Treatment Guidelines

Draft treatment guidelines & tips from professionals, peer specialists, colleagues & clients with lived experience.

Introduction

Guiding principle

What works to give "ease" to working with plural, DID & OSDD systems in therapy? What gives resistance? What would make therapy thousands of times easier if only singular therapists would understand it?

Disclaimer

These are suggestions from the experiences of other practitioners with lived experience only. Please use your own wisdom, seek out supervision or case consultations as needed, and make sure you're in alignment with your industry's ethics and local laws when dealing with your clients. Clients with DID/OSDD & C-PTSD should not be treated much differently than other clients overall, and at the end of the day you need to trust your own instincts and you are responsible for your own behavior with your clients. None of this constitutes professional advice, and none of the contributors to this article are liable for your implementation of or adherence to these guidelines.

Best Practices

These are principles that will help your overall practice, which is especially important with clients who have C-PTSD, are rejection-sensitive, and who are exceptionally highly attuned to people around them (a trauma-based skill learned when one has unpredictable caregivers).

• Believe your clients. Clients who waste time paying professionals to lie about their experiences is far more rare than DID. A client's experience is valid, even if it might not objectively be based on exactly what they think it is. When we meet clients where they are, often we discover an excellent explanation for what they're experiencing; we can figure it out when we take the time to listen. Respect is paramount in the client-pro relationship and respect counteracts shame. [Fossam & Mason, 1986 Facing Shame: Families in Recovery. Carl Rogers, Person-Centered Therapy.]
• All experiences are valid. Even when subjective experiences are unexpected, don't seem to make sense, appear contradictory to our other expressed experiences, they are valid for those who experience them. Paired with "Believe your clients" this means that it's important to meet the client where they are, validate their experiences even if it seems like nothing you will ever experience yourself, and understand that even if something cannot be objectively validated, that doesn't mean it cannot be someone's subjective experience.
• Be genuine. As mentioned above, people with C-PTSD may be extraordinarily sensitive to secrets, emotional withholding, hidden agendas, etc. You are not here to push therapy on your client(s), but to create a relationship with them, that they consent to, and that will help them move forward to their own goals. When you are more transparent, and genuinely in collaboration with them, your clients will build rapport faster. Otherwise they'll know something is off and be defensive.
• Empower clients. Treating a client like a child or perpetuating their helplessness by taking care of them, including imposing agendas, therapy, or treatment plans on them, will not help them to move forward to having a more empowered life. They need to be both allowed and taught how to take increasing control over their own outcomes and agendas. This should really go for all clients, but is even more important with trauma survivors who have been systematically disempowered. Anything else is reenacting aspects of traumatic relationships. If a client is fawning, is not allowed to collaborate or say no, is phoning it in, checked out, not on-board with, or a partner in creating a treatment plan, it's doubtful that significant progress will be made. A slow path of continually improving their tolerance of and ability to handle being in control and having power over their own group life will help them move from victim in therapy to a client who can co-create a productive therapeutic relationship with their professional team. This means their professionals need to be ready to relinquish control to the client as appropriate and monitor readiness to make progress in taking successively more and more control over the therapeutic agenda.
  • Encourage Re-parenting. As a sub-item for this, redirect system children back to their system for caregiving, boundary enforcement, guidelines, reassurance, etc. Basically treat their system kids like you would any child client: they are not your child, and while they may look to you to become a new parent figure, it is more appropriate to help their system set up in-system care for their young alters/headmates. This empowers their system, and sets that child alter/headmate for 24/7/365 in-system care, which is much more appropriate. You may then consult with their system caregivers, and help them develop their care-giving abilities. Feel free to spend time with their system children, so long as you defer to their system caregivers the same ways you would with any external person's children.

Specifics about DID/OSDD & Dissociative Disorders

All too often, academic learning about DID/OSDD & dissociative disorders is little more than a sidebar in class. This is compounded by myths of movies, supervision or academia rumor-mills, personal beliefs & opinions, and coercion & pressure from the industry overall.

Clients have enough going on without being burdened with debunking professional bias and attempting to overcome the weight of centuries of singular-centrism and plural-oppression that drives high-grossing films & TV/soap opera franchises exploiting DID as a modern boogieman with which to frighten audiences and create an air of mystery or gotcha-jump scare plot tactics.

