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Dissociative Identity Disorder: What About Multiple Personalities?

Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder (MPD) or Split Personality, is a challenge to even the most experienced clinician. Patients often experience confusion, fear, suspicion, anger, helplessness, and a myriad of other feelings. Proper diagnosis is often difficult, but the greatest difficulties come in the treatment phase.  The movies “Three Faces of Eve” (1957) and “Sybil” (1973) introduced the general population to the phenomenon of dissociation. The shocking exposé led some viewers to question their own sanity when periods of time were missing from their memories. Thus, there was a surge of the MPD diagnosis in the 80s and early 90s, when it was diagnosed too frequently.

A sharp decline in the DID diagnosis followed in the mid-to-late 90s, as the False Memory Syndrome Foundation questioned the validity of dissociation and “recovered” or “repressed” memories. Both the clinical professions and the world-at-large are ready for some clarity and “sanity” in the diagnosis and treatment of this puzzling disorder. Diagnosis DID is defined in DSM IV as “the presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).” At least two of these identities or personality states recurrently take control of the person’s behavior. There is an inability to recall important personal information that is too expensive to be explained by ordinary forgetfulness.

The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.  DSM-IV also describes other Dissociative Disorders.  Dissociative amnesia has as its essential feature “inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetting.”  Dissociative fugue is defined as “sudden, unexpected travel away from home… with inability to recall one’s past.” It may be so extensive that the individual does not even remember his name or any personal information about himself or his life, present or past.

Depersonalization disorder involves the “persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body.”  The previous diagnostic training guide, DSM-III-R, gave a helpful elaboration: There are four types of memory disturbance that may be associated: localized (circumscribed), in which there is failure to recall the events occurring during a specific period of time; selective, in which one recalls only some, not all, of the events occurring during a circumscribed period of time; generalized, in which one recalls nothing from his entire life; and continuous, in which the patient cannot recall events from a specific time through the present. Dissociation protects against trauma in two ways. First, it blunts or obliterates the reality of the trauma while it is in progress. And second, it blocks the memory so it prevents repetitive flashbacks. It is a splitting off of a personality or personality state that holds the memory of the trauma.

This enables the personality state that has forgotten the trauma to go on with life as if nothing has happened. The cause always seems to be severe emotional trauma, often beginning in childhood, generally of a repetitive nature.  Levels of Dissociation In my clinical practice, I continue to see dissociation all along a continuum. Almost everyone learns to have a minor form of conscious splitting. This may be referred to as level one. At times we choose our “business side” or professional persona, while other times we may be casual and relaxed. We may even play different roles, as we put on our parent hat or act the dutiful daughter. This serves us well in lives that demand a wide range of behavior.  On a more serious level, we may have learned that our society or our families have certain standards regarding our feelings or behaviors. Some things are acceptable; some are not. We learn to hide specific feelings from others, perhaps anger for women or crying for men, pretending that everything is just fine. This is level two.

In a social situation, someone asks, “How are you?” We may be furious or frightened or hurt, but smile and say the perfunctory “fine.” It is not an attempt to deceive anyone, but involves putting on a public face because it is expected in this superficial situation.  Some keep that public face on most of the time, never revealing to anyone certain painful events that have occurred in their lives. This is not DID nor repression of memories, but simply choosing to hide their feelings or what has happened to them from others.  A third level of splitting involves the hiding of feelings or past events from ourselves. This is what is diagnosed as DID. It involves blocking, dissociation or repression, and it comes in a wide variety of forms. Some may have amnesia for one event, while others block out everything about their lives, even their names and identities (though this is very rare).

In milder forms, a person may block out a certain feeling for a particular person. In more serious forms, a person might block out all feelings (also rare).  The fourth and final level is the multiple personality disorder that became popularized by the movie, Three Faces of Eve. In this Dissociative Disorder, a person has more than one personality. These personalities alternately take over complete control, with no conscious awareness of another part or parts.  DID Treatment In the healing process for all levels, each of the splits—or parts that are “not acceptable”— will need attention. There is a story behind each part of a person who has gone through any level of splitting, and those stories need to be told— along with the associated feelings. Although it sounds easy, it is a serious business. At levels three and four, professional expertise is essential. Any counselor who chooses to be involved will need to be in continual prayer for wisdom and guidance due to the complexity of the therapeutic process, as well as the numerous dangers to the client.  Establishing trust is an ongoing challenge throughout treatment of DID. Because of the extreme and often repetitive trauma experienced, trust has been shattered.

The perpetrator is often a family member or someone in close proximity, which increases the fear and distrust, especially if the perpetrator was at times caring or kind. The feelings of betrayal are devastating when any abuse occurs, but greatly intensified when the abuser is a trusted caretaker.  Parents have been placed in the role of protecting their children from abuse and harm, and the Lord intended them to be the most trustworthy people in their children’s lives. If the parent becomes the abuser, a child often develops DID, learning to trust no one, including God. Even when they encounter a kind, caring therapist, they often continue to be wary, anticipating abuse or rejection. An even greater challenge is the necessity of establishing trust with every split-off part. This may take years, if it ever occurs.

