IDENTITY PERSONALITY DISORDERS AND DISSOCIATIVE DISORDERS IN CHILDREN

 

Dr. M. C. Barreda-Hanson   email
Director, Department of Psychology
ACT Community Care
and The Canberra Hospital

DSM-III describes the onset of DID as occurring in early childhood or later but rarely is it diagnosed before adolescence. There are several hypotheses about why the diagnosis of DID is not made earlier in life. Some reasons are due to the fact that some of these children do not display symptoms that draw the attention to this disorder. Many of the behavioral presentations of these children are misdiagnosed or misinterpreted and in many cases the doctors and the professionals do not ask the right questions.

Identity Personality Disorder, once called "Multiple Personality Disorder" is one of the most dramatic and controversial diagnoses made famous by books and films such as "The Three Faces of Eve" and "Sybil". Patients contend that totally different personalities inhabit their minds and can take over their bodies from time to time. These personalities (identities) might be of a different sex, age, skill, hand preference, motivation and emotional style from the usual persona. The identities are dissociated parts/memories that the patient experiences as separate from each other. After a switch back to the base or core identity, the patient cannot remember the period during which the other identities were in control.

Putnam, defined dissociation as the ongoing process in which certain information (such as memories, feelings, and physical sensations) are kept apart from other information with which it would be normally logically associated. He noted that dissociation is a psychological defense mechanism that also has psychobiological components. Generally, dissociation is thought to originate in "...a normal process that is initially used defensively by an individual to handle traumatic experiences [that] evolves over time into a maladaptive or pathological process..." (Putnam, 1989, p. 9).

The theory is that in the face of some extreme trauma, often childhood sexual abuse, the mind deals with overwhelming stress by producing an alternative identity (personality) that experiences the shock, so protecting the core identity, for whom the terrible event never occurred. Thus, dissociation is a defense mechanism and it is available to all people in various degrees.

These alternative personalities are also called identities, parts, disaggregate self states, parts of the mind, or parts of the self, by various clinicians. Each of these is a distinct identity or personality state that has a relatively enduring pattern of behaving, perceiving, relating to others and thinking about the environment, self and other identities.

This workshop is aimed at gaining a better understanding of DID in children, how to assess it and how to provide therapeutic interventions. The breakdown of the workshop will be as follows:

WORKSHOP PROCEDURES:

The workshop will consist mostly of overhead presentation of material with interactive discussions. Examples of cases will be utilized and participants will be encouraged to bring forth their own experiences, participate in discussions and comment on techniques they have found successful.

OBJECTIVES OF WORKSHOP:

  1. Gain an understanding of the manifestations of trauma responses and DID in children
  2. Learn current techniques in the identification and assessment of the severity of dissociative symptoms and DID in children
  3. Be able to differentiate between DID, Dissociation, Repression and imaginary friends
  4. Learn current approaches/techniques in designing a “safe-oriented” treatment intervention plan aimed at increasing integration and reducing dissociation.
  5. Be aware of the role of the therapist and be able to design and set therapy goals that include the child’s “world” and promotes self-acceptance and resolution of conflicting feelings while encouraging self-regulation
  6. Find out about the uses of adjunctive treatments, such as pharmacotherapy in the treatment of DID

DESCRIPTION:
As with adults, the essential features of all dissociative disorders is a feeling of detachment from surroundings and/or themselves - as if in a dream or living life in a slow motion.

ESSENTIAL FEATURES IN DID
- disruption in the usually integrated functions of consciousness, memory, identity, or perception in the environment.

CLINICAL PRESENTATION
Feelings created by experience of unreality:

  • depersonalization - temporary loss of sense of one’s reality due to alteration in perception.
  • derealization - loss of sense of “realness” of external world.

Symptoms of unreality are prevalent (dissociation from reality). It can be part of a more serious set of conditions where reality, experience, and even one’s identity disintegrate.

A note of caution is that the symptoms of depersonalization and derealization are not uncommon in adolescents and if these can be exacerbated by substance abuse (Carrion & Steiner, 2000).

WHAT IS DID?

DID is a normal defense mechanism that is available to all people in various degrees. There are individual differences in the “ability” to dissociate depending in part to biological/genetic endowments, individual personality temperament, pre-existing or latent mental disorders and coping styles, the intensity/severity and duration of the trauma, proximity to it, how the trauma is perceived, recovery environment (environmental reinforcers or support systems within family or social supports).
In summary, there is an interaction between:
- biological/genetic endowments,
- individual personality temperament,
- pre-existing or latent mental disorders and
- coping styles,
- the intensity/severity and
- duration of the trauma and proximity to it,
- how the trauma is perceived,
- recovery environment (environmental reinforcers or support systems within family or social supports
- the traumatic experience(s) and individual factors.

The capacity to dissociate is greater in childhood, particularly in females. Relationship patterns can foster/enhance the ability to dissociate or to over-rely on dissociation as a defense.

DSM-1V CRITERIA FOR DID

  1. Presence of two or more distinct identities or personality states each having their own relatively enduring pattern or perceiving, relating to, and thinking about the environment and self.
  2. At least two of these identities or personality states recurrently take control of the person’s behavior.
  3. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
  4. Not due to the direct effects of a substance (e.g. blackouts due to alcohol intoxication) or a general medical condition (e.g. complex partial seizures).
    • In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

SOME THEORIES OF DID

There is still no consensus as to an exact etiology/etiological pathway for the development of DID. Newer theoretical models on dissociation are stressing “impaired parent-child attachment patterns (Barach, 1991; Liotti, 1999; Ogawa, Scroufe, Weinfield, Carlson & Egeland, 1997) and trauma-based disruptions in the development of self-regulation of state transitions (Putnam, 1997; Siegel, 1999). …. dissociation may be seen as a developmental disruption in the integration of adaptive memory, sense of identity, and the self-regulation of emotion.” (in ISS Task Force, 2003).

BRAUN AND SACHS’ THEORY OF DID (1985)
There are four factors in their theory:

  1. biological capacity
  2. traumatic experience, usually inconsistent stress, yet predictable cues (e.g. shadows on wall just prior to abuse), that overwhelms the ego’s capacity to adapt
  3. presence of shaping influences that determine the dissociation symptomatology
  4. lack of stimulus barriers and restorative experiences

SPIEGEL AND CARDENA’S THEORY OF DID (1991)
According to these researchers dissociation is a “structured (organized) separation of mental process such as thoughts, memory, feelings, and sense of identity”.

PUTNAM’S THEORY OF DID (1985)
For Putnam it is a “psychophysiological process that produces an alteration in one’s consciousness” when triggered by a psychodynamic event.”

ROSS’S THEORY OF DID (1989)
Ross sees dissociation as “the opposite of association” and believes it has two origins – as a “failure of normal association” or as “an abnormal dissociation”.

SOME BACKGROUND HISTORY/CAUSES OF DID

DID clients often describe:
- a history of recurrent episodes of abuse
- abuse is usually of a sexual nature, with life threatening experiences and beginning in childhood (Barach, 1996; Ross et al., 1990).

While in therapy, many clients also recover memories of abusive events that have been previously unknown/not remembered by them. Memory recovery can occur both inside and outside of therapy sessions.

There is controversy amongst clinicians in regard to the origins of clients’ reports of bizarre abuse experiences. Some believe the reports could be the result of extremely sadistic events experienced by the client, perhaps distorted or amplified by the patient’s age and traumatized state at the time of the abuse. Others believe that there could be alternative explanations to explain these reports. Regardless of the therapist’s point of view it is important that a neutral position be taken and that the client be given the freedom to progress in therapy, clarifying memories and reaching, if possible, historical accuracy of such memories or accepting that this may not be possible.

FUNCTIONS OF DISSOCIATIVE SYMPTOMS (Courtois, 1988)

  1. escape from an intolerable, “unescapable” situation
  2. “amnestic barrier” to keep traumatic memories out of awareness
  3. analgesia against pain
  4. escape from experience/sequelae of trauma (eg. guilt)
  5. hypnotic negation of the self.

The child usually says, “I went away in my head” or “I flew up” or “got inside the woodwork”.
DID is a creative survival skill. The child can dissociate thoughts, feelings, memories and/or perceptions of the traumatic experience. The child separates them off psychologically so s/he is allowed to function as if the trauma had not occurred.
Children that have “practiced” this defence use it more often – even in anxious producing situations that are not abusive (eg. cut off in social situations that makes them feel uncomfortable).
“Practiced” children can also carry the leftover patterns of defensive dissociation into adulthood, long after the abuse has past.
Dissociation can be so frequent and so extreme that memory can become terribly impaired. Thus, discontinuity in learning of age appropriate skills may be common.

ETIOLOGY OF DID

(Reference lost) 98 to 99% of children assessed with DID had developed DID as a consequence of overwhelming, life-threatening trauma at an early, sensitive age, before the age of nine.

ADULTS:
68% to 83% reported sexual abuse as children
60% to 75% reported physical abuse as children

ADOLESCENTS:
73% reported sexual abuse
100% reported some previous trauma. This included death, witness of murder of other, another’s violent death, injury, hospitalisation, surgical or medical trauma
73% reported physical abuse
82% reported emotional abuse

DIFFERENCES IN DISSOCIATION:

  • Normal Dissociation: daydreaming, absorption in a book/TV. etc. (e.g. driving distraction)
  • Shift to Abnormal Dissociation: when it causes a disruption in day-to-day life, in normal integrative functions of consciousness and/or identity
  • Abnormal Dissociation: a defensive dissociation that protects the child’s ability to function within the environment by removing overwhelming sensations, memories, and feelings from consciousness.