Often clients are stuck educating their professional team about these myths, plurality, DID, OSDD, dissociative disorders, treatment concerns, and the basic features of their disorder. Here's some principles & guidelines to do the right thing and take this on as your own educational journey.

• Learn about DID. There's a lot to learn about dissociation and how it can show up. It's hard to find credible resources and skilled consultations or supervision, trainings can be hit-or-miss. Here's some credible resources New — please don't make your clients train you in the generic issues around the disorder on their therapy time.
• The opposite of dissociation is presence New. Let's not conflate switching & dissociation, nor vilify dissociation or switching. A client system can be more present to their senses and to the present, while also switching. When trying to help a client reduce undesirable dissociation, do not shame or coerce clients around switching overall.
• Lean in to Systems Theory. Concepts from systems theory work for plural, DID & OSDD systems. Family therapy, organizational psychology, and other group therapy practices can be leveraged to bring successful principles into your therapy sessions with plural systems. It's not magic or rocket science: internal plural systems are informed by the external systems that surround them, whether it's dysfunctional family dynamics, or introjecting relationships & concepts inspired by group dynamics we see in media. Once we're understood as a system, it's clear that driving wedges between system members, or trying to cram them all into one system member by force are not the pathway forward.
• Boundaries New. For many reasons, clients may struggle with maintaining, defending, or identifying appropriate external boundaries. It is up to their professional team to both role-model and encourage appropriate boundaries, often explaining what boundaries are and ways to defend them. You may need to revisit information on this yourself so that you can explicitly help your clients to learn what they are, how to define them, and how to defend them. At the same time, they also need to learn how to have appropriate internal boundaries. Don't mistake poor internal boundaries between alters/headmates to be a milestone on the pathway to healing; poor internal boundaries generally leads to more distressing depersonalization, intrusive emotional flashbacks, and an inability to identify who in their system requires assistance and care.
• Supporters. Similar to having insufficient or broken boundaries, often clients do not have an accurate yardstick by which to measure people's behavior and what is or is not supportive behavior. They certainly need supporters such as friends, family (whether legal or intentional), and other care team members. Good guidelines to help them assess who their safest contacts are include whether they feel free to talk without excessive self-editing, fear of (or an actual history of) their supporter being overly reactive, whether their supporters have active biases regarding the client, and whether their feedback to the client is non-judgmental, supports the client's sense of inclusion & belongingness, and is generally helpful.
• The Latest Neuroscience. Trauma is not at all simply a mental, mind or consciousness issue. It is very much a physiological, neurological issue. The body stores trauma reactions in neural pathways. In addition, PTSD & C-PTSD cause changes to the structures of the brain. A client can create or change neural pathways, trauma reactions can be rewired, but a client cannot simply "just" get over it or stop a panic reaction or trauma reaction through purely force of will. [Bruce Ecker, Stephen Porges, J. Douglas Bremner, Bessel van der Kolk, and others.] That said, we do learn to self-manage some portions of our neurology by way of switching headmates. Each headmate has different access to and is affected differently by sensory information, and so there is a chance the same stimulus can have very different effects depending on which alters/headmates are active (and more than one can be active at the same time).

Session Etiquette

Here's tips about holding sessions with plural & DID/OSDD systems:

• Make space. Allow alters/headmates time to talk about their concerns, share their opinions, and learn what they want from therapy. Also note that a client talking too much (dominating a conversation) may be a coping or avoidance mechanism employed by some trauma survivors, or specific alters/headmates to protect/deflect against triggers and discomfort.
• Monitor Rapport building. Trust may be gained even more slowly with a DID System.
• DID Systems often don't present like on TV or in books. Clinicians will not always see the symptoms of covert systems initially. We do a lot of masking etc. Knowledge of the system is safeguarded.
• System kids vary in interests, skills & ability. Child alters/headmates may or may not be OK to be left alone. For us some are and some would be down at the river playing with otters all day.
• Not all headmates have the same knowledge. Know that some headmates/protectors may try to tell the therapist they don't have DID or act in other ways that may cause some level of discredit/confusion. (Not funny but it's true)
• Everyone is a protector. One way of looking at system member's behavior is to consider what role they may be playing in the system. Even a headmate who fawns is still potentially protecting the system. The classic ideas of protectors & persecutors is full of stigma and some myths. When we move away from shaming behaviors, try to meet them where they're at, help them become more present, and improve how everyone communicates with them — we can then help them reframe their activities and how they protect the system.