Central Considerations in the Treatment of Dissociative Identity Disorder

Central Considerations in the Treatment of Dissociative Identity Disorder

Written by Colin A. Ross, M.D.

From ESTD Newsletter Volume 2 Number 3, June 2012 > read the original article in our newsletter


            I was in medical school in Canada from 1977 to 1981 and did my psychiatry residency in Canada from 1981 to 1985. During this eight-year period I received no lectures, case conferences, reading assignments or other teaching on childhood sexual abuse, physical abuse or neglect. In the 1980 edition of the psychiatry textbook we all used in our residency, The Comprehensive Textbook of Psychiatry, which was over 3000 pages long, there was one short chapter on incest in a section at the back called ‘Topics of Special Interest.’ In this chapter there was one paragraph on the epidemiology of incest with a reference to a 1955 study saying it occurred in one family out of a million in America. Needless to say, I also received no teaching about dissociative disorders.

            I diagnosed my first case of multiple personality disorder as a third year medical student in 1979. When I asked my supervisor who I could talk to about multiple personality disorder, he said he didn’t know anyone who had treated a case. When I asked him what I could read on the subject, he said he didn’t know. I had to hand-search the journals in the medical school library to find references for the paper I eventually published on the case (Ross, 1984).

            I have been treating dissociative disorders in a specialized hospital unit in Texas since I moved here in 1991 and have published a series of books on trauma and dissociation (see bibliography). I also have Trauma Programs I consult to in Michigan and California. What have I learned about the treatment of dissociative identity disorder (DID) since I diagnosed my first case in 1979?

The Principle of Therapeutic Neutrality

            In the late 80’s and early 90’s, there were a lot of therapists in the field who lost sight of therapeutic neutrality. This error occurred in the early years of the dissociative disorders field, and tends to occur early in the practices of individual therapists. It is easy to be over-involved, over-caring and over-fascinated by the first case or two or three of DID. It is very helpful to have several difficult cases at once because it is hard to be over-involved in a number of cases at the same time. Thus, we learn that patients can survive and grow without our over-involvement.

            Adopting the rescuer position, reflexively believing all the client’s trauma memories, loosening one’s boundaries, and too much caring by the therapist are common problems in the field. It feels nice for the client to be believed, validated, cared about and special. It feels good for the therapist to be undoing his or her own trauma by being the rescuer for the client (which undoes the unresolved trauma of the absent rescuer in the therapist’s childhood but, like any addiction, needs to done and redone endlessly).

            What is wrong with abandoning therapeutic neutrality? The client has been betrayed, abused and abandoned, and surely could use some validation and support. The problem is this: the therapist who actively believes the client’s trauma memories inevitably becomes the rescuer. Although this feels good temporarily, it places the client in the position of a dependent child who requires the therapist to tell her what is real and what is not. It’s great to be validated, until the client realizes that there is a wolf inside the sheep’s clothing. This perception by the client leads to a transference re-enactment of the bad perpetrator inside the good parent, which in turn sets up a dissociated transference, a fear that the good therapist will transform into the bad therapist, and a fear that the therapist will see the evil nature of the bad child-client and abandon her, just like the perpetrator did when the good parent disappeared.

            Abandoning therapeutic neutrality also fuels an escalating set of more and more extreme trauma memories. The client tries to earn more and more special status in order to be the good victim-child and earn the love of the good rescuer-therapist. This is hard to do with an average trauma history. Therapeutic neutrality means neither believing nor disbelieving the client. In the false memory wars of the 1990’s, the skeptics actively disbelieved while the therapists actively believed. The skeptics set the agenda and the therapists played into it by taking the opposing believer position. The better move would have been to step out of the dance and insist that the task of the therapist is to remain neutral.

            It is very helpful when a client “remembers” being at the same Satanic ritual as the therapist. Then the therapist gets it that clients really can have complex false memories, even though many of their other trauma memories may be painfully real.

The Central Paradox of Dissociative Identity Disorder

            Both believers and non-believers in DID often fail to grasp the central paradox of DID: it is real and not real at the same time. Non-believers get angry when you say it is real, and believers get angry when you say it is not real. Both camps are missing half the story.

