Guidelines for Treatment

Guidelines for Treating Dissociative Identity Disorder
(Multiple Personality Disorder) in Adults (1997)

Copyright © 1994, 1997, by the International Society for the Study of Dissociation. These guidelines may be reproduced without the written permission of the International Society for the Study of Dissociation (ISSD) as long as this copyright notice is included and the address of the ISSD is included with the copy. Violations are subject to prosecution under federal copyright laws. Additional copies of the guidelines (US $5 for members, $10 for nonmembers) can be obtained by writing to the ISSD at 60 Revere Dr., Suite 500, Northbrook, IL 60062 USA.

Members of the committee were Peter Barach, PhD (chair), Elizabeth Bowman, MD, Catherine Fine, PhD, George Ganaway, MD, Jean Goodwin, MD, Sally Hill, PhD, Richard Kluft, MD, Richard Loewenstein, MD, Rosalinda O’Neill, MA, Jean Olson, MSN, Joanne Parks, MD, Gary Peterson, MD, and Moshe Torem, MD.

Members of the 1996 Executive Council were Elizabeth Bowman, MD, James Chu, MD, Colin Ross, MD, Nancy Perry, PhD, Jean Goodwin, MD, Marlene Steinberg, MD, John Curtis, MD, Peter Barach, PhD, Susan Oke, Bsc OT (C), and Esther Giller, MA.

 

Introduction

By Peter M. Barach, Ph.D.
Former Chair, Standards of Practice Committee

At its meeting in Vancouver, BC, Canada, in May 1994, the Executive Council of ISSD adopted "Guidelines for Treating Dissociative Identity Disorder (Multiple Personality Disorder) in Adults (1994)." The guidelines present a broad outline of what has thus far seemed to be effective treatment for dissociative identity disorder. The guidelines are not intended to replace the therapist’s clinical judgment, but they do aim to summarize what most commonly has been found to benefit dissociative identity disorder patients. Where a clear divergence of opinion exists in the field, the guidelines attempt to present both sides of the issue.

Guidelines like these are never finished. This revision is the first since the adoption of the guidelines in 1994. The Executive Council is aware of several areas that the present guidelines overlook, such as partial hospitalization/day treatment programs and the treatment of children with dissociative identity disorder. In addition to adding new domains, future revisions of the guidelines will take account of new knowledge arising in the dissociative disorders field.

The guidelines were written by the members of the ISSD Standards of Practice Committee, a diverse and opinionated group who nevertheless found much common ground. Following seven revisions in three years, the committee invited input from ISSD members by publishing a draft in the October 1993 ISSMP&D News. I received about 100 letters from members of the society. Most of the respondents liked the document but wanted minor changes. I summarized their comments and passed on another draft to the committee members. The committee’s feedback was incorporated into a final draft that received minor changes from the Executive Council. The Executive Council updated the guidelines in 1996.

I would like to thank the members of the committee for their contributions. Writing this document was a time-consuming and exacting job requiring thought, creativity, and tact from all contributors. I would also like to thank members of ISSD who sent comments after reading the draft published in ISSMP&D News. I hope that ISSD members will continue to provide suggestions and comments to the Executive Council to aid in the next revision of the guidelines.

Given the complexity of dissociative disorders, patients have been frequently misdiagnosed for a period up to 20 or more years. However, considerable progress has been made in the diagnosis, assessment, and treatment of dissociative disorders during the past decade, as reflected by increased clinical recognition of dissociative disorders, the publication of numerous scholarly works focusing on the subject, and the development of specialized diagnostic instruments. As there are at present no controlled outcome studies of different treatment regimens, future research, depending upon the use of new specialized clinical and research tools, will further add to our present understanding of the efficacy of the various therapies for the dissociative disorders.

The guidelines attempt to summarize the numerous publications on the dissociative disorders, including case reports, open clinical trials, and investigations utilizing standardized tools. The guidelines reflect current scientific knowledge and clinical experience specific to diagnosing and treating dissociative identity disorder (DID), supplementing generally accepted principles of psychotherapy and psychopharmacology.

Given the fact that ongoing research on the diagnosis and treatment of dissociative disorders will undoubtedly lead to further developments in the field, therapists are advised to consult relevant published literature subsequent to the publication of these guidelines. It should be noted that the guidelines are not intended to dictate the treatment of specific patients, as treatment should always be individualized. Therapists should always conform to the local mental health code and related laws, as well as to ethical principles of their professional disciplines.

