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2011 ISSTD Treatment Guidelines Graphic Text Only

This is the text for the synopsis of the 2011 treatment guideline overview, presented in a logical order for screenreaders. The visual graphic can be found as part of the Unification article here. New

ISST-D DID Adult Treatment Guidelines (per our research/study)

This is a process and you can expect different system members to be at different steps at the same time — this is OK!

Note: You don’t need to decide whether to pursue Unification during Stage 1 or Stage 2. In fact, you probably shouldn’t. The paths are the same, and it’s impossible to have everyone’s clear non-trauma-time input on the decision until you reach Stage 3.

Stage 1: Stabilization

Therapy starts here!

  • Onboarding Headmates
  • building in-system trust & communication (working towards community)
  • mindfulness/presence skills
  • introspection
  • ensure safety
  • build trust/rapport with T (therapist)
  • learning about C-PTSD & DID
  • emotional regulation
  • safety agreements
  • coping mechanisms
Note: spontaneous merges may happen (during this stage)

Some folk don’t go through trauma work, and they don’t HAVE TO! They can continue to work towards building community, healthy relationships, meaningful activities, work/life goals, etc. and stay in Stage 1. (Lowenstein 1994)

Side note: Keep in mind many people with DID also quit therapy before going into Stage 2 or reaching Stage 3.

At this point there's an arrow pointing to Stage 2.

Stage 2 - Trauma Work (Optional)

  • Processing traumas
  • pacing is vital
  • prevent flooding
  • maintain safety/stability
  • avoid overwhelm
Note: spontaneous merges may happen (during this stage)

At this point there's 2 paths shown with arrows. One points back to stabilization, the other labeled "Finished?" points to Stage 3.

The arrow pointing back to stabilization has a side note: Guidelines include alternating between trauma work and going back to stabilization techniques for emotional regulation between trauma sessions & to help “new” headmates develop trust, communication, skills, etc.

Stage 3 - Restoration

Text bubble says: After trauma work is complete, decide on final treatment outcomes as a community/team, implement final treatment outcomes. This is where the paths diverge between whether to attempt unification vs. healthy multiplicity.

This bubble has 2 arrows in it — a choice in paths - pointing to the Fusion Attempts and Restoration bubbles, all within Stage 3

“Restoration” aka Healthy Multiplicity: continue building internal community, learn more about living life post-trauma as plural.

Fusion attempts: begin process of deliberate alter merging in attempt to either lower headcount, or achieve unification.

Also in this stage are:

  • meaningful activities
  • healthy relationships
  • work/life goals
Note: spontaneous merges may happen (during this stage)

A thought bubble above Stage 3 reads: We have taken the liberty to give a neutral term to Stage 3: In the ISST-D guidelines, it has been called “Identity integration and rehabilitation” or just plain “Integration”— and in the body of the guidelines mentions an alternate “Resolution” if there will be no final fusion and the client will remain plural.

A warning bubble below Stage 2 and Stage 3 reads: Ableism alert: the treatment guidelines imply you’re not living a meaningful life until Stage 3. In reality, rather than treatment models, healthy relationships, work, life goals, and meaningful activities can and do take place regardless of which stage folk are in. Many folk with DID have great relationships, raise kids, have careers, contribute, create meaningful art, etc. during treatment, or without ever seeking treatment.

Graphic credits: © 2021 Rev. Criss Ittermann, aka The Crisses, Eclectic Tech LLC, chart only. This chart is based on the 2011 ISST-D DID Adult Treatment Guidelines, and not our United Front trainings or our suggestion to have 5 Stages of therapy — adding in Community Building & Empowerment as discrete stages between Stages 1 & 2. See for that talk.

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