WHAT CAUSES DIAGNOSTIC DIFFICULTIES

The prevalence of DID in children is not currently well known and there is no real consensus about the diagnostic criteria (ISSD Task Force, 2003).

  • DID is difficult to diagnose because no specific symptom clusters or single feature has been identified as pathological.
  • Diagnosis, doesn’t in itself give much information about the nature the child and his/her world.
  • There are inadequate assessments for child trauma
  • The literature is meager. Parry-Jones (1992) described children as “the neglected victims”.
  • Carers, in many cases may not acknowledge the children’s suffering (Yule, 1992) and so deny the need for investigation and treatment (Yule & Williams, 1990)
  • Children in inadequate, disorganised, or chaotic environments may appear to have difficulties in the area of dissociation and it may be impossible to determine whether the dissociative behaviour is primarily a product of the environment or due largely to the child’s psychopathology.
  • Petit mal seizures can be misinterpreted as dissociative disorder and dissociative behaviour and trance-like states can be misinterpreted as being petit mal seizures. Complex partial seizure episodes are generally brief (30 sec. – 5 min.) and do not involve the complex and long-lasting structures of identity and behaviors observed in DID children. Furthermore, DID children do not respond to anti-seizure medication. Visual hallucinations are common in childhood dissociative disorders.
  • Naive clinicians may confuse DID with childhood schizophrenia. Negative symptoms of schizophrenia such as occupational and social deterioration, emptiness, and loss of drive are not features distinctive of DID but may be symptoms of accompanying depression. DID children respond poorly to neuroleptics. In schizophrenia, the voices are usually perceived as coming from outside the head. DID tend to perceive them as coming from inside the head (Coons, 1984; Kluft, 1985; Putnam. 1989; Ross, 1989). In about half DID children and adolescents, auditory and visual hallucinations diminish rapidly. This is not typical with schizophrenia.
  • Symptoms of PTSD are common in DID and these children may warrant diagnosis for both dissociation and PTSD. There is a strong correlation between traumatic events and dissociative symptoms such that some children may present with both trauma and dissociation while others will just present with the history of trauma and yet, others with no symptoms or history (as in cases of amnesia). Because of this comprehensive assessment for trauma (e.g. types of abuse), ongoing assessments, particularly as new information arises and assessments in various different venues (e.g. home and school) are crucial.
  • Phobias, eg. Agoraphobia (e.g. ritual abuse carried out in an enclosed room caused fear in one identity to venture out of “safe room”, and phobia may be due to unfounded, unreasonable fears of danger stimulated by young identities and/or by the host, fearing that something that is out of his/her control may happen. (e.g. of shower, where skin scalded or bathtub because of drowning attempts took place), or social phobias due to group ritual abuse.
  • Obsessive compulsive symptoms may be part of the hypervigilance of a traumatized child or the child’s attempt to stay organized, particularly if time has been missed.
  • Acute stress disorder has prominent dissociative symptoms.
  • Children with unpredictable, perplexing changes in attitude and behavior and not responding to the usual therapeutic interventions, may be seen as having borderline personality disorder, particularly if they self harm.
  • Eating disorders are not uncommon in DID (Putnam, Guroff, Silberman, Barban & Post, 1986). One identity state may purge to get rid of another identity’s food intake. Food deprivation or purging may be associated with somatic memory of forced oral sex.
  • Sexual promiscuity may be due to a promiscuous identity. The host identity may not remember or be aware of an identity’s promiscuous behavior. Aversion to sexual activity is common for the host identity state.
  • Symptoms that characterize ADHD may be confused with DID, but ADHD behaviors do not have trance-like states, periods of amnesia, nor marked fluctuations in behavior. DID children are distracted by internal voices, made impulses, made behaviors. They may not follow instructions because they are attending to these phenomena. (e.g. an identity taken over school attendance as host, threatened with severe punishment if she “talked”, found it easier to remain silent/”away”)
  • Pervasive developmental disorders sometimes have symptoms of DID. In these disorders, however, the fluctuations in behavioral abilities are environmentally specific, ie. the regressive or stereotypic behavior occurs with a repeated stimulus. When such a diagnosis is made, DID is preempted.
  • Young children may lack verbal memory but show memories of traumatic events through non-verbal modalities, e.g. sensorimotor or somatic symptoms and unreasonable fears (Fivush, Pipe, Murachver & Reese, 1997; Stein &Wateers, 1999)
  • Psychiatrists tend to underdiagnose and psychologists tend to overdiagnose.

DID children have a high rate of comorbidity with other disorders (Hornstein & Putnam, 1992; Hornstein & Tyson, 1991; Peterson & Putnam, 1994) Most common ones are: Attentional Deficit Disorder, Oppositional Defiant Disorder, Conduct Disorder. Symptoms may be exacerbated at puberty and become confused with the developmental roles which are part of adolescence. A diagnosis should be made if these are due to switching of identities, the host personality or one of the identities.

REASONS FOR FAILURES TO IDENTIFY DD / DID IN CHILDREN:

Unluckily, children are not often diagnosed with DD or DID because of several reasons:

  • Dysfunctions existing in the family that cause or contribute to the development of DD or DID will not allow or will prevent family from seeking help.
  • Health workers may lack familiarity with symptoms / presentations of dysfunction in children and may overlook or misdiagnose these children.
  • Initial presentation distracts from real diagnoses. These children are usually referred because of complicated psychiatric histories, including multiple caregivers/placements, and behavioral difficulties that have not responded well to a variety of interventions, including pharmacotherapy.
  • Presentations of DD or DID in children, is more subtle and different than those seen in adults. Thus, identification is more difficult.
  • As with adults, children mistrust workers, and protect himself or herself from showing alternate identities.

DIFFERENCES BETWEEN DD AND DID

The specific criteria differentiating DID from DD are :

  1. In DID there is the presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self.
  2. This is not noted in DD, where there only is the dissociation – lack of memory of an event, action or feeling.
  3. In DID at least two of the above recurrently take control of the person’s behavior.
  4. In DD the child does not loose control of the behavior, only forgets it.In DID each individual identity is complex and integrated with its own unique behavior patterns and social relationships. DD children only have one identity (personality), which is usually complex.
  5. In children with DID the alternate identities are less differentiated, less invested in separateness, and emerge for relatively brief periods of time as compared to those alters of adults with DID.

DIFFERENCES BETWEEN DID AND “IMAGINARY FRIENDS”

  1. DID Identities are distinct identity states, with distinct patterns of relating and behaving.
  2. Children with “imaginary friends” have only one distinct pattern of relating and behaving, one of which is the “relationship” with an imaginary friend. Some children may have more than one imaginary friend.
  3. DID identities will recurrently take control of the child’s behaviour.
  4. The child with an “imaginary friend” does not loose control of the behavior and may actually feel has control over the behavior of a friend.
  5. Identities held by the child with DID are usually dramatically different to the child and may cause trouble to the child, acting out in ways that can either hurt the child or others and cause retaliation on the child. The child very rarely remembers these acts, though at times, the child is conscious of the behavior, but sees it as someone else controlling it.

The child with the “imaginary friend” is aware of the behavior and usually says to know what the “imaginary friend” said or did and engages in communication, actions as if the friend were there, next in proximity, not “inside” and “taking control”. In many situations the “imaginary friend” is “used” as an ally or accomplice and blamed for actions.
Neither the DID child, nor the child with the imaginary friend may have an awareness that the “friend” or “voice” are of their own projection. Thus, in this, the “imaginary” friend parallels the process of the host alters in DID.
Young, pre-school children, at the concrete operations stage do not understand the concept of cause and effect. Thus, if asked if the “imaginary friend” is real, they may say “Yes” if they do not understand that they brought their perception of imaginary companion into being.
Age levels must be considered in assessment as pre-operational children may not be able to differentiate between “inside me” voices as opposed to “out there”.

DISSOCIATION AS DIFFERENT TO REPRESSION:

Dissociation is different to “repression” in that

  • repression implies that it is “motivated” into the unconscious. This is not the case with dissociation – it is an unconscious process carried out by “looking away” from unwanted stimuli and “looking into” a less scary experience.
  • However, as Dr. Hans Steiner said both follow a “focusing/paying attention” process – repression by “ignoring” and DID by both ignoring an undesirable event/stimulus and focusing on a less painful one.

IMPORTANCE OF EARLY RECOGNITION

Early intervention with children is crucial for five main reasons:

  1. DD and DID are among the sequela of childhood trauma, particularly sexual abuse. Thus, early recognition makes early intervention possible.
  2. Early intervention is desirable because children often respond rapidly to appropriate therapeutic intervention, unlike their adult counterparts, who take many years.
  3. If not treated the condition usually is for life though switching decreases with age. Different identities appear over years in reaction to new life situations but usually this is if the dissociation “skill” is practiced (e.g. a new part after 16 years when having marital difficulties, but had dissociated through this time).
  4. Pattern of dissociation can remain and significantly affect the person, causing serious dysfunction in work, social life and daily activities (e.g. cutting off at social gathering because of fear of groups).
  5. Repeated dissociation may also result in a series of separate entities, or mental states, that eventually take identities of their own (eg. a client, no longer in traumatic environment, but associating children with her past trauma, had one of the “identities” care for her children and she could not remember bringing them up. Another client had an identity going to work/university).

