contd. from

Developing a cognitive framework is also an essential part of stabilization. This involves sorting out how an abused child thinks and feels, undoing damaging self-concepts, and learning about what is "normal". Stabilization is a time to learn how to ask for help and build support networks. The stabilization stage may take a year or longer--as much time as is necessary for the patient to move safely into the next phase of treatment.

If the dissociative disorder is Dissociative Identity Disorder (DID), stabilization involves the survivor's acceptance of the diagnosis and commitment to treatment. Diagnosis is in itself a crisis, and much work must be done to reframe DID as a creative survival tool (which it is) rather than a disease or stigma. The treatment frame for DID includes developing acceptance and respect for each alter as a part of the internal system. Each alter must be treated equally, whether it presents as a delightful child or an angry persecutor. Mapping of the dissociative personality system is the next step, followed by the work of internal dialogue and cooperation between alters. This is the critical stage in DID therapy, one that must be in place before trauma work begins. Communication and cooperation among the alters facilitates the gathering of ego strength that stabilizes the internal system, hence the whole person.

Revisiting and reworking the trauma is the next stage. This may involve abreactions, which can release pain and allow dissociated trauma back into the normal memory track. An abreaction might be described as the vivid re-experiencing of a traumatic event accompanied by the release of related emotion and the recovery of repressed or dissociated aspects of that event (Steele & Colrain, 1990). The retrieval of traumatic memories should be staged with planned abreactions. Hypnosis, when facilitated by a trained professional, is extremely useful in abreactive work to safely contain the abreaction and release the painful emotions more quickly. Some survivors may only be able to do abreactive work on an inpatient basis in a safe and supportive environment. In any setting, the work must be paced and contained to prevent retraumatization and to give the client a feeling of mastery. This means that the speed of the work must be carefully monitored, and the release painful material must be thoughtfully managed and controlled, so as not to be overwhelming. An abreaction of a person diagnosed with DID may involve a number of different alters, who must all participate in the work. The reworking of the trauma involves sharing the abuse story, undoing unnecessary shame and guilt, doing some anger work, and grieving. Grief work pertains to both the abuse and abandonment and the damage to one's life. Throughout this mid-level work, there is integration of memories and, in DID, alternate personalities; the substitution of adult methods of coping for dissociation; and the learning of new life skills.

This leads into the final phase of the therapy work. There is continued processing of traumatic memories and cognitive distortions, and further letting go of shame. At the end of the grieving process, creative energy is released. The survivor can reclaim self-worth and personal power and rebuild life after so much focus on healing. There are often important life choices to be made about vocation and relationships at this time, as well as solidifying gains from treatment.

This is challenging and satisfying work for both survivors and therapists. The journey is painful, but the rewards are great. Successfully working through the healing journey can significantly impact a survivor's life and philosophy. Coming through this intense, self-reflective process might lead one to discover a desire to contribute to society in a variety of vital ways.

next: What are the Effects of Dissociative Disorders?

References

Braun, B. (1988). The BASK model of dissociation. DISSOCIATION, 1, 4-23. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Loewenstein, R.J. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14(3), 567-604.

Mills, A. & Cohen, B.M. (1993). Facilitating the identification of multiple personality disorder through art: The Diagnostic Drawing Series. In E. Kluft (Ed.), Expressive and functional therapies in the treatment of multiple personality disorder. Springfield: Charles C. Thomas.

Putnam, F.W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Press.

Ross, C.A. (1989). Multiple personality disorder: Diagnosis, clinical features, and treatment. New York: Wiley.

Steele, K., & Colrain, J. (1990). Abreactive work with sexual abuse survivors: Concepts and techniques. In Hunter, M. (Ed.), The sexually abused male, 2, 1-55. Lexington, MA: Lexington Books.

Steinberg, M., et al. (1990). The structured clinical interview for DSM III-R dissociative disorders: Preliminary report on a new diagnostic instrument. American Journal of Psychiatry, 147, 1.

Tasman, A., & Goldfinger, S. (1991). American psychiatric press review of psychiatry. Washington, DC: American Psychiatric Press.

Turkus, J.A. (1991). Psychotherapy and case management for multiple personality disorder: Synthesis for continuity of care. Psychiatric Clinics of North America, 14(3), 649-660.

Turkus, J.A., Cohen, B.M., & Courtois, C.A. (1991). The empowerment model for the treatment of post-abuse and dissociative disorders. In B. Braun (Ed.), Proceedings of the 8th International Conference on Multiple Personality/Dissociative States (p. 58). Skokie, IL: International Society for the Study of Multiple Personality Disorder.

Joan A. Turkus, M.D., has extensive clinical experience in the diagnosis and treatment of post-abuse syndromes and DID. She is the medical director of The Center: Post-Traumatic & Dissociative Disorders Program at The Psychiatric Institute of Washington. A general and forensic psychiatrist in private practice, Dr. Turkus frequently provides supervision, consultation, and teaching for therapists on a national basis. She is co-editor of the book, Multiple Personality Disorder: Continuum of Care.

* This article has been adapted by Barry M. Cohen, M.A., A.T.R., for publication in this format. It was originally published in the May/June, 1992, issue of Moving Forward, a semi-annual newsletter for survivors of childhood sexual abuse and those who care about them.

next: What are the Effects of Dissociative Disorders?

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Reviewed: 06/1992