By John R. Rifkin, Ph.D.

Probably you’re wondering what all of those acronyms mean in the title of this article. DID stands for Dissociative Identity Disorder, which was once called Multiple Personality Disorder. PTSD stands for Post-Traumatic Stress Disorder, and the XYZ is meant to imply that DID is the most intensive of the entire spectrum of Trauma from which therapists are challenged to help their clients recover.

DID does refer to someone who suffers from multiple personalities. Perhaps you remember The Three Faces of Eve, which was a book and a movie about a psychiatrist dealing with a client who had several personalities. DID is still considered quite controversial and rare in most research circles. However, most psychotherapists who have been in practice for an extended period of time have worked with someone suffering from this problem. Perhaps because of the huge amount of trauma in life, it is less rare than most people think.

Let me first clarify PTSD (Post-Traumatic Stress Disorder). This occurs when someone is exposed to a traumatic event where actual or threatened harm to the self or others occurred and the person experienced fear, helplessness and or horror. The traumatic even is re experienced in significant ways along with heightened arousal and avoidance of things that remind them of the event. Post-Traumatic Stress Disorder is quite common, and happens both in military situations and also in the context of modern life with situations involving abuse or violence.
The treatment of PTSD, in and of itself, can be quite complicated, and those who suffer from it, find it causes a great deal of distress in their lives.
DID, however, is another magnitude of difficulty.
In my book, The Healing Power of Anger: The Unexpected Path to Love and Fulfillment, I attempted to categorize the levels of damage we all experience in growing up. I started with Category One, where your parents try to kill you, and gradually descended to Category Seven, where you have good, loving parents, who still manage to cause some level of damage as a result of not being able to be perfect parents. Perfect parents would always show up emotionally for their children and never reverse the Parent-Child relationship by asking the child to meet their needs. At the time it was written, I believe that I was the first to begin to categorize the levels of damage in childhood.

Since having written the book, I have realized, through my work with some people who suffer from DID, that there should, in fact, be a Category Zero. This would be where a child is not only threatened with death, but is actually tortured as well. Sexual abuse may well be a part of the torture. It is these kind of circumstances that generate people who suffer from DID.
In the midst of torture, people are faced with absolutely untenable positions. You are being faced with a situation in which you are completely out of control and under the control of someone else who is intent on inflicting pain. There is no escape, and no likelihood of rescue, though rescue fantasies are common. The pain, frustration, fear and horror are pervasive and overwhelming.

In the face of this kind of situation, our brains use dissociation as a defense mechanism. Dissociation enables us to literally go away from the unbearable context by escaping inward. We “go away” from the reality with which we are faced by becoming unconscious of it. However, we do not entirely lose consciousness. Since our sense of self has withdrawn from this unacceptable reality and is no longer aware of what is going on, the consciousness that is left must now deal with the reality of the torture.
This is a process that is repeatable, and can happen very rapidly. In the context of a half hour of torture, someone may generate as many as hundreds of new “alters,” or new identities who are trapped into facing the ongoing process of abuse. This is especially true for children, who’s understanding of reality is as yet completely formed.

It is this dissociative process that escalates DID into the most serious of psychological diagnoses. People with DID have at least two identities or personality states, each with its own particular way of relating to the world.

Let’s look at the case of Mary. Mary was the fourth of seven children, living in a small town not far from a university in the southern part of the United States. Her father was working at building an insurance business, and her mother was overwhelmed with taking care of all the kids.

When she was three, with a one year old sister and an infant brother, her mother’s youngest brother, Mel, came to live with them in their basement. It wasn’t clear why he was living with them, but he was attending classes at the university.

Mary’s mother’s family had been a mess. Alice, Mary’s mother, was the oldest of six children in her own family, and her father was an alcoholic. Alice’s mother had worked as well as tended to the kids. Her father was physically and emotionally abusive to Mary’s mother, as well as to the other children in the family. Her youngest brother, Mel, had had significant physical problems as a child, and had been hospitalized and required surgery a number of times as a young man.

When Mel came to live with Mary’s family, no one was aware of how damaged emotionally he was. In fact, he was very bright, yet severely traumatized himself from having been left at the hospital as a child and having to undergo multiple surgeries.

Mary was exposed to Mel’s abuse in the basement on a number of occasions, since that was where the children’s play room was as well. He was quite sadistic with her. He was introverted and depressed. He was not in his right mind, though he did not show these issues to his sister or her husband. It was only Mary, who frequently drifted down to the basement to play, who was exposed to the nightmare of her adolescent cousin’s damaged psyche.

Mel quickly began to abuse Mary. It started out with his sexual abuse of her but quickly moved on to his threatening to kill her and her whole family if she told or didn’t cooperate with him. He physically abused her to where she would lose consciousness on a number of occasions. He constantly demeaned her and told her that she was really bad and deserved to be punished. Simply describing what he did to her doesn’t begin to convey how completely out of control he was with her and how terrified she was of him.

Mary, as a three year, with a mother who was out of touch and overwhelmed with her other children, was completely vulnerable. Though she was being terrorized, her family didn’t notice much other than that she was not very demanding and was quiet and withdrawn.

Mary continued to be quiet throughout much of her adult life. She went through a series of adolescent experiences with young men who forced sex upon her against her wishes. At times she was able to fend them off, but often she was vulnerable to their unwanted advances. It was all quite confusing to her.

