dissociative Identity Disorder in Adults
(ISSD, 2006). Participants were asked, on a scale of 0 (never)to4
(very often), “Please indicate how frequently you believe the
following treatment activities should be used with DID or DDNOS
patients at each stage of treatment.” The survey took approxi-
mately 15 minutes to complete and was approved by the institu-
tional review board of Towson University.
The interventions listed in the TADD were divided into ratio-
nally derived topic areas (see Table 3). TADD interventions de-
noted as “potentially risky interventions” were not recommended
by the Guidelines; rather, they were devised as a means of deter-
mining if therapists were overengaging in techniques that can be
detrimental to patients, particularly if used frequently. The inter-
vention “stabilizing from intrusions from alleged perpetrators” was
included because of DD patients’ distress and destabilization after
contact with people who are, or were, abusive (ISSD, 2006;
ISSTD, 2011). In line with the ISSD/ISSTD Guidelines and the
clinical literature (ISSD, 2006; ISSTD, 2011; Chu, 1998, 2011;
Courtois, 1997; Courtois & Ford, 2009; Kluft, 1999), the TADD
presents the treatment of DD as occurring in phases. We asked
therapists to describe the interventions they recommend using to
treat patients with DID or DDNOS at five stages of treatment. The
description accompanying Stages 1, 3, and 5 were labeled, respec-
tively, “stabilization and establishing safety,” “processing memo-
ries of trauma with full emotion (i.e., prolonged exposure, abre-
actions) and grieving related losses,” and “integration and
reconnection within self and with others.” Stages 2 and 4 did not
have descriptive anchors.
Results
We were unable to conduct statistical analyses because of the
small sample. Thus, we used qualitative descriptions to convey our
findings.
Interventions by Stage
Stages 1 and 2. Early in treatment, clinicians recommended
using most of the interventions frequently (see Table 3). In Stage
1, the vast majority of clinicians “very often” used assessment and
safety strategies, daily functioning skills, and psychoeducation, as
well as cognitive–behavioral therapy (CBT) focused on changing
distorted cognitions. One of the most agreed-on interventions in
the study was a very high level of the relationally focused inter-
vention of working to establish and repair the therapeutic alliance
in Stage 1. The experts agreed that they did not frequently discuss
Table 1
Characteristics of Expert Clinicians (n36)
Variable % (n)
Discipline
Psychiatry 38.89 (14)
Psychology 50.00 (18)
Other
a
11.12 (4)
Gender
Male 52.78 (19)
Female 47.22 (17)
Country of practice
United States 63.89 (23)
Canada 5.56 (2)
Europe 11.11 (4)
Australia/New Zealand 19.44 (7)
Treatment settings
Private practice 83.33 (30)
Clinic/hospital outpatient 33.33 (12)
Inpatient/partial program 19.44 (7)
Forensic 11.11 (4)
Other
b
5.56 (2)
a
Other included occupational therapy, nursing, expressive therapy, and an
undefined discipline.
b
Other included government-funded programs and
university settings.
4BRAND ET AL.
the therapeutic relationship as a way of helping the client under-
stand past and current relationships until Stages 2 and 3. Clini-
cians’ recommended use of emotion regulation was similar across
Stages 1 and 2. No clinicians endorsed frequent trauma focused
work early in treatment, although the majority of clinicians sup-
ported sometimes using exposure or abreaction techniques and
processing delayed recall of trauma.
Stage 3. In the middle stage of treatment of patients with DD,
clinicians continued to recommend “very often” using assessment
and safety, daily functioning, psychoeducation, relationally fo-
cused, emotion regulation, and addressing dissociation interven-
tions. In contrast to Stages 1 and 2, therapists emphasized trauma-
focused work, with almost half of clinicians endorsing the use of
exposure or abreaction and processing delayed recall of trauma
“very often.” In addition to the use of trauma-focused interven-
tions, it was during this stage that therapists most highly endorsed
the use of CBT techniques, perhaps as distorted, trauma-related
cognitions were challenged and reconsidered.
Stages 4 and 5. As opposed to the earlier stages of treatment,
there was less uniformity among therapists during the final two
stages of treatment; thus, the modes of each intervention ranged
from 1 (rarely)to4(very often). Increasing daily functioning skills
remained an activity recommended for use “very often,” as did
relationally focused work and emotion regulation. The relationally
focused interventions were recommended at the highest frequency.
Support for the use of psychoeducation remained high. Percent-
ages of clinicians recommending activities aimed at addressing
dissociation became less frequent, and the emphasis on trauma-
focused work decreased.
While many interventions varied in the frequency of recom-
mended use across treatment stages, stabilizing the patient after
intrusions from reported perpetrators was consistently recom-
mended across the stages of DD treatment. There was a slight
decrease over time, but stabilizing from current-day stressors and
crises also appeared to occur fairly consistently across treatment
stages. Potentially risky interventions including playing with child
self states and using touch were not frequently endorsed by any
clinicians in any stage of treatment.
Interventions According to Therapist Experience
Differences in intervention according to years of experience.
There were relatively few differences between clinicians who had
less experience treating DID (“fewer years” range 9–20 years,
n18) versus those who had more experience (“more years”
range 21–40 years, n18). Participants were divided into these
two experience categories using a median split. See Table 4 for a
listing of the interventions that were endorsed at different frequen-
cies (i.e., differing by two points or more on the 5-point scale)
depending on the therapists’ years of experience. The group dif-
ference between the assessment of medications is unlikely to be
due to differential training in psychiatry, because the number of
psychiatrists in both the less experienced (n6) and more
experienced (n8) groups were similar.
Differences in intervention according to number of unifica-
tions. The sample was divided using a median split to learn
about the differences between those with many successful unifi-
cations of patients with DD (high unification group range 6to
over 300, n15) versus those with fewer unifications (low
unification group range 0–5, n21). See Table 5 for a listing
of interventions that differed by one or more points on the fre-
quency scale. None of the differences, according to number of
unifications, were two or more points, in contrast to the larger
differences in interventions found when the therapists were split
into low and high number of years of experience.
Discussion
Therapists’ Current Practices and Training
Participants in this study were seasoned DD practitioners and
included some of the pioneers in the field. Thirty percent of the
participants had received training in DD as a student, intern,
postdoctoral fellow, or resident. Because therapists were required
to have at least nine years of experience treating patients with DD,
this finding indicates that, for at least a decade, systematic training
has been available to those seeking it. Research is beginning to
Table 2
Participant Experience in the Field of Dissociative Disorders
Variable NMean (SD) Mode Range
Number of years treating DD patients 36 22.53 (8.39) 20 (n4) 9–40
Number of years treating traumatized patients 36 24.94 (7.98) 30 (n7) 11–41
Number of trauma publications 27
a
31.04 (50.69) 30 (n3) 0–225
Number of DID patients treated for more than one year 36 42.69 (70.55) 25 (n3) 3–400
40 (n3)
Number of DDNOS patients treated for more than one year 36 29.31 (41.56) 20 (n8) 1–200
Number of patients currently being treated for DID 36 8.75 (10.12) 3 (n7) 0–40
Number of patients currently being treated for DDNOS 35
b
5.57 (5.90) 2 (n8) 0–15
Number of patients currently being treated for dissociative amnesia 28
b
1.14 (2.77) 0 (n18) 0–13
Number of patients currently being treated for dissociative fugue 25
b
0.13 (0.61) 0 (n23) 0–3
Number of patients currently being treated for depersonalization disorder 29
b
0.86 (1.01) 0 (n14) 0–3
Number of DID patients treated from diagnosis to unification 36
c
7.76 (7.41) 5 (n7) 1–30
a
Not all participants reported trauma publications; therefore, these data reflect the results for those who have published in the field of trauma and
dissociation.
b
Not all participants reported that they had worked with individuals with DDNOS, dissociative amnesia, dissociative fugue, and
depersonalization. These sample sizes represent those who endorsed currently treating patients with these disorders.
c
Two respondents indicated they had
integrated over 185 patients. Due to being outliers, their data were not included in this row.
