This programme is a treatment manual for mental health professionals. It assumes specific clinical training in the treatment of complex trauma and dissociative disorders, and a regular supervision framework. It does not replace your clinical judgement or your professional ethical responsibility. The diagnostic criteria are rephrased here in our own words, never reproduced. Three warnings specific to this indication. Suicide risk and self-harm are common and are reassessed regularly, section 9. No memory recovery technique — hypnosis, guided imagery, interpreting symptoms as evidence of abuse — is used, section 35. And this manual does not cover direct work on traumatic memories, which requires specific training and supervision, section 36.
1. The programme at a glance
Indication. Adult with dissociative identity disorder or partial dissociative identity disorder, 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. This manual covers the first phase and the shared decision on the second, in a practice that avoids suggestion.
Format. Sixteen key sessions over eight to twelve months, often longer. Weekly sessions of 50 minutes, sometimes two a week during difficult periods. No extended sessions centred on memories.
Targeted mechanism. Reduce dangerous behaviour, lost time and flashbacks, widen the capacity to stay in the present and tolerate emotions, foster continuity of experience and cooperation between identity states, 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 |
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 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
Who this programme is for
Psychologists, psychiatrists and psychotherapists trained in the treatment of complex trauma and dissociative disorders, under supervision. It is not intended for patients or for their families.
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? Suicide, self-harm, revictimisation, self-neglect. Section 9.
3. Is the person currently in danger — a violent relationship, exploitation? Section 26.
4. Who is on the team? A doctor for comorbidities and medication, a crisis framework. Section 10.
5. Do you have the necessary training and supervision? If not, refer.
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 that has been misdiagnosed.
Severe addiction or a serious eating disorder that is not stabilised, which come first.
What this programme is not
It is not an exploration of identity states, nor a mapping of "systems", nor a search for hidden memories. Nor is it a refusal to acknowledge what the person is going through.
How to use it
Read sections 3 to 15 first, then sections 32 to 35 before the first session. Section 43 sets out what not to let go.
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 — feeling estranged from oneself, from one's body. Derealisation — the world seems unreal. Voices, often heard inside the head. Somatic symptoms — pain, numbness, non-epileptic seizures.
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. The estimates are themselves at the heart of the debate, section 4. In clinical settings the diagnosis is made more often in women.
Course
Often several years of care before diagnosis, with other diagnoses beforehand. A chronic course in the absence of appropriate treatment, 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. 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 concludes in its favour.
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.
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, 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, suggest nothing, and remain neutral about the history. Section 33.
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. Above it: hyperarousal — panic, anger, flashbacks, impulses. Below it: 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.
Phase-oriented treatment
Phase 1: safety, stabilisation, symptom reduction, skills. Phase 2: work on traumatic memories, carefully paced, when the person is stable and chooses it. Phase 3: integration, rebuilding a life, relationships. The phases are not strictly sequential; you return to stabilisation whenever needed. For many people, phase 1 brings most of the improvement.
What the model explains to 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.