Treatment Approaches for Dissociative Identity Disorder

Dissociative identity disorder is characterized by ongoing dissociative symptoms, amnesia, and the presence of alternate identities (“alters”). Alters typically function independently of each other, so they tend to have their own memories and ways of expressing themselves. 

In general, the causes of DID are mainly attributed to childhood trauma, as dissociation is a way of protecting the mind from significant emotional overwhelm. Understandably, such symptoms and causes can lead to intense distress and affect people’s well-being and ability to function in daily life. Therefore, stabilization is typically the main treatment concern in the immediate aftermath of diagnosis. 

However, once people are stabilized and their safety is ensured, different therapies can be used to address the traumatic memories that have caused their dissociative identity disorder. The aim is to integrate these memories into the person’s sense of the world. Yet, the way this is done depends on the therapy’s specific modality.^1,2 

The following sections cover the different forms of therapy commonly used to treat DID.

Trauma-Focused Therapy for DID

Many types of therapy can be trauma-focused, including all the following types discussed in this article. For instance, cognitive-behavioral therapy (CBT) isn’t necessarily trauma-focused for everyone, but it can be when needed. The same goes for psychodynamic therapy.

The important thing is that the therapist is “trauma-informed.” This means your therapist understands the severe consequences of trauma and how best to tailor their words and actions to make your sessions feel safe. Therefore, they won’t push you too far or make you remember things in a way that could be triggering.³ 

Trauma-informed therapists will be concerned with your safety and enquire about your sense of emotional and physical safety in life. Plus, your work may involve developing new ways to feel safe, so you can eventually no longer be preoccupied with defending or protecting yourself.³ 

Additionally, trauma-informed therapists typically pay particular attention to keeping any promises they make to you and strive to be reliable. This may be crucial in your journey towards feeling safer in relationships.³ 

Since some people may be triggered by certain treatment procedures, trauma-informed therapists often strive to keep you as actively involved in decisions as possible.⁴ This is because a key part of psychotherapy for trauma is bringing your attention to how it is impacting your current symptoms, thoughts, and behaviors. While this may sound obvious to some, outlining this connection clearly is often crucial to recovery.⁴ 

And finally, trauma-informed therapy focuses on cultivating a sense of empowerment and autonomy, as well as developing coping and grounding skills for managing overwhelm.

Psychodynamic Therapy for DID

Alters in DID serve a protective purpose for a traumatized person, and they’re maintained by their persistent defence mechanisms, inner conflicts, memories, and distorted thoughts.⁵ Therefore, as previously mentioned, therapy techniques for DID typically focus on working with each alternate identity. 

Psychodynamic therapy is particularly ideal for this kind of work because it’s interested in things like defence mechanisms, inner conflicts, and repressed memories.⁶ In fact, the psychodynamic approach believes multiple alters to be fragments of a single identity, not many distinct personalities. So, if there are conflicts between different parts of the person’s psyche, these are considered to be inner conflicts. A psychodynamic therapist can bring these conflicts into awareness and help individuals confront and resolve them.⁷ 

When these conflicts are brought more into consciousness, the therapist can explore them in sessions and provide validation and reassurance to each alter. The goal is to create “solutions” for each. For example, one may feel the need for safety, and another may seek revenge. Working through these needs should render the alters unnecessary, allowing the person’s true and whole personality to emerge.⁵ 

Cognitive-Behavioral Therapy (CBT) for DID

Cognitive-behavioral therapy (CBT) is a promising treatment for people with both post-traumatic stress disorder (PTSD) and DID. The approach focuses on the beliefs, thoughts, and behaviors that perpetuate mental health conditions, and can be tailored to fit a DID recovery plan.⁸ 

When CBT is tailored to DID, it focuses on unhelpful or inaccurate beliefs about dissociation and avoidance behaviors. For example, I can’t remember what happened may be reworked into I am too afraid to remember because I think I’ll get overwhelmed and lose control.⁸ 

It’s important to note that this method is based on the avoidance model of dissociation, which suggests dissociation is not an automatic reaction but an active avoidant coping strategy. Some experts disagree with this view and instead use grounding and relaxation exercises to counter dissociation as an automatic response.⁸ Therefore, whether someone believes CBT to be an appropriate treatment for you may come down to who you’re talking to – and your unique needs. 

Within the avoidance model, therapists may invite people to directly approach their traumatic memories and feel the fear of losing control. The CBT view is that people can then overcome their fears by having them disproven, for example, by witnessing themselves not losing control when remembering something painful.⁸ 

Additionally, some models will involve a “farewell ritual” in which people can say goodbye to alters that once had a helpful purpose but are no longer needed. This might be a useful opportunity to thank the alters for their role and achieve closure.⁸ 

As may be clear, compared to other therapeutic approaches, CBT for DID doesn’t dwell too deeply in the trauma, but focuses on present-day actions that can fuel symptoms. This may not be everyone’s preference for treatment.

Dialectical Behavioral Therapy for DID

Dialectical behavioral therapy (DBT) is a method based on CBT principles and adapted for people with intense emotions. As a result, it’s known as a “gold standard” treatment option for those with borderline personality disorder (BPD), a condition characterized by intense feelings and impulsivity.¹ 

DBT can also be further adapted to meet the needs of people with dissociative identity disorder. However, it doesn’t focus on trauma until other issues have been addressed. For example, DBT typically first targets issues like suicidal ideation, self-harming, and any other impulsive behaviors, such as substance use or angry outbursts.⁹ It does so by helping people tolerate distressing emotions and by teaching mindfulness and emotional regulation techniques.

Further, DBT views the existence of alters as important parts of the whole person. Though one state may be assertive and another is timid, one cannot be “gotten rid of” as though it were a separate being. In other words, DBT views each as a valuable part of the person’s identity, which is why DBT practitioners don’t assume switching between alters to be a bad thing. In fact, switching may serve therapeutic functions, such as learning more about the whole person and accessing repressed thoughts or memories.⁹ 

While a DBT therapist typically accepts someone’s sense that they are many people at once and tend to each part, they’ll also assert that these are parts of one whole person. This helps them non-judgmentally accept themselves for where they are right now and take the therapy from there.9 Therefore, this approach may be more suitable for people who feel apprehensive about “losing” their alters.

Eye Movement Desensitization and Reprocessing (EMDR) for DID

EMDR is a technique for relieving the distress associated with disturbing memories – without overly discussing them. In sessions, the therapist invites the person to recall a specific traumatic memory and guides them through lateral (side-to-side) eye movements. This technique is thought to reduce the emotional “charge” of such memories, helping people discuss them more easily.¹⁰ 

Theoretically, when traumatic memories are less charged, someone can process them more easily and strip them of their power to cause anxiety and avoidance. Though we don’t know exactly why EMDR works, it’s proven to be a useful treatment for many conditions, including PTSD and DID.¹⁰ 

However, in order to be a candidate for EMDR therapy, people must be able to tolerate some emotional discomfort. For instance, they shouldn’t shut down emotionally or become overwhelmed too easily.10 Therefore, EMDR therapy for DID is often not recommended until someone is more stable and has sufficient coping skills.¹¹ 

In addition, EMDR therapy should be part of other treatments. For example, if someone were having DID counseling, it may involve psychodynamic techniques alongside EMDR. Further, therapists won’t just begin EMDR until they’re familiar with your history, as this allows them to work safely and help determine which memories to focus on first.¹¹