DIAGNOSES OF DD AND DID

Accurate clinical diagnosis of dissociative disorders is crucial in order to implement early and appropriate treatment.

Because of the less differentiated alternate identities and the briefness of their presentation, diagnosis of these children requires careful observation and sensitivity to the various ways that dissociative episodes can be manifested through various behavioral symptoms. The use of structured interviews, and standardized tests to supplement a clinical assessment to confirm a clinical diagnosis or to identify a previously undetected case can be useful. These tests and interviews, now available commercially, are not designed to replace the clinical diagnosis but to assist in the diagnosis and treatment plan.

As screening tools and psychological tests are not able to diagnose a dissociative disorders, patients identified at risk off, or as possibly having a dissociative disorder should be evaluated with:
- more comprehensive methods,
- standardized tests to supplement and confirm a clinical assessment and diagnosis
- through several sessions that involve observations at various venues and experiences in the child’s day-to-day life.

Essential in any clinical assessment for diagnosis of dissociative disorders should consist of:

  • A comprehensive mental status examination that includes comorbidities and questions concerning dissociative states. Specifically, the patient and Carers should be asked about episodes of identity alteration, depersonalization, derealization, identity confusion, amnesia and fugue, (Steinberg, 1995) as well as age alterations
  • regressions or above age level and hearing voices (usually internal) (Putnam, 1991)
  • Clinical interview (structured and non structured) of familial, berhavioral, social and educational history (including post-traumatic symptoms, self-injurious behaviours, imaginary friends and all areas/situations of dissociation, e.g. when reading and family history of dissociation).
  • Psychological tests, self/other questionnaires and other screening tools.
  • Medical evaluation (to rule out disorders that mimic DID, such as seizures or other neurological disorders, effects of illegal drugs, exposure to toxins, etc.)
  • Professional observations at various venues and activities

Assessment requires accredited professional training, skills and knowledge in:

  • child development (normal and abnormal)
  • knowledge of child’s normative responses to questions
  • knowledge of child’s idiosyncratic use of language
  • training in child therapy
  • training in a variety of trauma treatment approaches for children
  • ability to phrase interviews in concrete, age appropriate manner
  • Therapists working with DID children should also have ongoing peer supervision or study groups and continuing education and keep abreast of new research and literature.

These children also present with an array of symptoms that can be very confusing to the workers. They are very distrustful, guarded, and not eager to disclose much at all about their experiences and inner world (e.g. client that had been threatened in the past and “tricked” to see if she disclosed, kept asking “do you play tricks?”

Braun’s (1986) four identification process should be considered:
- behavior,
- affect, sensation and
- knowledge, as dissociation can occur in one, several or all of these processes.

Assessment should be an ongoing process, as new information arises, with awareness of the possibility of
- confabulation,
- distortion, or
- other inaccuracies reported by the child and the family, particularly as the memory of children is affected by rehearsals and needs (e.g. need for parental nurturing may put aside memory of abuse).

Children’s memory is also affected by language acquisition so it is important to observe and consider in any assessment the child’s play, behaviors and somatic complaints.

There should be several parts to data gathering before making diagnoses:
History / Clinical Interview
The interview technique should be well structured in order to discriminate between more normative childhood fantasy, the spectrum of dissociative conditions, and a host of other diagnoses that may become confused with dissociative disorders.
Lewis (1996) has a helpful, flexible sequence of questions.
Putnam’s Child Behavior Checklist is also of assistance (Putnam, Helmers, & Trickett. 1993)
Braun’s (1986) four process of identification.

No matter what interview technique is employed, the therapist must rely on an empathic attitude, a sound knowledge base on the conditions and comorbidities, wits and creativity.

There should be several parts to data gathering before making diagnoses:
- history taking (caregivers, schools and other service providers),
- observations (at play, school, home, etc.),
- formal and informal assessments)

HISTORY TAKING:

History taken from caregivers, family constellation, teachers, etc., on nature of family stressors, living environment, child’s behavior and developmental milestones attained (or lost), and emergence of symptoms, will usually reveal the following:

  • loss or several separations from caregivers
  • history of abuse and trauma (need to check in detail, as well as duration) – any not disclosed before
  • perpetrators of abuse, other than any individual(s) previously disclosed (e.g. mother disclosed in therapy a gang rape and a grandfather’s abuse)
  • any ongoing abuse
  • destructive or self-destructive behaviors engaged by the child
  • witnessing family violence
  • behavioral problems, mainly oppositional behavior and conduct disorder
  • poor learning from experience
  • history of forgetfulness and fluctuations in access to knowledge attained in the past
  • regressive behavior (acting younger than the child’s age) and the opposite – advanced behavior (a young child of 4 acting like an adolescent)
  • sleep problems
  • medical problems, mainly mood disorders, psychotic symptoms and somatic symptoms
  • hospitalizations/treatment (reasons for these and duration)
  • variety of symptoms (emergence, circumstances, precipitators and ameliorators)
  • family history of trauma, abuse, substance abuse, DD or DID in childhood, illnesses, psychiatric conditions
  • imaginary playmates
  • sexually inappropriate (outside age level) behaviors
  • Educating the child about dissociative defenses should begin early in the interview, usually it is helpful to start with the description of the experience of blocking pain.

OBSERVATIONS (AT PLAY – PROJECTIVE AND DIRECTED, AT SCHOOL, etc.):

Observations should be carried out when the child is in similar neuropsychological states to that which caused DID, through narratives, games, location assessments, etc.. In these situations the “trauma” or “memory” is “retrieved” because of the highly stimulated neurological, psychological and physiological state.
Memories are activated/retrieved by the association/ conditioning that has occurred in the past, which are similar to the “recreated” state during the observation/ assessment.

Outside of the main presentations (above) there are various symptoms that should be observed/considered in the assessment of DID children:
a vast variety of symptoms, particularly:

  • Post traumatic stress disorder symptoms (e.g. nightmares, night terrors, intrusive traumatic thoughts /memories/flashbacks, disturbing hypnagogic hallucinations, traumatic re-enactment, numbing and avoidance) and differentiating these with DID
  • self injurious behaviors
  • fears that are unusual or exaggerated for their age or their situation (e.g. terrified of shower, where skin scalded or bathtub because of drawing attempts took place), or social phobias in adolescence, due to group ritual abuse.
  • somatic concerns / complaints
  • high anxiety levels
  • significant behavioral inconsistencies/shifts/ fluctuations that occur between settings, tasks, abilities, age appropriate, etc. activities, during different environmental settings, etc. or during observations conducted over extended periods
  • calling/referring to oneself in third person, using or answering to other names – a belief of the existence of other identities that take over or of having imaginary friends that control their behavior
  • requests to be called by a different name or treated differently
  • marked mood swings and circumstances
  • fluctuation moods and behavior, including rage states indicating lack of self-regulation
  • mood disorders / intermitted depression (e.g. seasonal; after a calm period representing periodical abuse)
  • depression or intense episodes of depression and suicidal feelings
  • trance states
  • amnesia and transient forgetting
  • inattentiveness/lack of concentration in some settings but not in others
  • excessive daytime dreaming “spacey” behavior
  • hysterical symptoms
  • sleep disturbances
  • sexually reactive or offensive behavior
  • auditory hallucinations/ hearing voices experienced “inside the head”(Schneiderian symptoms include auditory hallucinations and passive influence experience)
  • sudden shifts in behaviors, postures, expressions, voice, language, etc.
  • tantrums or destructive behaviors
  • inconsistent consciousness / fluctuation of attention, such as trance states or black-outs
  • denial of behavior observed by others, specially behaviors considered negative (believed to be lying)
  • extreme inconsistencies in knowledge, skills and abilities, accompanying personality switches. Developmental issues are inconsistent / inappropriate, e.g. active imagery companionship, inappropriate sexual behavior.
  • physical complaints or injuries of vague origin
  • substance abuse in older children / adolescents
  • * feeling of dividedness, experienced as discrete alter states, hallucinated internal voices, or behavior outside the child’s control – most important finding in assessment.

FORMAL OBSERVATION MODEL

- Johnson’s (1992) behavioral systems model for nursing:

  • Ingestive – idiosyncratic changes in the preferences for food or fluid intake (e.g. hoarding, binging) and may accompany reenactment of abusive experience, changes of mood or identity switching.
  • Eliminative – rituals, avoidance, fears or preoccupation around eliminative functions that may include encopresis and/or enuresis and may accompany mood/identity changes. These may also be flashbacks to abuse.
  • Aggressive-protective – aggressive identities are common in DID children and this usually precipitates entry to therapy. Aggressive identities usually follow periods of great vulnerability or are a response to threat in children with inadequate self defense or forced in passive/victim roles.
  • Affiliative – “adult” identities may emerge as a self-defense, need to assert self. Shifts towards adults and the use of pseudoadult voice should be observed.
  • Sexual – inappropriate age or gender behaviour, object sexualization. These may accompany mood/identity shifts and may represent repetition of abuse and/or identification with abuser/s or be a self-defense to neutralize perceive threats.
  • Restorative – bedtime anxiety and sleep disorders to around times of decreased internal stimuli and associated to bedtime abuse.
  • Achievement – inconsistencies/delays of mastery of developmental tasks noted at different times. Identities may have different levels of skills/abilities so fluctuations in performance. May be associated to mood/identity changes.
  • Dependency – avoidance of and difficulty in eliciting nurturance. May request help in doing tasks can do on own and is sensitive to redirection. May shift from clinging to withdrawing or acting out.