Mary was so unhappy in her abusive marriage that she finally found her way into therapy. She had no idea that she was suffering from DID, and neither did her therapist. She would frequently become quiet in the course of her sessions, and appeared to be confused. Her therapist’s support both reassured and confused her, as well as upset her.

She attempted a brief round of marital counseling, but that simply established that she was really alone in her marriage. As Mary moved towards divorce, she became more and more unstable. Her therapist referred her to a psychiatrist, as he thought that the instability was related to her moods.

As Mary underwent a few different medication trials, she continued to get worse and worse. After a number of months, it gradually became clear to her psychiatrist and her counselor that there were significant dissociative aspects to Mary’s case. Eventually, Mary began to realized that she was suffering from DID. There were a number of events that took place where it was clear that she had broken things, but she retained no memory of these events.

Gradually, over time in treatment, various alters (alternative personalities) began to appear and participate in treatment. All of this was extremely upsetting for Mary. As it became clearer and clearer that she had alters, they began coming out more and more frequently, and all of them were completely terrified. There were several incidents where alters who were feeling suicidal appeared, and hospitalization was considered at many points.

Once the alters began to come out, it was like a flood. They would appear one after another until it seemed like an endless parade of new personalities, all of whom were traumatized and disconnected from themselves, their memories of the trauma, and from each other.

At this point, there were very few medications that were very helpful, other than occasional major and minor tranquilizers. Mary’s focus was on surviving and healing.

Over the course of the next five years, gradually the sense of overwhelm began to decrease. Mary started to accept her alters as parts of herself, which was really quite helpful. Each new one had to be calmed and oriented to all of the events of her life that had taken place. She described the initial realization that she had been so traumatized as a shattering of her self.

This same sense of shattering was associated with some of the early memories of trauma that gradually began to coalesce into a narrative. Little fragments of memories gradually built into little sequences that eventually connected with other sequences. All of these memories had been completely repressed, though some of them had appeared briefly earlier in her life during times of intense stress.

It’s difficult to portray the true level of suffering that had occurred to Mary, both in her past, and in her present as she began to reconnect to the reality of the emotional and psychological damage to which she was exposed. She would frequently spend weeks in bed, only getting up to work, eat, sleep or attend her psychotherapy sessions. She frequently would need almost daily sessions of psychotherapy. She cried enough to fill up lakes with her tears. Her anger would be overwhelming and threatening even to her at times. Her fears would cause her whole body to tense in ways that caused severe physical pain. Hours and hours of bodywork would hardly begin to relieve her suffering. At one point, she had so much tension in her jaws that her teeth began to crack and needed repairs.

Her therapist worked with each of her alters. She did her best to soothe and orient each of them to be able to relate to being in the here and now. For most of the alters, when they first appeared, it was as if it was literally the next moment to the last second of abuse before they had fled into dissociation. They were usually terrified and desperate to disappear. Trusting another person, specifically her therapist, was extremely challenging. Mary’s relationship with her therapist was tested many times over the years of treatment. Mary had learned that you could really trust or depend on no one in life.

Gradually, over the years, her trust in her therapist increased, based on the experience of her therapist’s consistent reliability. Also, as each of the alters developed more experience with being out and present in the here and now, each began to come to the realization that the actual trauma was over. Additionally, each alter had to work through all of the feelings about their particular aspect of the trauma. This would lead to increased continuity of the memories and a greater understanding of all that Mary had suffered.

The first stage of treatment was completed when Mary no longer suffered from being constantly emotionally triggered by the internal experience of recovering the memories and getting all of her alters out to the surface of consciousness.
The second stage of treatment was learning to deal with external triggers, things that that Mary would experience in daily living that would remind her of the traumatic experiences of her childhood. This stage is more similar to a normal PTSD treatment.

Throughout treatment, Mary and her therapist worked to help develop a co-consciousness between her alters. The treatment went better when the alters could become aware and accepting of each other. Frequently, when new alters would come out, they would be extremely mistrustful of the other alters. This was simply because they were others, and all of the alters had huge trust issues with deal with anyone who was “other.”

Mary was lucky to be able to afford her intensive treatment. She was able to work outside of an office environment most of the time, and never really lost her ability to work. This partly related to her innate intelligence and also to her incredible will to survive.

Her commitment to her healing process was, for her, a struggle between life and death. She showed an intense courage to keep pushing forward through round after round of the re traumatization of recovering memories which were like living in a horror movie.

Every person in therapy demonstrates a commitment to healing and recovery that is inspirational, but people like Mary, who work through the most terrifying and confusing events of early childhood trauma are an inspiration to all of us.
Mary had been almost completely isolated from everyone during the first stage of her treatment that lasted for five years. As she moved into the second stage, she slowly worked into developing a small, supportive social network. This was still a very fragile time for her, as she continued to be vulnerable to external triggers that were fairly innocuous for others, but could be terrifying to her.

Gradually, she became more comfortable in developing a life that included relationships with other people. She was hoping to accomplish the goal, eventually, of what is called integration. This is where all of the alters remain intact and available, but the amnesia related to dissociation gradually withdraws so that Mary could flow seamlessly between the alters who had been previously isolated.

The process of fully healing from DID is a challenging task that can require decades of psychotherapy and time. Those on the road to this healing deserve all of our admiration and support.

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