Dissociation is a mental process in which a person unconsciously disconnects from his or her thoughts, feelings, memories or sense of identity in response to a traumatic event or a series of traumatic events. It has been hypothesized that dissociative states develop as protection against overwhelming negative stimuli. Lowewenstein (1996) describes dissociation as “a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma”. Some of the ways that people dissociate include separating themselves from that or other negative experiences when they occur or when situations occur that are similar to those earlier negative experiences. They may block them from their memories entirely or they may find that they feel disengaged from their emotions, have blank spells, drift away without realizing it, feel disconnected from their bodies, or feel that times they are living in a dream. Dissociative Identity Disorder (DID), is the most extreme form of dissociation.
Dissociative Identity Disorder
One of my clients who has a diagnosis of Dissociative Identity Disorder (DID) recently told me that she thinks DID brings with it a social phobia because life as a DID can be so confusing to her and to others. She is a lovely, gentle woman who in general seems perfectly normal. She is married with children and grandchildren. Her husband is well-respected at his business and they have a comfortable income. Yet, she feels isolated and as much as she wants to make friends when the opportunity arises she is afraid because of her DID and her lack of certainty of what will happen.
She agreed to let me share what she told me.
Sometimes it is as simple as going to my in-law’s house for dinner. In such a small intimate affair, I’m so afraid that they might see through me this time. The same thing happens when I run into people at the grocery store. Can they see through me? When I talk to people I ask myself who am I supposed to be? It is like when I still was involved with my kid’s school. I went with the school to the beach as a chaperone and I had to share a room with another mom. We got to talking about our lives and I felt like I had to be someone else. When she asked about my childhood, I felt like I was making up a story or a telling lie. It makes it so hard to be around anyone. I’m never sure what to say and later I may not remember what I did say. I feel like everyone can see my shame and guilt all over me.
Despite being in therapy all her adult life she could not find a therapist who understood what she was going through and could help her. She was told she had anxiety or that she was depressed. She was given medications that didn’t seem to change anything. Eventually, she diagnosed herself with derealization/depersonalization and kept looking.
DID clients share many of the same problems and symptoms regardless of economic or family backgrounds, They can include:
- Finding drawings, notes, or entries in their journals sometimes in handwriting they don’t recognize and can’t remember doing, yet they know they must have done.
- Having conversations with people they don’t remember having.
- Looking in the mirror and not recognizing the person looking back at them.
- Running into people who know them and call them by name, or perhaps another name, but not having any idea who those people are.
- Feeling as though they are having an out-of-body experience standing next to themselves or watching themselves do something just as if they were someone else.
- Hearing voices inside their head telling them to do things or commenting on things that they are doing.
- Missing time. One minute they are in one place and the next thing they know they are in another place and they have no idea when or how they got there.
Finding a therapist who is experienced in working with DID clients can be a daunting task. More often than not, what they find is a general lack of knowledge about DID, a lack of training about how to work with DID clients, or a fear or even an unwillingness to take a DID client on. In addition, there are those who simply do not believe that the condition is real and instead are inclined to give a diagnosis of schizophrenia, bipolar, or borderline personality disorder.
Following is a script showing what can go on in the mind of someone with DID as she (or he) makes the initial step for therapy and what it is like for me when I begin working with that client.
I know something is wrong with me. Things haven’t been right for a long time and they are getting worse. I lose things, I have things in my closet I don’t remember buying, people I don’t know walk up to me and call me by a name that isn’t mine. I get calls or texts from people I don’t know. I am in one place and the next thing I know I am another place and I don’t know where I’ve been or how I got there. Sometimes I hear voices in my head chattering to me or even to each other. I feel like I’m going crazy but I’m afraid to tell anyone because they might think I’m crazy too. Maybe they will lock me up or institutionalize me. I need help and don’t know what to do and I’m really scared.
I made an appointment with a therapist and now I have butterflies in my stomach. What do I say? How much do I say? What if the therapist tells me I’m crazy or schizophrenic? Well, I’ll try to keep the appointment, but I won’t tell her everything. I’ll say just enough to maybe get some answers and maybe get some medication. I keep forgetting things and missing appointments, so I’ll write the appointment on some paper and stick it to the refrigerator.
