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Section 1
Dissociative Identity Disorder: Meeting Alter Personalities

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On this track, we will discuss meeting the alter personalities of a client with dissociative identity disorder.  As you know, the DSM states that the diagnosis of dissociative identity disorder can only be made after the therapist has met one or more alter personalities and determined that at least one alter personality is distinct and takes full control of the individual’s behavior from time to time. 

But how do you go about meeting alter personalities in a client suspected to have a dissociative identity disorder?  In a groundbreaking book, Frank Putnam indicates that alter personalities can be discovered in one of three ways.  Three ways of meeting the alter personalities are: the alter personalities "come out," indirect inquiry, and direct inquiry.  Are you currently treating a client you feel may have alter personalities?  If so, you might consider applying some of the techniques on this track in your next session.

Three Ways of Meeting the Alter Personalities

#1  Alter Personalities "Come Out"
First, let’s discuss when alter personalities "come out" voluntarily.  As you may already know, NIMH, the National Institute of Mental Health, data suggests that in about half of all cases the meeting is initiated by one or more alters who "come out" voluntarily and identify themselves as being different from the client.  Have you found that it is fairly common for an alter personality to approach a therapist in person, by phone, or by letter? 

In Julie’s case, her alter identified himself as a friend of Julie in a letter I received.  Julie, age 39, had not presented with signs or symptoms of DID.  However, this spontaneous revelation of diagnosis occurred shortly after the death of her mother.  Have you found that crisis in your client’s life may lead to the discovery of alter personalities?  But what if the alter personality or personalities do not "come out?"

#2  Indirect Inquiry
Next, let’s discuss indirect inquiry.  In my practice, this is generally my first approach if I suspect a client of having DID.  For example, I suspected that Alan, age 37, have a dissociative identity disorder.  In a previous session Alan had failed to recall some personal information that seemed too extensive to be explained by ordinary forgetfulness.  Therefore, I asked, "Have you ever felt like more than one person?"  Alan responded, "Sometimes I don’t know who I am.  I feel like I might be a lot of people.  Maybe there really isn’t a me." 

Occasionally you may get a more direct response such as, "Yes, there is another part of me and her name is Beth."  However if your client answers somewhat ambiguously like Alan, you might follow up by asking, "Do you ever feel as if there is some other part of yourself that comes out and does or says things that you would not do or say?"  When I asked Alan this question, his answer was again ambiguously positive. 

So, I began to ask for specific examples.  For example, Alan had admitted to a number of dissociative symptoms and said that at times he felt as if he was someone else.  Alan vaguely described the someone else as hostile and angry.  I then asked, "Can this other part of you come out and talk to me?"  Have you found that similar questions can cause distress in clients with DID?  It seemed that Alan felt barely able to suppress the appearance of his undesirable alter and did not wish to have me inviting the alter personality to come out. 

Have you found that it is not uncommon for the host to feel in competition with the alters for the therapist’s attention?  Alan appeared reluctant to introduce his alter personality.  He stated, "It’s not possible for the other part of me to come out right now.  I’ve got more control than he does!" 

At this point, therapists dealing with DID may become nervous.  I know I have.  I find myself asking questions like, ‘How do I get these personalities to come out?  What will happen if they do come out; are they dangerous?  What if I am wrong and there really aren’t any personalities; will I actually create some by asking for them?’  However, the basic way to meet alter personalities is by asking directly. 

#3  Direct Inquiry
So in addition to when alter personalities "come out" voluntarily and indirect inquiry, a third method for meeting alter personalities is direct inquiry.  Direct inquiry can sometimes be harder for the therapist than for the client.  For example, you might feel unnecessarily foolish.  In my practice, to overcome these feelings, I focus on what needs to be done. 

The first question is that of ‘who’ to ask for.  Would you agree that asking for the alter that you have the most information about can be productive?  For example, Alan had described losing several jobs due to angry outbursts that he could not remember.  Therefore, when I implemented direct inquiry with Alan, I stated, "I would like to talk directly to that part of you who came out last Wednesday at work and told your boss to stuff it."  With Alan, I found that the chances of eliciting his alter increased with more direct specification of the suspected alter.  If you have a proper name use that, but a repeated description of an attribute or function can also be useful.  For example, Alan’s angry and hostile alter became known as ‘the angry one.’

Regarding some do’s and don’ts which pertain to direct inquiry, you already know that requests for an alter personality should be made in an invitational tone rather than as a demand.  But would you agree that avoiding the word ‘personality’ can also help?  Most clients are aware of why you are asking certain questions.  Therefore I prefer to use terms such as side, (pause) facet (pause), part (pause), or aspect to avoid negative connotations.

After I asked Alan directly about his alter personality, nothing appeared to happen.  I observed Alan closely for behavior that may indicate a switch in character.  If this becomes the case with your client, you find yourself wondering if the alter personality really exists.  I ask myself, "Does this client appear to be made uncomfortable by my request?"  In my experience, clients who do not have DID are not seriously distressed by requests to meet a nonexistent part.  Clients without DID wait it out or simply say, ‘I don’t think there’s anything there.’ 

However, clients with DID often show significant discomfort with persistent attempts to elicit an alter.  For example, Alan began to complain of somatic discomfort in the form of a headache and stomach pain.  In some cases, clients may enter an unresponsive trance like state.  However, even though Alan showed evidence of significant distress with my requests, I persisted.  Regarding ethical treatment of clients, how long to persist becomes a judgment call.  Not all alters emerge at the first request, and of course, your undiagnosed client may not have DID at all.

Because Alan appeared distressed and I wasn’t sure if he switched, I asked, "What are you feeling now?"  Alan replied, "Angry!"  I asked, "Why do you feel angry, Alan?"  Alan replied, "My name is Vaughn!"  If, unlike Alan, your client continues to provide strong evidence that he or she is having frequent dissociative episodes, but you are unable to elicit an alter personality by direct request, then you may want to consider the use of hypnosis.  Later on this course we will discuss hypnosis further. 

For now, how can the three methods of meeting alter personalities benefit you in your practice?  Would asking some direct questions help you uncover a client’s alter personalities?

On this track we have discussed meeting the alter personalities of a client with dissociative identity disorder.  Three ways of meeting the alter personalities are the alter personalities "come out" voluntarily, indirect inquiry, and direct inquiry. 

On the next track we will discuss personality histories.  Four basic lines of questioning are outlined on the next  track to help with obtaining a psychopathological personality history.  They are naming each personality, determining physical aspects of the alter, determining perceived function, and chaining. 

Peer-Reviewed Journal Article References:
Huntjens, R. J. C., Wessel, I., Hermans, D., & van Minnen, A.(2014).  Autobiographical memory specificity in dissociative identity disorder. Journal of Abnormal Psychology, 123(2), 419–428.

MacIntosh, H. B. (2015). Titration of technique: Clinical exploration of the integration of trauma model and relational psychoanalytic approaches to the treatment of dissociative identity disorder. Psychoanalytic Psychology, 32(3), 517–538.

Pica, M. (1999). The evolution of alter personality states in dissociative identity disorder. Psychotherapy: Theory, Research, Practice, Training, 36(4), 404–415.

Online Continuing Education QUESTION 1
What are three ways of meeting the alter personalities of a client with dissociative identity disorder? To select and enter your answer go to CEU Test.

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