SYMPTOMS VARY

  • may be less severe and constant
  • there may be sporadic demonstrative episodes
  • normal developmental dissociation in children, much as fantasy may create diagnostic problems. Children normally go through changes in behavior and affect during interviews and these should be differentiated from dissociative symptoms.
  • developmental levels influence presentations

FORMAL TESTS and INTERVIEWS (OBSERVER CHECKLIST AND CLIENT COMPLETED CHECKSLISTS)

Though most tests for dissociative disorders should be used with caution as they are relatively new and have not been extensively trialed clinicians are finding out that using a diagnostic interview for diagnosis can be as reliably as any other psychiatric diagnosis for which a structured interview exists.
Adolescent Dissociative Checklist (Putnam, Helmers & Trickett, 1993)
Validation studies indicate that a score of 4.8 is the mean for dissociative adolescents with a standard deviation of

  • Adolescent Dissociative Experience Scale-II (A-DES) (Armstrong, J., Carlson, E,.B., Putnam,F. )
    This is a self report checklist of 30 items with a 10 point scoring scale
  • Children Depression Inventory
  • Child Dissociative Checklist (Putnam, F.W., Helmers, K., & Trickett, P.K.; 1993) So far, this has been the most extensively evaluated test. It is an observer checklist and consists of 20 items. A cut-off point is considered to be 12 or higher.
  • Child/Adolescent Dissociative Checklist (Reagor, Kasten, and Morelli, 1993) Another Observer Checklist consisting of 17 items
  • Child Dissociative Checklist (CDC), Version 3 (Putnam, F) A 20 item checklist with false and true scoring.
  • Child Dissociative Problem Checklist (Peters, G.; 1991 Children’s Perceptual Alteration Scale (Evers-Szoslik & Sanders, 1992) The client completes this scale
  • Dissociative Experience Scale (for adults - to be used with parents, as this condition runs in families)
  • Dissociative Features Profile (Silberg, 1996) To be used with a psychological test battery, including TAT. Drawings, Sentence Completion and WISC-III. The test has two parts Part I (Behaviors) and Part II (Markers-describes actual test responses)
  • Educational testing (with core identity and alternates)
  • Family Relations Test
  • Imaginary Friends Questionnaire (Silberg, 1996) It helps differentiate between normal imaginary friends phenomena and more pathological dissociative projections.
    Item numbers 1,3,4,5,7, and 10 are more characteristic of children with DID and Dissociative Disorders not Otherwise Specified. The remainder items, acknowledged as “true” are typical of normal children with imaginary friends.
  • Multi-Dimensional Inventory of Dissociation (MID; Dell, 2002; Ruths, Silberg, Dell &B Jenkins, 2002)
  • Psychological testing (with core identity and alternates)
  • Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D; Steinberg, 1994)
    A structured interview that can be used with adolescent who can maintain adequate attention and a have a high level of cognitive functioning. Is a self-report questionnaire that is proving a good diagnostic tool for adolescents.
  • Trauma Symptom Checklist for Children (Briere, 1995) This checklist includes a dissociative subscale plus five other scales for: anxiety, depression, PTS, sexual concerns and anger

For older children, adolescents and carers, some of the adult screening tools can be adapted:

  • Dissociation Questionnaire
  • Dissociative Experience Scale
  • Questionnaire of Experiences of Dissociation
  • Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) (Steinberg 1994a, 1994b), can be adapted for children, adolescent and Carers as they allow the clinician to systematically evaluate and document the severity of specific dissociative symptoms and disorders.
  • Dissociative Disorder Interview Schedule (Ross, 1989). This is a highly structured interview developed to diagnose dissociative and other psychiatric disorders, and
  • some commercially available informal office interviews can also be employed (Bernstein & Putnam, 1986; Loewenstein, 1991; Riley, 1988; Vanderlinden, Van Dyck, Vandereycken, Vertommen, & Verkes, 1993).

Testing for comorbidities is also important, thus the clinician will also have to use tests and other tools to assess for developmental disorders, behavioural disorders including Attention Deficit Hyperactive Disorder, Obsessive-Compulsive Disorders, Eating Disorders, Substance Abuse and other affective and personality disorders.

Other psychological tests believed to be helpful by some:

  • Rorschach - to help improve understanding of the patient’s personality structure (Armstrong, 1991).
    However, other clinicians believe some tests contribute to the misdiagnosis of dissociative disorders, such as:
  • MMPI and Wechslers (Bliss, 1984; Coons & Sterne, 1986).

Once a diagnosis is established, the therapist must then sort out how symptoms relate to dissociative episodes. Observation of symptoms and changes should be carefully carried out before attempt at therapy or medication.

DIFFERENTIAL DIAGNOSES:

Many of the vast symptoms presented by children with DD/DID suggest/mimic other psychiatric disorders. Frequently found symptoms that may appear to represent other diagnoses consist of:

  • Brief amnestic periods
  • Switching between alternate personalities
  • Affect disturbances
  • Thought process disturbances
  • Somatoform symptoms
  • Anxiety PTSD
  • Borderline personality

A SUMMARY GUIDE TO DIFFERENTIAL DIAGNOSIS

  1. ATTENTION AND MEMORY PROBLEMSADHD
    Mania
    PTSD
    Schizophrenia
    Neurological conditions
  2. AGGRESSION (fighting, injury to others)
    ADHD
    Depression
    Mania
    PTSD
    Schizophrenia
    Oppositional Defiant Disorder
    Conduct Disorder
  3. RISK-TAKING (reckless disregard of danger)
    ADHD
    Depression
    Mania
    PTSD
    Schizophrenia
  4. SELF-INJURY
    ADHD
    Depression
    Mania
    PTSD
    Schizophrenia
    Borderline Personality Disorder
  5. MOOD AND MOOD LABILITY
    ADHD
    Depression / Bi-polar
    Mania
    PTSD
  6. SLEEP PROBLEMS
    ADHD
    Depression
    Mania
    PTSD
    Pervasive Developmental Disorder
  7. ANXIETY AND HYPERAROUSAL
    ADHD
    Depression
    Mania
    PTSD
    Schizophrenia
    Neurological problems
  8. THOUGHT DISORDER
    Depression
    Mania
    Schizophrenia

THERAPEUTIC TREATMENT MODELS

Children recover quickly (between 1 to 2 years) once appropriate therapy has started and they have been placed in a safe home, with good parenting. Given the opportunity they move naturally towards healing and integration, letting go of the identities and continuing with normal development.

Though relapses occur with new traumas they learn, through therapy, to see these as a natural process (going back to a known defense), as relapses they can overcome and learn from

TREATMENT MODALITIES

No primary treatment model has been found to be most useful with DID children. Instead, an eclectic approach that is flexible and adapts ideas found successful by researchers and other clinicians into the professional’s most comfortable framework has been found to be of most value.

Any treatment plan has to be made in relation to the individual circumstances of each child. Although the child’s needs, feelings and preferences as well as the Carer’s ability to support therapy need to be explored and considered when devising and implementing a treatment plan, it is the therapist, not the patient, who has the ultimate decision in drafting and deciding on the best possible treatment plan and desired outcomes. Treatment teams may include a variety of professional disciplines, depending on the child’s developmental stage and arrested stage, as well as to remediate any learning difficulty/ educational lapse the child may have had

Eclectic Modality:
A preferred treatment modality by many clinicians is often an eclectic one, through Case Management given on an individual, outpatient approach that has psychodynamically aware psychotherapy technicques (Putnam & Loewenstein, 1993). For example, a child adapted narrative approach with cognitive therapy techniques can be modified to help clients explore and alter dysfunctional trauma-based belief systems. Because DD and DID clients are high risk children, crisis management strategies used with high risk cases, such as PTSD, Abused and Trauma victims should be incorporated into therapy.

Behavioral Techniques
Behavioral analysis, or operant conditioning, has not been shown to be an optimal primary modality for treating DID. 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.

Non-Verbal Therapies
Most children respond very well to nonverbal therapy techniques such as art therapy, music and dance/movement therapy, sand tray therapy, other play therapy derivatives, and recreational therapy. Occupational therapy can also be a helpful adjunct.
Nonverbal therapies need to be conducted by appropriately trained persons and be well timed and well integrated into the overall clinical treatment plan. Keeping a journal – by Carer and older children has also been found valuable.

Non-Clinical Therapies
Though several other non-clinical therapies or strategies may be used to aid in the process the clinician must be careful that these therapies do not, in any way, duplicate any part of a ritual or past abuse, e.g. Exorcism.

Hypnotherapy
Hypnosis is employed by most therapists as a modality in the treatment of DID (Putnam & Loewenstein, 1993), more commonly used for calming, soothing, containment, and ego strengthening.
In using hypnosis, because of the child’s vulnerability and need to fill in memory gaps the therapist should be very conscious of the line of questioning used and minimize the use of leading questions that may in some cases alter the details of what is recalled.

