Dissociative Identity Disorder

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The treatment of dissociative identity disorder is the subject of a voluminous literature, most of which addresses the role of hypnosis to some extent. Numerous articles by the author, summarized in Kluft (1992a,b), and a more recent text by Phillips and Frederick (1995) focus on hypnotic approaches. Dissociative identity disorder involves lesions of identity, consciousness, and memory. Ideally, treatment should help the patient achieve a subjective sense of a unified identity by integrating the personality states, and eliminate amnestic gaps by both achieving a confluent identity in the here and now and by uncovering amnesia for the past so that the patient develops a coherent and cohesive sense of personal identity and personal history. it is understood that much of what emerges in such treatments cannot be verified, but nonetheless exercises a compelling degree of control over the patient. It is not assumed that all that emerges is accurate (Kluft, 1984, 1996), but it is appreciated that the bulk of the available evidence (summarised in Kluft, 1997a) indicates that this is a genuinely traumatised population, regardless of whether the traumata uncovered in therapy are themselves historically accurate. It is well established that patients with documented trauma may not report that material, but may instead give reports of other traumata for which no verification is available (Williams, 1994).

Another approach to treatment popular in hypnosis circles is to use the ego-state model of Watkins and Watkins (1997) to bring about a more felicitous collaboration of the alternate identities. This may or may not progress to integration, and may or may not address trauma, depending on clinical circumstances. This approach is inherent in the more definitive therapies, especially in their early stages. However, many dissociative identity disorder patients are too unstable to be candidates for a definitive therapy, and can benefit considerably from this modality.

For dissociative identity disorder, the triphasic model described above is apparent in the more complex models put forth in the literature. For example, the model proposed by Kluft (1991) describes nine stages: (a) establishing the therapy, (b) preliminary interventions, (c) history gathering and mapping, (d) metabolism of the trauma, (e) moving toward integration/resolution, (f) integration/resolution, (g) learning new coping skills, (h) solidification of gains and working through, and (i) follow-up. Herman's (1992) stage of safety includes (a) through (c); remembrance and mourning is the equivalent of (d); and reconnection encompasses (e) through (i).

When a patient cannot achieve the goals of stages (a) through (c), he or she should not progress to systematic uncovering work with regard to trauma. When traumatic material breaks through, it should be contained and detoxified expedi-tiously, and therapy should return to a supportive and adaptation-oriented focus as rapidly as possible. The decision to begin the systematic exploration of traumatic material should not be made lightly. For some patients it will never be appropriate to go after traumatic material, and for some years of preparatory work may be necessary, and, if the patient becomes stable and functional with that preliminary work, it may be counterproductive to go forward, regardless. Guidelines to inform such decisions have been published (Kluft, 1997c).

The majority of hypnotherapeutic interventions will find a place in work with the polysymptomatic dissociative identity disorder population. Some which have proven useful on a regular basis are listed in Table 13.1, and several will be discussed briefly.

It is important to appreciate that most of these techniques are in the service of stabilization and making it possible to do abreactive work without risking massive regression. Modern practice is concerned with accessing alters in order to gain their collaboration and relieve the symptoms and behaviors associated with their impact, and less concerned with an aggressive search for traumatic material unless it is found in connection with exploring a dangerous or disabling symptom. Currently, most historical material is offered by the alters without the use of specific memory-

Table 13.1. Varieties of hypnotically-facilitated interventions useful with dissociative identity disorder

1

Accessing alters

12

Time sense alterations

2

Alter substitutions

13

Distancing maneuvers

3

Reconfigurations

14

Facilitating integrations

4

Ideomotor questioning

15

Temporary Mendings of alters

5

Provision of sanctuary

16

Integration rituals

6

Bypassing or attenuating intense

17

Recheck protocols

affect

18

Symptom relief and symptom

7

Slow-leak techniques

substitutions

8

Curtailing abreactions

19

Teaching autohypnosis

9

Fractionated abreactions

20

Suppressive measures

10

Facilitating abreactions

21

Trance ratification

11

Gathering historical data

22

Relapse prevention

enhancing techniques, or emerges spontaneously when previously available material is processed. However, there remain many instances in which such explorations are appropriate.

