Abstract

The treatment process with chronic complex dissociative disorders (hereafter DID) often becomes problematic, even painful, for patient and therapist alike. These difficulties can be categorized as 1) disruptions, in which the flow of the therapeutic process is derailed for a period of time, often in an emotionally conflicted manner; 2) impasses, which are declared when the treatment is derailed not simply in an acute situation, but the dysfunction achieves a state of chronicity in which progress has been frustrated for a sustained period of time; and 3) treatment resistant or refractory circumstances, often defined by a patient’s failure to improve even after two appropriate state of the art treatments and/or by the efforts of two therapists of acknowledged expertise.
This presentation approaches such phenomena from a perspective analogous to reverse engineering; i.e., efforts are made to deconstruct or take a finished product apart to see how it works. Here the product is the problematic situation in the treatment. Efforts are made to acquire information, to identify problematic elements, to achieve a more thorough and pervasive understanding of relevant concerns, and to devise an improved model of function which addresses the problematic situation in a manner that both offers a comprehensive grasp of what has taken place and hopefully devises an improved model with which the problematic situation can be addressed.

Multiple Reality Disorder would be an appropriate alternative designation for DID. Alters and narrative distortions subserve the supporting and sustaining of efforts to manage and/or supplant intolerable realities. No theoretical model encompasses all the problems DID patients suffer. Consequently, many issues may be bypassed or neglected when treatment is conducted within a preferred model, risking the creation of a hermeneutic therapy that privileges certain concerns and may immunize itself against course-correction. To either minimize the risk of misadventure or to begin to analyze what has gone amiss, it becomes important to maximize the collection of information and explore alternative models of understanding. It is useful to formulate each case or situation from the perspectives of several paradigms and to generate and maintain a comprehensive problem list. These efforts provide meaningful safeguards for the work of therapists who identify strongly with a particular model of treatment, and may be prone to overlook the potential contributions of those they find less congenial.

This presentation will review the wide range of concerns that may compromise therapeutic work with DID, and present a reformulation of the “negative therapeutic reaction” for work with this condition. It will discuss Kluft’s (2022) six-level description of dissociative phenomena and contrast approaches to understanding and addressing problems with dissociative processes and dissociative structures.

Clinical examples will illustrate efforts both to explore the etiologies of several failure narratives and to breath new life into distressed treatment enterprises.

Potential to distress: yes