Hypnosis or amytal interviews may be helpful when alternative diagnostic measures have failed to yield a definite diagnosis or when there is urgency to establishment a diagnosis (e.g. medical necessity, particularly with older children and adults. However, it should be noted that amytal and hypnosis alter the patient’s state of consciousness and thus, may bring forth 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.

Hypnosis has also been found helpful in the recovery of “unconscious” memories and in bringing forth “identities” in adults but is controversial with children. The therapist must be careful as some severely abused children, such as survivors of ritual abuse may have been hypnotized and will be further traumatized with this method. Also, it may cause the child to create new personalities to please the therapist, or push the child into an episodic experience that the therapist is not yet ready for.

Some DID experts believe that hypnotic techniques can be useful in helping clients manage crisis, stop spontaneous flashbacks and help them to reorient themselves to external reality when these occur outside therapy. Some also believe it helps in calming aggressive expressions, in the safe expressions of feelings, in the relief of painful somatic reprocessing of traumatic material and for cognitive rehearsal.

Hypnotic techniques can also be useful for ego strengthening, for supporting clients during crises and to help them remain stable between sessions in which they are recalling or discussing traumatic material that may bring other associations outside of therapy.

A further role of hypnosis is in aiding and increasing communication between identities and in bringing identities into communication with the therapist.

Some clinicians also believe that hypnotic techniques can be useful in the retrieval of memory and that it facilitates memory processing. However, there is the danger that this process may cause increases in mislabeling fantasy as real memory and thus, increasing the belief in the “retrieved” imagery that may actually be fantasized. The therapist needs to be aware that hypnosis may bring forth both real as well as fantasy memories which may not be able to be confidentially discerned and that the client may be left with an unwarranted level of confidence in the accuracy of the details of memories recovered in this manner.

The existence of DID might also be unexpectedly revealed during hypnotherapeutic treatment of another condition. This is particularly so when treating older children and adults. Patients diagnosed with DID when using hypnosis do not differ in diagnostic criteria and symptoms from DID patients diagnosed without hypnosis (Ross & Norton, 1989).

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

The therapeutic use of hypnosis should be conducted with appropriate informed consent provided to the patient concerning its possible benefits, risks, and limitations.
A further issue is that information attained through hypnosis is not admissible in the legal system.

INPATIENT TREATMENT

Inpatient treatment for children with DID is not the preferred treatment modality. If necessary, when existing complexities are present, it should be used only for the achievement of specific therapeutic goals and outcomes, mainly, to stabilize behavior and to stop self-destructive behaviors. The environment should be well structured and have very experienced staff.

Inpatient treatment should then be in the context of a well-identified goal-oriented strategy designed to build strengths and required skills and stabilize and restore the child to a stable level of functioning so he/she can be transferred as soon as possible to an outpatient treatment modality. If possible, inpatient treatment should be planned and contracted for with child and Carer prior to an admission or as soon as possible.

With children lacking the support of a nurturing environment a planned inpatient period to deal with traumatic material/abreactive work that will require containment and a very supportive structure would be beneficial, particularly if aggressive and self-destructive identities are expected to emerge.

Clients that are dysfunctional, are massively decompensating or require to be stabilized because of experiencing severe present-day trauma, may require prolonged inpatient treatment in order to be restabilized. To be successful, these inpatient treatment episodes should be well structured, have realistic, well defined goals, be outcome oriented, be client-focused and encourage independence and progression.

Length of stay should be in relation to the outcome desired and should consider the possibility of dependency, yet also consider the risk of readmission if too early discharge.

DID clients with comorbidities, particularly if these are mental disorders (severe depression, suicidal ideation, eating disorders, substance abuse/dependency), will require intercurrent hospitalisation.

GROUP THERAPY

Group psychotherapy is not a viable primary treatment modality for DID. However, later on in therapy, depending on the client’s needs and symptoms, it could be a valuable adjunct to individual psychotherapy as it can promote a sense in the client that he/she is not alone as others have also experienced traumas and are dealing and coping with the memories and finding resolution. Depending on comorbidities, e.g. depression or eating disorders, a group situation might also be beneficial. In some cases it has also been found beneficial as a psychoeducational intervention and to build positive peer interactions and resiliency. The groups, however, would have to have a high therapist/co-therapist-to-patient ratio and be structured very carefully, with clear boundaries. Planning and structure should be similar to an inpatient modality, with clear focus, well outlined outcomes and clear time frames.

Some clinicians have found that open-ended and “marathon” therapy groups are not productive as they destabilize clients and promote acting out among the group members and do not have a positive outcome.

TELEPHONE THERAPY AND TELEPHONE AVAILABILITY

DID clients are prone to crises at certain points in treatment and at times of environmental, seasonal, anniversary or other reminders. Because of this therapist’s availability in emergencies can be important. However, clients and Carers need a clear statement about the boundaries of this availability. Generally, offering regular, unlimited telephone contact is not helpful. The therapist can allow a limited availability, under certain conditions, to both the child and the Carer and provide a Crisis Intervention number for other times. Except under unusual circumstances, regular calls initiated by the therapist to check in with the patient are not recommended.

If the client is a private client, paying for the services, then the payment policy for telephone contact should be discussed with the patient at the initiation of therapy.

CONSIDERATIONS IN ANY TREATMENT

Coordination:
Close coordination with other medical specialists may be required when there are:

  • physical consequences of the abuse suffered by the child
  • psychophysiological symptoms or notable somatic expression of traumatic material (i.e., sensory or functional changes that correlate with the history of abuse)
  • phobias or fears about medical care or similar symptoms.

Comorbidities:
Comorbidity is a frequent problem and thus, these may also require specific treatments. Frequent comorbidities may include:

  • eating disorders
  • sexual disorders
  • mood disorders
  • sleep disorders
  • behavioral disorders
  • relational disorders
  • fears and phobias
  • anxiety
  • addictions in older children (e.g. alcohol)
  • learning difficulties (caused by developmental arrests, identities taking over or failure to attend school)

Awareness of legal Involvement
Clients may be also having legal involvements, which may require supportive intervention. With clients involved in legal proceedings, it is important to avoid planned therapeutic interventions that may compromise the credibility of the patients in forensic proceedings at a later point in time, such as hypnosis and other therapies that may not hold strong validity in court.

Working with Memories
An integral and central part in the treatment of DID is dealing with the memories of past abuse and traumas that caused the dissociation and the creation of identities and the relationship that this material has to present beliefs and behaviors.
All memories, regardless of the believe that they are fantasy or real must be dealt with, within the context of appropriate timing in therapy. Therapist and client should discuss early in therapy the possibilities of fantasy memories and the fact that sometimes the “real” truth may not be available but that therapy will also deal with this.

There has been and continues to be a strong debate on the issue of recovered memories. Some professional groups working in this area have concluded that it is possible to forget memories of abuse for a long time and to accurately remember them much later in life (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). However, these same professionals noted that it is possible that some people may construct pseudomemories of abuse or mix true experiences with fantasies, confabulate, feel in gaps, expand or condensate several events. They also noted that it is sometimes impossible for therapists to know the extent to which someone’s memories are accurate in the absence of external corroboration. Because in many, if not most instances, it is difficult for either client or therapist to discern truth from fantasy, calling the memory false will not benefit the client. Instead, a neutral position should be taken, recognizing that memories do change with time and that the need to work with what the client remembers is more important.

Some of the traumatic memories may be present at time the therapy starts but others may surface during the intervention, either spontaneously or through the planned therapy process. Abreaction (the planned process to recover memories) is a valuable treatment technique but not therapy itself. Recovery of memories should be cautiously done so as not to encourage false memories. The clinician must all times create an environment that gives the client a sense of control and mastery.

Process and Strategies:
There are several planned processes employed by therapists: giving information, exploring experiences / perceptions / believes / etc., amongst other strategies. When working with the recall of memories it is also important that the client be taught strategies to reorient themselves to external realities and stop or delay the intrusiveness of memories in their day-to-day life. Key words or phrases can also be used/taught to help children identify changes in mood or identities and associated behaviors, so they can learn to control these.

Setting Boundaries
Establishing clear, well-defined boundaries is a very important part of the therapy and child-client relationship and should be discussed and defined in the first therapy session. Most abused or neglected children have generally lived in environments where personal and other boundaries were either not established or not followed/respected. Clear and firm boundaries will allow for containment in therapy and clear expectations. These boundaries may be challenged, forgotten or change with the progression of therapy so ongoing reviews and reminders are important.

DID children generally lived in environments where all boundaries were either not established/not followed/respected. Establishing clear, well-defined boundaries/expectations is a very important part of the therapy and child-client relationship and should be discussed and defined in the first therapy session. This will also allow for containment in therapy. These boundaries may be challenged, forgotten or change with the progression of therapy so ongoing reviews and reminders are important.

Boundaries should include:

  • place for therapy (always the therapist’s office)
  • days and times for therapy sessions (always set days/time); length of therapy (1 to 2 hours for young children, more for older children)
  • length of therapy
  • type of documentation and their security/ confidentiality (e.g. videos and other recording outside of files);
  • behavioral requirements (e.g. no hurting self or others and how this will be managed; “touching” rules for both therapist and child)
  • duration of sessions and frequency
  • limits of confidentiality and therapist’s ethical and legal responsibilities and duty of care
  • who should be involved in the therapy and under what conditions
  • out of therapy calls or unscheduled sessions
  • when would hospitalization be recommend and process for this
  • any legal involvement, ramifications and therapist’s role and responsibilities and what will be admissible/not admissible in Court if required to testify

Ethics and Guidelines
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.

