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The Therapeutic Alliance As Experienced by a Multiple with DID

by ‘Wispy’

It is impossible to over-estimate the value of a sound and loving therapeutic relationship, particularly as experienced by one who is suffering from DID. It may well be that the therapist’s presence introduces the first positive influence into the client’s life, a life that comprises a complex system of dissociated alter personalities who co-exist in chaos and confusion. Such a person never feels safe, until, that is, she learns to trust, and it is that ingredient in the therapeutic alliance that is of the utmost and absolute importance, for without it there can be no progress. In parallel with the development of trust there will grow an increasing sense of affirmation, and hope that life can, indeed, change. Without this hope the client might find herself damned to live out a life handicapped by profound bouts of memory loss, and answerable for actions of which she has no recollection.

It may help to try and explain a little how this is experienced by an SRA survivor who has DID. As an adult, her everyday life may seem a horror world to her. Over any 24 hour period she may find herself completely lost in a different city or location, feeling ‘possessed’ and driven by an inner dictator, incoherent with fear, in the daytime or at night-time, at work or in the home, in public places dressed or undressed, wet or dry, at conferences, in cupboards, in the arms of strangers or abusers, or learning at college again, flat-seeking, counselling, crippled with body pains, at seminars or facing difficulties in a marriage that has no shared history.

Good therapy can change this horror world, but the therapist needs a stout heart and an unequivocal belief that love never fails. For into the client’s chaotic existence s/he can bring a calmness and a certainty that can only come from his/her rootedness in their own identity, in their own sense of being one who is unconditionally beloved1. The client will intuit this almost at the first meeting. It will transcend her fear and suspicion, and alert that deep unconscious part in her that has sought a place of safety all her life. Only those who are safe with themselves can be a place of safety to others.

This sense of safety will provide the foundation upon which the therapeutic relationship can develop into a deep and trusting one where good work can be done. Sometimes this safety will be experienced vicariously by an inner watching alter who might see the therapist as one who:

Perhaps, most importantly, the therapist must be willing (and able) to enter into the hitherto unmentionable areas of the client’s life with her as she tentatively owns for herself the utterly dreadful grief and pain, the killings, the sacrifices and losses, the terrible, agonizing and unspeakable memories, the profound sense of guilt for actions committed and the shame for actions experienced. It is important to remember here that there will never have been anyone else who has ever indicated to the client that it is acceptable to speak of these things. And because the details are so graphic and cruel, the client will feel disgusting and cruel in the telling of them. There will be parts of him/her that will descend into irrational fear as they hear what the client is saying, and the therapist must be especially constant in the expression of his/her unconditional love and regard at this stage. The client’s greatest fear will be that her therapist will no longer hold her in the same regard once s/he hears of these events.

Another anxiety may be that her therapist views her merely as ‘a client’ and not as one who has entered into a genuine relationship in order to share at this level. For a client to feel that she is simply one of many clients with whom her therapist works is experienced as crushing in the extreme, as she has invested all that she has to give into the relationship. At this stage in her therapy it will be inconceivable to her that her therapist may have other, similar relationships, or that s/he is not wholly present for her. However, at a later stage it is possible to work this through to a place where she can recognise that her therapist can have other relationships without impacting on or devaluing her own. But it is important to understand that this will not happen, and indeed cannot happen, until the insecure attachment issues that are at the root of the problem, are resolved.

In many cases, those with DID have never formed a secure attachment with a loving and trustworthy adult when they were a child. If an attachment subsequently forms with the therapist (and some would argue that this is a necessary stage in the healing process), then the client experiences the therapist’s actions as disproportionately magnified. For example, when the therapist goes away, or is suddenly or inexplicably unavailable, or does not do what s/he promises, or is not clear about the times and method of contact, the client is likely to become overwhelmed by fear or feelings of anxiety and distress. Past experiences of powerful adults leaving and/or returning have undoubtedly been associated with punishment and the setting of impossible tasks (commissions), and so the same feelings in the present can catapult child alters back into the nightmare scenarios of the past. In the here and now the client will probably feel very ambivalent about the therapist’s return, as the feelings she experiences will be sourced from within her internal family. It is helpful if the therapist is sensitive to this apparently irrational behaviour surrounding their relationship as it can be very distressing to the client. It may also explain why a client is so easily derailed by the therapist’s absence.

It might seem that the depth of relationship that this amount of trust and safety creates could only be experienced as positive and beneficial. However, as indicated, this is not always the case and it can create problems of a different nature if this is not recognised by the therapist. The resulting distress to the client can cause a catalogue of grief and pain, flooding of recovered memories and even a re-enactment of the disempowerment experienced by her as a child or young adult. For example, internal conflict can unintentionally be created by a therapist who assumes the role of protector, as this may be experienced by the client as control, especially if decisions are made on the client’s behalf for her ‘own sake’. Feelings of outrage, abandonment or rejection can resurface so powerfully that a client may well experience self-harm or even suicidal ideation. For there is nowhere to place these feelings – certainly they cannot be accorded to the therapist (who surely is only acting in the client’s best interest) – and so they are turned inward once again and exacerbate the brewing of self-harm and despair. Blue prints of the past are repeated, as how could the child place her feelings of righteous anger and grief upon the parents on whom she depended for her survival?

It seems to me that working with clients with MPD/DID is far from easy and requires a long-term commitment. It can take several years for all the dissociated parts to learn to trust a therapist sufficiently to lower the walls of amnesia. But it can be life-transforming work, both for the client and the therapist. The intensity of the work requires them to be strangely vulnerable to one another and this generates space for God to move. Certainly my own spirituality has been enhanced and developed within this unique relationship. God has touched my soul and awakened me to a source of nourishment that is implicit and available in the space created when client and therapist work at this depth. This spiritual encounter, together with the presence of my therapist, has recreated the conditions necessary for human flourishing, and I now feel safe, accepted and loved for who I am, and not judged for a history and upbringing that I did not choose.

‘Wispy’, November 2002.

1 See Henri Nouwen, Life of The Beloved