 

I. Diagnostic Procedures

Accurate clinical diagnosis of the dissociative disorders allows for early and more appropriate treatment and may be supplemented by standardized tests. Such tests, while not designed to replace the clinician’s judgment, may provide additional information critical to both diagnosis and/or adequate treatment planning. A mental status examination augmented with questions concerning dissociative symptoms is an essential part of the diagnostic process. Specifically, the patient should be asked about episodes of amnesia, fugue, depersonalization, derealization, identity confusion, and identity alteration (Steinberg, 1995) as well as age regressions, autohypnotic experiences, and hearing voices (usually internal) (Putnam, 1991).

Screening tools such as the Dissociative Experience Scale, Dissociation Questionnaire, Questionnaire of Experiences of Dissociation and informal office interviews are available to identify patients who are at risk for a dissociative disorder (Bernstein & Putnam, 1986; Loewenstein, 1991; Riley, 1988; Vanderlinden, Van Dyck, Vandereycken, Vertommen, & Verkes, 1993). While some investigations also indicate that psychological testing, such as the Rorschach, may help to improve understanding of the patient’s personality structure (Armstrong, 1991), other investigators note that the use of tools such as the MMPI and WAIS-R contribute to misdiagnosis of dissociative disorders (Bliss, 1984; Coons & Sterne, 1986). As screening tools and psychological tests are not able to diagnose the dissociative disorders, identified patients should then be evaluated further to rule out a dissociative disorder utilizing more comprehensive methods.

Structured interviews for the detection of dissociative disorders are now available and can be used to confirm a clinician’s diagnosis or to identify a previously undetected case. Such tools include the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg 1994a, 1994b), which allows clinician to systematically evaluate and document the severity of specific dissociative symptoms and disorders, and the Dissociative Disorder Interview Schedule (Ross, 1989), a highly structured interview developed to diagnose dissociative and other psychiatric disorders. Investigations using a diagnostic interview demonstrate that the diagnosis of dissociative identity disorder can now be made as reliably as any other psychiatric diagnosis for which a structured interview exists.

The existence of dissociative identity disorder might also be unexpectedly revealed during hypnotherapeutic treatment of another condition. Patients with dissociative identity disorder who are diagnosed by using hypnosis do not differ with respect to diagnostic criteria and symptoms from dissociative identity disorder patients diagnosed without hypnosis (Ross & Norton, 1989). When alternative diagnostic measures have failed to yield a definite conclusion and diagnosis is necessary or in situations of urgency when the establishment of a diagnosis is a matter of medical necessity, hypnosis or amytal interviews may be helpful. However, it should be noted that amytal and hypnosis, which alter the patient’s state of consciousness, may yield symptoms that mimic dissociative pathology in patients who do not have DID. Such procedures should avoid leading and suggestive questions and should be used by trained practitioners.

 

II. Comprehensive Treatment Planning

Depending on individual circumstances, treatment teams may include a variety of professional disciplines. Goals are symptom stabilization, control of dysfunctional behavior, restoration of functioning, and improvement of relationships. These goals must be addressed in an ongoing way, both through direct approaches and through psychotherapeutic work that leads to increased coordination and integration of mental functioning. Close coordination with other medical specialists may be required when there are;

(1) physical sequelae of child abuse or other violence, 

(2) prominent somatic expression of traumatic material (i.e., functional or sensory changes that correlate with the patient’s reported abuse history) or other psychophysiological symptoms, 

(3) fears about medical care or similar symptoms. 

When comorbidity is a problem, the associated diagnoses may require specific treatments. Frequent diagnoses in this category include addictions, eating disorders, sexual disorders, mood disorders, and anxiety. Treatment plans may also include psychoeducational interventions, especially when illness has intruded on normal development. Such interventions may include retraining, education, bibliotherapy, expressive therapies, and other treatments. Patients may have multiple legal involvements, which also may require supportive intervention. In patients who have legal involvement, it is wise to try to avoid planned therapeutic interventions that may compromise the credibility of the patients in forensic proceedings at a later point in time.

