July Membership Meeting Write-Up — Douglas Green, LMFT

Working with Dissociative Identity Disorder

Presented by
Cristina Mardirossian, LMFT

If you’re anything like me, an early part of your journey toward becoming a therapist was having the bejeezus scared out of you, and your entire brain and soul fascinated, by reading and/or seeing Sybil and The Three Faces of Eve, bestselling books and award-winning films about extreme cases of Multiple Personalities. Maybe you even, like me, have always harbored a bit of disappointment that, much as you have treasured your clients, none has given you that astounding jolt, of changing from one person to another in front of you completely naturally, like an undrugged Dr. Jekyll and Mr. Hyde.

If so, July’s SFV-CAMFT presentation by Cristina Mardirossian, MFT, might have eased your distress a bit. Her presentation, Working with Dissociative Identity Disorder, explained that those with a dissociative disorder are not always so dramatically expressive in their switching as Sybil and Eve. Rather, clients with DID can be challenging to detect, as their switching might be extremely subtle. Additionally, therapists who work with complex trauma have probably dealt with Eves and Sybils in their practices, but just not recognized DID or ruled it out.

Mardirossian explained at the opening of her presentation that all people dissociate to some degree, and that dissociation (defined as “an adaptive defense in response to high stress or trauma characterized by memory loss and a sense of disconnection from oneself or one’s surroundings”) is on a spectrum, one we each deal with in our lives and work every day. Think of the times you have driven home and you know the route so well that you all of a sudden realize you are home; this autopilot is actually a low form of dissociation. The difference between common dissociations and the disorder lies in the afflicted suffering “episodes that are disruptive, recurrent, and impair functioning,” as well as losing track of time or suffering with amnesia.

Mardirossian explained that no one is born with DID. Instead, it is created as a defense against recurrent trauma. DID is not formed from a one-time incident. It is formed from ongoing, chronic abuse (including ritual abuse, cult abuse or child trafficking). She quoted Steinberg and Schnall (2001) that the three main factors that influence propensity towards dissociation and amnesia are: 1- the nature of the traumatic event, 2- their frequency, 3- the age of the person experiencing them.

On that last note, she points out that a person over the age of ten who experiences repeated abuse will not likely gain Dissociative Identity Disorder. They will of course suffer trauma and post-traumatic symptoms, but DID develops in a developing mind. If one thinks of Erickson’s description of adolescence as Identity versus Isolation, it makes sense that this extreme damage to one’s sense of identity would come only in a pre-adolescent stage, when identity work had not yet begun in earnest.

The signs and symptoms of DID are many, and fascinating. In adults they range from waking up sucking their thumbs to unexplained pain in genitals to having no memory of recent personal experiences. And in children, losing track of the time of day (common for children who have been repeatedly abused at night), forgetting names of important people in their lives, or quickly fluctuating in tastes, athletic abilities, or handwriting.

Understandably, professionals have often mistaken DID for Schizophrenia, especially as many DID sufferers hear voices. However, Mardirossian gave a detailed list of differences between the disorders, such as that people with Schizophrenia hear “other” voices, while people with DID hear voices they identify as their own, and the fact that most DID voices are of children or even animals, not adults. Interestingly also, in Schizophrenia, thoughts and impulses seem to “insert” into the sufferer’s mind from an external source, whereas with DID they’re most often sensed as inserted or blocked (one personality “remembering” something but keeping it hidden from the others) from an internal part of themselves.

(Similarly, while some people with Gender Dysphoria may have been misdiagnosed with DID, the former’s feelings of being transgendered are constant, while the latter’s experiences of being wrongly-sexed are only at certain times – and of course there are people with DID who also identify as transgender.)

While there are numerous terms for the different personalities, Mardirossian will ask the client’s preference of how they would like to be addressed. Common terms include “Parts” or “Alters” (though the latter term can be triggering for people who were abused in religious settings!). The “Front” (or “Apparently Normal Person” or ANP) is the dominant personality, the one most other people see most often. The other alters, most often, perform a protective role in the person’s internal system, to help cope with the trauma endured. Some can be “Helpers,” dispensing repressed wisdom and knowledge, “Kids” who hold memories and playfulness but are far more prone to fear and shame, “Protectors” who hypervigilantly protect the child parts but often act like the person’s abusers, and “Doers” who have a specific role — the one who can drive a car, the one who has sex, etc.

Because Dissociative Identity Disorder is a reaction to trauma, the treatments for it are slow and involve much trust-building and connection (“If you think you might be moving out of town or having a baby soon, don’t take on one of these clients! This is not a case for Solution-Focused Therapy!” she warned). Mardirossian gave detailed lists of ways to work with these clients, from strong boundary-setting (most clients have to test the therapist before they can trust them, and years of hypervigilance makes them great at seeing through any weaknesses or untruths) to helping them build the three C’s: co-consciousness, cooperation, and collaboration.

This is especially helped by having “Internal Meetings,” in which the different Alters work together almost as a family, making decisions from “what kind of coffee do we drink today” to “what shall we discuss in therapy.” These meetings help the client build internal trust and communication amongst parts, break down the walls of amnesia that keeps parts stuck in time, and learn how to have integrative functioning (whether or not the client wants to fully integrate).

The goal of this therapy overall, thereby, is not to “eliminate” any of the parts of the client, but to improve communication between them so that the client can work from all their parts when they wish, to help the “Littles” to mature and develop with confidence and self-esteem — to eliminate the trauma-based walls separating one “Alter” from another. This will result in an increase in the client’s Window of Tolerance, the range of input they can absorb without going into hyper-arousal or hypo-arousal.

Much of this is accomplished through Grounding Techniques, from mindfulness to taking walks to a Bilateral Music (the sound moving from side to side, as in EMDR), to creating a “Container,” in which certain memories can be placed on purpose, and thereby held away from consciousness till the next session. These all serve to help the client differentiate past from present, both in the mind and in the body.

It was clear that Cristina Mardirossian’s information-packed presentation didn’t begin to tell all that she knows about this endlessly fascinating topic. She will be offering more extensive workshops on DID soon, and while none will receive any Oscar or Emmy attention, they promise to be as electrifying as any Hollywood split-personality tale ever made. And on a personal note, I loved it — ALL of me did.

Douglas Green, MA, MFT, has a private practice in Woodland Hills and West Los Angeles, where he specializes in helping children and teens live lives they can be proud of. To find out more, you can contact Doug at 818.624.3637, or DouglasGreenMFT@gmail.com. He's also often at our chapter meetings, serving as the volunteer coordinator. His website is www.DouglasGreenMFT.com.