5
SURVEY OF PRACTICES FOR DISSOCIATIVE PATIENTS
Table 3
The Use of Interventions Across Stages of Treatment
Intervention
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
% Endorsing
very often Mode
% Endorsing
very often Mode
% Endorsing
very often Mode
% Endorsing
very often Mode
a
% Endorsing
very often Mode
a
Assessment & Safety
Diagnosing psychiatric illnesses 88.89 4 (n32) 36.11 4 (n13) 33.33 4 (n12) 16.67 2 (n9) 30.56 4 (n11)
Assess response to medications 66.67 4 (n24) 38.89 4 (n14) 44.44 4 (n16) 27.78 4 (n10) 33.33 4 (n12)
Acceptance of DD diagnosis 75.00 4 (n27) 47.22 4 (n17) 52.78 4 (n19) 30.56 4 (n11) 30.56 4 (n11)
Establishing safety 97.22 4 (n35) 75.00 4 (n27) 69.44 4 (n25) 22.22 3 (n13) 25.00 1 (n10)
Daily Functioning Skills
Stabilizing following intrusions from alleged perpetrators 58.33 4 (n21) 38.89 4 (n14) 38.89 4 (n14) 33.33 4 (n12) 38.89 4 (n14)
Stabilizing from current day stressors/crises 80.56 4 (n29) 61.11 4 (n22) 55.56 4 (n20) 50.00 4 (n18) 47.22 4 (n17)
Psychoeducation
Teaching/practicing self-care 86.11 4 (n31) 66.67 4 (n24) 50.00 4 (n18) 44.44 4 (n16) 44.44 4 (n16)
Educate about disorders and treatment options 91.67 4 (n33) 63.89 4 (n23) 55.56 4 (n20) 30.56 3 (n14) 36.11 4 (n13)
CBT focused on cognitions 63.89 4 (n23) 50.00 4 (n18) 72.22 4 (n26) 33.33 4 (n12) 25.00 2 (n15)
Relationally Focused Work
Establish/repair alliance 97.22 4 (n35) 72.22 4 (n26) 75.00 4 (n27) 44.44 4 (n16) 44.44 4 (n16)
Processing patient’s reactions to therapy 58.33 4 (n21) 50.00 4 (n18) 52.78 4 (n19) 41.67 4 (n15) 41.67 4 (n15)
Discussing therapeutic relationship 41.67 4 (n15) 55.56 4 (n20) 52.78 4 (n19) 47.22 4 (n17) 44.44 4 (n16)
Teaching/discussing attachment 50.00 4 (n18) 47.22 4 (n17) 50.00 4 (n18) 30.56 2, 4 (n11) 27.78 3, 4 (n10)
Developing healthy relationships 83.33 4 (n30) 75.00 4 (n27) 55.56 4 (n20) 47.22 4 (n17) 55.56 4 (n20)
Emotion Regulation
Teaching/practicing containment 80.56 4 (n29) 66.67 4 (n24) 75.00 4 (n27) 11.11 3 (n16) 11.11 1, 2 (n16)
Teaching/practicing grounding 94.44 4 (n34) 61.11 4 (n22) 63.89 4 (n23) 30.56 4 (n11) 19.44 3, 4 (n7)
Ego strengthening activities 77.78 4 (n28) 58.33 4 (n21) 50.00 4 (n18) 38.89 4 (n14) 41.67 4 (n15)
Awareness of emotion 58.33 4 (n21) 52.78 4 (n19) 50.00 4 (n18) 36.11 4 (n13) 47.22 4 (n17)
Awareness of body sensation 33.33 3 (n16) 33.33 3 (n14) 61.11 4 (n22) 41.67 4 (n15) 41.67 4 (n15)
Affect tolerance and impulse control 81.82 4 (n27) 72.73 4 (n24) 69.70 4 (n23) 45.45 4 (n15) 36.36 4 (n12)
Addressing Dissociation
Processing when and why dissociation occurs 66.67 4 (n24) 58.33 4 (n21) 55.56 4 (n20) 36.11 4 (n13) 36.11 4 (n13)
Cooperation with parts 52.78 4 (n19) 72.22 4 (n26) 83.33 4 (n30) 50.00 4 (n18) 36.11 4 (n13)
Identify/work with parts 47.22 4 (n17) 58.33 4 (n21) 69.44 4 (n25) 36.11 4 (n13) 22.22 2 (n10)
Trauma Focused Work
Exposure/abreaction to traumatic memories 0.00 0 (n15) 0.00 2 (n14) 47.22 4 (n17) 25.00 3 (n12) 11.11 2 (n15)
Processing delayed recall of trauma 0.00 1 (n14) 0.00 2 (n18) 44.44 4 (n16) 19.44 2 (n12) 11.11 1 (n13)
Processing trauma with EMDR 0.00 0 (n16) 0.00 0 (n11) 16.67 2 (n10) 13.89 2 (n9) 2.78 1 (n13)
Potentially Risky Interventions
Playing with child personalities 0.00 0 (n29) 0.00 0 (n26) 0.00 0 (n28) 0.00 0 (n28) 0.00 0 (n31)
Using physical contact 0.00 0 (n23) 0.00 0 (n19) 0.00 0 (n18) 0.00 0 (n16) 0.00 0 (n23)
Note. EMDR eye movement desensitization and reprocessing.
a
In cells with two modes, both are listed.
6BRAND ET AL.
emerge from Asia and other non-Western countries about the
prevalence and existence of DD (Gingrich, 2009; Van Duijl,
Carden˜a, & De Jong, 2005; Xiao et al., 2006); however, no experts
were found in Asia, South America, or Africa.
While considerable numbers of patients with DID and DDNOS
were being treated by study participants, only one therapist reported
treating dissociative fugue outside of its occurrence in DID, and few
cases of depersonalization disorder were being treated by these highly
experienced therapists. The lack of fugue cases supports the planned
elimination of dissociative fugue as a free-standing DD from the
forthcoming Diagnostic and Statistical Manual of Mental
Disorders–5 (American Psychiatric Association).