 

III. An Outline of Psychotherapy for DID

 

A. Integration as an overall treatment goal

The dissociative identity disorder patient is a single person who experiences himself/herself as having separate parts of the mind that function with some autonomy. The patient is not a collection of separate people sharing the same body. The terms personality and alter (short for alternate personality) refer to dissociated parts of the mind that alternately influence behavior in dissociative identity disorder patients. Some clinicians prefer terms such as disaggregate self state, part of the mind, or part of the self.

Wherever possible, treatment should move the patient toward a sense of integrated functioning. Although the therapist often addresses the parts of the mind as if they were separate, the therapeutic work needs to bring about an increased sense of connectedness or relatedness among the different alternate personalities. Thus, it is counterproductive to urge the patient to create additional alternate personalities, to urge alternate personalities to adopt names when they have none, or to urge that alternate personalities function in a more elaborated and autonomous way than they already are functioning in the patient. It is counterproductive to tell patients to ignore or get rid of alternate personalities. Also, the therapist should not play favorites among the alternate personalities or exclude unlikable or disruptive personalities from the therapy, although such steps may be necessary for a period of time at some stages in the treatment of some patients.

Additionally, the dissociative identity disorder patient is a whole person, with alternate personalities of adult patients sharing responsibility for his or her life as it is now. In the psychotherapeutic setting, therapists working with dissociative identity disorder patients generally ought to hold the whole person to be responsible for the behavior of all of the alternate personalities.

 

B. Framework for Outpatient Treatment

The optimal primary treatment modality for dissociative identity disorder is usually individual outpatient psychotherapy. Although the patient’s feelings and preferences need to be explored while devising and implementing a treatment plan, the therapist, not the patient, ought to be the primary architect of the treatment plan. The minimum number of sessions provided per week should reflect the patient’s functional status and stability. The minimum recommended frequency of sessions for the average dissociative identity disorder patient with a therapist of average skill and experience is twice a week. Some therapies, especially with patients of high motivation and strength, can be conducted on a once-a-week basis either with a single prolonged session or with a single session. Some therapists of considerable skill and experience are able to treat many such patients in once-a-week psychotherapy. With some patients, a greater frequency of scheduled sessions (up to three per week) aids the patient in maintaining the highest possible level of adaptive behavior and (as an alternative to hospitalization) in containing disruptive behavior. For patients newly discharged from inpatient treatment, a period of sessions at a greater frequency may sometimes be necessary to help the patient make the adjustment from the high frequency of sessions provided in many inpatient programs. If more than three sessions per week are routinely provided, the therapist should note the risk of fostering regressive dependence on the therapist.

Marathon, or lengthy sessions (i.e., sessions longer than 90 minutes), if used, should be scheduled, structured, and have a specific focus such as completion of amytal- or hypnosis-assisted processing of traumatic memories and imagery, or administration of a diagnostic battery. Lengthy sessions may also be used judiciously for the provision of structure and support in dealing with difficult material. They may also be indicated when logistics force the patient to come to the therapist infrequently, but to work intensely when there.

Opinions diverge on the length of treatment. Early anecdotal reports on treatment outcome showed that over 2-3 years of intensive outpatient psychotherapy, patients could reach a relatively stable condition in which they did not experience a sense of internal separateness. However, most therapists now see 3-5 years following the diagnosis of dissociative identity disorder as a minimum length of treatment, with many of the more complex patients requiring 6 or more years of outpatient psychotherapy, often with brief inpatient stays during crises. The length of treatment varies with the complexity of the patient’s dissociative pathology, usually lengthening with severe Axis II pathology or other significant comorbid mental disorders.

The most commonly cited treatment orientation is psychodynamically aware psychotherapy, often eclectically incorporating other techniques (Putnam & Loewenstein, 1993). For example, cognitive therapy techniques can be modified to help patients explore and alter dysfunctional trauma-based belief systems; however, standard cognitive therapy protocols for depression and anxiety usually require modification when used in the treatment of dissociative identity disorder. Most therapists employ hypnosis as a modality in the treatment of dissociative identity disorder (Putnam & Loewenstein, 1993). The most common uses of hypnosis are for calming, soothing, containment, and ego strengthening.