The way I explain the central paradox to clients is to say, “If I took an X-ray of your head, we wouldn’t see a bunch of little skeletons in there. There aren’t literally separate people with separate bodies all crammed inside your body. DID isn’t literally, concretely real.”

“On the other hand, people with DID really do have the experience of coming out of a blank spell in a new location, not knowing how they got there. These experiences are perfectly real. So DID is very real, subjectively and psychologically, it just isn’t literally real.”

            I’ve never had a client object to that explanation. Therapy involves keeping a foot in both realities, for both therapist and client. If the therapist steps too far into the not-real side of the central paradox, all empathy is gone and the therapist isn’t meeting the client where she’s at. This is the extreme skeptical position. In the opposite direction, the therapist loses track of common sense, present day reality, and regular goals and problems. The therapist gets lost in the internal world of the client, with all its layers, levels, codes, cues, characters and dramas. Therapy goes on forever, there is always another layer or level of alters, always a new set of memories, and increasing dependency of the client on the therapist.

            This logic is no different from how we understand auditory hallucinations in schizophrenia or an elevator phobia: the person with schizophrenia really hears the voices, although the voices aren’t objectively real; the person with an elevator phobia really experiences terror, an elevated heart rate and a rush of adrenalin, but the elevator isn’t really that dangerous.

            DID is a mental disorder. We work to treat it to integration so the person no longer has it. DID should not be romanticized, although many therapists and clients do romanticize it. There’s a flaw in the romantic view, however: if DID is a clever, creative survival strategy, then why should therapists treat it? Actually, both things are true at once: DID certainly is a creative survival strategy in childhood; but in adulthood it has become conflicted, dysfunctional and out-of-context. It comes to cause more problems than it solves, and therefore needs treatment. Here we have a variation on the logic of the central paradox.

Orientation of Alters to the Body and the Present

            Over the years I have moved orientation of the alters to the body and the present closer and closer to the beginning of therapy. I do this by explaining the difference between the inside world, where the alters have separate bodies, and the outside world where there is only one body (which may be rather old and wrinkled). I have alters look at the hands, feet, clothing and jewelry and explain to me how “her” watch or ring got on “my” hand or wrist. I suggest that the alters look out through the host’s eyes while at the supermarket or while watching TV, to see the present date. I suggest that the alter(s) check out the present-day cars, clothes and hair styles and I have shown child alters my I-phone and explained computers and the internet to them.   

            I also explain how life is much safer in the present than back in the 1970’s (providing the abuse has stopped). The alters no longer live with the parents and have not been abused for a long time, plus there is a really cool dog at home now. The purpose of this is to create distance between the alter and the trauma, de-escalate the system, and reduce the need for secrecy, internal threats, fear of perpetrator retaliation, and the need for desperate strategies and defenses like self-mutilation. I explain that this is not an instant cure and that there is still a lot of work to do.

            Orientation of alters to the body and the present is combined with working on co-consciousness earlier in the therapy process. I have clients practice this by the host making a point of staying ‘awake’ and listening when an alter comes out. This is done with permission from the host and the alter, and I make sure to keep the content non-threatening and non-traumatic during the practice. In comparison, decades ago, I tended to think of co-consciousness as a down-the-road outcome of a lot of trauma work.

The Problem of Host Resistance

            Over the years I have realized more and more the many ways in which the alters are not the problem. They are the solution to the problem. In order to preserve a functioning host, the alters had to hold a lot of the feelings and conflicts. Now, the host wants the therapist (rescuer) to agree that the alters are the problem (perpetrator) and the host is the helpless victim of their machinations and bad behavior, not to mention allegiance to Satan. It took me a while to realize that the cult-programmed alters who wanted to join the father-High Priest for a Satanic ceremony were actually expressing the positive side of the client’s conflicted, ambivalent attachment to her father.

            The good Christian host personality never wants to see her evil father again: the cult alters do but they are not her, they are programmed “others” and not even Christians. It is a double-defense against a painful disavowed reality. What are the Satanic alters actually saying?

