Claudine, a 34-year-old community college student, responded to the advertisement while seeking for the help with her severe panic attacks. She also reported insecure feelings and having troubles in her relationships with her boyfriend Rick. Additionally, she complained of the nightmares and strange “blackouts”, when she could not remember what was happening or what she was doing. The woman mentioned an increase in her anxiety over last few months when her mother started drinking. Being upset all the time, Claudine had difficulties in concentrating on her studies. She had low-paid job as a waitress and did not expect anything good from the future. Rick did not understand her problems and seemed to be an alcoholic.
At the session, Claudine revealed her long story of emotional and physical abuse by her classmates and school bullies. At the age of ten, she was attacked and sexually abused by a senior student. Her mother did not support her telling it was all her own guilt. Lately, Claudine was diagnosed with dissociative identity disorder (DID) and posttraumatic stress disorder (PTSD).
The first steps suggested by the therapist were reducing the level of severity and frequency of her panic attacks. Therefore, practically, she was learning stress-reducing techniques and distress management practices. Other activities of the course included functional behavioral treatment in order to identify the triggers of the panic attacks episodes.
Attending group therapy, she learned more distress modulating strategies. All those techniques brought her the sense of being able to control her life better. Still, Claudine had some drawbacks. Her condition became worse from time to time, especially when she had quarrels with her boyfriend. He abused her orally and sometimes hit her. Such dysfunctional relationship created her alternative identity — a cruel teenager Claire who drunk and fought with her boyfriend.
During the therapy, Claudine mentioned that she was afraid of Claire as the latter may commit the crime or kill somebody. From time to time, Claudine stopped seeing the positive outcome of the situation and was considering a suicide. Moreover, Claudine had occasionally difficulties while expressing her feelings, as she often lacked words to describe them. Next, she did not want to feel hurt thinking of the past at times.
The therapist suggested Claudine to invite Claire to tell more in terms of talking about the traumatic fact. The point was to allow Claire to come only to the therapist’s office in order to control the switches. Claudine started feeling safer as she sensed protected meeting Claire only in the office with a therapist nearby. As a result, the non-switching periods became longer. Claudine started developing some self-esteem. Meanwhile, wasting fewer efforts on inner conflict, Claudine could concentrate on her studies more, which contributed to her sense of dignity.
Afterwards, Claudine realized that she is not happy with Rick, and his behavior enhances her mental issues. Thus she broke up with him, which triggered several dissociation episodes. Claudine heard Claire commanding to teach Rick a lesson. There was a fight as Rick was leaving. Having switched back, Claudine felt dreadful because she hated the cruel side of herself.
The therapist discussed the necessity of keeping the treatment and giving herself another chance. Claudine agreed not to do any harm either to herself or to Claire. She also decided to give another chance to group therapy which she was not enthusiastic about. What happened to Claudine is a good illustration that the flow of DID is not smooth at all. During rather long treatment period, a patient may experience both ups and downs, which make the process of recovering from DID one of the most complicated issues.
All the mentioned information enables one to conclude that Claudine suffers from the dissociative identity disorder as her condition corresponds to the defined by DSM-V diagnostic criteria:
- Two or more distinct identities are present — in the considered case, they are Claudine and her alter ego Claire. Claudine herself reported the presence of Claire. She mentioned hearing Claire talking to her.
- Cases of amnesia —Claudine did not remember several times herself doing specific actions or having certain conversations with other people.
- The disorder has a bad influence on some of the person’s major areas of life — Claudine had troubles in concentrating on her studies due to her panic attacks.
- The disturbance is not a part of normal cultural or religious practices — Claudine is not religious and does not consider Claire as “a spirit” or similar personality. Claudine considers Claire more like a shady version of herself.
- The above-mentioned symptoms cannot be related to any experiences of substances being taken. Claudine experienced all her symptoms while she was free from any substance influence.
In conclusion, diagnosing people with dissociative identity disorder presents a certain problem. Therefore, a therapist must verify the diagnosis excluding other similar conditions. The Diagnostic and Statistical Manual of Mental Disorders specify five major symptoms analyzed above; but there are some others such as depression, headache, etc. Being rather acute nowadays, the problem of dissociative identity disorder still needs to be researched deeper.