The International Society for the Study of Dissociation (ISSD, 1994) published guidelines for adults and included some for children. These are quite extensive.
Knapp & VandeCreek (1996) made 6 recommendations:
1- maintaining clear boundaries
2- diagnosing carefully
3- using sound, reliable clinical techniques
4- showing concern for family relationships
5- documenting carefully (eg. Taping; videos)
6- consulting with other professionals

Silberg and Waters see clients from 3 months to 7 years, depending on client factors and have a 5-phase intervention:
1- Assessment and identification of personality system
2- Building Internal Cooperation
3- Processing trauma
4- Integration
5- Post-unification treatment

Braun’s (1986) treatment goal is congruent with his BATS: behavior, affect, thought and sensation.

PHYSICAL CONTACT AND PHYSICAL RESTRAINTS

Physical contact in therapy or as a restraint, is not recommended with any client as part of the treatment intervention, particularly with DID clients, not only because of the ethical considerations but also because of the connotations that touching can have for a DID client.

Sometimes a client may ask for hugs or hand-holding. In these situations the therapist needs to explore the reasons and meanings for this requests instead of fulfilling them. Simulated breast-feeding or bottle feeding are unnecessarily regressive techniques that have no role in the therapy of DID.

Some therapists find that for some clients 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 but there are other methods than can be employed and taught to the client before the abreaction. Even in planned touching is employed during abreaction, there is the risk of the client misinterpreting such contact, thus, it should be avoided.
There are several varied opinions as to the value of voluntary physical restraints in treatment. Some therapists believe it to be helpful as a last resort when physically aggressive or self-destructive identities are otherwise unable to participate in therapy. Others therapists believe that voluntary physical restraint is inappropriate and that verbal techniques are enough to involve all the identities in therapy. Again, the use of restraints, be it voluntary or not, may replicate the trauma experienced by the child, re-traumatize the client and may create a trusting breach between client and therapist.

If a therapist frequently uses physical restraints or does so for long periods, then the therapist should reassess the pace, dynamics and nature of the therapy and the patient-therapist relationship.

If clients or Carers in name of the child request referral for massage therapy or other types of body work, the risks and timing of such therapy should be carefully discussed with the patient.

MY MODEL

In general, I prefer a Case Management approach involving all those that relate to the child – other professionals as well as parents, teachers and meaningful others, though at times this is not possible.

Intervention takes a non-leading approach – no “yes/no” questions, etc. Several experts caution about the suggestibility of children. There have been several articles on the issues of repressed memory and the claim of iatrogenic creation of false memories as an artefact of therapy or by deliberate implantation by the therapist. The therapist must recognize the powerful position of their role as a “reinforcer” and the need to ensure the child is encouraged to be open, speak freely and use his/her own language, without constraints.

I use a seven phase therapeutic treatment that starts at the time of the assessment. This model is much in line with other therapists involved in this area,. Though these are not discrete, they assume relative temporal predominance:

  1. Establishing a safe, trusting, nontraumatic, nurturing environment, in accordance to the child’s needs. A safety contract is important for both therapy rooms and home and home safety should be closely monitored. This is a must, as without it therapy should not commence.

    I start by carefully explaining and educating the child on the reasons for therapy and the dynamics underlying trauma, dissociative symptoms, PTSD symptoms, etc.

    Therapist must create an accepting, understanding relationship with the “whole” child, which means each of the identities, their experiences, memories, regardless of level they are at or their acceptability by the child or other identities are unconditionally accepted and communicated with. Through this, assist the child in understanding himself/herself as a “whole” person and achieve self-knowledge, self-acceptance and a sense of cohesiveness about his/her identities, memories, beliefs, experiences, fears, feelings, cognition and emotions. This is what eventually leads to “integration” and the child’s ownership of the whole person as the “Me/I/mine”.

    The environment should be re-assessed according to the child’s need as the child progresses, or fails to make progress and changes are made. In doing this, the family’s environment and need for therapy, even if the child is not there, should also be worked with, in order to safeguard the child. The environment should be regularly assessed for safety and stressors as these may cause failure to progress or cause regressions.

    There should be continual reassurance of physical safety not only for the core identity but also for the identity (“I will keep all of you safe. No one will hurt you when you are with me, in this room. I will not allow it”). These children commonly misinterpret their physical and social environment and require assistance to clarify misconceptions and decrease dissociative episodes. The child’s environment should be stabilized.

    Assaultive and destructive behaviors should not be interpreted as attack to the therapist but seen in context of the child’s past. Assaultive and destructive acts, however, should not be accepted. Safety boundaries, should be established and the child should be encouraged, gently and in line with his/her coping abilities and resources to accept limits and responsibilities.

    Though in therapy the child should have no consequences as it is the therapist’s duty to ensure safety, at home and at school, with discussions involving the child, the child or the identity performing the destructive act, should have consequence – e.g., time out.

    In all situations, the child/identity should be informed that they are all responsible for the behavior and that they should help each other next time so that they don’t hurt others or themselves again. Use of words such as “getting into trouble again” should be used with caution as there could be associations to certain words.
  2. Gathering individual and system history to form a positive - accepting - therapeutic alliance that can contain behaviors that are destructive to the child and others. This is done in order to explore and retrieve information that was previously unavailable in order to chain together the dissociated memory traces so as to understand the full meaning of the experience in the child’s present reality.

    All identities of the personality system should be identified (without a voyeuristic fascination that may encourage symptoms or the creation of more identities). All identities should be accepted, and their names respected. It is important to know the name of each identity, age when created (and if age has shifted), where it was created, how and why (what role/functions the identity has). The issues of each identity must be worked through. Through this, help the child and identities to know the history, to accept each other, eventually have inter-identity communication, do team-building so that eventually they can assist each other, till there is integration.

    Attempts at integration should be left for last, after Child has acquired good coping skills. The child’s readiness (e.g. not wanting to give the parts up as s/he “might need them” when forced to see an abusive parent that still is in denial) should be considered.
  3. Improve overall ego functioning and management of disruptive/destructive emotions and behaviors by targeting for therapy those emotions and behavior categories that interfere most with the child’s ability to meet his/her needs. There are three main goals here:
    • for the child to learn adaptive and flexible ways to manage affect while integrating experiences between past and present,
    • to promote autonomy and encourage self-regulation and self-monitoring of emotions and changes in identities by identifying precursors to changes and finding more positive alternatives
    • to achieve compatibility between behaviors in different categories, so that the child is able to effectively try and acquire more functional and adaptive problem solving skills and meet his/her needs in all areas and progress to new, more normalizing experiences. The child’s motivation for growth and success should be enhanced and he/she needs to be encouraged to participate in age level activities with peers. Isolation should be prevented as this may reinforce DID.
    Dissociative barriers are decreased by encouraging the child to tolerate and explore feelings and thoughts that are present in dissociated parts of self and to accept and deal with memories. Do not assume the impact of these, nor interpret them (e.g. identity seeing a mutilation was more traumatized by not knowing the name of the youth being sacrificed and by the dismembered parts of her body not buried all together). Allow the client to do the interpretation. Develop a narrative of the traumatic events and process these memories on many levels. Creating alternative endings, e.g. excavating parts and burying them all together in a safe, secret place of peace (caution should be had with this if child is going to Court as this will interfere with true memory).

    The child should be encouraged and reinforced for learning to call on various identities to help them in difficult situations. However, great caution (early contract on this is useful) to not encourage the host to create more identities or to have these act out. Care should be taken for host to gain control.

    The child’s individual and collective strengths are identified and discussed with the child and are viewed as equally desirable and important and allowed to exist without criticism. Explore the conscious memories of the child, as a whole, including alters and fragments, in order to restructure distorted cognitions, perceptions and sensory experiences. The therapist can help by speaking to all the identities at once and seeking their assistance in reconstructing memories, explaining behaviors and reinforcing acceptable behaviors.

    The integration of this self-soothing capacity follows over time and integrates with the child’s developing self-definition.

    The main therapy work, however, should be done mainly with the “core”/client (different to adults) because of developmental issues and the risk of reinforcing and shaping influences in response to the treatment intervention. I thank/praise identities for the great job they have done to help/protect host and let them know they can now relax – not needed as host able to care for self and cope).
  4. Systematic meeting of identities, broadening the scope of tolerable affect, increasing the range of coping strategies, decreasing dissociative barriers, and abreaction and working through of traumatic memories and conflict-laden issues.

    Through therapy the child’s capacity to tolerate a variety of feelings, memories, and experiences grows and this results in a diminution of the need to dissociate, as well as increased mastery over his/her behavior and the development of age-appropriate coping skills.(e.g. young identity asks “Do you fly? Do you go inside? What do you do when you don’t like it?” is told “No, I deal with it without flying” and youth asks “”Can I learn to do that?”). This is also part of ongoing education to deal with the feelings (e.g. pain), when dissociation is no longer used.
  5. Integration of identities (Resolution) is carried out after developmental tasks have been achieved and personality has been integrated.