Interventions by Stage
In general, these recommendations from DD clinicians are consis-
tent with staged treatment advised by treatment guidelines and expert
clinicians (ISSD, 2006; ISSTD, 2011; Courtois, 1997; Courtois &
Ford, 2009; Kluft, 1993a; Herman, 1992). Across all stages of treat-
ment, the following interventions were frequently used: diagnosis of
psychiatric disorders; psychoeducation; alliance building and repair;
processing reactions to therapy; assessing the adequacy of medication;
increasing awareness of emotion; developing affect tolerance and
impulse control; managing daily functioning and current relation-
ships; and stabilizing patients following stressful life situations and
intrusions from reported perpetrators. Given the consistency across
therapists and the high frequency of use of these interventions over
time and across cultures, we conclude that these interventions make
up the core treatment processes and structure used in treating severely
dissociative patients. That these core interventions target modulation
of affect and impulse control, stabilization from crises, and improving
interpersonal skills is consistent with viewing DD viewed as complex
trauma-based disorders(ISSTD, 2011; Courtois & Ford, 2009; Her-
man, 1992; Putnam, 1998). Research indicates that staged treatment
addressing these deficits results in better treatment outcome and lower
rates of dropout than standard exposure treatment for chronic PTSD
patients with histories of childhood trauma (Cloitre et al., 2002, 2010).
Beyond the core interventions, the experts recommended the
following interventions early in treatment: grounding (i.e., tech-
niques such as movement or touching an object to control “tranc-
ing” or dissociating, passive influence, and switching); contain-
Table 4
Interventions That Differed by Modal Frequency According to Therapists’ Years of Treating DD
Intervention
Therapists with 9–20 years of
experience (n18)
a
Therapists with 21years of
experience (n18)
a
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Assessment & Safety
Diagnosis 4 4 2, 4 21, 4 43,441, 2 4
Assessing medication response 4 3 4 21 44 444
Establishing safety 4 4 4 2, 3 144 43 4
Daily Functioning Skills
Stabilizing after intrusions from alleged perpetrators 4 3 22,444444 4
Trauma-Focused Work
Processing trauma (e.g., exposures or abreactions to
traumatic memories 0 0, 2 42,32 1243 1
Eye movement desensitization and reprocessing 0 022201, 2 33, 4 1
a
The numbers listed are the most commonly recommended frequency for a given intervention (i.e., the modal frequency for the intervention) for that stage.
In cells with two modes, both are listed. Modes that differed between groups of therapists by two or more points are in boldface.
Table 5
Interventions That Differed by One or More Modal Points According to Number of Completed Unifications
Intervention
Therapists with 5 or fewer
unifications (n21)
a
Therapists with more than 5
unifications (n15)
a
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
Relationally Focused Work
Teaching/ discussing attachment 4 4 4 3244443
Addressing Dissociation
Cooperation with self states 3444444444
Identify/work with self states 3444344442
Trauma-Focused Work
Processing Trauma (e.g., exposure or abreaction
to traumatic memories) 0 2 43202341
Processing delayed recall of trauma 0243312322
a
The numbers listed are the most commonly recommended frequency for a given intervention (i.e., the modal frequency for the intervention) for that stage.
In cells with two modes, both are listed. Modes that differed between groups of therapists by one or more points are in boldface.
7
SURVEY OF PRACTICES FOR DISSOCIATIVE PATIENTS
ment (i.e., techniques including self-hypnosis and imagery to
specifically control the intrusiveness of traumatic material); ego
strengthening (i.e., interventions to promote better overall func-
tioning including self-hypnosis, reaffirming statements, relaxation
training); cognitive–behavioral work to change trauma-based cog-
nitions (e.g., techniques to resolve confusing past and present,
self-blame for abuse, and delusions of separateness among disso-
ciated self states); and focusing on safety issues (i.e., discussing
the antecedents to, and functions of, self-destructive, suicidal, and
aggressive behavior toward others, as well as developing safety
agreements and crisis management plans).
Like controlled treatment studies of chronic or complex PTSD
associated with childhood trauma (Cloitre et al., 2002; 2010), the
current data show that DD experts recommend skill-building in the
early stages of treatment. Experts in the current study suggest that
the skills be expanded for patients with DD to include controlling
dissociative and PTSD symptoms, maintaining safety, and replac-
ing trauma-based cognitive distortions. The importance of skill-
building in this first stage of treatment likely contributes to the
length of treatment for successful resolution of DID. There were
four interventions that therapists recommended using with increas-
ing frequency in the middle stages of treatment; three of these
treatments are directly related to traumatic material: processing
delayed recall of traumatic memories, using exposure or abreac-
tion, and employing eye movement desensitization and reprocess-
ing to process traumatic memories. It is important to recognize that
therapists did not recommend frequent use of memory processing
interventions in most Stage 3 sessions. Thus, even in the stage
characterized by processing trauma, highly experienced DD ther-
apists recommend the continued use of interventions aimed at core,
foundational DD work to enable patients to tolerate the challeng-
ing trauma-focused work. In general, the clinical literature sup-
ports the use of modified exposure techniques in these patients,
careful titration of affect levels, and taking many sessions to fully
process specific memory material so not to overwhelm or flood
these polytraumatized patients. Without titration, the patient can be
“retraumatized,” and may have significant problems with mainte-
nance of safety and stability (Kluft, 1989b; Kluft & Loewenstein,
2007). These data suggest that treatment should not become solely
focused on traumatic material, even in the middle “trauma pro-
cessing” stage of treatment. The fourth intervention recommended
for the middle stage of treatment—enhancing awareness of body
sensations—may relate to processing traumatic memories. Fre-
quently, dissociated traumatic memories present as inchoate body
sensations known as somatoform flashbacks or, colloquially as
“body memories” (Rothschild, 2000; van der Kolk, 1994). The
increased focus on the patient’s bodily sensations during the mid-
dle stages of treatment is likely related to patients needing to make
sense of physical sensations that are emerging as dissociated
traumatic material as well as using “grounding” techniques to
decrease dissociation.
Patterns Related to Therapist Experience and
Unifications
When looking at treatment interventions across stages of treat-
ment, it appears that there was consistency in the interventions
used in Stages 1, 2, and 3 regardless of therapists’ experience.
There was less consistency in Stages 4 and 5. The consistency of
recommendations in the first three stages is likely related to the
clear, well-delineated descriptions of these stages in available
guidelines (ISSD, 2006; ISSTD, 2011). The guidelines are some-
what less specific about the tasks for the final stages of treatment,
during which treatment seems to become more individualized. For
example, while every patient with DD needs to learn how to
recognize and regulate emotion in order to gradually relinquish
avoidance of emotion through dissociation, not every patient needs
to address career, existential, or spiritual dilemmas to the same
extent. Many of the earlier tasks are likely to continue in the last
stages but with a different focus. For example, psychoeducation
continues in late-stage treatment but focuses on living as a non-
dissociative, unified individual, in contrast to the early treatment
psychoeducation about symptoms and their management.
