Some useful scales in assessing and diagnosing dissociative disorders are:
“The Dissociative Disorders Interview Schedule” in Multiple Personality Disorder Diagnosis, Clinical Features, and Treatment by Colin Ross (1989, p 314‑334),
“The Dissociative Experiences Scale” (DES) by Eve Bernstein Carlson and Frank Putnam (1990),
“The Child Dissociative Checklist” (CDC) by Frank Putnam (1990).
Some questions from these scales to ask adults are:
• Do you have a history of incest or other abuse?
• Do you have a history of injuring yourself or attempting suicide?
• How do you experience time?
• Do you ever experience lost periods of time or time lapses where you are amnesiac?
• Do you ever hear voices from inside your head that tell you to do things or comment on things that you do?
• Do you ever use the pronoun “we” instead of “I” to refer to yourself?
• Do you ever feel like you have personality shifts or different parts of yourself ?
• Do others report seeing personality shifts or behavior that you cannot remember?
• Do you ever find art work, writings or articles for which you cannot account?
• Do you ever have inexplicable skills like playing a musical instrument which you do not remember learning?
• Do you ever get severe headaches?
• Do you have inconsistent handwriting ?
Some useful questions to ask children are:
• Do you daydream a lot or feel like you are in a different world?
• Do you ever use a different name?
• Do you forget things a lot?
• Do you get called a liar much?
• Do you ever feel like you are good at school, work, sports, music, or skills and then other times you are not?
• Do you ever feel like you have different parts of yourself?
• Do you have any imaginary friends?
• Do you ever want to injure yourself or kill yourself or wish you were dead?
• Has anyone ever hurt you seriously?
Unless the alters switch right out and say they are there or an alter actually initiates the therapy, the therapist needs to use hypnosis or guided imagery. Usually dissociative clients are highly hypnotizable because they went into a trance to cope with the abuse. Sometimes they do not want to trust anyone or to let them know they exist and will not show themselves the first or second time the therapist asks for them. The therapist needs to explain that he understands they have different body images and ages in their internal world, but that in this world they share the same body. He must let them know he only sees the same body with each alter and they must let him know who is present in the body when they switch. Sometimes there are dramatic face and voice changes between alters and often there are not.
Once the therapist has developed rapport, trust, and a therapeutic alliance with the client by casually explaining some facts, the client can see that the therapist is not afraid yet can empathize with the client’s feelings of fear and threat. The therapist can use different kinds of inductions to get the client relaxed and then use ideomotor signals (a system of finger signals to communicate while in a trance) to decide whether to invite the alters out. The therapist can ask: “Which part of you is here now?”
Switching Back To The Host
After talking to the alters, find out which other alters in the system they know and if they are willing to meet the others. The therapist can then introduce the alters to each other by saying: “Let the deeper mind guide each of you to a level of relaxation where you can both be co‑conscious and meet each other. I can either hear both of you talk to each other aloud or one of you can translate and fill me in on how it is going.” After some practice, the alters can check in with each other and send out the ones who are in need of some time with the therapist. They can support each other afterwards with older alters taking care of younger alters internally. Ideally, the therapist can allow enough time before the end of the session for the host to transition back into the body and process the session. The therapist can ask the alters to go back inside to their quiet places and can say: “Go inside,” to themselves and can tell the host to come on out and say, “Come on out,” to herself. If there is difficulty coming back, the therapist can say: “As I count from five to one, let the different parts of your body come back to normal. Let yourself come on back as if a magnetic force is pulling you on out. Let your deeper mind guide you to a level of relaxation where you can come out easily and comfortably as I count from five to one.”
After the therapist gets to know the internal system and key players, and when everyone seems ready to deal with memories safely, the therapist can have them view each memory on a movie screen. First, it is important to contract with all the alters as a group, and contract regularly with each alter that is dangerous, not to hurt anyone inside or outside their system on purpose or accidentally. It usually helps alters make a contract if they can feel understood about their strong desire to escape the intensity of pain about the abuse and the sense of hopelessness that these intensely painful feelings will never end. After the therapist has been empathic with their pain and hopelessness, he can emphasize the difference between experiencing feelings and acting on feelings inappropriately or impulsively. He can then contract with the alters for time to work through the intensity of these feelings. Hypnotic subjects take language quite literally. The therapist needs to be very careful in wording contracts that are time‑limited to the next appointment by saying: “Until the next time I see you in a session.” This will cover any cases in which something happens to the therapist and he does not make it to the regular meeting time, and is especially necessary with suicidal alters.
It usually helps alters make a contract if they can feel understood about their strong desire to escape the intensity of pain about the abuse and the sense of hopelessness that these intensely painful feelings will never end.
When the alters are ready to look at the memory, an alter or internal self‑helper (ISH) is often able to read the mind of the persons with the memory and inform the therapist as much as possible before an abreaction. The therapist can ask the deeper mind to count backwards from fifteen to one (or whatever ages are appropriate for that client). The therapist can say: “Scan the year from the fifteenth birthday to the sixteenth birthday for any memories that need to be discussed in therapy. Now, scan the year from the fourteenth birthday to the fifteenth birthday, etc. ” The memories that need to be discussed in therapy and the number of memories in each year can be indicated with finger signals. As mentioned earlier, angry alters or alters that are introjects or imitators of their perpetrators need to look at their first memory to see how they came into existence. Hospitalization is often indicated at these times. After they abreact or feel the intensity of the feelings of that memory or series of memories, angry alters are often more willing to help the others with their memories.
After an abreaction and once the therapist has invited the alters to go back to their quiet places, it is usually a good time to deepen the trance to place some positive messages, such as Corey Hammond (1990) recommends. Sometimes it is good for the original personality or the host to be co‑conscious during the sessions. This does not always work because someone might be blocking or not trusting the host. Sometimes the host is not up to dealing with the memory yet, but the alter still needs to proceed with an abreaction. So the host might not be present during this abreaction, or the host might recall the memory and feelings later at a safe pace. It is important to work these things out when possible and have as few secrets as possible. It is also important to respect the system by asking the alters permission to break the secrets, whether that means meeting other alters or recalling memories. Sometimes the memory is too much to handle at the time so the therapist can suggest the memory be stored.
It is usually best for the host to be the one that begins and ends the session. This gives her a feeling of control and keeps her from panicking or getting amnesiac, but this does not always work. Once in awhile, the alters are more highly functioning than the original personality or the host for a particular time or for extended periods of time so these alters hill enter and leave the session. It is important to work out agreements. Sometimes the host is glad to have a break if she can trust the alter in charge. Other times an alter might need to take a destructive alter away or lock them up inside somewhere like a penthouse suite or a meadow until the next time that alter meets with the therapist. Of course, the hospital needs to be used any time the MPD client needs to be safe and cannot control a destructive alter with an internal hospital or quiet place.
Sometimes alters will advance in age before looking back in time to their memories. When they get to an older age, they can re-decide many irrational decisions they made about the events, themselves, and the world with more information and from an adult perspective. Before alters can more permanently advance to an older age, the other alters need to share the feelings of the memories. Sometimes an alter can range in age or represent a group of alters of different ages. This technique works better with clients who are healthier such as those with DDNOS.
Often the alter will advance to an age where there is a repressed memory like in their teen years and stop there until that memory or memories are worked through. As with any technique, sometimes they do not work and child alters do not advance in age. As they get their turn, they will hopefully draw closer together and become more of a team or integrated as a whole where they all co‑exist and eventually are co‑conscious as one person.