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violenttransempire) wrote2017-12-17 07:22 pm
okay got it
The psychiatric and psychological research on Dissociative Identity Disorder is a rapidly-growing, often contentious field of study. While experts have made headway in recent years toward proving that the disorder exists and examining new methods of treatment, there are still important aspects of DID that remain to be studied. I will focus on one of these and will show, though survey, discussion, and citations of stories from people with DID and the similarly-manifesting Other Specified Dissociative Disorder type 1, that current literature is lacking in one crucial point: treating alters as individuals rather than fragments or parts of the original personality.
Some attention has been paid to alters’ identities, especially to the stereotyped “roles” they play in a given system, but virtually no researchers have looked at alters as actual people or treated them as equals with the “main” patient. This oversight leads many DID systems to suffer emotionally and psychologically in ways that deserve to be studied more than in the one survey I have done. Also, the focus in the literature on integration therapy, while it has somewhat fallen out of favor, is still prevalent as the “gold standard” of treatment, and this not only does not work in the vast majority of cases but can actively cause harm, as my survey shows. I will argue that such a holistic method of understanding DID will not only revolutionize the way it is studied and understood, but it will lead to better methods of treatment that allow everyone in a system to cooperate.
The first matter that needs clarification is how this view can make sense. DID is known to originate nearly all of the time from severe childhood trauma that causes the original person to dissociate enough to split into one or more “alternate personalities” or alters. It seems true by definition, then, that alters are only parts of the original person and not people in their own right. Yet, most DID scholars acknowledge that alters behave in ways that at least seem like people: the International Society for the Study of Trauma and Dissociation reiterated and endorsed Richard Kluft’s previous observation that an alter
has crucial psychodynamic contents. It functions both as a recipient, processor, and storage center for perceptions, experiences, and the processing of such in connection with past events and thoughts, and/or present and anticipated ones as well. It has a sense
of its own identity and ideation, and a capacity for initiating thought processes and action. (Kluft 1988, cited in ISST-D 2011 pg. 125)
This description seems to suggest that alters can think, feel, and process information just as the original personality can, or as non-DID individuals can. So, while they originated from fragmentation of the original personality, they develop over time into psychodynamic entities virtually indistinguishable from individual people, except that there are many in a single body.
Recent psychological literature has recognized this fact but only at a surface level: citations and statements like the ISST-D’s are common, but equally as common are articles like Amy Fingland’s 2014 dissertation on alternate-gendered alters. In it, whenever she uses the name of an alter, she places it in quotation marks, such as “Samuel reported that his female alternate identity, ‘Stacey’” (74), etc. This implies skepticism of the alters’ identities to an extreme degree: not only are they not individual people with feelings and identities, but their names are implied to be less real. The primary reason for this way of referring to alters is explicitly to avoid “reinforce[ing] a belief that the alternate identities are separate people or persons rather than a single human being with subjectively divided self-aspects” (ISST-D 121). Common knowledge in the literature indicates that promoting such a belief will intensify dissociation among alters and make it more difficult to recover, and especially make it difficult to achieve full integration.
However, the common knowledge in the literature is at odds with what seems to be common knowledge, or at least belief, among individuals with DID and OSDD1, the latter of which was included due to manifesting similarly enough to be considered a subtype of DID and thus being treated similarly. I recently conducted a survey which garnered 18 responses from people with DID/OSDD1 with the specification that only one individual per system respond, with various questions involving the treatment of alters as parts as opposed to people—full text and statistics of responses can be found in the Appendix below. Relevant here is the number of patients that were negatively impacted by having their alters (or themselves, if an alter was the one responding) treated as parts. Of the 9 patients who had been treated according to this idea by a mental health professional, only 1 explicitly endorsed the claim that this had helped their psychiatric recovery.
18 systems chose to indicate specific harms they felt were due to this treatment, in therapy and otherwise. Of this latter group, to name a few:
· 13 experienced lowered self-esteem and/or feelings of self-loathing
· 11 experienced urges to commit self-destructive behavior, such as reckless/risky drinking, driving, or sexual activity, with 4 indicating that they had acted on those in some way
· 7 experiences thoughts or urges to self-harm, with 1 indicating that they had acted on those
· 7 experienced suicidal thoughts or urges
A few also detailed specific harms beyond the options offered, indicating, for instance, “[this idea] triggers intense dissociation, and often causes whomever is fronting to spiral into a self-hating cycle” and “One system mate attempted to erase himself after up and deciding he wasn’t a ‘real person’; in-system suicide, essentially” (full responses in the Appendix). These data clearly show that treating alters as parts is often at odds with their own self-image and many DID patients report being actively harmed by this paradigm.