There was also a substantial degree of consistency about psy-
choeducation and emotion regulation interventions, regardless of
the number of years of experience or unifications therapists had
helped patients complete. Participants in this study recommend
“very often” teaching and using containment, grounding, ego
strengthening, awareness of emotion and body sensations, and
affect tolerance and impulse control across the five stages of
treatment. Furthermore, they consistently recommended a decrease
in the frequency of using containment and grounding as treatment
progresses, suggesting that patients in the later stages of treatment
are less frequently overwhelmed by unintegrated traumatic mate-
rial and dysregulated dissociative symptoms. The uniformity of
recommendations indicates that these core interventions have been
found by experts around the world to be clinically useful with a
wide variety of patients with DD. These findings could be seen as
the beginning of developing best practices for treating severe DD.
An important next step would be for researchers to develop manu-
alized treatments that emphasize these psychoeducation and emo-
tion regulation interventions for patients in the early stages of
treatment in order to empirically test their effectiveness.
Do the differences in intervention lead to greater numbers of
patients unifying? Unfortunately, causal attributions cannot be
made with these data. It is possible that the most highly experi-
enced therapists have better outcomes. However, differences in
rates of unification as well as in recommended treatment interven-
tions may be related to nonrandom patient characteristics in the
therapists’ practices. Most of the therapists in the low unification
group had fewer years of experience (M18.9 years). Thus, the
findings may be a function of time, with more experienced ther-
apists having had more time to treat patients with DD and, there-
fore, more opportunities for unification.
The clinical literature describes three groups of patients with
DID according to their degree of complexity and treatment respon-
siveness; they are referred to as high, medium, and low trajectory
patients (Kluft, 1994a, 1994b; Loewenstein, 1994). It is likely that
differences in the types of patients seen by the experts strongly
influence the number of unifications they have helped patients
attain. For instance, many of the expert therapists practice in
specialized inpatient treatment programs or other settings to which
patients are referred because they have repeatedly failed to respond
to prior treatments, and/or because the patients may be demoral-
ized, disabled, highly self-destructive, and may have many serious
medical comorbidities. Some of these patients may be invested in
their dissociative world, have self states with limited willingness to
work toward awareness (Kluft, 1994a), or may strongly identify
8BRAND ET AL.
with their existence as a disabled trauma survivor. Others may
have limited social supports or resources for an intensive treatment
that could result in fusion or integration. Finally, the failure of
most mental health training programs and many countries to pro-
vide systematic education about and support for treatment of
patients with complex trauma or DD results in many potentially
treatable patients spending years of clinical time misdiagnosed
with other disorders and being treated with relatively limited
response. Even if correctly diagnosed, many patients are unable to
find reasonable clinical care and/or do not have the financial
resources to fund reasonable clinical care. This results in many
patients developing a syndrome of chronic demoralization and
“chronicity” that depletes the psychosocial resources necessary for
a treatment that could result in unification.
One unexpected finding is the relatively low number of patients
with DID treated through unification by this group of expert
therapists. While the low trajectory patients, estimated to be one
third of patients with DID, have been previously described as too
impaired to achieve unification, the high and middle trajectory
patients were thought to be capable of responding to long-term,
specialized treatment with gradually improving functioning and
less internal dividedness, eventually resulting in unification of
dissociated self states (Kluft, 1994a; Loewenstein, 1994). The
current study suggests a very different picture; that is, that unifi-
cation as a result of skilled treatment will be less common than
expected, even among highly experienced clinicians. Some of the
experts who participated in our study worked in settings—such as
inpatient acute hospital units and forensic clinics—that limited the
extent to which they could work long term with patients. Many of
these therapists were likely referred the most treatment-resistant,
low trajectory patients; but even still, fewer patients with DID than
previously thought were able to, or chose to, achieve unification.
Despite the fact that one might expect these experts to have more
success helping patients with DID achieve integration than other,
less experienced therapists, the data suggest that fewer patients
with DID than previously thought were able to, or chose to,
achieve unification.
The findings about unification need to be interpreted in light of
two methodological issues. First, we did not ask therapists the
criteria by which they determined unification. Second, it is com-
mon for patients who have achieved unification to later reveal
additional hidden dissociated self states or to have self states
become dissociated despite having initially been fully unified (e.g.,
Kluft, 1984). Determining unification is a difficult process, depen-
dent on the patient’s honest responses to questions about dissoci-
ation and self states, the patient’s ability to know what may still be
dissociated, and the therapist’s ability to detect subtle dissociation.
Whether or not unification takes place or the extent to which it
endures, most severely dissociative patients, even those in the
lowest functioning group, can improve during specialized therapy
that focuses on dissociation (e.g., Brand et al., 2009c; Coons,
1986; Ellason & Ross, 1997; Kluft, 1984; Ross & Dua, 1993).
Throughout treatment, most patients become more aware of self
states and better able to negotiate compromises regarding internal
conflicts, resulting in improved adaptive functioning. Thus, this
may be the most realistic goal for the majority of patients with
severe dissociation. Future research needs to systematically follow
patients with DD over the course of treatment to determine more
clearly what percentage achieve unification versus partial unifica-
tion and what therapist and patient factors contribute to successful
unification.
Areas of Debate
When examining the extent to which controversial treatment
interventions are utilized in patients with DD, the data are consis-
tent on the importance of talking directly about and with dissoci-
ated self states in order to facilitate patients’ understanding of and
willingness to work collaboratively with their self states. All of the
therapists recommended this intervention, and the most experi-
enced ones recommended it from the beginning of treatment at a
frequent level.
The experts were also in agreement that providing comfort, such
as hand holding, should be avoided in almost all situations involv-
ing patients with DD. Touch is likely to have so many negative
associations for patients with DD that it can be easily misunder-
stood and lead to boundary problems and reenactments that un-
dermine therapeutic progress (e.g., ISSTD, 2011). A therapist
working with a patient with DD should carefully consider the
accuracy of the patient’s reality testing and the quality of the
therapeutic alliance, as well as discuss the potential meanings of
touch, prior to touching the patient.
The data are also consistent on exposure or abreaction. None of
the therapists recommended exposure or abreaction in Stage 1;
however, almost all recommended it at least at a level of “often”
in the middle stage of treatment. While almost all of the clinical
literature suggests exposures or abreactions are a necessary part of
DID treatment (Kluft, 1993; Putnam, 1989), a single case from
Turkey (S¸ar & Tutkun, 1997) as well as two from the United States
(Gold et al., 2001) have reported on patients who attained unifi-
cation without using exposure or abreaction. Other clinicians,
including coauthor Richard Loewenstein, have reported unifica-
tions without full abreactions among occasional, rare patients who
seem to have developed self states primarily due to attachment
disruptions that interfered with the patient receiving comfort and
protection from circumscribed early childhood abuse (Kluft,
1984). Typically, these rare patients have substantial ego strength
and do not report the severe, sadistic abuse reported by other
patients with DD. There also may be cultural factors that influence
the clinical features and course of patients with DD. Future re-
search needs to compare treatments that use exposure or abreaction
techniques to those that do not to determine the relative effective-
ness of each approach across cultural groups.
Training, Treatment, and Research Implications
While a minority of the participating experts were able to find
specialized training in DD as part of systematic education in
internships, residencies, and postdoctoral fellowships, this kind of
training is not widely available. Given the prevalence of complex
trauma and related psychological disorders, much more training in
conducting carefully paced, staged treatment needs to be made
available to mental health professionals.