Behavioral analysis, or operant conditioning, has not been shown to be an optimal primary modality for treating dissociative identity disorder. Aversive conditioning is particularly not recommended because the therapeutic relationship and treatment procedures may unconsciously resemble abusive experiences. However, behavior modification techniques may be useful when taught to the patient as self-control techniques for symptom management.

 

C. Inpatient Treatment

There is general agreement that inpatient treatment for dissociative identity disorder should be used for the achievement of specific therapeutic goals and objectives. Treatment should occur in the context of a goal-oriented strategy designed to restore patients to a stable level of function so that they can resume outpatient treatment expeditiously. This remains the case, whether the hospitalization is emergent or planned, on a specialized or a general psychiatric unit. Efforts should be made to identify what factors have destabilized or threaten to destabilize the dissociative identity disorder patient and to determine what must be done to alleviate them, if possible, and to minimize their impact. Emphasis should be placed on building strengths and skills to cope with the destabilizing factors. Optimally, these interventions should be planned and contracted for prior to or very early during an admission, but it is acknowledged that this may not be possible. Planned judicious processing of traumatic material (sometimes called abreactive work), confronting traumatic material in the supportive structure of a hospital setting, and working with aggressive and self-destructive alters and their behaviors are frequent concerns.

There is a general agreement that decompensation or failure to improve during a hospitalization may occur in several circumstances. There is consensus that dissociative identity disorder patients often require hospital care for other intercurrent mental disorders, such as major depression or anorexia nervosa. There is consensus that a small minority of dissociative identity disorder patients, including massively decompensated and dysfunctional individuals, and those destabilized by severe present-day trauma, may require prolonged inpatient treatment in order to be restabilized. Treatment-related factors that may impede clinical improvement include unfocused inpatient treatment or inpatient treatment with global and unrealistic goals, such as “getting out all of the memories,” an exclusive focus on past traumatic material to the exclusion of contemporary issues, or pushing for rapid integration early in treatment.

There is a divergence of opinion as to whether brief stays are less likely to be associated with regressive dependency than longer stays. Some find instances in which they suspect that longer hospital stays are conducive to regression. Others find instances in which it appears that a pressure to keep hospital stays short leads to discharge of the patient in an insufficiently stable state and at greater risk for readmission or undue suffering. Regardless of the length of the patient’s hospitalization, the therapist should maintain a stance that encourages progression and independence.

There is agreement that dissociative identity disorder patients optimally should be treated in a manner that prepares them to do the work of therapy on an outpatient basis, including processing traumatic material when necessary. There is also agreement that for some overwhelmed patients and for a variety of patients under some circumstances, the structure and safety of a hospital setting make possible therapeutic work that would be impossible or prohibitively destabilizing in an outpatient setting.

 

D. Group Therapy

Group psychotherapy is not a viable primary treatment modality for dissociative identity disorder. However, some believe that time-limited groups are a valuable adjunct to individual psychotherapy in promoting a sense in patients that they are not alone in coping with dissociative symptoms and traumatic memories. Carefully structured groups with a high leader-to-patient ratio, a clear focus, and clear time frames seem indicated. Some have found that open-ended therapy groups promote acting out among the group members and do not have a positive outcome; others report that such groups have been a helpful adjunct to individual psychotherapy, particularly where the leader describes clear expectations in areas such as extra-group contact among members and therapeutic boundaries (see Appendix 1). Some patients utilize 12-step groups effectively as an adjunct to their individual psychotherapy. Marathon groups (i.e., longer than 2 or 2_ hours) may prove destabilizing for some dissociative identity disorder patients.

 

E. Electroconvulsive Therapy

ECT has not been shown to be an effective or appropriate treatment for dissociative disorders, but it may be important in relieving an associated refractory depression.

 

F. Psychosurgery

There is no evidence to support the use of psychosurgery in the treatment of dissociative identity disorder.

 

G. Pharmacotherapy

Psychotropic medication is not a primary treatment for dissociative disorders, and specific recommendations for pharmacotherapy of dissociative disorders await systematic research. However, anecdotal reports support the use of various medications for purposes such as treating some anxiety-related dissociative symptoms, posttraumatic stress disorder symptoms, and coexisting affective symptoms or disorders. Most therapists treating dissociative identity disorder report that their patients have received medication as one element of their treatment (Putnam & Loewenstein, 1993). Therapists prescribing medication need to make patients aware when any medication protocol is experimental in nature, following applicable ethical and legal guidelines. Doctors who prescribe medication and therapists who treat patients on medication need to be aware that personality states within the same patient may report different responses and side effects to the same medication.

