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Dissociative Identity Disorder (DID), is an adaptive response to a pathological environment, that is rooted in severe, pervasive child abuse, neglect, and disrupted attachments. The onset of DID is correlated to trauma occurring before the ages of five to seven years old. The abuse often involves multiple perpetrators, and the child has little if any protective factors present (Fisher, 2017; Sar et al., 2017; Zeligman et al., 2017). This abusive childhood environment affects every aspect of the child’s biopsychosocial development throughout the lifespan if untreated or if receiving inadequate treatment. This paper is a general analysis of a complex adaptation from a human development perspective that attempts to highlight the implications for counselors to acquire a developmental lens when encountering and treating a client with DID. The aim of this paper is to aid in decreasing the re-traumatization of this vulnerable population that suffers many barriers to care. It also proposes from the views of those with DID, the implications for further research of what is effective in counseling the DID client to improve treatment.

Prenatal Period in Relation to DID

The developmental disruptions of clients with DID, more likely than not, started prenatally. It is common knowledge that unhealed trauma is intergenerational (Sar et al., 2017). As Broderick and Blewitt (2014) point out, an unborn child is affected by the mother’s environment such as addictions to unhealthy substances and cortisol levels from stress. Newer research shows a genetic predisposition to dissociation (Sar et al., 2017). Nature versus nurture coaction is becoming more understood as more research and medical advances can explore genetics, the brain, and neurophysiological processes (Sar et al. 2017). The neurobiological processes of a chronically dysregulated nervous system oscillating between over and under activation, are seen in the post-traumatic stress disorder (PTSD) brain on magnetic resonance imaging (MRI). Research shows an overactive amygdala and overactive prefrontal cortex region for multitasking in the brains of those with DID (McLean Hospital, 2019).

DID is also associated with high comorbidities. This is not surprising as high stress levels and the constant dysregulated nervous system coincide with complex PTSD. People with increased ACE scores, like those with DID, have increased rates of earlier deaths, heart disease, cancer, and diabetes. Stress also negatively impacts the immune system which subsequently increases the likelihood and frequency of illnesses (“About the CDC-Kaiser ACE study,” 2021).

Infancy and Childhood in Relation to DID

Erikson’s developmental crises can be useful to understand the areas and corresponding ages the person with DID is compromised. This is useful when treating different parts (alters) of a DID system or the system overall. Viewing the development of DID from the perspective that the trauma is pervasive and ongoing and is due to a lack of protective factors before the age of 5 to 7, could lead one to believe that the beginning interrupted stage of life would be infancy and/or childhood. Based on Erikson’s Grande theory, the DID individual will mistrust or view the world as unsafe, and will be riddled with toxic shame, doubt, and guilt. This is typical for abuse survivors.

A person with DID also feels inferior. They report feeling as though they are “too much”, “not enough”, “unworthy”, difficult” “taking up space in the world”, and perceiving they are a burden to others and should not have any needs. There is a significant lack of confidence, esteem, and agency all overlaid with learned helplessness despite this creative, unique, survival mechanism that has kept them alive. A childhood of fear, solely based on the task of surviving, not thriving, will be grossly lacking in an ability to trust, feel safe and secure, explore, and feel self-competent.  The DID client will also lack self-esteem, self-worth, self-agency, and have difficulty embracing adult roles (Broderick & Blewitt, 2014; Jacobson et al., 2015; Sar et al., 2017; Zeligman et al., 2017).

Adolescence and Adulthood in Relation to DID

It is not uncommon for DID survivors to fall into the helping systems during adolescence. Identity, biology, and high-risk behaviors culminate in the perfect storm in conjunction with the person’s trauma, unsafe environments, and lack of protective factors. In addition, the person is dissociated from their autobiographical experiences and multiple selves. Middle adulthood is another stage where a person with DID is more likely to seek treatment. There is the increased potential for midlife or existential crisis. Strained relationships, difficulties with intimacy, job security and satisfaction, and faced with aging all may precipitate a decrease in dissociative and/or amnestic barriers. Often, by middle adulthood, the amnestic and/or dissociative barriers have begun to weaken as the defense mechanisms are no longer needed in the same way that they were needed during childhood (Fisher, 2017; Kolk, 2015).

As the survivor becomes more aware of their trauma history, the DID, and the chaos in their life, this can be thought of as Erikson’s self-absorption stage. Life goes on hold to find appropriate help, stabilize, and devote the selves to the healing journey. Often those with DID will refer to this part of the experience as being thrown into trauma time which is due to flooding of flashbacks (Kolk, 2015). Nervous system dysregulation is ever present and the DID survivor does not yet have alternative, healthy coping techniques.