Dissociative identity disorder is a serious problem that significantly affects a person’s life. The International Society for the Study of Dissociation defines dissociation as “an ongoing process in which certain information (such as feelings, memories, and physical sensations) is kept apart from other information with which it would normally be logically associated”. It is also mentioned that “dissociation can be a psychological defense mechanism that also has psychobiological components”. There is a certain disagreement in shaping the exact definition of DID; but according to DSM-V, the key factor here is the presence of one or more alternative identities that are expressed differently in a person’s behavior.
As DID is a complex trauma disorder, it is reasonable to apply the phase-based approach. It is noteworthy that diagnosing somebody with DID is a complicated process since many other psychiatric problems have similar symptoms. According to the ISSD, the main goal of the treatment is personality integration. Once being diagnosed, the treatment includes the following phases: stabilization, trauma processing, and integration. These three phases are mutually related, and it is possible to sometimes have them in linear order. As the phase of stabilization is vital for curing the illness, some therapists make it recurrent to assure the host is safe from the harm caused by the alter egos. To diagnose DID, a therapist may conduct several oral interviews and apply some screening tools (e.g. dissociative experience scale, dissociation questionnaire, questionnaire of experiences of dissociation) and structured interviews (e.g. structured clinical interview for DSM-V and dissociative disorder interview schedule). These tools have been developed to evaluate and document the presence and severity of the specific dissociative symptoms and disorders. Sometimes, the cases of DID can be revealed during the hypnotherapeutic treatment session. However, it is wise to verify any of such a diagnosis by other identifying methods in order to exclude the possibility of the dissociative pathology mimicking.
In general, the treatment of DID is long-term, multi-modal, and eclectic in terms of causing multiple difficulties. The first phase is stabilization and safety. This sphere of work is vital as the alternative identities (“alters”) may endanger the life of initial identity (“the host”), who is afraid of being “killed” during the therapy. Safety issues may be addressed through cognitive behavioral therapy or dialectical behavior therapy to help the patient deal with the cognitive distortions and stabilize dysregulation that frequently provoke unsafe behaviors.
In the case of Claudine, I would suggest trying cognitive therapy techniques as the way for her to realize and correct the dysfunctional system of views. In order to do it, I would ask Claudine to spend 15 minutes a day putting down her thoughts and feelings she experienced and to send these reports to me. During the sessions, I would discuss the reported situations to help her understand what way of thinking causes her feeling bad and how to overcome it. Furthermore, I would do my best to make an agreement both with her and with Claire that neither she nor Claire are going to hurt or kill themselves. In order to make sure that both Claudine and Claire are stabilized, I would try to help the former to see the positive side of Claire’s presence as it helped her to survive and not to feel so lonely.
The next phase is the stage of working with traumatic experiences. The main goal is to gain the sense of control over the experience and the reaction to it. During this period, it is possible to work with the host and the “alters” while considering them as different parts of the same person.
As for Claudine, I would divide the stage into two parts. The first one is working with abreactions and processing painful memories. During the sessions, I would role play and analyze the dialogues with Claire to help Claudine get the same knowledge and lessen the separateness. The second one consists in applying fusion rituals when it is clear that Claudine is clinically ready for them. The problem of safety becomes acute again. To reduce the tense, I would suggest Claudine working with her dreams (e.g. “draw your bad dream” activity) and keeping applying stress-reducing techniques (e.g. diaphragmatic breathing). In case she or “the Claire part of her” feels awful, there would be a possibility to call me between the sessions any time she needs it.
Lastly, the stage of integration comes. Though the first steps to the internal integration have been taken at the previous stage, this level is vital as it provides further practice on “synthesis” and self-acceptance. At this moment, the person should continue the fusion processes, and therapy flow becomes smoother. The patient, as more unified person, may want to have a fresh look at the trauma to reprocess it and start living at present but not in the past. While continue working on self-integrity, the person may need help with learning how to live in a non-dissociative manner.
Claudine may need to work more on developing self-empathy. To develop this quality, I would suggest the techniques aimed at increasing self-acceptance (e.g. “the criticizer, the criticized, and the compassionate observer” activities). I would also suggest Claudine doing some voluntary work (e.g. in the animal shelter).
In conclusion, DID is a complicated mental disorder which is characterized by the presence of one or more alternative identities. The therapy is usually long-term and rather eclectic. The main goals of the therapy are developing better integrated functioning and overcoming the trauma effects. The phase-based approach is often used for the DID treatment. The stages here are the stabilization, the work with the traumatic experience, and the integration. The most difficult are the first two phases. To sum up, the successful rehabilitation of a patient is possible on conditions that close cooperation of the person and the specialist is realized.