 

H. Therapist telephone availability

Because many dissociative identity disorder patients are prone to crises at certain points in treatment, patients need a clear statement about the therapist’s availability in emergencies. Generally, offering regular, unlimited telephone contact is not helpful, but providing for limited availability to the patient on a predefined basis is essential. Except under unusual circumstances, regular calls initiated by the therapist to check in with the patient are not recommended. The payment policy for telephone contact should be discussed with the patient in advance wherever possible.

 

I. Scheduling extra sessions

Although extra sessions are sometimes needed, when the patient frequently requests or requires the scheduling of extra sessions because of crises, the therapist needs to examine whether the patient perceives the scheduled frequency of sessions to be adequate for his or her needs. As in any requested gratification of a patient’s need, the therapist needs to examine such requests in the light of the patient’s unconscious wishes for reparenting or for other emotional gratification from the therapist. Repeated crises may also reflect the patient’s inability at that time to function outside a structured full or partial hospital setting.

 

J. Physical contact

Physical contact with a patient is not recommended as a treatment technique. Therapists generally need to explore the meanings of patient requests for hugs or hand-holding, for example, rather than fulfilling these requests without careful thought and consideration. Simulated breast-feeding or bottle feeding are unduly regressive techniques that have no role in the psychotherapy of dissociative identity disorder. Some therapists find that for some patients undergoing planned abreactions, holding the patient’s hand or resting a hand on the patient’s arm may help the patient stay connected to present-day reality. However, other therapists feel that patients may misinterpret such contact and that it should be avoided. Some patients may seek out massage therapy or other types of body work; the risks and timing of such work should be carefully discussed with the patient and the adjunctive therapist.

Sexual contact with a current patient is never appropriate or ethical. Laws and ethical standards of the various healthcare disciplines regulate such contact with a past patient. Because dissociative identity disorder patients have a relatively high vulnerability to exploitation and because of the intensity of the therapeutic interactions that dissociative identity disorder patients have with their therapists, any sexual contact a therapist might have with his or her former dissociative identity disorder patient would be likely to be exploitive and therefore inappropriate.

 

K. Physical restraint

There is a divergence of opinion on the value of voluntary physical restraint in treatment. Some believe that the technique is a helpful last resort when physically aggressive or self-destructive alternate personalities are otherwise unable to participate in therapy. Others believe that voluntary physical restraint is inappropriate and that verbal techniques will suffice to involve all the personalities in therapy. If physical restraint is being used with great frequency and/or for prolonged periods, the therapist should reassess the pace of the therapy and the dynamics of the patient-therapist relationship.

In inpatient treatment, seclusion and physical restraint may be indicated for the dissociative identity disorder patient who is acting out violently and has not responded to verbal or pharmacological interventions. These treatment modalities should always be applied in accordance with the legal and ethical standards applicable to the inpatient unit and the professional disciplines involved in implementing them.

 

L. Hypnotherapy

dissociative identity disorder experts generally agree that hypnotic techniques can be useful in crisis management to help patients terminate spontaneous flashbacks and reorient themselves to external reality when these states occur outside therapy. Hypnotic techniques are also useful for ego strengthening and for supporting dissociative identity disorder patients during crises, and to help patients remain stable between sessions in which they are recalling or discussing traumatic material. Other commonly described uses of hypnosis include its roles as an aid in the safe expression of feelings (e.g., the “silent abreaction” for the release of anger), cognitive rehearsal and skill building, relief of painful somatic representations of traumatic material, and fusion rituals (when previous psychotherapeutic work has caused a particular separateness to no longer serve a meaningful function for the patient’s intrapsychic and environmental adaptation and when the patient is no longer narcissistically invested in maintaining the particular separateness). In the hospital, staff can be trained to calm the patient exhibiting violent behavior by means of temporizing techniques but without using formal hypnosis unless credentialed to do so by the hospital (Kluft, 1992). When these techniques are employed, the patient is generally informed beforehand and the intervention becomes part of the nursing treatment plan.