    Even though work at integration starts from the beginning, through the awareness and acceptance process (in and out of therapy as identities become known), it is neither discussed nor approached until the end parts of the treatment. It is a process carried through:
    • self-acceptance and self-love of each part of the self;
    • the learning to have freedom to choose new coping mechanisms;
    • learning how to relate better to self, to life and to others, and later in therapy to own feelings, emotions, thoughts, etc. as an “I/Me/Mine”.

    The child with DID is not a collection of separate people sharing the same body. She/he is a single, whole person who experiences himself/herself as having separate identities of the mind that function with some autonomy. These identities share responsibility for the client’s life and as such, the therapist should hold the whole child to be responsible for the behavior of all of the identities.

    Wherever possible, treatment should move the patient toward a sense of integrated functioning. Though in therapy I often addresses the identities as if they were separate, the therapeutic work should bring about an increased sense of connectedness or relatedness among the different identities. This I do by sharing experiences, commonalities, internal awareness and communication through narratives, tapes and drawings. Because of this it is crucial that the client not create additional identities nor give names to identities that have none. Similarly, the child must be discouraged to give roles or functions to passive identities or make them more autonomous. On the other hand, it is counterproductive for the therapist or the child to ignore or get rid of identities outside of the due process of therapy. 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.
  6. New coping skills start early but are reinforced at this phase of therapy and checked for success, and post integration therapy and follow-up at regular intervals through adolescence, to ensure maintenance of integration and new learned skills; and
  7. New social networks and educational supports for school and socialization. This may include linking to appropriate resources for training, retraining, remedial training, bibliotherapy, expressive therapies and other required treatments.

    Post therapy follow up should be scheduled at set, agreed on intervals in order to solidify skills learned in therapy and ensure the continuation of safety and familial, social and educational supports.

LENGTH AND FREQUENCY OF TREATMENT
Therapy with children and adolescents is not as lengthy as with adults. There is no firm rule/recommendations as to frequency and length as this will depend on the child’s age, severity of the case, support systems, family/environmental circumstances/resources and therapist’s expertise. The therapist must be flexible and assess conditions well, particularly the possible need to stabilize child’s environment/family before entering intensive therapy.

Number of sessions should be in accordance to the expertise of the therapist and the child’s functional status, stability and supports available/given in the environment.

The minimum recommended frequency of sessions are twice a week for therapists having adequate skills. Some very skilled therapists are able to treat in once-a-week sessions but, with some patients, particularly in the later stages of integration, a greater frequency of scheduled sessions (up to three or more per week) is advantageous as this maintains the highest possible level of adaptive behavior and better contains disruptive behavior. Frequent outpatient sessions is also a preferred alternative to hospitalization.

For patients newly discharged from inpatient treatment, a period of intensive and frequent sessions may be necessary to help 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 dependency.

Lengthy sessions - over 90 minutes – are not recommended for children though some adolescents can cope well with them. These should be scheduled, planned in advance and discussed with the client and Carer. They should have a structured plan and have a specific focus, as with adolescents, the completion of amytal - or hypnosis-assisted processing of traumatic memories and imagery, or administration of a comprehensive diagnostic battery.

Lengthy/marathon sessions may also be beneficial for the provision of structure and support in dealing with particularly difficult material or an unresolved memory requiring closure. They may also be indicated when the client cannot come often enough to sessions because of traveling distance or other complications.

Historically, treatment outcomes indicated that over 2-3 years of intensive outpatient therapy was enough for clients to attain a relatively stable condition without experiencing a sense of internal separateness. However, most therapists now see 3-5 years as a minimum length of treatment.

The length of stay in treatment will vary according to the complexity of the client’s pathology (see Axis II), comorbidity, support structure and interfering medical/educational conditions and needs for interim hospitalizations. More complex clients will require 6 or more years of outpatient treatment.

Therapy Techniques that are helpful:

  • play therapy
  • structured and unstructured games
  • sand tray
  • art therapy: drawings and paintings
  • dance, music
  • poetry and singing (writing own poems/songs)
  • narratives / story telling
  • computer-assisted communication
  • writing
  • imagery rehearsals

PHARMACOLOGY

DID children as well as adults do not respond to medication in consistent and predictable ways.

Psychopharmacology is not the primary therapeutic approach for dissociative symptoms and medication should not be used as the sole treatment modality. Furthermore, systematic research in the use of psychotropic medication with dissociative disorders is still forthcoming.

Many children with DID/DD do not need medication and should not be exposed unnecessarily to their potential side effects.

There is no medication that treats the most problematic core symptoms of dissociative disorders: amnesia, instability of consciousness, and identity alteration.

Before pharmacology, first commence psychotherapy and observe the client’s changes. If needed, only the absolutely required to treat the entire personality system, or most of the predominant identities, should be initiated.

Medication can be helpful as an adjunct to psychotherapy in severe symptoms and/or comorbidities, such as treating some anxiety-related dissociative symptoms, severe sleep problems, hyperarousal, posttraumatic stress disorder symptoms, depression overwhelming anxiety, ADHD, and coexisting affective symptoms or disorders, that may interfere with daily functioning and progress in psychotherapy.
Therapists must make clients and Carers 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 identities within the same patient may report different responses and side effects to the same medication.

A QUICK GUIDE TO MEDICATION FOR CHILDREN WITH DISSOCIATIVE DISORDERS
(Elaine D. Nemzer)

1. If there is no drug-responsive target symptoms or co-
morbid conditions, then use psychotherapy only (no medication)

2. If patient has PTSD, identify the main symptoms.
a. For intrusive thoughts, avoidance, numbing, sleep maintenance problems or nightmares: consider SSRI or TCA
b. For hyperarousal, consider clonidine, guanfacine, or propranolol.
c. For sleep-onset problems, consider oral clonidine, antihistamines, or trazodone.
d. For night terrors, consider short-term low dose TCA or BDZ

3. If patient has ADHD, consider stimulants, clonidine, buproprion, or TCA

4. If patient has a major depression or dysthymia, consider SSRI, buproprion, or TCA

5. For co-morbid bipolar disorder, consider lithium, valproic acid, or carbamazepine.

6. For anxiety or panic disorder, consider SSRI, TCA, buspirone, short-term BZD, or antihistamine.

7. For obsessive-compulsive disorder or eating disorder, consider SSRI or clomipramine.

9. If patient is aggressive, consider clonidine, propranolol, lithium, or anticonvulsants.

10. If patient is disorganised or psychotic, consider an antipsychotic such as risperidone.

THERAPY GOALS

Treatment goals should me aimed initially at symptom stabilization, control of dysfunctional behavior (particularly therapy interfering behaviors, such as aggression and avoidance), restoration of functioning, control over self and behavior, and improvement of relationships. These goals should be dressed in an ongoing way, in each therapy encounter, both through direct approaches and through psychotherapeutic work that leads to increased coordination and integration of mental functioning. The goals should be consistent and be carried over at home, school and any other environment attended by the child.

Therapy goals may follow the following sequence:

  1. To confront and relive early trauma in a way that the individual gains control over the horrible situation events, as they continue to occur in the child’s mind in the present and to make the trauma simply a terrible memory of a particular past period.
  2. Significantly reduce symptomatology by desensitizing traumatic memories and teaching more functional behaviors/attitudes to sequela of trauma.
  3. Encourage growth, autonomy, self-regulation and teach age appropriate functional coping skills.
  4. Develop in the child positive self esteem and self acceptance of the whole person.
  5. Achieve in the child a sense of cohesiveness about the identities, emotions, cognitions and associated behaviors.
  6. Conflict resolution of feelings, needs, wants, etc.
  7. Fulfill the child’s familial and social interpersonal relationships, if possible.
  8. Integration of parts


VERY IMPORTANT IN TREATMENT

  1. Trust - therapeutic alliance
  2. Diagnosis/acceptance (patient and therapist)
  3. Therapist must be consistent yet flexible
  4. Therapist must not take accusations/abuse personally
  5. Establishment of boundaries between the therapist and the client (“I am your therapist…”)
  6. Therapist must be cautious of the “double bind” as this has usually been the style of interaction experienced by DID clients.
  7. Therapist must be aware of the potential problems associated with suggestion in therapy
  8. The therapist should be well informed about contemporary memory research
  9. Don’t accept “revelations” as “facts”
  10. Constant “Grounding” - differentiation of “past memory” as different to the “now”
  11. Setting treatment plan that will define:
    • safety area
    • communication with all parts
    • which part would like to meet therapist first
    • assessment of past treatment(s) and what helped /did not help
    • assessment of developmental/past history:
      • when aware of dissociations
      • memories held/by what identity
      • gaps in memories
      • affects in daily life and job
    • getting names of each identity and their role
    • how were identities created
    • why did each identity appear (why were they created) in terms of precipitatives and perpetuating events associated with its development? Are they present now? Why still present at this time in life? Genesis of each part and duration of time it has executive control of the body.
    • where was client at time of each creation (where was each identity physically created in real world; inside the head and in the power structure). Where does each idetity fit in the power structure, and where each identity fits into the system of the client’s personality.
    • the function of each identity and how he or she aids the system as a whole
  12. Setting limits
  13. Respect and equal treatment for all parts
  14. Making a Contract (or hospitalize) with host and all parts, as needed:
    • type and regularity of treatment
    • be part of “the therapy team”
    • no set time for duration of sessions/treatment, though a minimum (1 to 2 hrs.) to a maximum (3 to 5 hrs) duration for therapy is suggested
    • use of specific procedures (eg, hypnosis) and written permission by Carer
    • no self hurt, suicide or homicide contract (eg: “I will not hurt myself or kill myself, nor anyone else external or internal, either accidentally or on purpose at any time.”)
    • Contracts will need to be renewed periodically as therapy advances and new issues arise. An issue to be contracted for will be the introduction of taping, cassette/video and how will these be reviewed with client. One of the final contracts will have to deal with the issue of resolution - integration and how will this be done.
  15. Taping sessions and taking good notes - clients tend to not remember great parts of the session because of shifts and defence mechanisms.
  16. Giving client copy of notes/drawings to remember session and when ready, with therapist present, go
    over tapes (helpful for client to get to know the other parts)
  17. Therapist must have great sensitivity to client’s reactions during therapy and must ensure client leaves in a well state.
  18. Therapist must be very aware of him/herself and possible reactions to horrific revelations and be able to deal with these, without showing disturbances or fear as identities will realize therapist’s inability to deal with issues and stop making themselves available to therapy and stop memory recovery process.
  19. Therapist must be available 24 hrs. a day for emergencies as clients, once memory starts to re-emerge, will have flashbacks during sleep and waking - at any time and will not be able to deal with these without help.
  20. Teaching new coping skills and problem solving.
  21. Social networking, educating and liaising as needed.

