"Evidence-based" treatment of DID?

[cara susanna]

Hi all,

Does anyone have any modern, evidence-based resources for treating patients with DID (I know DID in itself is controversial and not agreed upon, but as evidence-based as possible)? I am familiar with the psychodynamic approach but, as you know all know, I am not psychodynamic.

Thanks.

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[smalltownpsych]

Hi all,

Does anyone have any modern, evidence-based resources for treating patients with DID (I know DID in itself is controversial and not agreed upon, but as evidence-based as possible)? I am familiar with the psychodynamic approach but, as you know all know, I am not psychodynamic.

Thanks.

Because of the overlap of trauma and Borderline with DID, I would lean towards treatments indicated for those. Target the symptoms that have an evidence base to treat and then use integrative language to suggest that they are one person with different mood states that when they become less intense, aka DBT, then the patient will not feel so split. This is sort of theoretical as it has been a long time since I had a patient with DID, but some of my mor intense Borderline PD patients with severe childhood trauma clearly had some symptoms along those lines and if I pushed them one way would likely develop alters and such. I think it’s healthier to push them toward integration and use standard treatments.

 

[borne_before]

Hi all,

Does anyone have any modern, evidence-based resources for treating patients with DID (I know DID in itself is controversial and not agreed upon, but as evidence-based as possible)? I am familiar with the psychodynamic approach but, as you know all know, I am not psychodynamic.

Thanks.

To me this stuff always seems so reinforced by attention (primary) or escaping a demand...

 

[smalltownpsych]

To me this stuff always seems so reinforced by attention (primary) or escaping a demand...

Yup, that’s why I think a good behavioral framework is essential. I give absolutely no attention to dramatic histrionics and then begin shaping better ways of behaving by attending to more adaptive ways of coping. The mo ment a patient talks about their alters I know I’m not going to attend to that. I have had numerous patients never mention that crap again when they find that I am more interested in what is actually going on in their life and that’s what we are going to talk about.

 

[smalltownpsych]

Just got a new client call in while I was responding above. Any takers on whether or not they have some DID stuff going on? 😁

 

[borne_before]

Yup, that’s why I think a good behavioral framework is essential. I give absolutely no attention to dramatic histrionics and then begin shaping better ways of behaving by attending to more adaptive ways of coping. The mo ment a patient talks about their alters I know I’m not going to attend to that. I have had numerous patients never mention that crap again when they find that I am more interested in what is actually going on in their life and that’s what we are going to talk about.

For real though, are they getting a ton of attention in online spaces?

I wonder if ACT and discussing the conceptualized story attachment/mindfulness or grounding would be useful. Have you ever pointed that reaction out? "hey, when you start talking about your alters - I tune out because I am more interested in your life than the verbal story you're telling me - you aren't your thoughts/words and minds can be tricky into believing some wild stories about ourselves that may or may not be true, but regardless they aren't helping us pursue meaning/values. We may not have control over that, but let's leave that battle and re-engage in our life with grounding and focus on what we can control - our behavior."

That would also confront the secret agenda.

 

[PsyDr]

“Your alter doesn’t have insurance. I can either only treat you, or your alter can pay my cash rate.”

Amazing how quickly that works.

 

[BuckeyeLove]

DBT. Because what that treats is usually the actual culprit.

 

[cara susanna]

Because of the overlap of trauma and Borderline with DID, I would lean towards treatments indicated for those. Target the symptoms that have an evidence base to treat and then use integrative language to suggest that they are one person with different mood states that when they become less intense, aka DBT, then the patient will not feel so split. This is sort of theoretical as it has been a long time since I had a patient with DID, but some of my mor intense Borderline PD patients with severe childhood trauma clearly had some symptoms along those lines and if I pushed them one way would likely develop alters and such. I think it’s healthier to push them toward integration and use standard treatments.

That makes a ton of sense, thank you! How did you balance using integrative language with also not making the patient feel invalidated?

 

[Fan_of_Meehl]

Hi all,

Does anyone have any modern, evidence-based resources for treating patients with DID (I know DID in itself is controversial and not agreed upon, but as evidence-based as possible)? I am familiar with the psychodynamic approach but, as you know all know, I am not psychodynamic.

Thanks.

Hey,

I've got a really good one. PDF is below. One of the finest applications of clinical psychological science I've seen, in fact. Title of the book it's from is "Case Studies in Clinical Psychological Science."

 

[smalltownpsych]

That makes a ton of sense, thank you! How did you balance using integrative language with also not making the patient feel invalidated?

Because I 100% validate the feelings that the patient is experiencing. One of my supervisors demonstrated how to validate underlying emotional content very well. True story, in group one day a floridly psychotic patient was ranting nonstop and with lots of details about how Admiral Buttmunch (not a real admiral, I am sure 😁) had a secret ray mounted on warships that was turning people in the navy into homosexuals. I had no idea how to respond to that at all. My supervisor calmly said something along the lines of, “it sounds like you have a lot of fears and it makes it hard for you to cope.” Patient reacted remarkably calmly and said yes that’s it exactly. It taught me a valuable lesson that I use to this day in all types of situations that are much less extreme.

More specifically to the DID, I just shift the language to parts of you as I describe intrapersonal conflict. I might even start at less integrative depending on where they are with language like, “some patients experience this as separate identities and others as very intense emotional states that make them feel like completely different people.” I also tell them very directly that the goal is integration of the identities into aspects of themselves and emotional and cognitive shifts that are experienced as part of a unified person experiencing these things. I have had a few drop the alters stuff immediately after that explanation of the goal and we get right into the standard DBT and Kohlberg type of work I do for people with Borderline Personality functioning.

Others might have a bit more dissociation going on and we talk about those different states and collaboratively develop that sense of self aka observing ego as we work at describing and understanding those emotional experiences. Painstaking chain analysis is good for that.

However, you might be referring to another type of patient. I have had a couple of patients who were clearly wedded to the sick role and especially the DID label and could not shift one iota from that and chose to seek another therapist that would validate and reinforce that. They clearly didn’t like that I wasn’t all excited about talking to alters. If that is the case, I doubt there is much you can do about that. 🤷‍♂️

 

[Justanothergrad]

+1 to DBT for the reasons mentioned.

 

[futureapppsy2]

Agree with the behavioral approach for teaching alternate behaviors to meet the underlying functions (and good data to determine what those functions are) and then additional modalities (DBT, CBT, CPT, etc) to treat any actual underlying psychopathology like depression, anxiety, PTSD, etc., once the behaviors related to DID have been reduced.

 

[DynamicDidactic]

Not treatment but I really like this conceptualization of the disorder.

Dissociation and its disorders: Competing models, future directions, and a way forward

Dissociative experiences and symptoms have sparked intense scrutiny and debate for more than a century. Two perspectives, the trauma model (TM), which…

www.sciencedirect.com

The full text is easily accessible through Google Scholar

 

[deleted1129370]

I am treating a patient with DID, and currently use the "Treating Trauma-Related Dissociation - A Practical, Integrative Approach" by Steele, Boon, and Van Der Hart.