There is a divergence of opinion concerning the role of hypnosis in the ongoing psychotherapy of dissociative identity disorder. Some believe that hypnotic techniques are useful in increasing communication between alternate personalities or in bringing alternate personalities into communication with the therapist. Some believe that hypnotic techniques are useful in memory retrieval; others believe that hypnotically facilitated memory processing increases the patient’s chances of mislabeling fantasy as real memory and increases the patient’s level of belief in “retrieved” imagery that may actually be fantasized. The therapist needs to be aware that hypnosis induced by the therapist may leave patients with an unwarranted level of confidence in the accuracy of the details in hypnotically retrieved material. The therapist should minimize the use of leading questions that may in some cases alter the details of what is recalled in hypnosis.

The therapeutic use of hypnosis should be conducted with appropriate informed consent provided to the patient concerning its possible benefits, risks, and limitations.

 

M. Veracity of the patient's memories of child abuse

Frequently, dissociative identity disorder patients describe a history of abuse, usually including sexual abuse, beginning in childhood. Many dissociative identity disorder patients enter therapy having continuous memory for some abusive experiences in childhood (Barach, 1996; Ross et al., 1990). In addition, most also recover memories of additional previously unknown abusive events, with recovery of material occurring both inside and outside of therapy sessions, and sometimes prior to the commencement of psychotherapy. Discussion of this material and its relationship to present beliefs and behaviors is a central aspect of the treatment of dissociative identity disorder.

Clinicians and researchers have issued several statements concerning recovered memories of abuse (American Psychiatric Association, 1993; Australian Psychological Society Limited Board of Directors, 1994; Working Group on Investigation of Memories of Childhood Abuse, 1996; Working Party, 1995). These statements all concluded that it is possible for accurate memories of abuse to have been forgotten for a long time, only to be remembered much later in life. They also indicate that it is possible that some people may construct pseudomemories of abuse and that therapists cannot know the extent to which someone’s memories are accurate in the absence of external corroboration. Patients’ recall of child abuse experiences, as well as their recall of other experiences, may at times mix literal truth with fantasy, confabulated details, or condensations of several events. Therapy does not benefit from telling patients that their memories are false. Neither does therapy benefit from telling patients that their memories are accurate and must be believed. A respectful neutral stance on the therapist’s part, combined with great care to avoid suggestive and leading interview techniques, seems to allow patients the greatest freedom to evaluate the veracity of their own memories.

There is a divergence of opinion in the field concerning the origins of patients’ reports of seemingly bizarre abuse experiences. Some believe that patients’ reports can be the result of extremely sadistic events experienced by the patient in childhood, perhaps distorted or amplified by the patient’s age and traumatized state at the time of the abuse. Others believe that alternative explanations suffice to explain these patients’ reports. Therapists who take extreme positions on either side in the therapy setting may diminish the likelihood of timely progress toward the patient’s clarification of the historical accuracy of such memories.

 

N. Management of Traumatic Memories (abreactions)

Traumatic material may surface spontaneously, or its processing may be planned; both situations occur in the treatment of dissociative identity disorder patients. The use of planned processing of traumatic material (abreactions) is a treatment technique of value with many patients but is not a therapy in itself. Patients benefit when the therapist helps them use planning, information, exploration, and titration strategies to develop a sense of control over the emergence of traumatic material. When patients spontaneously experience intrusive traumatic imagery, they often benefit from learning strategies that help them delay or control the level of intrusiveness of the traumatic material into their daily functioning. However, some patients develop such control more rapidly than others.

Clinicians experienced in treating dissociative identity disorder agree that therapeutic attention to emergent traumatic material is an essential part of the resolution of dissociative pathology. Ignoring this material does not make it “go away,” although the timing and nature of therapeutic attention paid to this material will vary according to the needs of each patient.

Many clinicians believe that occasionally extending preplanned trauma memory-processing sessions beyond their usual length is of distinct value in the treatment of some patients. At certain times such a session will unavoidably extend past its scheduled endpoint, but the therapist should try to minimize this. Therapists need to attempt to help patients to reorient themselves to external reality and end processing of traumatic memories before the scheduled end of therapy sessions, although they can only influence, never control, the patient’s ability to reorient to the present.