The current study provides several categories of useful treat-
ment interventions that can provide the basis for a manualized
treatment for early stage patients with DD. The field urgently
needs randomized controlled studies that use manualized treatment
to determine definitively whether treatment is responsible for the
9
SURVEY OF PRACTICES FOR DISSOCIATIVE PATIENTS
decreased symptoms that have been documented in the currently
available yet uncontrolled treatment outcome studies.
Conclusion
Study Limitations
The treatment implications based on this sample of highly
experienced DD therapists may not reflect the recommendations
all experts would make. Their recommendations may be biased by
the clinicians’ theoretical backgrounds, the types of patients re-
ferred to them, or other influences. Because of the small sample
base, we were unable to determine whether the differences in
interventions according to the therapists’ experience or number of
unifications were statistically significant or to explore cross-
cultural differences. We were unable to recruit experts from Asia,
South America, or Africa. The patterns observed in the data may
be influenced by referral patterns and nonrandom patient charac-
teristics, so the extent to which they generalize to other patients
and DD experts is unknown. Therapists may have been subject to
social desirability in their responses, particularly about the number
of patients they have helped achieve unification. These DD experts
generally recommended a structured, stage-oriented treatment for
patients with DD consisting of three basic phases. In the initial
phase, they advocated for emphasizing skill-building in the areas
of emotion regulation, impulse control, interpersonal effectiveness,
grounding, containment, challenging trauma-based cognitive dis-
tortions, and maintaining safety. Additionally they suggested that
clinicians identify and work with dissociated self states beginning
early in treatment so to foster internal communication and coop-
eration among disavowed parts of self. In the middle stage, the
experts advised the use of occasional modified exposure or abre-
action techniques balanced with core, foundational interventions.
The last stage of treatment was less clearly delineated and more
individualized, although this may be an artifact of limited data
about the later stages. The data suggest that unification of self
states occurs in only a minority of patients with DID, at least
among this sample of clinicians, although this may be related to the
types of patients referred to these experts. More DD training for
therapists and treatment outcome research is needed; this study
provides directions that can be pursued in both areas.
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Received September 8, 2010
Revision received January 30, 2011
Accepted March 14, 2011
11
SURVEY OF PRACTICES FOR DISSOCIATIVE PATIENTS
... The taboo nature of DID means that this disorder is frequently perceived by the sufferer as shameful and thus hidden, meaning individuals often suffer in silence while painfully aware of their dissociation and complex identity. Research has found that approximately 1% of the general population lives with DID (Brand et al., 2016; International Society for the Study of Trauma and Dissociation, 2011). Scroppo, Drob, Weinberger, and Eagle (1998) conducted a study with 42 female subjects recruited from outpatient mental health settings and physician referrals. ...
... Dissociative phenomena are not confined to individuals living with DID. Research indicates that some level of dissociative experiencing is often present and is a core element within emotional disorders originating from stressful or traumatic life events (Brand et al., 2016;van der Hart et al., 2006). At the milder end of the spectrum, dissociation can be seen as a coping mechanism or defense mechanism enabling an individual to minimize or tolerate stress, and symptom presentation can be at times difficult to identify (van der Hart, van der Kolk, & Boon, 1998). ...
... Understanding, diagnosing, and treating dissociation can be challenging. Relatively few clinicians receive training in accurately diagnosing and treating DID, despite the existence of expert consensus guidelines and treatment recommendations (Brand, Lanius, Loewenstein, Vermetten, & Spiegel, 2012;Brand, Myrick, et al., 2012;ISSTD, 2011). In the context of treating complex trauma, you are highly likely to encounter trauma survivors with dissociative symptoms. ...
Book
Full-text available
This book is a clinician's guide to understanding, diagnosing, treating, and healing complex posttraumatic stress disorder (C-PTSD). C-PTSD, a diagnostic entity to be included in ICD-11 in 2022, denotes a severe form of posttraumatic stress disorder (PTSD) and is the result of prolonged and repeated interpersonal trauma. The author provides guidance on healing complex trauma through phase-oriented, multimodal, and skill-focused treatment approaches, with a core emphasis on symptom relief and functional improvement. Readers will gain familiarity with the integrative healing techniques and modalities that are currently being utilized as evidence-based treatments, including innovative multi-sensory treatments for trauma, in addition to learning more about posttraumatic growth and resilience. Each chapter of this guide navigates readers through the complicated field of treating and healing complex trauma, including how to work with clients also impacted by the shared collective trauma of COVID-19, and is illustrated by case examples. Topics explored include: Complex layered trauma Dissociation Trauma and the body The power of belief An overview of psychotherapy modalities for the treatment of complex trauma Ego state work and connecting with the inner child Turning wounds into wisdom: resilience and posttraumatic growth Vicarious trauma and professional self-care for the trauma clinician It is important for clinicians to be aware of contemporary trends in treating C-PTSD. Healing Complex Posttraumatic Stress Disorder is an essential text for mental health practitioners, clinical social workers, and other clinicians; academics; and graduate students, in addition to other professionals and students interested in C-PTSD. It is an attractive resource for an international clinical audience as we work together to heal, affirm, and unburden clients following this time of shared collective trauma.
... The taboo nature of DID means that this disorder is frequently perceived by the sufferer as shameful and thus hidden, meaning individuals often suffer in silence while painfully aware of their dissociation and complex identity. Research has found that approximately 1% of the general population lives with DID (Brand et al., 2016; International Society for the Study of Trauma and Dissociation, 2011). Scroppo, Drob, Weinberger, and Eagle (1998) conducted a study with 42 female subjects recruited from outpatient mental health settings and physician referrals. ...
... Dissociative phenomena are not confined to individuals living with DID. Research indicates that some level of dissociative experiencing is often present and is a core element within emotional disorders originating from stressful or traumatic life events (Brand et al., 2016;van der Hart et al., 2006). At the milder end of the spectrum, dissociation can be seen as a coping mechanism or defense mechanism enabling an individual to minimize or tolerate stress, and symptom presentation can be at times difficult to identify (van der Hart, van der Kolk, & Boon, 1998). ...
... Understanding, diagnosing, and treating dissociation can be challenging. Relatively few clinicians receive training in accurately diagnosing and treating DID, despite the existence of expert consensus guidelines and treatment recommendations (Brand, Lanius, Loewenstein, Vermetten, & Spiegel, 2012;Brand, Myrick, et al., 2012;ISSTD, 2011). In the context of treating complex trauma, you are highly likely to encounter trauma survivors with dissociative symptoms. ...
Chapter
Full-text available
Dissociation has been described as one of a constellation of symptoms experienced by some survivors of complex trauma as a result of physical abuse, emotional abuse, sexual abuse, or neglect. Though symptoms of dissociation are common in many disorders, such as posttraumatic stress disorder and acute stress disorder, this chapter focuses on dissociation as a common sequela of complex trauma. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) specifies that dissociation is a disruption to the usually integrated functions of consciousness, memory, identity, or perception of the environment. Dissociation is at the very heart of trauma; consequently, it is necessary as part of trauma-informed care to understand its causes and symptom presentation in addition to its clinical significance in the context of complex trauma treatment. This chapter provides a description of the role, purpose, and function of dissociation from a trauma-informed perspective. The chapter explores how dissociative experiencing can be measured within a clinical setting, utilizing the Scale of Dissociative Experiences II. Following this review of the clinical tool, this chapter explores the signs and symptoms of dissociation before considering the practice implications of working with dissociative clients. Finally, strategies to orient a client to the present moment are illustrated via clinical vignette.