In addition, 6 respondents fully endorsed the idea that all members of a system be treated as people in treatment. Another 11 answered “it depends” and 5 of these gave further responses such as “If a system feels it’s better for their health to act as parts of a whole, that’s fine, but generally headmates/alters should be treated as individual people.” Essentially, they indicated that the beliefs and self-identifications of system members should be taken into account, even if they feel themselves to be parts, as was more common in the case of those with a form of OSDD1. Only 1 respondent said that alters should always be treated as parts. So, most systems endorsed that not only had viewing alters as parts directly harmed them, but they believed that others with DID should not be treated this way either, presumably to prevent harm to them.
Another, more subtle way of treating alters as parts is through the use of system roles, which do have their uses: they function as a convenient shorthand to allow a treatment team to keep track of alters, which is particularly helpful in cases with high levels of amnesia and poor communication between alters, as well as polyfragmented systems. An example comes from psychiatrist and trauma specialist Elizabeth Howell, where she describes working with a polyfragmented DID system. She gives examples of alters in terms like “The Driver, who takes care of safe driving when other parts have become too upset” or more simplistically still, “The Sexy One” and “The Little Girl in the Torn Dirty Slip” (16). Perhaps in Dr. Howell’s case, such roles were necessary, as she mentions that many alters in this system did not have names, and she had to recognize them by their behavior (16). However, in many cases, casting alters as manifestations of stereotypical and often hyper-specific roles is another way of seeing them as merely fragments of an original person.
This problem arises because the roles assigned to alters can be reductive or overly simplistic, often creating and reinforcing the perception that a given alter is and has only the qualities described by that role. For instance, if one alter likes cleaning and the others don’t, they might make a deal where the first does all the cleaning while the others take care of different responsibilities. From an outsider’s perspective, it may appear as though the first alter is simply “The Cleaning Alter” and nothing else, when in reality that alter simply cleans most frequently. Imposing system roles based on behavior, therefore, runs the risk of being reductive and of obscuring other factors like in-system agreements or a given alter’s preferences that may be the true cause of that behavior. Some DID systems themselves have criticized this: a system of comic book artists by the collective name of LB Lee explained, “You don’t like to be told you’re nothing but a behavior pattern, and we’re no different” (3). A survey respondent also brought this up without prompting: “we are not simply different emotions or a bad mood.”
To be fair, many system roles are not as narrow as Howell’s examples. Some, like “protector” and “little” or “child alter,” are descriptions of an alter’s general personality and characteristics that may serve as general guidelines for the therapist as to what to expect—a protector may get defensive easily, while a little may be sensitive and trusting. Some DID systems may also willingly adopt labels like these for themselves. So, system roles can be helpful if they are used as descriptors of an alter’s general personality, rather than all-encompassing and reductive descriptions of observed behavior. They are likely to be most helpful if they are consented to and chosen with input from members of the system, though in cases of severe dissociative barriers or polyfragmentation, this may not be feasible; care should still be taken to keep roles, if they must be used, flexible and with the understanding that a given role is unlikely to encompass every aspect of an alter.
On the other hand, some roles are too broadly descriptive. The aforementioned dissertation by Fingland concerns alters whose gender identity is opposite to the body’s sex, interpreting their existence in a system solely as indications of phenomena like “presence of a homosexual drive” and “disrupted gender identity development” within the original personality (68). Interpreting a basic aspect of an alter’s identity as their only noteworthy aspect is clearly doing them a disservice and is just as constraining as a narrow system role. Furthermore, while there are many convoluted psychological theories that can be invented to explain alters like these, such theories miss the purpose that psychological and psychiatric treatments ought to serve: enabling systems to work together and function on their own terms, if they can manage and wish to do so.
The above goal is also currently at odds with the commonly recommended treatment for DID, integration therapy. While many sources acknowledge that only a minority of systems are capable of full integration (eg., ISST-D 133-34) and patients in this state are often prone to re-formation of alters under stress (Brand 498), it is still the gold standard treatment. Foundational ideas like Kluft’s ranking scale, of categorizing high, medium, and low trajectory patients based on their willingness and perceived ability to integrate, are used with more caution and researchers are beginning to advocate forms of “partial integration” as a more realistic goal (Brand 498). However, integration in some form is still assumed to be a primary treatment goal, and problems ith integrating are sometimes blamed on the patients themselves: the ISST-D remarks that “significant narcissistic investment in the alternate identities” may contribute to patients’ inability to integrate (133-34).