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INITIAL CONTACT: PROVISION OF WRITTEN MATERIAL REGARDING BOUNDARIES & EXPECTATIONS IS RECOMMENDED TO COVER THE FOLLOWING:
“Trauma Memory and Dissociation” , p.9 Australian Association of Trauma and Dissociation Inc.
4th Annual Conference (1995)

• Office hours and availability
• Telephone contact availability
• Interruptions during sessions
• Confidentiality
• Scheduling of sessions and changes of appointments
• Availability of extra sessions
• Length of continuing attendance
• Client lateness and effect on session time
• Payment of sessions
• Payment of missed sessions
• Minimum time required to terminate sessions without incurring fee for the session
• Physical contact between therapist and client
• Client/therapist relationship inside and outside of the sessions
• Therapist’s role
• Expectation of client’s commitment to therapy activities and home support
• Mention of further material to be referred to regarding informed consent and contamination concerns if child abuse has occurred or is thought to be a possibility

ETHICAL THERAPEUTIC PRACTICE ON COMMENCEMENT OF THERAPY
“Trauma Memory and Dissociation” , p.12 Australian Association of Trauma and Dissociation Inc.
4th Annual Conference (1995)

• Provide written information regarding boundaries and expectations
• Obtain a written case history by the client in addition to verbal interviewing
• Provide information about informed consent and contamination where abuse is reported or queried
• If using hypnosis, provide informed consent including its effect on litigation cases
• Provide appropriate information/resources re abuse and the delayed memory debate
• In the interests of avoiding contamination by therapeutic (as well as legal) issues request that until certain stages of therapy are reached that the client:
 Does not read material or accounts of abuse OR of false memories of abuse
 Does not attend seminars, conferences, workshops, other educational forums without ascertaining the therapist’s recommendation or otherwise
 Does not discuss abuse/details of abuse with other survivors or join unsupervised survivor/support groups where details of abuse or other contaminating material may occur
 Does not watch TV programs on the subject of abuse OR false memories
 Does not expose him/herself to any material
 Does document any material he/she is exposed to
 NB: these become important sources of support and corroboration when timing is carefully considered by the therapist (rather than becoming part of the problem)
• Provide opportunity to discuss and clarify any material before the client signs
• Discuss ethical, therapeutic and legal issues – documentation of pre-therapy memories of abuse and as they arise
• Provide the option for documenting sessions if the client wishes – i.e. audio or videotaping (with therapist owning and securing these)
• Ensure documentation of the client’s wish for A/V use and record any changes to this desire and the reason why with the client’s signature
• Explore the literature around the delayed memory controversy
• Inform clients about the delayed memory controversy and backlash – both extremes
• Avoid taking ‘sides’ and focus on the issues critically
• Discuss the nature of memory being shaped by various factors and explain the research on the difference between normal memory and the encoding of traumatic memory neurobiologically
• Emphasize not to automatically take images or associations with abuse at face value as ‘memories’ but allow the time to explore if they are:
1. accurate in detail, i.e. literal, historical truth reported or queried
2. purely symbolic
3. a blend of accurate, distorted and symbolic material
• Do not recommend confrontations – these are irresponsible to both the client and the person(s) alleged to have been abusive in the earlier stages of therapy where apparent memories may not be clear and the motivation may equally be confused
• Discuss the client’s feelings about contact with reported abusers/families. Where contact is overtly abusive it is advisable to suggest to a client to cease contact or at least reduce it. Continued contact may also make progress in therapy more difficult. A detailed explanation to the alleged abuser of why is not recommended given the danger of inaccurate memories as well as perpetrator denial and retaliation which may be retraumatising to a client insufficiently through his/her process to deal with this. The client can simply express appreciation of support through the alleged abuser(s) acknowledging his/her request to be allowed undisturbed time and space to work through the various issues the client feels he/she needs to sort out.
• Do recommend family mediation sessions where the client wishes to remain in contact with the family once he/she has disclosed abuse by a family member(s)
ETHICAL PRACTICE IN GENERAL

“Trauma Memory and Dissociation” , p.14-15 Australian Association of Trauma and Dissociation Inc.
4th Annual Conference (1995)

• Be aware of leading, assuming, suggesting or interpreting a client’s material – utilize skills to avoid this and to place responsibility with the client
• Cover solid ground work well before memory processing or re-association work, e.g. issues of responsibility and self-care; boundaries; containment; internal communication; internal/external support systems; fallibility of memory, etc.
• Clarify the therapist’s role is not to verify the client’s memories (unless a witness or without corroborating evidence) but to offer an opinion in relation to the client’s presentation and what research indicates about trauma
• Keep to your role as therapist – not police officer; investigator
• Consider countertransference, Secondary Traumatic Stress Disorder/Vicarious Traumatisation and the impact on therapy
• Beware of the client’s attempts to sabotage therapy/therapist – i.e. resistance OR apparent progress or resolution and “integration”
• Be mindful of a client’s assumptions (or giving indications) of what you “want or expect to hear” and the potential for the client to embellish along these lines
• Understand the pattern of victims of abuse to minimize, rationalize, excuse abuse, self-blame or to repress or dissociate it and to identify with perpetrators as a coping strategy or defence mechanism (Stockholm Syndrome)
• Do not accept recanting of abuse, no matter how convincing, as any more or less reliable and true than details of reported abuse
• If regressive therapy techniques are used, recognise their limitations and that these are only part of the process and will not be the resolution in and of themselves
• Be familiar with psychological abuse dynamics
• Encourage clients to be responsible for sessions – structuring therapy; regular setting of long and short term goals, written evaluations of how to best tailor-make the process and trouble-shoot
• Recognise you cannot ‘make’ a client take up what you offer
• Document the therapy process
• Obtain records from previous therapists where possible
• Obtain written consent before speaking with a client’s family or others
• Be prepared to have clients choose deny or not pursue abuse
• Offer referral elsewhere if a client expresses dissatisfaction and the matter cannot be resolved
• Encourage independent assessment of a dissociative client’s children:
a) By virtue of having a dissociative parent this will impact a child
b) Possibility exists of learned dissociative behaviors to manage difficulties/stress
c) Possibility exists of abuse which the client (parent) is amnesiac about others or self having perpetrated or is not disclosing or is not aware of
• Graciously decline and document money, rewards or such offered by client or others related to a client
• Do not suggest law-suits – this is the client’s choice and not an expectation or requirement of therapy or personal well-being or trauma recovery
• Do not accuse anyone of sexual abuse but comply with legal requirements when such action is necessary
• Seek supervision
• Seek VT/Secondary traumatic Stress Disorder consults
• Obtain relevant literature and audiovisual material
• Educate colleagues, community – be proactive
• Join/start study groups
• Attend educational opportunities; professional workshops, seminars, conferences
• Join professional bodies, i.e. AAT&D Inc.; ISSD
• Always behave with integrity and honesty

ETHICAL PRACTICE REGARDING MEDIA INVOLVEMENT

“Trauma Memory and Dissociation” , p.15-16 Australian Association of Trauma and Dissociation Inc.
4th Annual Conference (1995)

• Beware assurances of a balanced perspective – controversy sells
• Request a condition to vet and pull out if editing distorts
• Tape-record or video the interview for documentation of what actually occurred
• Complain about misrepresentation by media to their sponsors
• Beware being an advocate for a client’s claims:
a) It may be an attempt to discredit therapist
b) It may be playing into sensationalism
c) Therapist may be being used as a pawn by perpetrators
• It is unethical to appear with a client and counter-therapeutic
• Beware client’s secondary gain
• Consider your own motives
• Be proactive not reactive – write to journals, letter to editors, lecture
• Do from your ‘own turf’ – optimize your control
• Know who else will be on a panel before agreeing to participate
• Plan your messages and reiterate – do not necessarily answer questions designed to detract from the issue
• Avoid if you have a pending court case
(Based on Perry, 1994)

 

Dr. M. C. Barreda-Hanson email