 

O. Nonverbal adjunctive therapeutic approaches

Like other victims of childhood trauma, dissociative identity disorder patients are often uniquely responsive to nonverbal approaches. Art therapy, occupational therapy, sand tray therapy, movement therapy, other play therapy derivatives, and recreational therapy are reported as helpful toward achieving treatment goals, including integration. Nonverbal therapies need to be conducted by appropriately trained persons and be well timed and well integrated into the overall treatment plan. Many psychotherapists find nonverbal techniques (such as patients’ drawings and journals) useful as part of ongoing psychotherapy.

 

P. Fees

Therapists should follow relevant legal and ethical guidelines concerning disclosure of fees, payment arrangements, barter, and collections procedures.

 

IV. Publications and Interactions with the Media

In all interactions with the media concerning dissociative identity disorder, the therapist’s primary responsibility remains the welfare of his/her patients. Thus, the therapist must maintain the highest ethical and legal standards of confidentiality with respect to clinical material.

Appearances by patients in public settings with or without their therapists, especially when patients are encouraged to demonstrate dissociative identity disorder phenomena such as switching, may consciously or unconsciously exploit the patient and can interfere with ongoing therapy. Therefore, it is generally not appropriate for a therapist actively to encourage patients to “go public” with their condition or history.
 

V. The Patient's Spiritual and Philosophical Issues

Like other victims of trauma by human agency, dissociative identity disorder patients may struggle with questions of moral responsibility, the meaning of their pain, the duality of good and evil, the need for justice, and basic trust in the benevolence of the universe. When patients bring these issues into treatment, ethical standards for the various professional disciplines specify the need to conduct treatment without imposing one’s own values on patients. Although patients may experience certain personalities as demons and as not-self, therapists should approach exorcism rituals with extreme caution. Exorcism rituals have not been shown to be an effective treatment for dissociative identity disorder, have not been shown to be effective for “removing” alternate personalities, and have been found to have deleterious effects in two samples of dissociative identity disorder patients that experienced exorcisms outside of psychotherapy. Exorcism rituals may provide a way for some patients to rearrange images of their personality systems in a culturally syntonic manner. Education and coordination between therapist and clergy can be helpful in ensuring that patients’ religious and spiritual needs are addressed.
 

VI. Patients as Parents

Because many dissociative identity disorder patients may have difficulty in parenting and a minority admit to being abusive toward their children, and also because dissociative identity disorder may involve a biological predisposition to dissociate, some have recommended that the children of dissociative identity disorder patients be assessed by a therapist familiar with dissociative disorders and indicators of child abuse. Other family interventions, such as couples therapy and sibling group sessions, may be indicated.
 

Appendix 1: Boundary Management

Victims of child abuse or neglect have generally grown up in situations where personal boundaries were either not established or were invaded. For this reason, their treatment ought to include a therapeutic relationship with clear boundaries. The therapist is responsible for clearly defining such a therapeutic relationship.

Boundary issues arise throughout treatment, with negotiation and discussion of these issues occurring as needed. Most experts agree that the patient needs a clear statement near the beginning of treatment concerning therapeutic boundaries. This statement may not always be understood immediately by the patient, may take several sessions to convey, and may require repetition at various points in the therapy. The discussion concerning therapeutic boundaries might include some or all of the following issues: length and time of sessions, fee and payment arrangements, the use of health insurance, confidentiality and its limits, therapist availability between sessions, procedure if hospitalization is necessary, patient charts and who has access to them, the use (or nonuse) of physical contact with the therapist, involvement of the patient’s family or significant others in the treatment, discussion of the therapist’s expectations concerning management by the patient of self-destructive behavior, legal ramifications of the use of hypnosis as part of the treatment (i.e., material recalled in trance is not likely to be admissible evidence in any legal action undertaken by the patient), among others.

Treatment should ordinarily take place in the therapist’s office. It is not appropriate for a patient to stay in the therapist’s home or for members of the therapist’s family to have ongoing extratherapeutic relationships with the patient. Treatment usually occurs face to face instead of on the analytic couch, though the latter is also acceptable for therapists with psychoanalytic training. Treatment should ordinarily take place at predictable times, with a predetermined session length under most circumstances. Clinicians experienced in treating dissociative identity disorder generally strive to end each session at the planned time.

Therapists need to follow relevant legal and ethical codes with respect to gifts exchanged by the therapist and patients, dual relationships, and informed consent for treatment.