What is recommended for DID patients is individual outpatient psychotherapy oriented by psychodynamics.
The treatment will take several years because it requires a re-education of the beliefs and modes of action that are deeply rooted in us.
"long-term, usually taking years, not weeks or months."
Psychotherapy sessions should be at least once a week or even more
"The opinion of many experts in this field is two to three times a week if resources permit."
"In some circumstances, a higher frequency of sessions (up to three or more) may be implemented for a defined time until the chaotic patient can maintain adequate functioning and / or (as an alternative to hospitalization) to contain self-destructive and / or severely dysfunctional behavior. "
The phased approach:
I. The phase of establishing safety, stabilization and symptom reduction
"The goals of phase I treatment include maintaining personal safety, symptom control, modulation of affect, building stress tolerance, increasing baseline vital function, in place or improving interpersonal skills.
Interventions should include: 1) information about the need for safety for treatment to work; 2) a function assessment of behaviors, which are unsafe and / or risky and emergencies; 3) development of repertoires of positive and constructive behaviors to be out of danger; 4) identify alternate identities that act insecure and / or control unsafe behavior; 5) development of agreements with these and with all identities to help the patient maintain his safety; 6) use of management strategies such as anchoring mechanisms, crisis planning, self-hypnosis and / or medications to offer alternatives to risky behavior; 7) manage eating disorders and drug use which may include the use of specialized treatment programs; 8) taking appropriate action if there is any question that the patient is abusive or violent towards children or vulnerable adults or towards another person (according to the laws in force where the clinician practices ); 9) help the patient with adequate resources to protect himself from domestic violence; and 10) insist that the patient seek the care best suited to their situation, including hospitalization, so that there is prevention of patient violence against themselves or others. "
II. The phase of confronting, developing and integrating traumatic memories
"In this phase of treatment, the heart of the work is around the memories of the traumatic experiences of the patient with DID. Effective work in this phase involves recalling, tolerating and integrating events from the past that overwhelm patients. .
The patient and therapist should discuss and come to an agreement on which memories will be placed in the center of interest, at what level of intensity they will be processed; what types of interventions will be used (for example: exposure, planned abreactions, etc.); what alternate identities will participate, how to maintain safety during work, and what procedures to contain traumatic memories if the work becomes too intense.
Patients benefit greatly when therapists help them use planning, information, exploration and dosing strategies (cf. Fine, 1991; Kluft, 2001; Kluft & Loewenstein, 2007; Van der Hart, 2006) to develop a form of control over the irruption of traumatic material.
These interventions help the patient to widen the range of emotions and affects among alternate identities, and to assist the patient, as a whole, to tolerate the affects associated with the trauma such as shame, horror, terror, rage. , abandonment, confusion, anger and mourning.
Modern approaches to abreaction include cognitive change and mastery in addition to the intensive discharge of trauma-related emotions and stresses; intense emotional discharge on its own can simply re-traumatize and is therefore contraindicated. A major mechanism of change is that of repeated access and association and thus the integration of the fragmented and dissociated elements of traumatic memories into a complete and coherent narrative (Van der Hart & Brown, 1992). Integration also means that the patient comes to an adult cognitive awareness and an understanding of his or her role and that of others in these events (Braun, 1988; Brown et al., 1998; Chu, 1998).
Some authors have used the term “synthesis” for this process (Van der Hart, Steele, Boon & Brown, 1993; Van de Hart, 2006). Successful synthesis must be followed by a process of 'realization' and 'personification' (Van der Hart et al., 2006), for example, a full awareness that has experienced the trauma but that this trauma is a thing of the past . So the patient gives this traumatic event a place in his personal biography.
As traumatic experiences are integrated, alternate identities can experience themselves as less and less separate and distinct. Spontaneous and / or facilitated mergers can also occur. Facilitated mergers often involve “fusion rituals”. These therapeutic ceremonies usually involve imagery or hypnosis which "... are seen by some ... patients as crucial rites of passage from a subjective feeling of division to a subjective feeling of oneness" (Kluft, 1986a, cited in Kluft, 1993a, p. 119). The patient's experience is that the alternating identities unify in an image of junction or unification ”… [These rituals] simply formalize the subjective experience of the work that the therapy has already done (Kluft, 1993a, p.120 ).
III. The integration and rehabilitation phase
In this third phase of DID treatment, patients have additional benefits in internal cooperation, coordination and integration. Usually, they begin to build a more solid and stable sense of Self and how they relate to others and the outside world. In addition, the patient may begin to focus less on past traumas, putting their energy into living better in the present and developing new perspectives for the future.
Integration, fusion and resolution:
"'Integration' refers to working, longitudinal, in all its forms, on dissociated mental processes throughout treatment. Kluft (1993a, p.109) defines integration as' [a] running process that undoes all aspects of the dissociative division which begins long before there is any reduction in the number or distinction of identities, persists during their fusion, and continues on a deeper level even after identities have mingled into each other. only one. ".
"Fusion" refers to a point in time when two or more alternate identities experience themselves as coming together with a complete loss of the sense of subjective separation. "Final fusion" refers to the point in time that occurs when the patient's sense of self changes from having multiple identities to that of a unified subjective self. Several members of the Task Force called for the use of the term "unification" to avoid confusion between early mergers and final merger. Kluft (R.P. Kluft, 1993a) asserted that the most stable treatment fate is the final fusion - complete integration, fusion and loss of separation - of all states of identities. According to this view, a more realistic long-term outcome for some patients can sometimes be a cooperative arrangement called "resolution", which means that the functioning is sufficiently integrated and coordinated between the alternate identities to allow the functioning to function effectively. optimally. However, patients who achieve this degree of cooperative arrangement rather than that of final fusion may be more vulnerable to subsequent decompensation (to Florida DID and / or PTSD) when under sufficient stress. "
Types of treatments recommended:
Training systems for emotional predictability and problem solving (Blum, Pfohl, St. John & Black, 2002)
Adaptive Trauma Remission Information and Therapy Group (Ford & Russo, 2006)
Acceptance and commitment therapy (Follette & Pistorello, 2007)
Security research (Najavits, 2001).
Dialectical Behavior Therapy (DBT English DBT; Linehan, 1993a, 1993b).
Cognitive behavioral techniques (a form of exposure therapy that transforms traumatic memories, overcomes phobic reactions)
hypnosis (calm, soothe, contain or strengthen the ego)
The theory of learning
family or expressive therapy,
re modulation
imaging and hypnosis techniques
Neuro-emotional integration through eye movements (EMDR)
Expression and Rehabilitation Treatments (Art Therapy, Horticultural Therapy journal Journaling, Music Therapy, Movement Therapy, Psychodrama, Occupational Therapy, recreational therapy)
Sensory-motor psychotherapy (Ogden et al., 2006) ("directed mindfulness")
Hospitalization, in which case?
“Hospital treatment may be necessary when patients are at risk of harming themselves or others, and / or when their post-traumatic or dissociative symptomatology invades them or is out of control. Inpatient treatment should occur within the context of an overall strategy oriented towards the defined goal of bringing the patient back to a level of functioning stability in order to quickly refer them to outpatient treatment.
Medication:
Medications for DID are usually best conceptualized as "shock absorbers," rather than curative interventions.
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