Dissociative identity disorder: safety, stabilisation and phase-oriented treatment — a therapist's manual

1. The programme at a glance

Indication. Adult with dissociative identity disorder or partial dissociative identity disorder (section 6), diagnosed after careful assessment, seen as an outpatient.

Reference model. The phase-oriented treatment described in professional guidelines for complex dissociative disorders: a first phase of safety, stabilisation and symptom reduction; an optional second phase of work on traumatic memories; a third phase of integration and rebuilding a life (section 5). This manual covers the first phase and the shared decision on the second, in a practice that avoids suggestion, that is, any influence from the therapist that could shape symptoms or memories (section 4).

Format. Sixteen key sessions over eight to twelve months, often longer. Sessions are weekly and last 50 minutes, sometimes two a week during difficult periods. Each key session may therefore take up two or three sessions: you move on to the next one when its criterion for moving on is met. The programme does not include extended sessions centred on memories.

Targeted mechanism. Reduce dangerous behaviour, lost time — those hours or days the person has no memory of (section 3) — and flashbacks, widen the capacity to stay in the present and tolerate emotions, foster continuity of experience and cooperation between identity states (section 3), reduce shame, and build a more stable daily life.

Phase	Session	Topic	Session output
I. Engaging	1	Meeting	Concerns and goals gathered
	2	Assessing, and what it is not	Differential diagnosis, comorbidities, risks
	3	Safety	Safety plan written
II. Understanding	4	Dissociation, without suggestion	Model explained, questions gathered
	5	Lost time and its triggers	Log and triggers
III. Stabilising	6	Coming back to the present	Three grounding techniques
	7	The window of tolerance	Signs at both edges, and what brings you back
	8	Communicating and cooperating inside	A safety agreement, a means of communication
	9	Nights and flashbacks	Evening routine, plan for flashbacks
	10	Mid-point review	Measures repeated, plan revised
IV. Living	11	Relationships and current safety	One risk situation worked on
	12	Shame and beliefs about oneself	One belief examined
	13	The question of memories	Stance of neutrality explained
V. Deciding	14	Preparing what comes next	Shared decision: trauma work or consolidation
	15	A more continuous life	Plans and routines
	16	Review and next steps	Measures repeated, plan for what comes next

Phases I to V in this table organise the programme and are not the same as the three phases of phase-oriented treatment (section 5): they all fall within the first. In the rest of the manual, "phase 1" always refers to this first phase of treatment. The window of tolerance is explained in section 5, and grounding — the techniques that bring attention back to the present — in section 34.

What the person takes away. Seven printable worksheets, listed in section 42: what I want, my safety plan, my gaps and my triggers, coming back to here and now, working together on the inside, my nights and my flashbacks, my plan for what comes next.

What sets this programme apart from the other manuals on this site. Three things. A diagnosis whose debate is set out honestly. Constant vigilance against suggestion, which guides every intervention. And work that begins, and sometimes ends, with stabilisation, without rushing towards memories.

2. Before you begin

The five preliminary decisions

1. Has the diagnosis been made carefully, through structured assessment and differential diagnosis? Sections 7 and 17.

2. Is risk being managed? In other words, has the risk of suicide, self-harm, revictimisation — being subjected to violence or exploitation again — and self-neglect been assessed, and is it clear who does what in a crisis? Section 9.

3. Is the person currently in danger — a violent relationship, exploitation? Section 26.

4. Who is on the team? You need a doctor for comorbidities and medication, and a crisis framework: whom the person calls between sessions, and what the team then does. Section 10.

5. Do you have the necessary training and supervision? If not, refer the person on.

What this programme does not treat

Direct work on traumatic memories, which is the subject of the second phase, section 36.

A psychotic disorder, epilepsy or a neurological condition mistaken for a dissociative disorder: differential diagnosis is there to identify them, section 7.

Severe addiction or a serious eating disorder that is not stabilised: these are treated first, section 39.

How to use it

Read sections 3 to 15 first, then sections 32 to 35 before the first session. Section 43 summarises the eight fidelity points, that is, what not to let go of in order to stay faithful to the protocol.

3. The clinical picture

Discontinuity of identity

The person describes or shows distinct identity states: different ways of perceiving, feeling, remembering, behaving and relating to oneself and others, with a loss of the sense that it is oneself who thinks, feels or acts. These states can take control of behaviour, or intrude from within as thoughts, emotions, voices, impulses or sensations that do not seem to come from oneself.

Memory gaps

Lost time: hours or days the person does not remember. Unexplained discoveries: purchases, objects, writings, messages they do not remember making. Forgetting personal information or skills. Gaps in childhood memories.

Other dissociative experiences

Depersonalisation is the feeling of being estranged from oneself or from one's body, derealisation the feeling that the world is unreal. Voices may be heard, often inside the head (section 7). Finally, dissociation can be expressed in the body through somatic symptoms: pain, numbness — a loss of sensation in part of the body —, non-epileptic seizures, which look like epileptic seizures but are not.

