Diagnosing and Treating Dissociative Identity Disorder

Acknowledgments
About the Author
Introduction

Chapter 1: Setting the Stage
Chapter 2: Trauma
Chapter 3: Attachment
Chapter 4: Dissociation
Chapter 5: Dissociative Identity Disorder: History and Prevalence
Chapter 6: Diagnostic Process
Chapter 7: Treatment Challenges
Chapter 8: Treatment Process, Phase 1: Stabilization
Chapter 9: Treatment Process, Phase 2: Trauma-Specific Work
Chapter 10: Launching Forth

Afterword
References
Appendix: Sample Treatment Plan
Index

Greg Nooney has worked as a therapist in the mental health field for more than 35 years. During that time, he has worked with hundreds of clients with severe trauma and dissociative symptoms, including many with dissociative identity disorder. He holds a master’s degree in social work from Loyola University in Chicago and is licensed in the state of Iowa as a licensed independent social worker. He is an adjunct instructor for the University of Iowa School of Social Work and Western Iowa Tech Community College. He has led numerous workshops and trainings over the years. He retired from a 10-year stint as the director of Burgess Mental Health in Onawa and continues to provide therapy and supervision on a part-time basis. He is available for workshops, trainings, and consultations and can be contacted through his website at www.gregnooney.com. He is married with four adult children and resides in Sioux City, Iowa.

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Diagnosing and Treating Dissociative Identity Disorder was reviewed by Nicole Marcum for the journal Social Work.

Gregory Nooney’s book Diagnosing and Treating Dissociative Identity Disorder: A Guide for Social Workers and All Frontline Staff is a huge welcome to literature on the topic of dissociative identity disorder (DID). Nooney provides an in-depth understanding of the vast complexities of DID and strongly encourages the absolute necessity to remain educated on DID, for successful outcomes with clients. Though retired, Nooney utilizes his 35 years of experience and research in the mental health field to continue providing education to the social work and other professional fields.

I have always been interested in what society historically referred to as “multiple personality disorder,” now known as DID. I have read various books and watched movies both fictional and nonfictional based on persons with DID, and I remain intrigued to the workings of the brain and how it attempts to cope with extreme trauma. As I continue to learn about DID, I have naturally asked myself whether I, along with the clinical teams I have worked with in various mental health settings, could have misdiagnosed or provided the wrong type of treatment to clients. I will be forever grateful for Nooney’s discussion of psychotropic medications being prescribed to DID clients and how a prescriptiod can be harmful to various alters within the system. Throughout the book, Nooney continues to emphasize why it is vital to stay up to date with professional development for successful client outcomes.

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This book is designed to assist those working with clients or patients who have serious dissociative disorders, whether they are new to therapeutic work or seasoned clinicians who have the skills and techniques but are leery of or uncomfortable with diagnosing and treating this population. My discipline is social work, and so many of the values and perspectives presented in this book are those of my profession. What I offer is especially applicable to social work students and social work clinicians but will just as easily speak to other mental health clinicians and substance abuse counselors. In addition, it is my hope that my extensive review of the profound effects of early trauma and attachment wounds on the development of all sorts of mental health problems will also be instructive.

Dissociative identity disorder (DID), previously known as multiple personality disorder, is often underdiagnosed because clinicians are overly cautious about asking the right questions, or they hold beliefs about the rarity of the disorder that prevent them from seeing what is there. In turn, clients who have distinct internal parts or identities will generally not reveal them to a clinician if they sense that they will not be heard, understood, or believed (International Society for the Study of Trauma and Dissociation [ISSTD], 2011; Schwarz, Corrigan, Hull, & Raju, 2017, p. 208). As a result, these individuals are often diagnosed with other disorders, such as substance use and various forms of depression and anxiety. They may well meet the criteria for these comorbid disorders, but treatment for them will generally be ineffective if the underlying dissociative condition is not recognized.

Clinicians who are already well versed in DID and want to get into the nittygritty of treatment might find it most helpful to start with chapters 7, 8, and 9 and return to the earlier chapters as desired.

