Essay on Dissociative Identity Disorder

From the Jason Aronson Collection

by Colin A. Ross

A curious paradox about Dissociative Identity Disorder (DID) is that although not accepted by many psycho-analytical psychotherapists, it in fact proves object relations theory better than any other disorder. Where else can one see identification with the aggressor behaviorally manifest in front of one's eyes, in the form of a paternal introject alter? Similarly, I heard about transient psychotic transference in my training, but never saw one until I saw the first of hundreds demonstrated to me by Dissociative Identity Disorder patients I imagine that the vast bulk of so-called psychotic transference reactions in the twentieth century have actually been dissociative in nature. Most of the constructs of object relations theory, which seem to be abstract inferences about non-DID patients, become concretely behaviorally manifest during Dissociative Identity Disorder treatment.

A case example will illustrate the complexities of DID as an object relations chess game.

A patient had a conflict with her mother that was acted out in the transference for two years before it was fully analyzed and understood. The problem arose from a childhood scenario, verified by the mother, in which the mother was deathly ill for prolonged periods of time and nursed for extended periods by the patient. In the patient's perception, the mother was kind and warm while skeletal and deathly ill. When she would become more physically healthy, however, the mother would become emotionally, physically, and sexually abusive, and would involve her daughter in organized sexual abuse by groups of men.

The mother was split into a sick mom and a healthy, perpetrator mom. The patient was split into a compliant, caring, nursing, loving daughter, and a hostile, murderous, bad daughter. Both of these states in the patient, which were represented by large groups of alters due to polyfragmentation, were based on incorporation/identification/introjection mechanisms, and also on the normal reaction to the corresponding behavior in the mother. Both identifications were projected onto the therapist, myself, who also had projected onto him the role of the scientifically curious pedophile doctor with whom the mother had an affair.

The good daughter alters disavowed the existence of the bad alters, and denied that the two groups of identities were parts of the same person, while the angry alters viewed the good alters as wimps, and persecuted them internally. The angry alters thought that the good daughters were idiots and that it was their fault that the perpetrator mother emerged: they attributed this emergence to the good alters' nursing care. The good alters wished that Mom would get better and live, while the bad alters wished that she would die, and saw her as a lazy dog that refused to get up, assume the mother role, and care for them in a normal fashion. The good alters believed that the bad mother didn't exist. The patient was deeply ashamed of her wish that mother would die.

The system bind was that if the mother got well and lived, they would be abused, while if she died they would be at the mercy of pedophile relatives. The good alters were idiots for not killing Mom when they could, and the bad alters were evil for wanting to kill her. At the same time, the alters only existed and were real for the perpetrator mom, and were reduced to existing in the mother's eyes only as delirious hallucinations when she was ill, and took the form of the good mom. To be real the alters had to be perceived by the perpetrator mom, which was to be abused. This need to be abused in order to be real had been acted out in a series of abusive relationships over the years, and had also been acted out by certain alters on others. This acting out at times took the form of precise superficial self-laceration in sets of parallel straight lines (the number of lines had private numerological significance).

The solution to the problem was to not be in this world in order not to be driven crazy by the double binds. However, not being crazy returned her to the everyday world, which drove her crazy, and made her leave the world defensively, which relieved her from the double binds and made her not crazy. The patient had carried a diagnosis of schizophrenia for years. Whenever she made progress in therapy and started to become healthier, she panicked, because this meant that the perpetrator mom projected onto the therapist and the world would begin to emerge. The ultimate solution was to withdraw into what she called "a spiritual dot." The analysis of the acting out of the permutations of this logic in her past and current relationships, internal world, and transference, took considerable time and effort. I invented the term dissociative identity disorder as object relations chess game to capture the structure, order, and complexity of the transference moves and countermoves. Part of the skill required of the therapist is to track the endless cycles of introjection, projection, reintrojection, displacement, projective identification, reaction formation, and traumatic reenactment that characterize the therapy in order to maintain a neutral therapeutic stance and not succumb to any given idealization, devaluation, or other transference distortion. The term also highlights the simplistic nature of any bimodal splitting mechanism as a model for tracking the permutations. This is the depth of psychology truth that refutes the contention that DID patients are "really just borderlines." They function several orders of complexity above any bimodal models of psychopathology.

Forming a Treatment Alliance with Persecutory Alter Personalities

One of the key interventions is making friends with persecutory alters. Too often these alters have been rejected, devalued, and hurt by the host personality and the referring therapist. Such alters have been locked in internal boxes, exorcised, feared, accused of ongoing participation in satanic human sacrifices (a claim they often make themselves), defined as "programmed by the cult," and otherwise hated. They have been defined as the problem, and usually the host personality regards the alters as the cause of her problems. From a systems perspective, the persecutor alters are like the identified patient in a family system. The behavior of the bad alters is not the problem: it is the solution to a problem. The therapist's job is to help understand what problem is being solved by the self-abusive behavior, and then to help the system find a more adaptive solution.