... The taboo nature of DID means that this disorder is frequently perceived by the sufferer as shameful and thus hidden, meaning individuals often suffer in silence while painfully aware of their dissociation and complex identity. Research has found that approximately 1% of the general population lives with DID (Brand et al., 2016; International Society for the Study of Trauma and Dissociation, 2011). Scroppo, Drob, Weinberger, and Eagle (1998) conducted a study with 42 female subjects recruited from outpatient mental health settings and physician referrals. ...
... Dissociative phenomena are not confined to individuals living with DID. Research indicates that some level of dissociative experiencing is often present and is a core element within emotional disorders originating from stressful or traumatic life events (Brand et al., 2016;van der Hart et al., 2006). At the milder end of the spectrum, dissociation can be seen as a coping mechanism or defense mechanism enabling an individual to minimize or tolerate stress, and symptom presentation can be at times difficult to identify (van der Hart, van der Kolk, & Boon, 1998). ...
... Understanding, diagnosing, and treating dissociation can be challenging. Relatively few clinicians receive training in accurately diagnosing and treating DID, despite the existence of expert consensus guidelines and treatment recommendations (Brand, Lanius, Loewenstein, Vermetten, & Spiegel, 2012;Brand, Myrick, et al., 2012;ISSTD, 2011). In the context of treating complex trauma, you are highly likely to encounter trauma survivors with dissociative symptoms. ...
Chapter
Full-text available
It is important to note that for many trauma survivors, the body can become a source of pain, intrusion, and shame. Therefore, survivors may often feel disconnected from their bodies. It has been established that exposure to the threat of trauma stimulates the autonomic nervous system, resulting in sympathetic hyperarousal and parasympathetic hypoarousal states accompanying survival responses such as fight, flight, submission, and freeze. The foundation of trauma healing begins with enhancing the survivor’s awareness and knowledge about the body’s responses to trauma, with the ultimate goal of locating a sense of safety within the body. This allows a client to operate out of deep self-awareness rather than classic conditioning. This chapter begins by providing an overview of the how trauma impacts the mind and body. Second, the significance of affective states is reviewed through the lens of the Modulation Model and Polyvagal Theory. This chapter explores the concepts of implicit memory and somatization in the context of complex trauma treatment. Finally, this chapter reviews the existing relevant literature exploring the relationship between chronic stress and immune system impairment.
... The taboo nature of DID means that this disorder is frequently perceived by the sufferer as shameful and thus hidden, meaning individuals often suffer in silence while painfully aware of their dissociation and complex identity. Research has found that approximately 1% of the general population lives with DID (Brand et al., 2016; International Society for the Study of Trauma and Dissociation, 2011). Scroppo, Drob, Weinberger, and Eagle (1998) conducted a study with 42 female subjects recruited from outpatient mental health settings and physician referrals. ...
... Dissociative phenomena are not confined to individuals living with DID. Research indicates that some level of dissociative experiencing is often present and is a core element within emotional disorders originating from stressful or traumatic life events (Brand et al., 2016;van der Hart et al., 2006). At the milder end of the spectrum, dissociation can be seen as a coping mechanism or defense mechanism enabling an individual to minimize or tolerate stress, and symptom presentation can be at times difficult to identify (van der Hart, van der Kolk, & Boon, 1998). ...
... Understanding, diagnosing, and treating dissociation can be challenging. Relatively few clinicians receive training in accurately diagnosing and treating DID, despite the existence of expert consensus guidelines and treatment recommendations (Brand, Lanius, Loewenstein, Vermetten, & Spiegel, 2012;Brand, Myrick, et al., 2012;ISSTD, 2011). In the context of treating complex trauma, you are highly likely to encounter trauma survivors with dissociative symptoms. ...
Chapter
Full-text available
The negative effects of layered relational trauma, particularly as experienced through childhood abuse and neglect, have long been recognized as contributing factors toward the development of complex posttraumatic stress disorder (C-PTSD), a diagnostic entity included in the International Classification of Diseases, 11th revision (ICD-11). According to the ICD-11, C-PTSD is associated with a broad spectrum of psychopathological symptoms and is conceptualized as including the core elements of PTSD such as re-experiencing the trauma, deliberate avoidance of internal and external traumatic reminders, and a sense of current threat expressed as hypervigilance and hyperarousal. The ICD-11 has also identified additional C-PTSD symptoms, including emotional regulation difficulties, persistent negative views of the self, and interpersonal problems characterized by difficulties forming and maintaining relationships with others. Endorsement of the ICD-11 definition of C-PTSD will come into effect on January 1, 2022. This chapter provides an overview of the emergence of C-PTSD, including an overview of symptoms and an explanation of how it is unique from other diagnoses. The chapter examines insecure attachment and relational trauma as diathetic factors in the development of C-PTSD. Following this overview, the neuroscience of complex trauma, with specific attention to the mind-body connection, will be critically explored. Subsequently, this chapter presents a measurement tool utilized to assess the impact of trauma in a clinical setting.
... Unless there is specific treatment of the DD/DID, comorbid disorders generally do not definitively improve (Brand et al., 2012;Jepsen et al., 2014;Sar et al., 2013). DD experts recommend a phasic treatment model with a foundation of patient safety and stabilization (Brand et al., 2012; International Society for the Study of Trauma and Dissociation, 2011). ...
... Unless there is specific treatment of the DD/DID, comorbid disorders generally do not definitively improve (Brand et al., 2012;Jepsen et al., 2014;Sar et al., 2013). DD experts recommend a phasic treatment model with a foundation of patient safety and stabilization (Brand et al., 2012; International Society for the Study of Trauma and Dissociation, 2011). In the Treatment of Patients with Dissociative Disorders (TOP DD) studies, Brand and colleagues (Brand, Schielke et al., 2019;Bride et al., 2009) found that a DD/DID diagnosis and DD/DID-specific treatment resulted in significant decreases in dissociative and co-occurring symptoms from baseline, including self-injury, suicide attempts, PTSD symptoms, etc., and increases in ability to regulate emotions and improved overall adaptive functioning (B. Brand et al., 2009Brand et al., , p. 2013Brand, Schielke et al., 2019). ...
