November 21, 2010
I would like to make a follow-up comment from a comment made on the “What Would Your Perfect Treatment Plan Look Like?” blog.
Specifically, a portion of heartofindigo’s comment includes the following paragraph:
a final comment: I wish that T’s would do exactly what you are doing, and ask. I have heard of so many… can’t think of a way to put this delicately… asinine demands on the patient. like the therapist doesn’t trust the patient’s process or intent or something. like the therapist has “superior knowledge.” unless one has DID, I don’t see how one can assume that they can make the judgment about what is working or not. that has to come from the patient, and so there HAS to be a partnership.
plus that will empower us to reclaim our power, which is the root of the problem in the first place.
This is an extremely important point.
The dissociative survivor IS the expert for what helps them.
And from what I can see in reading through the comments in the previous blog, the normal 50-minute hour is far from helpful. For most dissociative trauma survivors, it’s not sufficient, it’s not enough, and in many ways, it’s not helpful. DID survivors simply need more time to make sufficient progress in therapy.
Should insurance panels be the final “experts” on how long sessions can be and on how many sessions a trauma survivor can have?
If DID clients are cash-paying for their therapy, can they make their own decisions about how much time they would like to have with their therapist?
Should therapists or counselors have the final say on how much time a dissociative client needs to work on their issues?
Should psychiatrists or doctors have the ultimate decision-making power to determine all treatment plans for dissociative trauma survivors?
Who gets to decide these things? Are clients allowed to have freedom of choice and the freedom to want or request something more or different than the norm? Do mental health professionals have the only vote about what is helpful?
In too many instances, treatment plans for dissociative survivors are designed by – and limited by — mental health professionals and insurance companies. And all too many DID survivors truly do not get their therapeutic needs met because the mental health professionals are setting “appropriate limits” to what they are willing to offer their clients. These limits are decided on based on the therapist opinion, and not on the clients’ needs.
In my personal opinion, a 50-minute session once per week is barely scraping the surface of what is needed to work with the dissociative population. Most DID survivors have a minimum of 5-10 insiders that could productively use the therapy session time at any given day, and the issues that these 5-10 insiders would be discussing would not be simple issues. Typically everyone in the DID system has complicated situations, painful issues, complex conflicts to discuss. Is this going to happen in 50 minutes? Not likely. Is everyone going to get a turn in 50 minutes? Absolutely not. In reality, it would be more likely that each and every insider could fill up a 50-minute session! To have to share such limited therapy time between so many inner people means that the pertinent and important issues just are not discussed in any great depth or detail. It takes a lot longer to make progress because so much just can’t be addressed.
Because of dissociative walls, the need to switch between inside parts, amnesia between many parts, time distortion, other dissociative complications, etc., it very often takes a DID survivor longer to dig into the issues of the day, and longer to get grounded and stabilized afterwards. Having the time to talk to a few of the insiders, to get their opinions about the topic, or to give them a chance to talk about their own issues does not happen quickly.
Part of what created and solidified dissociative identity disorder in the first place was having no where to discuss complicated, painful emotions, turmoil, and distress. For the therapy hour to remain a drop in the bucket in terms of meeting the needs, it leaves the dissociative survivor feeling like they will never get through the healing process. And in some ways, that is too close to being true.
But is it therapeutic exploitation to “allow” clients to have longer sessions and / or more than one 50-minute session per week?
When is too much? If a DID client needs more than normal, even for the dissociative population, should they be allowed to have more sessions than normal?
Should therapists be “required” to set an “appropriate limits and boundaries” by insisting on short sessions, even if DID survivors say and believe they need more time in therapy?
If clients say they need 2-hour or even 3-hour sessions, should they be allowed to have extended sessions? OR should therapists have the right and responsibility to limit these sessions to “normal limits” instead?
Whose opinion is correct?
In these situations, do therapists know best or do dissociative trauma survivors know best?
In case of a disagreement between the client and therapist, who should have the final say in length of sessions and frequency of sessions?
As heartofindigo stated, a big part of the healing process is about reclaiming personal power that was not allowed during the years of trauma.
Is freedom to decide length and frequency of sessions part of client empowerment? Or part of therapeutic responsibility?
What are your thoughts about this dilemma?
Kathy Broady LCSW
Copyright © 2008-2010 Kathy Broady LCSW and Discussing Dissociation
July 14, 2009
When you have dissociative identity disorder (DID/MPD), and you’re thinking as a multiple personality — thus having a multitude of different thoughts at once time — it can be very difficult to make decisions.
How do survivors with DID ever make up their minds?
How do survivors with DID decide whose opinion to follow?
How do survivors with DID ever decide what is best for them?
How do survivors with DID sort out having a dozen different opinions at once?
It is complicated to think like a multiple.