In doing this work I have become increasingly aware of the problem of host resistance. The alters were created, originally, to solve a problem, which was the overwhelming impact of the trauma on the organism's defenses, so they are the solution not the problem. The problem is that the host personality does not want to integrate the traumatic memories and their attendant affect back into herself. She therefore defines the bad alters as bad, not part of herself, and the problem, in order to avoid the real work of therapy. If the therapy threatens to center the badness inside herself, she projects it out onto the unit, nurses, doctor, therapist, or hospital administration. Unfortunately, outside regulators are too often too quick to identify with these patient projections, not having been sobered by direct experience of the distortions and misattributions.

As quickly as possible, we move to form a treatment alliance with the key persecutor personalities involved in the presenting problem, reframe their behavior as positive in intention, and increase interpersonality communication and cooperation. The idea is to shift the system from a civil war mode of function to one of negotiated compromise. To do this within an average length of stay of three weeks requires focus and concentration of treatment effort and a minor emphasis on trauma memory recovery and processing.

To illustrate a few strategies, I usually point out to the host that it was the suicidal behavior of the persecutor alters that got her into the hospital. I say that they have been doing their job all along, and that they are part of her overall survival strategy. One of their major functions was to hold all the anger for years so that the host, who is anger phobic, would not have to deal with it. It is hardly fair, given that fact, to fault the persecutors for being angry. I then define anger as a positive, powerful form of energy, if channeled in a healthy direction. I point out that the women's movement brought child abuse out of the closet, which in turn made the unit and the patient's current treatment possible, based on accurate, legitimate anger. I say that rage is the biologically normal response to chronic childhood sexual abuse. In fact, I say, it would be abnormal not to be extremely angry, given the patient's childhood.

With the persecutors listening in from the back of the system, which they usually do, I point out that the host personality has gotten into many abusive situations over the years due to trusting too much and not being assertive enough. This is a natural consequence of the dissociation that was required to survive childhood (the problem now is that the body has grown up, the abuse stopped long ago, and the defenses are not working). Explosive angry outbursts by the persecutors when boyfriends make sexual advances are destroying the possibility of a healthy marriage, for instance.

What is required is for the host and persecutors to share skills, so that the host is more cautious, self-protective, and assertive, and therefore less at risk for date rape, while the persecutors learn to tolerate normal, healthy intimacy. The persecutors are not bad for being angry any more than the host is bad for not being angry (both have skills to contribute to the whole).

I then point out to the host, sometimes through a clinical fable, that the angry alters must be feeling hurt, rejected, and lonely because of the host's devaluation of them, and I say that angry retaliation is not an unexpected reaction for traumatized children when they are subjected to further rejection. I say that the persecutors, like the host, have been hurt far too much already and don't deserve more internal abuse. If the persecutors are perceived as monsters or demons, I point out that this is their job in order to protect the host from the bad feelings they hold, they have to take on a frightening identity to ensure that the host does not come too close. Inside the scary costume, I say, is a hurt child who is trying to help. Although it might not be technically correct, I may say that it is unfair for the host to fault the demons for being demons, since she is the one who created them and gave them that identity (they are just doing what they have been created to do).

Working directly with the persecutors, I review all of the above, promise to undertake negotiations with the host on their behalf, and promise to work on correcting host cognitive errors, but only if they agree to no more self-abusive behavior. I agree to consult with them on devising other strategies to meet their needs, which are basically to protect the host from traumatic memories and affect. I also hire the persecutors as consultants to the therapy, stating that they have far more expertise on the internal system than I do and therefore can help me avoid needless errors and confrontations by giving me information.

Mindful of the complexities of behavioral analysis required, I also point out to the persecutors that they share the same treatment goal as I have, namely discharge as early as possible. I have discussed the workings of the health care system, our average length of stay, and financial realities with persecutor alter personalities identified as demons or Satan himself, with good results. Usually this treatment approach is a revolutionary experience for the persecutor alters, who have never been treated with respect and dignity before. To define these alters as iatrogenic artifacts is abusive, and will likely result in their transitory disappearance. In most cases certainly in those seriously dedicated to recovery, making friends with the persecutors usually has a dramatic impact on the level of suicidal ideation within two or three weeks of inpatient treatment.


Part I: Does Dissociative Identity Disorder Exist?
Part II: Theoretical Controversies Part III: Treatment Controversies

13808 Dissociative Identity Disorder, edited by Lewis Cohen,
Joan Berzoff, and Mark Elin Publisher's Price: $50.00