TREATMENT MYTHS AND MODALITIES

Excellent resources already exist for clinicians who want to work with clients with dissociative disorders (ISSTD, 2011; Ross & Halpern, 2009; Schwarz et al., 2017; Steele et al., 2017). However, these resources do not adequately address the difficulties faced by clinical social workers who are struggling to treat some of their most difficult clients. There is often an implicit or explicit assumption that those who have multiple problems, who appear to be less than fully motivated for treatment, who are taking multiple psychotropic medications, who have frequent psychiatric hospitalizations, who show signs of psychosis, who are chronically suicidal, or who are considered difficult to treat can simply be referred elsewhere.

Most of my career has been spent working in community mental health centers, where clients on the bottom end of the socioeconomic ladder seek help with few, if any, other resources. Consequently, the clinicians who work in these facilities are the ones who will most often be working with these clients. This book provides day-to-day practical suggestions and methodologies for doing so.

Many of these clients have learned to survive through methods that are often perceived as manipulative or problematic. This book is designed to be a primer on how to work effectively with these clients, many of whom will have severe dissociation and some of whom will meet the criteria for DID. Similarly, many clients seeking treatment for chemical dependency will also fall into this category. Unfortunately, because of reimbursement rates, it is often the case that those working in community mental health centers, inpatient psychiatric units, and chemical dependency treatment centers are the youngest, least experienced, and least trained clinicians, and they are expected to work effectively with these clients, often with insufficient supervision and with high expectations for productivity. It is my hope to provide some guidance and practical assistance to these mental health and substance abuse counselors and therapists.

I begin by dispelling some myths about this disorder and encourage those on the front lines of mental health and substance abuse systems to step away from their preconceptions and fears. The goal of this book is to provide clinicians with the knowledge and understanding to empower them to make a DID diagnosis when appropriate, attune themselves more effectively with these clients, and begin the treatment process in a way that does not do more harm to them.

FRAME OF REFERENCE

To begin to work with individuals struggling with dissociation, one needs a frame of reference. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM- 5; American Psychiatric Association [APA], 2013) and the medical model cannot be ignored because they have a powerful influence on the culture of psychotherapy and psychopharmacology; however, as I explore in more detail in chapter 1, they not suitable frames of reference. Instead, I have turned to Daniel Siegel’s (2011a) concept of interpersonal neurobiology and his focus on balancing the two powerful forces of chaos and rigidity through a process of integration. This model fits well with the tendency of people who are stuck in a trauma cycle, and those with DID in particular, to swing back and forth between chaos and rigidity. When sufficient integration can be achieved, a sense of well-being, which Siegel calls “mindsight,” is achieved.

TRAUMA AND ATTACHMENT

With interpersonal neurobiology as a useful frame of reference for working with people with dissociation, in chapter 2 I explore the weighty issue of early childhood trauma in some depth. I discuss types of trauma and its history and prevalence, as well as the many negative effects that can result from trauma, both in the brain and in the life cycle. Finally, I discuss Colin Ross’s (2007) seminal trauma treatment model, which focuses on the attachment to the perpetrator, the locus-of-control shift, and the victim–rescuer–perpetrator triangle.

Understanding trauma is not sufficient in treating dissociative disorders because attachment issues also play an important part. In chapter 3, I review Mary Ainsworth’s 1970 seminal Strange Situation Study (Ainsworth & Bell, 1970) and the Adult Attachment Interview (AAI; Siegel, 2011a, p. 173) and outline the strong impact these early childhood experiences have on humans. Working with those with severe dissociation is challenging because of the profoundly negative effects of insecure attachment. The most damaging form of insecure attachment is called “disorganized attachment,” and it often sets the stage for dissociation. Fortunately, however, because of the brain’s plasticity and the effectiveness of trauma-specific treatments, an earned secure life narrative is possible. In other words, even those individuals with the most serious damage can heal.

DISSOCIATION DIAGNOSIS

In chapter 4, I take a look at dissociation, viewing it first from the DSM-5’s nonetiological point of view. Finding this viewpoint lacking, I combine my understanding of trauma with that of attachment issues to arrive at a viable hypothesis of the causes of the most severe form of dissociation, DID. The dissociative continuum illustrates this understanding. In chapter 5, I explore the history, prevalence, and etiology of DID.

