Over the past several years, I have had the privilege of working with a handful of clients who have Dissociative Identity Disorder (DID) or what was once called Multiple Personality Disorder. I use the word privilege because gaining the trust and confidence of these clients is difficult but so worth the effort.

Generally speaking, DIDs have endured enormous childhood trauma, almost every type of abuse, abandonment by friends and family, rejection from society and mental health professionals, or intense fear of themselves and others. They routinely feel disconnected, frightened, discouraged, confused, threatened, hurt, violated, overwhelmed and scared. Their thoughts oscillate between disorganized/orderly, obsessive/decisive, and self-defeating/arrogant. All of this results in tumultuous relationships, difficulty holding down a job, and a sense that they are losing it.

Working with a DID is not for the faint of heart and requires as much commitment on the part of the therapist as well as the client. Here are the important things I have learned while working with them:

  1. Double- and triple-check the diagnosis. This is not a go-to diagnosis and should only be considered after other diagnoses have been ruled out. Disorders such as schizophrenia, bipolar, schizoaffective, borderline, paranoid, substance abuse/dependency, traumatic brain injury, and other medical conditions must be eliminated first. It is possible that a DID will have co-mingling disorders. Double-check the diagnosis with a colleague, psychiatrist, or other mental health professionals before concluding the person has DID.
  2. Dont prematurely share the diagnosis. Sharing this information with the client can be a traumatic event, especially if they are unaware of the switching. There must be a strong bond of trust prior to discussing the diagnosis which has been developed over time.
  3. This is a long-term relationship. There are no quick therapies for DIDs. Each personality must work through the therapeutic process at their pace. As soon as possible, establish the expectation that the patient/therapist relationship is ongoing and not temporary.
  4. Know all close relationships. If possible, meet with the family members or close friends with the client. Some psychoeducation or relational therapy may be required to help maintain a safe home environment. Have all emergency contact information handy for times when it might be needed.
  5. Progress is slow. Most people with DID take four steps forward, two back, three steps forward and two back. Be patient with the progress and resist becoming frustrated or annoyed when things dont progress. This is why it is important to establish an expectation of a long-term relationship.
  6. Identify and name the personalities. As the personalities appear, begin taking notes on the different characteristics, facial expressions, body language, change in voice tone or volume, emotional expression, approximate age, handwriting, and thinking patterns. Each personality will have its uniqueness. It is acceptable to ask for personalities’ names so as to distinguish them later.
  7. Provide a safe/steady environment. For each personality to appear, they must have a feeling of safety and stability. Not all personalities will appear each time; sometimes only the dominant one is present. Dont ask for a personality to appear unless there is a specific purpose. Each time a switch occurs, the client is drained emotionally. This could cause unintentional harm to the client. Some of the stories may seem unbelievable, but it is essential that the therapist accepts the clients truth and empathizes fully with each personality.
  8. Awareness of all personalities is the objective. The objective for the client is to get to a place where they are aware of each personality, the differences between each, can hear the thoughts and feel the emotions of each one without further trauma. The dominant personality should have a sense that they are able to maintain control despite the inner conflict.
  9. Each personality perceives trauma differently. A person dissociates because the trauma is so bad that the only way they can cope is to completely detach. Many describe the incident as an out-of-body experience resulting in the birth of a new personality who is better able to handle the abuse. Thus, for each harrowing event, one or more personalities may be experiencing it at the same time. The healing process is different for each personality and may take more time than others depending on the impact.
  10. Recognize triggers for each personality. Certain environments, people, words, images, new stories, and emotions may cause a personality to appear. Some personalities manifest when anxious, others when angry or sad. Teach the client to become aware of what prompts or aggravates each personality especially if there is a personality that struggles with suicidality.
  11. Partial integration is the goal. Some therapists work toward full integration. I prefer partial. If the dominant personality is steady and healthy, then I dont want to fully integrate it with a hostile or depressed personality. Rather, the goal is to integrate the weaker personalities with the stronger ones, allowing a couple to remain. This method seems to create stability for the client better than full integration, which may splinter in the future.
  12. Integration is never forced. Dont insist on integration until it has been discussed for several sessions, each personality is willing, and there is a benefit to integrating. For the integration process, I use a guided imagery such as an English garden where the personalities are separated by a row of bushes, a house with rooms, or a farm with fences. As one personality assimilates into another, the bush, wall or fence is removed. Do only one per session to ensure that the process was successful and did not add to any trauma.

It is wonderful to witness the transformation of an unstable DID client into a healthy one whose relationships are steady, emotional functioning is stable, thinking is balanced, and work is constant. Working with these clients can be a rewarding and satisfying part of a practice.