“How would you work within an ISTDP framework with someone who has a diagnosis of dissociative identity disorder and who switches during sessions into very distinct ego states?” Thanks to Anne for a fascinating question!

First of all, the term dissociation is often used so widely for so many phenomena that it has lost its specific meaning, referring sometimes to daydreaming, to detaching, to distancing, all the way to distinct personalities. In ISTDP we reserve the term dissociation for the defense used as part of the resistance system of projection, where the patient engages in splitting and projection, and dissociation is the result of splitting. Further, we view dissociation proper as a defense that occurs when the patient’s anxiety is discharged into cognitive/perceptual disruption.

Often patients claim they are “dissociating” but their anxiety is in the striated muscles, and they have the capacity to isolate affect through intellectualization and rationalization. In these cases, patients are simply detaching. Sometimes they will intellectualize about different “parts” of their personality, but their anxiety is in the striated muscles and their ability to intellectualize lets us know that their so-called “dissociation” is really a form of detaching within the resistance system of isolation of affect.

I note these distinctions because I have seen a number of cases in treatment and supervision where patients or therapists wrongly thought dissociation was in operation. In fact, it is quite rare in the form described here: a defense resulting from splitting within the resistance system of projection where anxiety is discharged into cognitive/perceptual disruption.

Within the spectrum of fragility, dissociation can take various forms: mind blanking out, feeling outside the body, or experiencing oneself as a separate personality. These correlate sequentially with increasing levels of anxiety discharged into cognitive/perceptual disruption. Thus, the sooner you intervene when anxiety shifts into cognitive/perceptual disruption, the sooner you can stop the regression into more severe forms of dissociation.

For the mind blanking out or an out of body experience, classic anxiety regulation techniques plus a summary of the process are usually enough to bring anxiety down into the striated muscles. Then we ask for feelings toward the therapist to build the patient’s capacity to bear feelings without resorting to splitting and dissociation. Many examples of this are in the anxiety chapter of my book, Co-Creating Change, and there is a case on the website on dissociation: the man who awoke from a coma.

If anxiety does not get regulated soon enough and the patient continues to regress, then we can see the separate personalities described in the literature of dissociation. Sometimes anxiety regulation restores brain functioning enough for these symptoms to remit. In these cases of severe fragility, the patient can tolerate only very slight amounts of mixed feelings. Thus, the work tends to be quite cognitive initially, focusing on integrating split off feelings. The therapist will remind the patient of split off feelings to build the patient’s capacity to cognize about separate experiences at the same time. Then gradually the therapist will help the patient experience the mixed feelings. Again, the rationale is always to help the patient bear mixed feelings inside so they don’t have to be projected outside, whether onto other people or, in this case, onto separate “personalities.”

Allan Abbass’ recent book, Reaching Through the Resistance, has a lovely chapter on severe fragility where he shows how to work with splitting.

Th: So we notice there’s a wish to look into this and at the same time a wish to pull back. Two urges inside you at the same time, and we’re just noticing these contradictory urges that come up. [Pressure to consciousness: reminding the patient of the split experiences to bring them together and undo splitting.]

Pt: [looks confused]

Th: Are you getting a little dizzy?

Pt: Yeah. [Cognitive/perdeptual disruption. Undoing splitting causes anxiety to rise.]

Th: So as we notice these two urges inside, for some reason you get a little anxious and your head gets dizzy. Something about noticing two urges triggers anxiety. Do you notice that too? [Regulate anxiety and remind the patient of the two split off urges to build the capacity to tolerate this awareness at this level.]

Pt: [tenses up in chair] Yeah, I feel like I want to pull back. [Ability to intellectualize. Progress]

Th: Yeah. There’s a wish to look into this and a wish to pull back and noticing these two urges inside you, how these two urges can exist inside you at the same time. And something about noticing this complexity in you stirred up some anxiety. [Cognitive summary brings the split experiences together and encourages her to observe and intellectualize rather than split.]

Pt: Yeah. I hadn’t thought of it as two urges inside me. [Patient can now intellectualize about her mixed feelings without splitting. Next we will move to higher levels of feeling to keep building her capacity.]

In ISTDP we do not explore the content of the “selves” because they are the products of defense. Instead, we help the patient gradually integrate and bear internally the previously split off aspects of her inner life. The goal is not just “integrating selves” as it is called in other approaches. The goal is to bear and integrate the mixed feelings inside for which the selves are merely defenses.







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