In chapter 6, I discuss the diagnostic process, including false-positive and falsenegative diagnoses of DID and issues of malingering. Various instruments and techniques that can be useful in making the diagnosis are outlined. Case studies illuminate this process, and distinctions and commonalities with the diagnosis of borderline personality disorder (BPD) are discussed.

This leads into chapter 7, where I detail the challenges of working with the population with DID, including connecting sufficiently with the client to establish a therapeutic relationship; dealing with internal barriers or walls; the risk of breaking those dissociative barriers too quickly; the inaccuracy of memory; the risk of rapid switching and decompensation, including suicidal risk; the risk to the therapist of secondary traumatic stress; and issues related to rigidity and chaos.

TREATMENT PROCESS

In chapter 8, I describe the first phase of treatment, focusing on the stabilization process that allows therapists to use the training and skills they already have but with a keen awareness of the uniqueness of, and the alterations needed in, treating those with a DID diagnosis. I first review the person-in-situation, trauma and attachment wounds, chaos and rigidity, attunement, ego-state therapy, psychoeducation, and the locus-of-control shift and then move forward to an 11-step treatment process.

Step 1 involves the crucial importance of resourcing. External interventions are explored, and details are provided regarding three domains of resourcing: mindfulness, cognitive–imaginative, and somatic.

Step 2 explores effective methods of getting to know the alternate personalities, or alters. Step 3 outlines the three Cs— inner communication, cooperation, and co-consciousness (Schwarz et al., 2017, pp. 210–212)—and shows how these simple yet challenging processes undergird the entire treatment process.

Step 4 involves the nitty-gritty of staying the course of the therapy, including discussions of obstacles, policies, trust, and informed consent. Step 5 looks at important safety issues, including abuse, suicide, and sexuality. Step 6 examines ways to assist the client in building an effective support system. Step 7 discusses collaborating with others on behalf of the client.

Step 8 involves effective ways to assist clients in dealing with ongoing crises, which frequently occur as a result of the chaotic lives of many clients with DID. Step 9 discusses how to create and use a trauma list. Step 10 involves journaling, and Step 11 outlines the value of regularly scheduled internal system meetings to enhance the three Cs.

Once the client achieves sufficient stabilization, the second phase of the treatment process can begin; this phase is described in detail in chapter 9. Unlike the earlier phases of treatment, this is the one for which I believe clinicians must receive specialized training in trauma-specific therapeutic processes. Otherwise, there is an increased danger of the client becoming retraumatized.

In this trauma-specific work, content needs to be processed in a resourcerich environment. At this point, the trauma list becomes important. The client can choose to work on a specific trauma memory that has already been discussed with the therapist but was set aside for later work or on a newly retrieved trauma memory. With clients with DID, it is essential that adequate preparation be made before beginning this work. The client must already be well versed in several effective resourcing techniques. There must be internal agreement among the alters to do a particular piece of work. With adequate specialized trauma-specific training, the therapist will be able to use the additional suggestions and modalities outlined in chapter 9 to assist clients with DID in the healing process in a safe manner.

MOVING FORWARD

I have observed the similarity between the inner world of those with DID and the dream state that people experience at night. This has led me to consider the importance of numinous experiences, myths, dreams, religion, and spirituality, which I frequently encounter in working with clients with DID. In the final chapter, “Launching Forth,” I have taken the time to explore in more detail the issue of ego-state work, the similarities between those with and without a diagnosis of DID, and the importance of religion and spirituality in this work.

When I encounter a situation in which there is no easy answer, or when I step too far down the rabbit hole, I remind myself that I am primarily treating the effects of trauma and insecure attachment. I also remind myself that before meeting me, the client has found ingenious ways to survive situations that no human being should have to endure and that there is reason to hope that their resilience and creativity will survive a time when I am no longer in their lives. These thoughts help me to stay humble and reflective so that I can more easily ground myself and remember self-care practices.

I invite the reader to join me in this journey, as they will join their clients on their journeys, one step at a time.