The day of the appointment arrives and I wake up late. I know there is something I’m supposed to do today but can’t remember what. I think I have an appointment. I go into the kitchen to get some coffee and I am sure I put a reminder note on the refrigerator. It’s not there. Oh no. Where was I supposed to be? Where did that note go? I remember. I have a therapy appointment today in two hours. I rush and take a shower and get myself together to go. I’m a nervous wreck and feel like I’ve been sabotaged again while I sleep.
When I get to the appointment, I have to wait a few minutes until I am called into the therapist’s office. I hear one of the voices in my head saying, “You are an idiot. I told you not to come. Don’t you know this time they are going to lock you up? They’ll never let you out!” I try to ignore the voice. Then I hear my name called. A lady is greeting me and she is bringing me into her office. She seems friendly enough and smiles at me. Okay. Maybe this isn’t so bad. Maybe she can help me. Then I hear the insistent voice, “keep your trap shut!”
Actually, this isn’t my first time to try therapy. I’ve done this before and every time it’s a bust. I start to tell the therapist what is going on but then get afraid. The last time I went I was told I was psychotic and should be hospitalized. I’m not going to let her do that. I was hospitalized once before, labeled as schizo something or other, and given a ton of medication, but nothing changed. Meanwhile, that voice is telling me to stop talking. I back up, try to make me seem less crazy but as I inch my way forward in the session, I can see that maybe she gets it. I really need help.
I walk out to greet my new client. When she made the initial contact by phone, I recall how distressed she seemed and how difficult it was for her to talk about what was going on. She did tell me she thinks she dissociates sometimes and has been having trouble finding a therapist who can help her. I told her that I do have experience working with people who dissociate and that we could talk about it more when we met. We made the appointment and now I invite her into my office. I can see how nervous she is and so, gently, carefully, I work towards making her more comfortable. She is hesitant but I wait, listen, ask some questions to get a better feel of what she is experiencing. I can see something in her eyes and gestures that indicate that there is more than she is willing to say. I can also see that she is testing me and is cautious when I ask her questions about her external and internal world. I make no judgments and know that if I make the wrong move, say the wrong thing, I may lose her.
Now, several weeks into treatment, I can confirm that she has DID. She meets all the criteria and I have met a few of her alter personalities. This is not new to me. I know that as her trust in me grows there may be other personalities or alters that surface. The work goes slowly but that’s okay because there is a lot of work to do and getting to know her alters is only one part of that work. This is only the beginning. The goal is to help her heal from the pain and suffering she endured as a child and possibly all her life. Because she is DID, the goal is also to help her have better internal communication so that she can live something akin to a normal life.
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When I met my first DID client, it came out of the blue. I was more than a little startled when one minute I was talking with an adult client and the next minute I was talking to a gum-chewing 5-year-old. The best I knew to do was to go with my instincts and respond to the “child” that was in my office. All went well and eventually, the child alters yielded to the adult. Beyond that, I had no idea what to do to help her and my clinical colleagues, psychologists, and counselors with who I worked and knew were able to help me because they had no experience or training in working with DID clients either. So I began my search and found the International Society for the Study of Trauma and Dissociation (ISSTD). This organization is headed by top experts in the world on trauma and dissociation that provides training, workshops, webinars, as well as an active listserv where you can connect with the experts and others for advice and support.
Since that time, much of my energy as a clinician has been devoted to learning how to work with this unique set of people who are survivors of trauma often severe and repeated. Without a doubt, I can say that working with DID clients can be complicated and requires commitment and patience. It pulls from all that we learned in graduate school and through years of working with clients about genuineness, acceptance, and non-judgment. It requires empathy, curiosity, creativity, and a willingness to be open-minded. It also requires the willingness to get specific training and to learn from others who have more experience with the work. But, in the end, it is worth the effort. Those DID clients who stay in therapy are some of the hardest working clients and the work with them can be among the most rewarding of clinical experiences.