The ISST-D is correct in that patients’ refusal to cooperate can pose problems with integration, but their dismissal of systems’ reasons for refusal is hasty and neglects systems’ actual viewpoints and feelings on the subject. LB Lee point out that, since alters often see themselves as fully-fledged people, “Losing your independent existence can sound like dying. It’s scary” (10). Between that fear of losing themselves and the fact that full integration is often unstable or doesn’t work in the first place, it should come as no surprise that 15 respondents (83% of the sample) said that they had not undergone integration therapy and did not wish to. Ultimately, it comes down to whether one views alters’ senses of self as an idea worthy of respect or not, with the knowledge that doing otherwise risks causing harm to them and their systems.
If systems are allowed to refuse integration, what else can be used to help? Even though their existence as multiple people is not inherently a problem, DID systems still deal with issues like amnesia when switching, poor in-system communication or even fights, and of course PTSD symptoms from trauma. General trauma therapy, like EMDR, exposure therapy, and talk therapy, can be helpful in allowing all system members to process trauma (Brand 492). It is also helpful for therapists to encourage communication and cooperation among system members and to work directly with alters; this is true regardless of whether integration is the goal and is already standard practice even among integration-focused therapists (Brand 490). Of course, integration should remain an option for the minority of DID patients who do wish it, provided that it is no longer held up as the ideal outcome for all patients.
Many psychiatrists and scholars may still balk at these suggestions and insist that, since alters formed from dissociation, they are only parts, and treating them otherwise will impede healing. They may say that viewing alters as individuals is, as per the ISST-D, “narcissistic” or delusional, and that encouraging such an idea is encouraging dissociative separation. This idea would not only impede traditional therapeutic practices like integration, but may have additional complicated legal, moral, and philosophical consequences. How should a system be treated in a legal case, for instance—should all system members be held responsible for the actions of one individual? What about the ramifications on how we think about personhood? Normally persons are assumed to exist as one per body; how would this view re-define what a person is?
These are all important questions, and sadly there is not room in this essay to answer them; such work must be left to further research and discussion (though a few initial, though flawed, attempts have been made: see Braude, who argues that alters should be treated individually in the legal system yet encourages integration therapy). However, I will say that it’s not necessary to answer these questions to begin reforming the way DID systems are treated therapeutically. All that is needed is to look at what gives the best outcome for patients. Given that treating alters as parts has more negative consequences than have been recorded in the literature thus far, it seems that this view requires more in-depth study to see if it is actually beneficial. If not, treating alters as individuals, at least in a therapeutic context, ought to be tested and studied to see the effects it has on treatment outcomes.
On that subject, the emphasis on dissociative separation as something to be fixed is a view that stems from integration-focused therapies. As discussed, this is far from an ideal or even possible outcome for many systems. As the focus on it hopefully lessens in response to new information, scholars will be less wary of “reinforc[ing] a belief that alternate identities are separate people” (ISST-D 121). Furthermore, it should not matter whether the belief that alters are separate people is a delusion or not. Mental health professionals who do not agree with this belief ought to treat it the same way an atheist professional would treat a religious client’s beliefs: with respect for the importance they have to that person and with the knowledge that attempting to disprove those beliefs likely will not work and will only cause harm to the client.
The psychiatric literature needs to change to respect DID system members’ senses of individuality. Treating them as parts appears to cause psychological harm, the depth of which needs further study. This idea also leads to undue emphasis on integration therapy, which fails in a majority of cases and is something patients frequently resist and reject. Treating alters as individuals promotes better cooperation, communication, and self-esteem among system members, and allows them to work toward the more realistic goal of being a functioning and stable system. While this idea has unexamined legal and philosophical implications, it can be implemented in current treatment programs without having to grapple with these immediately; all that is needed is a focus on what promotes the best outcomes for DID systems.
Works Cited
Brand, Bethany L., et al. “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, vol. 4, no. 5, 2012, pp. 490-500.
Braude, Stephen E. “Counting Persons and Living With Alters: Comments on Matthews.” Philosophy, Psychiatry, & Psychology, vol. 10, no. 2, 2003, pp. 153-156.
Fingland, Amy. Mapping Unchartered Territories: Understanding Gendered Alternate Identities. Massachusetts School of Professional Psychology, ProQuest Dissertations Publishing, 2014. DOI: 3624478.
Howell, Elizabeth F. Understanding and Treating Dissociative Identity Disorder: A Relational Approach. Routledge, 2011.
International Society for the Study of Trauma and Dissociation. “Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision.” Journal of Trauma and Dissociation, vol. 12, no. 2, 2011, pp. 115-187.
Kluft, Richard P. “The phenomenology and treatment of extremely complex
multiple personality disorder.” Dissociation, vol. 1, no. 4, 1988, pp. 47–58.