Article
Full-text available
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) revised the diagnostic criteria for dissociative identity disorder (DID) to more accurately reflect the symptom profile of DID patients. No study has examined how this change affects clinical diagnosis of DID. The present study examined clinician reports of patient symptoms in relation to DSM-IV-TR and DSM-5 DID diagnostic criteria. Data were analyzed from 169 clinicians who participated in the Treatment of Patients with Dissociative Disorders Network Study with a patient they assigned a DID diagnosis. Clinicians evaluated their patients with respect to DSM-IV-TR and DSM-5 DID diagnostic criteria. Researchers determined a clinician-assigned DID diagnosis as “accurate” when the patient’s reported dissociative symptoms matched DSM-IV-TR and/or DSM-5 criteria for DID. Most of the clinicians (95.27%) accurately diagnosed DID. Of those accurately diagnosed, 83.85% of patients met DSM-IV-TR and DSM5 DID criteria, 9.94% only met DSM-IV-TR DID criteria, and 6.21% only met DSM-5 DID criteria. Further examination of responses suggested that possible idiomatic responses to the negative wording of the DSM-5 exclusionary criteria might have accounted for the DSM-IV-TR appearing to fit for a greater number of cases in this study. Changes in the DSM criteria for DID did not substantially change the frequency or accuracy of assigned DID diagnoses, but the removal of the requirement in DSM-5 that self-states regularly take control of an individual’s behavior slightly increased the number of individuals meeting criteria for DID.
Article
Full-text available
Background: Dissociative disorders (DDs) are characterized by interruptions of identity, thought, memory, emotion, perception, and consciousness. Patients with DDs are at high risk for engaging in dangerous behaviours, such as self-harm and suicidal acts; yet, only between 28% and 48% of individuals with DDs receive mental health treatment. Patients that do pursue treatment are often misdiagnosed, repeatedly hospitalized, and experience disbelief from providers about their trauma history and dissociative symptoms. Lack of dissociation-specific treatment can result in poor quality of life, severe symptoms requiring utilization of hospitalization and intensive outpatient treatment, and high rates of disability. Objective: Given the extensive and debilitating symptoms experienced by individuals with DDs and the infrequent utilization of treatment, the current study explored barriers to accessing and continuing mental health treatment for individuals with dissociative symptoms and DDs. Method: A total of 276 participants with self-reported dissociative symptoms were recruited via online social media platforms. Participants completed a survey which featured 35 possible barriers to accessing treatment and 45 possible reasons for discontinuing treatment, along with open text boxes for adding barriers/reasons that were not listed. Results: Results showed 97% of participants experienced one or more barriers to accessing treatment (M = 9 barriers) and 92% stopped treatment with a provider due to at least one of the reasons captured in the survey (e.g. limited insurance coverage, poor therapeutic alliance, disbelief from providers, etc.; M = 7 barriers). Conclusions: The most frequently endorsed barriers were structural barriers, such as those related to finances, insurance, and lack of provider availability. It is imperative more service providers are trained to treat dissociation and that insurers and health care systems recognize the need for specialized, dissociation-focused treatment.
Article
Full-text available
Background: Dissociative disorder (DD) patients report high rates of self-injury. Previous studies have found dissociation and self-injury to be related to emotional distress. To the best of our knowledge, however, the link between emotion dysregulation and self-injury has not yet been examined within a DD population. Objective: The present study investigated relations between emotion dysregulation, dissociation, and self-injury in DD patients, and explored patterns of emotion dysregulation difficulties among DD patients with and without recent histories of self-injury. Method: We utilized linear and logistic regressions and t-test statistical methods to examine data from 235 patient-clinician dyads enrolled in the TOP DD Network Study. Results: Analyses revealed emotion dysregulation was associated with heightened dissociative symptoms and greater endorsement of self-injury in the past six months. Further, patients with a history of self-injury in the past six months reported more severe emotion dysregulation and dissociation than those without recent self-injury. As a group, DD patients reported the greatest difficulty engaging in goal-directed activities when distressed, followed by lack of emotional awareness and nonacceptance of emotional experiences. DD patients demonstrated similar patterns of emotion dysregulation difficulties irrespective of recent self-injury status. Conclusions: Results support recommendations to strengthen emotion regulation skills as a means to decrease symptoms of dissociation and self-injury in DD patients.
Article
Full-text available
Background: Most individuals with dissociative disorders (DDs) report engaging in self-injury. Objective: The present study aimed to understand the reasons for self-injury among a clinical sample of 156 DD patients enrolled in the TOP DD Network study. Method: Participants answered questions about self-injury, including a prompt asking how often they are aware of the reasons they have urges to self-injure, as well as a prompt asking them to list three reasons they self-injure. Results: Six themes of reasons for self-injury, each with subthemes, were identified in the qualitative data: (1) Trauma-related Cues, (2) Emotion Dysregulation, (3) Stressors, (4) Psychiatric and Physical Health Symptoms, (5) Dissociative Experiences, and (6) Ineffective Coping Attempts. Participants reported that they were able to identify their reasons for selfinjuring sometimes (60.26%) or almost always (28.85%), with only 3.20% unable to identify any reasons for their self-injury. Conclusion: Results suggest that the vast majority of DD patients (92.31%) reported being at least partially unaware of what leads them to have self-injury urges, and many individuals with DDs experience some reasons for self-injury that are different from those with other disorders. The treatment implications of these findings are discussed.
Article
The concept of identity is pervasive in psychology and culture, but clinicians have lacked a conceptual framework for addressing problems related to identity. After reviewing the development of identity, I distinguish four of the most common categories of such problems and consider approaches to each: identity diffusion, distorted identity, threats to identity, and difficulty integrating disparate aspects of one’s identity. While making identity a focus of clinical attention can strengthen the alliance and place the treatment within a larger context, doing so raises moral questions about the clinician’s role as an agent of validation or change.
Thesis
The aim of this thesis is to examine the prevalence of dissociation and Dissociative Disorders (DDs), and the role of trauma and parent-child dynamics as etiological factors, to assess the validity and plausibility of the Trauma Model and Fantasy Model of dissociation. Its meta-analysis found 11% of college students (N = 2,148) meet the criteria for a DD following assessment by a structured clinical interview; 17% (N = 4,061) had clinical levels of dissociation on the Dissociative Experiences Scale (DES); students were experiencing dissociative symptoms 17% (N = 26,821) of the time; and DES scores were highest in countries that were comparatively unsafe. Using a short version of the Multidimensional Inventory of Dissociation (MID-60) at least 8% of participants at an Australian university (N = 313) had clinical levels of dissociation, and participants reported experiencing dissociative symptoms 13% of the time. In females 51% of MID-60 scores were predicted by secure attachment, the number of sexual abuse episodes, the number of different types of sexual abuse and physical abuse, and being choked. In males 53% of MID scores were predicted by the number of sexual abuse episodes, a father who was not kind and caring, and parents who preventing independence by organizing and problem solving on the child’s behalf. Fantasy factors, including therapist suggestion, hypnosis and organic amnesia could not account for these findings. The second study (N = 309) compared three university groups (normal, elevated, and clinical levels of dissociation) and a group of inpatients and outpatients diagnosed with a DD. This found DDs, and levels of dissociation consistent with a DD, occur in individuals that report a childhood history of interpersonal trauma (particularly sexual abuse and life threatening trauma) alongside negative interpersonal dynamics between themselves and their parents, including an insecure and fearful attachment style. Odds ratios for a DD diagnosis in iii females include an insecure attachment style (72 : 1), negative parent-child dynamics (21 : 1), the mother’s role in, or response to, maltreatment being negative (45 : 1), any sexual abuse (16 : 1), being choked (28 : 1), choking or smothering and sexual abuse (106 : 1). There were strong similarities in antecedents reported by the university group with clinical levels of dissociation and the group of patients diagnosed with a DD and both groups had the highest rates of corroboration for abuse claims. The findings of this study provide strong support for the Trauma Model.