Attachment Theory in Relation to DID

There are also significant implications in examining Bowlby and Ainsworth’s attachment theory in relation to DID. Attachment styles are present throughout life. An earned secure attachment is possible with healing unresolved attachment wounds in the presence of a safe securely attached individual (Fisher, 2017). A counselor is often the first person that a DID client will learn to feel safe, and experience a healthy relationship (Jacobson, 2015). The disorganized attachment style, which significantly impairs relationships with selves and with others, is the predominant style among those clients with DID. (Fisher, 2017; Kolk, 2015; Sar et al., 2017; Zeligman et al., 2017). Disorganized attachment manifests as a push-pull dynamic. This is the relational dynamic that evolves from having a caregiver that is desperately wanted and needed by a child, and also being the source for terror (Fisher, 2017; Sar et al., 2017).

Cognitive Processes in Relation to DID

The cognitive development of various parts in DID can also be viewed through Piaget’s stages of cognition (1977). The DID client will have disruptions amongst various parts such as lacking object permanence in certain dissociated states. Other aspects of cognition that are disrupted manifest as the lack of a coherent autobiographical narrative, amnesia, dissociated self-states, compartmentalized memory with impaired retrieval, affect inhibition, and affliction of depersonalization and derealization, to name a few (Sar et al., 2017; Zeligman et al., 2017).

Sociocultural Model versus Post traumatic Model in Relation to DID

The sociocultural model is no longer accepted as an etiology for DID. There are still those practicing that will claim that DID does not exist or is caused by medical illness or suggestions by a therapist. The research on both trauma and DID shows otherwise. Severe childhood trauma is accepted as a major causal factor of DID and it would be more accurate to view the manifestations of DID as a function of the social and cultural environments (McLean Hospital, 2019; Sar et al., 2017).

Counseling Implications

A counselor’s understanding of DID from a developmental perspective may help to decrease re-traumatization in the counseling environment and provide frameworks to improve quality of care and increase the effectiveness of care and clinical outcomes. Development throughout the lifespan stages provides a psychoeducational tool for the counselor to use with the client to help understand themselves and others. The impact of disrupted development due to childhood trauma and as manifested in the DID client can inform treatment. Relational trauma of this severity requires an understanding of the developmental disruptions as the therapeutic alliance is the most effective counselor tool for healing with DID (Fisher, 2017; Kolk, 2017; Sar et al., 2017; Zeligman et al., 2017).

Some of the key counselor qualities identified by DID clients are empathy, being engaged, validating, unconditional positive regard, genuineness, transparency and flexible boundaries. Some of the effective approaches/techniques identified are grounding processes, a secure structure, pacing of sessions, reviewing of sessions, and coping skills (Jacobsen et al., 2015). Counselor acceptance and validation while slowly creating a safe therapeutic space and building trust is internalized slowly by the DID client. The DID client will gradually earn secure attachment and heal the developmental wounds through relationship with the counselor, gradually with the selves, and eventually extending to others. Healing involves creating a cohesive autobiographical narrative which is the effect of process the trauma and decreasing dissociative barriers. (Fisher, 2017; McLean Hospital, 2019).

-Written By Michelle

References

About the CDC-kaiser ACE study. (2021, May 21). Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Fabout.html

Broderick, P. C., & Blewitt, P. (2014). The life span: Human development for helping professionals. Pearson Higher Ed.

Fisher, J. (2017). Healing the fragmented selves of trauma survivors: Overcoming internal self-alienation. Taylor & Francis.

Jacobson, L., Fox, J., Bell, H., Zeligman, M., & Graham, J. (2015). Survivors with dissociative identity disorder: Perspectives on the counseling process. Journal of Mental Health Counseling, 37(4), 308-322. https://doi.org/10.17744/mehc.37.4.03

Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma.

McLean hospital | Mental health treatment, research, and education (Belmont, MA). (2019, February 17). https://www.mcleanhospital.org/

Piaget, J. (1977). The essential Piaget; ed. by Howard E. Gruber & Jacques Voneche.

Sar, V., Dorahy, M., & Krüger, C. (2017). Revisiting the etiological aspects of dissociative identity disorder: A biopsychosocial perspective. Psychology Research and Behavior Management, 10, 137-146. https://doi.org/10.2147/prbm.s113743

Zeligman, M., Greene, J. H., Hundley, G., Graham, J. M., Spann, S., Bickley, E., & Bloom, Z. (2017). Lived experiences of men with dissociative identity disorder. Adultspan Journal, 16(2), 65-79. https://doi.org/10.1002/adsp.12036