Dissociative Identity Disorder (DID), which used to be called Multiple Personality Disorder (MPD), like so many other topics in therapy is hot one day and almost non-existent another. Our profession, like so many others, is subject to trends and hot topics. When I studied to be a therapist over thirty years ago, MPD was a hot topic. It was quite controversial. There were many conferences held where it was taught and discussed. There were new books coming out monthly by specialists who researched and wrote about their treatment of it, there were hospitals with entire wings dedicated to the Dissociative Disorders.
When I left teaching at Webster University just over a year ago, to the best of my knowledge, if it was mentioned, it was incidental and accidental. The young therapists we were training were not being taught about it. Other newer, hot topics have grabbed our attention. The hot new topic seems to be Trauma and its impact. Trauma occurs in response to a natural disaster such as Hurricane Katrina, the tornado in Joplin, or the earthquake in Haiti. Also, some have experienced trauma as a result of war, it can impact soldiers or their families. Members of our society have been in combat for over a decade, experiencing death, dismemberment and dislocation. We have a natural interest in trying to figure out how to handle the traumatization of these soldiers and their families and communities. Therapists want to know which interventions work and how they can streamline responses to traumatic events like 9/11 to make them effective. Where can we obtain the knowledge and expertise to actually be helpful? What works? These are important questions and they need the answers now and in the future. There is much being written currently about the ongoing cost to America of the medical and psychological damage being experienced by soldiers and their families over the last decade. When they come home, even if they were not physically wounded, there are likely to be after shocks and damage from the emotional stress they experienced. What about the emotional stress of their wives and children? Whose responsibility is it to help? How will that help be administered and by whom? And most importantly, what works best with this type of client, and why?
Trauma and DID are interconnected. There are things we know about how people survive traumatic stress and horror, one of them is what is called the dissociative process. When people are in situations where they cannot physically escape from horror, when they can’t run away and hide or the situation is totally out of their control, they learn to run away “inside.” The ability to run away inside is a highly sophisticated adaptive coping and survival strategy. It is unconscious and almost anyone can do it. Running away inside can happen on a range, or continuum. It can be the simple defense mechanism of repression in which our stress is just suppressed and squelched by our will. An example is someone afraid of needles and has to get a bone marrow test. They could be put to sleep so that they would not be aware, but medical professionals warn about the potential damage of anesthesia and that we should avoid it if the situation is not critical. Consequently, the needle fearing patient must “muscle up and take it!” The patient can learn skills like anticipatory set and breath control, they can try to distract themselves by watching something on the TV at the doctors office, having a conversation with their wife, or reciting the times seven tables in their heads. They refocus their awareness onto some other channel so that the pain and fear of the needle is minimized in their awareness.
An example of the extreme end of the continuum would be someone in a combat situation. They are in a foxhole surrounded by enemies, they don’t know if they will survive the night. There are bullets and grenades coming their way and they lose themselves in the “fog of combat” until the immediate danger has passed. When it is over, then they often fall apart. Or they may have nightmares, traumatic memories or triggers which make them “go away” again.
A friend of mine discussed one of her clients with me, a Bosnian refugee who was a prisoner of war. The Serbs made him drive a truck across areas they thought were mined. His job was to be the so-called canary in the coal mine. If he got blown up then they would know where the mines were. Every day for months he had to drive the truck, with the constant expectation that he would be maimed or killed. He survived and immigrated to the United States. He now has a job in America, and you guessed it, he drives a truck every day! He wonders why he can’t sleep, has anxiety, and panic attacks. He struggles with depression and a sense of helplessness. But he can’t quit his job because he needs the money to support his family and he has no other transportable skill.
For most of us, these situations and our experiencing of them are situational. They happen, we survive, and then they are over, even though they may leave behind psychological residue and damage. However, some people live in environments where trauma is a daily experience. They can’t just endure it for a day or two, or a week or two, have it be over and have it be just a bad memory. They live it day in and day out for years. Their adaptive defenses must be more organized, sophisticated, and effective than the mere suppression, or refocusing skills. These defenses need to be systemic patterns which are endurable and highly organized. We call this DID, dissociative identity disorder. These people learn how to mentally split themselves into vertical compartments. We say vertical compartments because each compartment (or identity) has a history of its own. Their awareness of this history is usually relegated to a channel for this identity, though there are usually some super channels which crossover and are aware of several other channels, including their histories, memories, and issues. A horizontal compartment would be something that causes a memory break which looks like a complete break with the past. Amnesia would be a horizontal memory break. This might present as “I don’t know my name or where I live or what has happened in the past, I just know my memories started last week when I woke up on a park bench in New York City.”
In this writing, I want to discuss the vertical channel. These are complex identities, with preferences, skills, memories, and relationships of their own, which may be kept secret from the other channels. Some signal tells these channels when they need to “go away” because they won’t be able to handle the stress of a given situation. So they just leave the conscious awareness. The body of the individual remains and a different channel becomes active. The different channel will be a new “person” who will be capable of dealing with the situation. Sometimes these channels are different ages, sometimes different sexes, and they all have different adaptive survival skills.
Helping these people therapeutically is one of the most challenging jobs in our profession. The therapist has to first accept the reality of what they are encountering. Then they have to remain calm (easier said than done) and have a respectful approach to embracing the reality of the client. Then they need to help them figure out how to survive with this incredibly complex set of survival skills. Questions to be discussed may include: How can I help you be “normal” and be in charge of your life if you think you are ten or twenty different people? What do these people have in common besides the use of your body and your legal identity? At the end of the day, what do you want? How do you want to live? How can we stop the traumatized past from dictating the rest of your life? How can you have relationships that work for you?
These are very real questions. I have worked with clients who suffered from these conditions and the work is very demanding. New therapists need to be taught about these disorders, and taught what is known about how to manage them in order to be helpful. These people are not sideshow freaks. They are real, hurting, damaged individuals who have suffered incredible trauma and survived. Let us honor their survival and their story. Let us learn how to work with them as professionals. I suspect that in the next decade, many therapists will find these individuals in their waiting rooms since the last decade has been so traumatic for so many people.