            “Boy, I sure would like to hang out with dad. I sure wish I could do something special to make him proud of me. I wish he wanted me to be part of his world.”

            Translated into ordinary English, that doesn’t sound very evil. The horrible alters are holding the host personality’s unresolved wish, hope and need for a good dad. Feeling both sides of the attachment conflict is too painful for the host so she erects two barriers between her and the wish for time with her dad: that’s them not me; and they are Satanists not Christians.

            The problem is the unresolved, conflicted attachment to dad. Let’s assume dad actually is a Satanist: it’s not hard to understand why his daughter has a conflicted attachment to him. Let’s assume dad is not actually a Satanist: that historically inaccurate picture of dad certainly expresses a profoundly conflicted attachment to him. It doesn’t matter which version of dad is historically true: the task of therapy is to resolve the conflicted attachment. To begin this process, the host has to develop some empathy for the cult alters and make friends with them. This work should be contained within the therapy. It’s a bad plan to confront dad with accusations if he really is a Satanist. It’s a bad plan to confront dad with accusations if he really isn’t a Satanist.

            In the early 90’s there was a big wave of Satanic ritual abuse “memories” among people coming to dissociative disorder units in America. The skeptics claim to have eradicated this epidemic of hysterical false memories. Bad news for them: the percentage of clients reporting such abuse has fallen a lot, but it hasn’t hit zero. The therapist needs to stay neutral on all trauma memories, except in the occasional cases where there is objective evidence. This is equally true whether the memories are mostly accurate or mostly inaccurate. If the therapist takes the believer position, this can often reinforce host resistance, because it reinforces the host’s belief that she is not implicated in or responsible for the horror. It’s the bad alters who get the blame for that. They’re the ones who are programmed.

            These are just brief accounts of a few of the lessons I have learned over the years. Back in the 1990’s, one day, I was reading reviews of my Satanic Ritual Abuse book on www.amazon.com. One reviewer said that I was personally responsible for an epidemic of false memories in America. Right under that, the next reviewer berated me for not believing the survivors. This is what it’s like in therapy: the therapist has to keep one foot in each reality, because “reviewers” in the DID system hold diametrically opposed opinions and viewpoints.



            Ross, C.A. (1984). Diagnosis of multiple personality during hypnosis: a case report. International Journal of Clinical and Experimental Hypnosis, 32, 222-235.

            Ross, C.A. (1989). Multiple Personality Disorder. Diagnosis, Clinical Features, and Treatment. New York: John Wiley

            Ross, C.A, (1994). The Osiris Complex. Case Studies in Multiple Personality Disorder. Toronto: University of Toronto Press.

            Ross, C.A. (1995). Satanic Ritual Abuse: Principles of Treatment. Toronto: University of Toronto Press.

            Ross, C.A. (1997). Dissociative Identity Disorder. Diagnosis, Clinical Features, and Treatment of Multiple Personality, 2nd Ed. New York: John Wiley.

            Ross, C.A. (2004). Schizophrenia. Innovations in Diagnosis and Treatment. New York: Haworth Press.

            Ross, C.A. (2006). The C.I.A. Doctors. Human Rights Violations by American Psychiatrists. Richardson, TX: Manitou Communications.

            Ross, C.A. (2007). Moon Shadows. Stories of Trauma & Recovery. Richardson, TX: Manitou Communications.

            Ross, C.A. (2007). The Trauma Model. A Solution to the Problem of Comorbidity in Psychiatry. Richardson, TX: Manitou Communications.

            Ross, C.A., & Halpern, N. (2009). Trauma Model Therapy. A Treatment Approach for Trauma, Dissociation, and Complex Comorbidity. Richardson, TX: Manitou Communications.

            Ross, C.A. (2009). Military Mind Control. A Story of Trauma & Recovery. Richardson, TX: Manitou Communications.

            Ross, C.A. (2012). The Rape of Eve. The True Story Behind The Three Faces of Eve. Richardson, TX: Manitou Communications.