The counselor is often bombarded with hate, terror and false accusations, as a new split unexpectedly surfaces. The age of the split will determine the behavior, and often includes a very young child who does not have the skills or ability to function.  So the therapist must be trained and competent in recovering an adult split, who is capable of driving, working, etc., before releasing the client from the session. This is where intensive day treatment or inpatient therapy is advisable, to enable the child part to stay with the feelings and memories, rather than being cut off and dismissed. Being alone during and after the horrors of abuse is perhaps the most devastating aspect of trauma. DID clients are retraumatized when abandoned in the middle of the process.

The client desperately needs to experience that “someone is here for me this time.”  Releasing feelings or managing the abreactions often become a life-anddeath possibility. It is also at this stage that most DID clients require intensive day treatment programs or an inpatient setting. The overwhelming terror, fear and anxiety cannot be dismissed with the plan to continue the following week, or even the following day. EMDR (Eye Movement Desensitization and Reprocessing) is a powerful tool to help move through the process quicker, but must not be used unless the therapist is highly trained to work with DID, since EMDR can also trigger other trauma.  The immediate and continued attention for the release of shame and guilt is even more critical, due to the high likelihood of self-harm and even suicide, when flooded with these feelings.

DID clients often believe, and may have been told, that they are at fault in causing the trauma to occur. Thus, looking at their own “badness”—real or imagined—is an essential element of the shame and guilt. Some have willingly participated in the abuse of others, thus placing themselves in the same category as their feared and hated abuser. Even when they were forced to participate, the self-loathing is so intense that suicide appears to be the only option. They often find it helpful to begin distinguishing between “guilt” (defined as “I did something bad”) and “shame” (defined as “I am all bad”).  To experience forgiveness and healing through Christ is incredibly life-changing, though learning to trust Christ can be a long and arduous process. Feelings of anger, helplessness and lack of control must also be faced and released. It is awe-inspiring to facilitate a fearful invitation by a traumatized client and witness Christ come as the gentle, suffering servant who is able to completely identify with the trauma and horror of the worst abuses.

The sadness and long-term grief of this abuse can generally be handled in the more traditional, less frequent outpatient counseling sessions. This includes the typical mild to moderate depression, which usually accompanies any loss or trauma. Severe depression will require intensive therapy, and often medication.  Dealing with lies. Cognitive weekly therapy will help identify the lies believed as a result of the trauma. This will generally include lies about oneself, about others, about the world and about God. As these lies are gradually replaced with God’s truth, the healing continues. Learning to see and look for the positive is a challenge for most DID clients. In fact, it’s often frightening to even hope for the positive, because of the fear of being tricked and hurt again.  A critical and essential task in therapy with a DID client is to avoid more than one trauma at a time.

Unless the knowledge and feelings of a trauma are released before moving to another one, the feelings will be so overwhelming that coping becomes impossible.  Late stages of therapy will include forgiveness of self, the perpetrator and God. Learning to risk again, beginning in small steps, involves trusting God, self and others in whatever way the trust has been broken. A huge task involves learning to identify safe people and allowing each person to be fallible, with strengths and weaknesses. Most DID clients see people as good or bad, and any failure or weakness catapults others into the “bad” or untrustworthy category.  Setting and reaching new goals, and allowing hope and dreams, is one of the most difficult, but healing, aspects of therapy. But it usually requires baby steps and frequent encouragement and praise. Assisting a client in determining reachable goals is critical, so they can experience success and begin to build both skills and confidence.

Group therapy with extreme DID clients may be inadvisable. Although there may be only four or five in a group, it immediately becomes apparent that many more are in attendance, considering all the splits. They are likely to be overwhelmed and triggered by the experiences of others. Splits that are new may rapidly emerge, sometimes becoming very verbally abusive and frightening to the other DID clients. Any attempt to resolve the negative interactions among the DID group members may result in denial and confusion, because the part that is currently in control had no awareness of how the other part acted. A more structured group, however, allows for more success, especially with less severe DID.

Vicarious Trauma A challenging risk for counselors of DID clients is to escape secondary traumatization. This should not be attempted without knowledgeable colleagues for emotional support and an objective perspective on the client. The stories are often unbelievably horrendous, heartbreaking and extremely difficult to hear. Unless the trauma is filtered through the spiritual eyes of hope and healing, it is overwhelming, frightening and discouraging to the therapist.  Conclusion DID clients and their counselors need the Church in a huge way. They need support of other Christians to survive the evil that has been perpetrated on innocent people.Take help from telephone psychologist.

There must be prayer support throughout this challenging process for success.  References 1 American Psychiatric Association, Desk Reference to the Diagnostic Criteria from DSM-IV (Washington, D.C.: (American Psychiatric Association, May 1994), 209-10  2 W.H. Reid and M.G. Wise, DSM-III-R Training Guide (New York: Brunner/ Mazel, 1989), 158.  _Arlys McDonald, Ph.D., is a clinical psychologist who has specialized in the treatment of trauma for more than 30 years. She is the director of the McDonald Therapy Center day-treatment intensive program in San Diego. Therapists and pastors from across the United States, Canada, Mexico, and Europe, have referred their clients for the intensive segment of therapy that cannot be done in regular counseling settings. She is also the author of Repressed Memories, Can You Trust Them? _

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