ABSTRACT – EVOLUTION OF THE 4^TH REVISIONS OF THE ISSTD TREATMENT GUIDELINES

The 4^th Revision of the ISSTD Treatment Guidelines for DID in Adults (ATG-4) underwent considerable evolution over the years since it was mandated by the ISSTD Executive Committee (EC) in 2020. ATG-4 expanded on the 3^rd Edition (ATG-3) that was more like a textbook on dissociation and DID. ATG-3’s structure was based on the idea that most clinicians do not have the clinical/theoretical framework for conceptualizing DID. Without a background in basic concepts about dissociation and DID, discussion of the generally accepted tri-phasic model (phasic trauma treatment – PTT) for DID would make limited sense to the inexperienced reader. The 2020 mandate from the ISSTD EC was to continue and expand that framework. We were tasked with providing the current state of the research data on DID that including phenomenological, epidemiological, neurobiological, and treatment outcome data, among others. We reviewed standards for treatment guidelines and clinical practice guidelines promulgated by the US Institute of Medicine and other professional medical societies. These models are based on the kinds of data generated by studies in internal medicine, surgery, pediatrics, and psychiatry (mood disorders, psychotic disorders, etc.) that are generally well-funded by academic grants. Because of lack of overall research support, much of our field’s research and clinical papers do not meet the rigor required of these sorts of guidelines.

The ISSTD Institute for Advanced Studies is the component of ISSTD that oversees many educational activities including the basic training courses in dissociation, CPTSD, and DD offered by the organization. They strongly urged that a major component of the ATG4 be a comprehensive discussion of the current, generally accepted clinical theory about all phases of DID treatment, as well as more granular aspects of that treatment (e.g., transference/countertransference, therapeutic alliance, establishing the therapy, working with DID self-states, establishing safety, etc.). This led to expanded sections on the most important models for conceptualizing DID: discrete behavioral states theory (DBST) and its relationship to developmental attachment, betrayal-trauma theory, affect theory, and data on the unique psychological organization of DID patients, among others. Other etiological theories of DID are subsumed under DBST and are not based on developmental data. They are generally organized around “reverse engineering” of the descriptions of adults (typically White, Western females) in treatment.

Also, there was general agreement that foundations of DID treatment required understanding the basics of psychodynamic theory and its applications to such treatment. The other foundational knowledge base for DID treatment is a sophisticated understanding of hypnotizability (DID individuals have the highest levels of any clinical group). Typically, there is conflation of “hypnosis” with the clinical setting, rather than understanding it as a patient trait that in DID can be affected by almost any clinical intervention. This trait can be utilized highly effectively in treatment, as well as being a potential liability for decompensation with premature use of trauma-intensive techniques such as EMDR, mindfulness meditation, and uncovering psychotherapy or hypnotherapy that “opens up” the patient. Initially, use of hypnotic techniques -formally and informally – should emphasize internal communication, collaboration, coordination, tolerance, and even empathy among DID self-states/systems. Also, hypnotic interventions can assist with crucial symptom management strategies like grounding, containment, past/present separation, etc. but are often of limited utility unless there is a beginning therapeutic alliance with the DID self-states/systems, and, if you will, a beginning therapeutic alliance among the DID self-states/systems themselves. In later stages, hypnosis – formal or informal – can effectively assist structuring and containment of stage 2 trauma work and facilitate work on fusion/integration in stage 3.

Other areas of the ATG-4 discuss psychopharmacology, inpatient treatment, group treatment, family/marital treatment, expressive and rehabilitation therapies, and applications of cognitive and DBT techniques to DID treatment. The consensus is that EMDR is not a treatment for DID, but an ancillary set of techniques that only should be used by clinicians fully educated in all aspects of DID PTT, and not during the stabilization stage. Unmodified EMDR mobilizes the high hypnotizability of the unstabilized DID patient, often with disastrous consequences (major PTSD/dissociative decompensation, self-destructive behavior, suicide attempts, etc.) that frequently necessitate inpatient stabilization or similar intensive interventions.

As the project evolved, it became a book-length document that we are now seeking to publish as a free-standing volume. This talk will emphasize a few of these areas but cannot provide a comprehensive discussion.