What you see in the consulting room

Most often, little that is spectacular: most people hide their symptoms, out of shame or fear of not being believed. Sometimes you notice forgetting what has been said, changes in tone, posture or vocabulary, absences, a fixed gaze. A theatrical, attention-seeking presentation is unusual and calls for careful assessment.

Common comorbidities

Post-traumatic stress, depression, self-harm, suicidal behaviour, eating disorders, addictions, sleep disorders, somatic symptoms. They are often the reason for seeking help.

Epidemiology

General population estimates are around 1%, with wide variation depending on methods, and higher in psychiatric settings (Şar, 2011). The estimates are themselves at the heart of the debate, section 4. In clinical settings the diagnosis is made more often in women.

Course

It often takes several years of care before the diagnosis is made, during which the person receives other diagnoses. In the absence of appropriate treatment, the course is chronic, with fluctuations linked to stress and triggers.

4. A debated diagnosis

Why this section exists

Because no clinician can work honestly with this diagnosis without knowing the debate, and because the debate has direct consequences for practice.

The trauma model

The disorder is seen as a consequence of early, severe and repeated trauma, occurring before identity was consolidated, in a context of disorganised attachment, that is, with attachment figures who were at once a source of comfort and of fear. Dissociation would first have protected the child, then become organised into distinct states. This model draws on the high frequency of reported trauma histories, on cohort studies, and on a review that brings this evidence together and concludes in its favour (Dalenberg et al., 2012; Dorahy et al., 2014).

The sociocognitive model

The disorder is seen as a social and cultural construction: vulnerable people — suggestible, in great distress, prone to fantasy, often with sleep disturbances — adopt the role of a person with multiple identities under the influence of the media, cultural expectations and suggestive therapeutic practices. This model draws on historical and geographical variations in the diagnosis, on the increase in identity states during certain therapies, and on research on memory and suggestion (Spanos, 1994; Lilienfeld et al., 1999; Pope et al., 2007; Lynn et al., 2012).

What there is consensus on

The suffering is real, and generally not feigned. Suggestion can shape the expression of symptoms and multiply identity states. Memories can be distorted or constructed. Trauma histories are common among people who receive this diagnosis. A cautious practice, centred on safety, stabilisation and the whole person — you address the person as a whole, without favouring or rejecting any part of them (section 33) —, is defensible under both models.

What this changes for you

You do not need to settle the debate to work well. You must acknowledge what the person is going through without reifying its expression, that is, without treating their identity states as separate people; suggest nothing; and remain neutral about the history, without confirming or disputing the truth of their memories. Sections 33 and 35.

5. The model

What dissociation does

Dissociation is a disconnection between elements of experience that are normally linked: thoughts, emotions, sensations, memories, the sense of agency. To a mild degree it is common — daydreaming, driving on autopilot. Faced with an overwhelming and inescapable threat, it protects by putting at a distance what cannot be lived through. When it becomes the habitual response to stress, it prevents experience from being lived and integrated.

The window of tolerance

Each person has a zone of emotional arousal within which they can think, feel and act (Siegel, 1999; Ogden et al., 2006). Above it is hyperarousal: panic, anger, flashbacks, impulses. Below it is hypoarousal: numbness, emptiness, absence, dissociation. In people who have experienced repeated trauma, the window is often narrow, and shifts from one edge to the other are rapid.

Triggers

Reminders of the past — places, smells, voices, dates, bodily sensations, emotions, types of relationship — activate old responses: fear, submission, fight, flight, collapse, and sometimes a switch to another identity state or lost time.

Identity states, in a non-suggestive reading

They can be understood as ways of functioning that became organised separately, each with its own memories, emotions and strategies, and that have not been able to link up into a continuous experience. Whatever their origin, they belong to one single person, and the aim is better communication and cooperation between them, then, if the person wishes, greater continuity. In the rest of the manual they are also called "parts", the most common term in clinical practice, or "parts of you" in sentences addressed to the person: these terms refer to the same thing.

Phase-oriented treatment

Phase 1 aims at safety, stabilisation, symptom reduction and learning skills. Phase 2 is carefully paced work on traumatic memories, when the person is stable and chooses it. Phase 3 aims at integration — greater continuity between identity states and between experiences —, rebuilding a life, and relationships (Herman, 1992; van der Hart et al., 2006; International Society for the Study of Trauma and Dissociation, 2011; Steele et al., 2017). The phases are not strictly sequential; you return to stabilisation whenever needed. According to the clinical experience reported in the guidelines, phase 1 brings many people most of the improvement.

What the model explains to the person

The model makes it possible to tell the person that what they experience has a logic, that dissociation may have protected them and gets in their way today, that their reactions have triggers, that it is possible to learn to stay in the present, and that all their experiences belong to them. This is the purpose of session 4.

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