There are gaps of missing time, non-sequential pieces of information, jumbled feelings and emotions, snippets of conflicting facts, confusion, voices from the past, fears of more punishment, flashbacks, internal arguing, programmed thoughts, insistent introjects, personal insecurities, etc. The chaotic internal workings of a dissociative trauma survivor can make it very difficult to think clearly.
Non-dissociative “singletons” (people who do not have multiple personality disorder) can experience simultaneous mixed feelings, opposing thoughts and conflicting perspectives on specific situations as well. Singletons can write out extensive lists of “pros vs. cons” on any number of situations. Non-dissociative singletons do not experience just one thought or one feeling at a time either. They see the big conflicting picture all at once.
So what makes decision making even more difficult for survivors with DID?
All too often, dissociative trauma survivors functioned through the difficult times of their life by separating their thoughts and feelings into individual compartments and using dissociative, amnesiac walls to keep these compartments separated. Having mixed emotions and conflicting beliefs at the same time was often too much to manage in the middle of a traumatic event. Dissociative survivors learned to split the different feelings and the different perspectives into different parts of themselves, blocking one perspective away from the other. It is easier to separate and contain overwhelming conflicting emotions when the two opposing emotions did not have to directly collide with each other.
For example, all children love their parents. But if a young girl has a father who is sexually abusing her, and a mother that is either pretending not to see that or is helping the father to abuse her, then huge conflicting emotions are going to occur. The child will want to please her parents, even in this painful abusive situation. But in order to do that, the child will have to find ways to separate her experience of the parents she loves from the parents who are hurting her. Dissociating the conflicts into separate parts help this to happen.
- The child can split off a part of herself that is willing to obey her father even to the point of acting like a passive or promiscuous young child that appears to want to be sexual with the father.
- She can split off a part of her that feels the physical pain and injury of the assault.
- She can split off a part of her that contains the intense betrayal by the mother.
- She can split off a part that holds the emotional pain, deep wounding, and heartbreak of the assault.
- She can split off a part that holds the anger and rage at having been assaulted by both of her parents.
- She can split off a part that holds the fear of being violently assaulted by her parents again and again.
- She can split off a part that is the happy little girl who goes to school the next day, blocking out all the pain, acting very connected to her parents, not showing any sign of having been through a horrendous assault the night before.
The person as a whole sees the situation as a whole. But if a dissociative trauma survivor has separated the different feelings and perspectives and kept that information separated locked and blocked behind various dissociative walls, then the survivor is aware of only some of the information at any given point in time. She is not aware of the whole picture, because she has it dissociated parts of it away from herself.
Dissociative people are accustomed to separating the intense conflicting emotions and managing only one or two at a time. This might help in the short-run, but it does not help in the long-run.
So how do dissociative trauma survivors make good decisions if they are used to looking at situations from the constraints of one limited perspective at a time? What happens when they cannot see the situation as a whole? How can they make a good decision if they cannot put the entire picture together at the same time?
This is a common problem for survivors with DID. The part of them that sees and recognizes the dangers cannot always communicate with the happy naïve part who is determined to believe she is safe and unharmed. The ones that believe they are out of harm’s way (and who wouldn’t want to hold tight to that belief?) refuse to connect with the fear, anger, pain of the trauma (because who would want to feel that?!)
The problem is that by not seeing the whole picture at one time, dissociative trauma survivors find themselves tangled into a variety of dangerous situations. For example, they can bond to dangerous people without recognizing the danger. They see only as much as the current perspective allows them to see, and they don’t even realize that there is trouble looming in the near future. By dissociating the perceptions and experiences that might better recognize the danger, dissociative survivors can put themselves in high-risk situations over and over and over again.
Building the strength, the courage, and the willingness to talk to all the other internal parts in your system is key to getting past the dissociative walls and being able to make decisions from a more complete perspective. Face your difficult emotions, confront the truth of your trauma, listen to all of your inner selves, and recognize that other internal parts have valid information. No one can make a good decision based on partial information. Be willing to look at the whole picture.
As you learn to trust your internal parts to give you the rest of the story, you will be less vulnerable to people who aggressively or suggestively tell you what to think. The more you can trust yourself, the less vulnerable you are to people who would manipulate your thinking by maneuvering behind your dissociative walls. Predators and perpetrators will have less ammunition to use against you when you can trust your own selves. They will not be able to abuse you as much if you are aware that it is happening. The less you dissociate time and information, the more you can appropriately handle life’s current day conflicts.
If you truly know the whole story of what happens in your life, both in the past and in the present, then you are less vulnerable to feeling or thinking or believing something just because someone else more aggressive tells you that you do. You can learn to connect to and trust in your own thoughts or feelings or beliefs, and to make your own assessment of a situation based on that.
Look at the whole picture and think for yourself.
Kathy Broady LCSW