Article
Full-text available
In the Netherlands, the diagnosis of dissociative identity disorder (DID) is widely accepted, although skeptics also have made their opinions known. Dutch clinicians treating DID patients generally follow the common three phase model for treatment of post-traumatic stress. Given the fact that they usually deal with complicated cases and enmeshed patients (cf. Horevitz & Loewenstein, 1994), most often treatment is restricted to Phase 1: stabilization and symptom reduction. Treatment of higher functioning patients, on the other hand, usually aims at processing of traumatic memories and complete personality integration as well. In this article, two Dutch cases are described in detail, with a special emphasis on the clinical deliberations which, in the first case, led to the decision to proceed to trauma treatment, and which led in the second case to the decision to refrain from it. The current standard of care with regard to the treatment of trauma-induced disorders, including post-traumatic stress disorder and many dissociative disorders, entails, among other things, the application of a phase-oriented treatment model (. Phase-oriented trauma treatment has its origins in the pioneering work of Pierre Janet (1898, 1919/25), who described three phases in the overall treatment: 1) stabilization and symptom reduction; 2) treatment of traumatic memories; and 3) personality reintegration and rehabilitation (van der Hart, Brown, & van der Kolk, 1989). In the Netherlands, clinicians usually follow Janet's terminology, while mentioning the following treatment goals for each separate phase: 1) overcoming the phobia of dissociative identities; 2) overcoming the phobia of traumatic memories; and 3) overcoming the phobia of normal life and attachment (Nijenhuis, 1994; Nijenhuis & van der Hart, in press; van der Hart & Boon, 1998). In actual clinical practice the model is not applied in a strict linear model, but rather takes the
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Abreaction refers to the discharge of pent-up affect through spoken language that relieves pathogenic intrapsychic tensions which are residua of trauma (Laplanche, 1967; Moore, 1990). This definition is inadequate and mired in Freud's early models of the mind, both the hydraulic and topographic models, and nineteenth century models of hypnosis. Abreaction may more usefully be defined as the verbal or non-verbal expression of intense affect, which when associated with a coherent narrative of experience, may provide relief of chronic anxiety states. Affect is the centerpiece of experience. It is the prime contextu-alizer of meaning. Ego mechanisms of defense all alter the meaning of experience in an effort to reduce threats to psychological equilibrium. The destruction of context and meaning via dissociative adaptations is an effective and primitive mechanism of protection from both external impingement and internal conflict. Isolation of affect (Freud, 1955), is a dissociative process. It is important to understand that dissociative phenomena do not bypass ego functions. Post-traumatic adaptations may include a profound secondary alexithymic state. This may seem hidden in the wake of powerful affective storms. The affect-phobic nature of the person prone to abreaction is a major impediment to treatment. The primary task of treatment is stabilization of the patient prior to "working through"the sequelae of trauma. The mid-phase of treatment may involve continued psycho-educational efforts to identify and name affects, the use of "dream-rules" in the interpretation of abreactive narrative, and a utilization approach which welcomes affect into the treatment setting in a safe, skilled environment. Management of countertransference responses to avoid enactment which could lead to boundary violations is essential.
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A female adolescent with dissociative identity disorder was assessed using structured interviews and the Rorschach test before and after one year of individual psychotherapy. In addition to improvement in several comorbid psychiatric disorders, according to the structured evaluation, criteria for neither dissociative identity disorder nor borderline personality disorder were met at the second evaluation. The main differences on the Rorschach assessments before and after integration were in the development of form-dominated color and human movement responses and a diminution in the externally focused coping style. The differences were interpreted as improvement in aggressiveness, impulsivity, anxiety, and better identification with social environment. This case study suggests that the Rorschach test can be used to evaluate the change of patients with dissociative identity disorder in psychotherapy.
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Praise for Rebuilding Shattered Lives, Second Edition. "In this new edition of Rebuilding Shattered Lives, Dr. Chu distills the wisdom he has gained from many years spent building and directing an extraordinary therapeutic community in a major teaching hospital. Both beginners and experienced clinicians will benefit from this book's unfailing clarity, balance, and pragmatism. An invaluable resource."-Judith L. Herman, MD, Director of Training for the Victims of Violence Program, Cambridge Health Alliance, Cambridge, MA. "The need for this work is immense, as is the reward. Thank you, Dr. Chu, for continuing to share your sustaining insight and wisdom in this updated edition."- Christine A. Courtois, founder and principal, Christine A. Courtois PhD & Associates, PLC, Washington, DC; author of Healing the Incest Wound: Adult Survivors in Therapy and Recollections of Sexual Abuse. Praise for the first edition: "Dr. James Chu charts a deliberate and thoughtful approach to the treatment of severely traumatized patients. Written in a straightforward style and richly illustrated with clinical vignettes, Rebuilding Shattered Lives is filled with practical advice on therapeutic technique and clinical management. This is a reassuring book that moves beyond the confusion and controversies to address the critical underlying issues and integrate traditional psychotherapy with more recent understanding of the effects of trauma and pathological dissociation." -Frank W. Putnam, MD. A fully revised, proven approach to the assessment andtreatment of post-traumatic and dissociative disorders-reflecting treatment advances since 1998. Rebuilding Shattered Lives presents valuable insights into the rebuilding of adult psyches shattered in childhood, drawing on the author's extensive research and clinical experience specializing in treating survivors of severe abuse. The new edition includes: Developments in the treatment of complex PTSD. More on neurobiology, crisis management, and psychopharmacology for trauma-related disorders. Examination of early attachment relationships and their impact on overall development. The impact of disorganized attachment on a child's vulnerability to various forms of victimization. An update on the management of special issues. This is an essential guide for every therapist working with clients who have suffered severe trauma.
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Sexual exploitation within therapy is founded upon inappropriate physical contact. Yet the use of touch in therapy remains a contentious issue. Some therapists purport that touch is a primary source of communication of which many clients, as children, were deprived. They argue that refraining from the appropriate use of touch in the counselling situation can be damaging to the client. This article considers the argument for the use of physical contact in therapy and counselling and its potential therapeutic value.
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This study is part of a larger project (Gingrich, 200418. Gingrich , H. D. 2004. Dissociation in a student sample in the Philippines, Quezon City, , Philippines: Unpublished doctoral dissertation, University of the Philippines. View all references) that examined dissociation in a student sample in the Philippines. High and low-moderate dissociators were identified from a sample of 459 freshman university students based on cutoff scores on two brief screening instruments. The Multidimensional Inventory of Dissociation (MID) and Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) were then used to determine if any of the participants met diagnostic criteria for dissociative identity disorder (DID) or other dissociative disorders (DDs). Comparisons were made between the frequency of specific DDs diagnosed by each instrument and an evaluation done of the usefulness of the MID and SCID-D as diagnostic tools in a Filipino student sample.