It is important to be able to access alters because the most common cause of therapeutic stalemate is the presence of additional alters not known to the therapist. It is often essential in order to map the system in the service of planning the treatment. If one can access alters, one can request that a dysfunctional alter be replaced by one able to handle the situation (alter substitution). When the patient is chaotic and many parts of the mind are imposing their feelings and ideas at once, the patient may become overwhelmed. A more salubrious arrangement of the alters (reconfiguration) combined with taking painful affect away (bypassing or attenuating intense affect) plus or minus suggesting that upset alters sleep between sessions (an example of time sense alterations) may prevent decompensation.

It is useful to use safe place imagery to create a place for alters to go when they are overwhelmed or need rest, and/or a place to put child alters so they do not interrupt the treatment or the patient's life (provision of sanctuary). For example, a patient whose days were dominated by childlike behavior was restabilized by creating an imaginary playroom in the patient's 'inner world' in which the child personalities could play. Slow-leak techniques (Kluft, 1988a) suggest that traumata or painful affects come into awareness at a pace that the patient can tolerate. Fractionated abreaction techniques, discussed above, are exceptionally useful for the dissociative identity population, for which they were developed (Kluft, in press).

Bringing alters to be able to talk to one another, and to spend time in coconsciousness or even in joint control of the body (copresence), allows them opportunities to break dissociative barriers and become less strange and ego-alien to one another (facilitating integration). This makes the process of integration less threatening, and is a major component of Fine's (1991) cognitive approach. They can be allowed to blend temporarily to share skill and assets to address particular problems (Fine, 1991). When alters have done their work and dealt with their issues, they may integrate with hypnotic suggestion if they have not done so spontaneously (integration rituals). Suggestions of merger and joining with imagery appropriate to the particular patient are often effective, and follow-up of hypnotically-facilitated integrations demonstrates good stability (Kluft, 1986a).

Often it is useful to touch bases with the alters not involved in day to day treatment in order to anticipate and preempt crises and to see whether alters represented as integrated have in fact become separate again (recheck protocols). Using ideomotor signals, a large number of alters can be asked if they have issues that need to be addressed in a very brief period of time. Cooperative patients can use autohypnotic techniques effectively, but some patients may subvert what they learn in the interests of resistance (Kluft, 1982). One use of autohypnosis is relapse prevention. Integrating patients can be taught techniques to stabilize themselves when intercurrent crises prove a threat to their hard-won integrations (Kluft, 1988b). Suppressive techniques were recommended by Allison (1974) in early papers. They are now a historical footnote, but retain relevance because they are often spontaneously used by patients to contain or confine alters that are deemed disruptive, and must be understood. Often complex negotiations with many alters prove necessary to deal with such internal 'solutions,' which may encourage ongoing hostility among the alters, with disastrous consequences in terms of self-harm or suicide attempts, often magically misunderstood by the alters as the attack of one separate individual upon another.

It is difficult to discuss the usefulness of hypnosis in the treatment of dissociative identity disorder patients simply in terms of the hypnotically-facilitated interventions that are undertaken. An awareness of hypnotic phenomena and a sensitivity to the fact that every interaction with such patients occurs in an ambience of hypnotic phenomena is a tremendous asset for the therapist to bring to his or her work with this patient population.

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Hypnosis Plain and Simple

Hypnosis Plain and Simple

These techniques will work for stage hypnosis or hypnotherapy, however, they are taught here for information purposes only. After reading this book you will have the knowledge and ability necessary to hypnotise people, but please do not practice hypnosis without first undergoing more intensive study.

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Responses

  • fatima clark
    Can Dissociative Identity Disorder be hypnotically induced?
    8 years ago
  • Ida
    How to stabilize dissociative disorder in early stages of therapy?
    7 years ago

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