CBT with Dissociative Identity Disorder (AKA Multiple Personality)

With this client it sounds as though you are dealing with Dissociative Identity Disorder (formerly known as Multiple Personality) rather than simple dissociation. I don't have a lot of first-hand experience with this problem but fortunately there are a number of articles available on CBT with DID:

Fine, C. G. (1994) Cognitive hypnotherapeutic interventions in the treatment of multiple personality disorder. Journal of Cognitive Psychotherapy, 8, 289-298. ABSTRACT: Discusses cognitive and cognitive hypnotherapy (CHT) considerations that aid the patient with multiple personality disorder (MPD) to achieve unification of all personalities. B. G. Braun's (1988) BASK (Behavior, Affect, Sensation, Knowledge) model of dissociation is examined, focusing on advantages and disadvantages of working along the model's knowledge dimension. Stages of CHT for MPD patients are outlined, including suppression of affect, uncovering each personality's underlying beliefs, cognitive restructuring, working with depressed and fearful personalities, cognitive reframing, and dilution of affect. Case examples and a prototype composite case are provided. It is argued that MPD patients' inability to cross stores of information and their ongoing use of trance logic impairs self-referential decision making. CHT can provide a structure that allows MPD patients to explore strategies geared toward protection, growth, and integration.

Fine, C. G. (1991) Treatment stabilization and crisis prevention: Pacing the therapy of the multiple personality disorder patient. Psychiatric Clinics of North America, 14, 661-675. ABSTRACT: Reviews the tactical integrationist's perspective in work with multiple personality disorder (MPD) patients. The foundation of this perspective is a cognitively based treatment paradigm geared toward controlled abreactions with cognitive restructuring throughout therapy. It is a suppression-dilution-of-affect model that focuses on the achievement of control and mastery for patient and therapist alike. This model helps maintain relative stability in a treatment that is often chaotic and presumes a collaborative stance between therapist and patient, just as between the MPD alters.

Kirsch, I. & Barton, R. D. (1988) Hypnosis in the treatment of multiple personality: A cognitive-behavioural approach. British Journal of Experimental & Clinical Hypnosis, 5, 131-137. ABSTRACT: Two hypnotic interventions based on cognitive-behavioral theories of hypnosis and behavioral treatments of other disorders were used to treat a woman with multiple personalities. The 1st technique involved the creation of a "hidden observer" by the therapist to obtain a case history. The 2nd intervention used successive approximation treatments in the task of fusing personalities. To reproduce responses elicited in hypnosis outside of hypnosis, the S was taught to establish verbal communication, subvocal communication, and shared experiences between pairs of personalities. These experiences produced improvement in level of functioning and lowered resistance to fusion of the S's personalities.

Ross, C. A. & Gahan, P. (1988) Cognitive analysis of multiple personality disorder. American Journal of Psychotherapy, 42, 229-239. ABSTRACT: Defines the basic cognitive map of multiple personality disorder (MPD), including 8 core assumptions that recur in the majority of cases. MPD patients commonly make the classical cognitive errors such as selective abstraction and dichotomization, but they also have a set of schemata and cognitions derived from their abusive childhoods that are specific for the disorder. It is noted that MPD is underdiagnosed but treatable with both cognitive and noncognitive methods such as abreaction, adjunctive hypnosis, negotiation between alters, and internal dialogs between alters.

Elzinga, B. M., de Beurs, E., Sergeant, J. A., Van Dyck, R. & Phaf, R. H. (2000) Dissociative style and directed forgetting. Cognitive Therapy & Research, 24, 279-295. ABSTRACT: Dissociative style may correspond to an enhanced ability to avoid conscious recollection of traumatic experiences, which may, however, remain dormant in nonconscious memory. This hypothesis was tested in two "directed-forgetting" experiments with affectively neutral words (experiment 1) and sex and threat words (experiment 2) employing a total of 83 first-year psychology students high and low in dissociative style, and 14 dissociative patients. Conscious and nonconscious memory were separated with the process dissociation procedure (L. L. Jacoby, 1991). Instruction to forget was expected to reduce conscious but to enhance nonconscious memory performance in Ss with a high dissociative ability. Results were opposite to predictions. Particularly for sex words, the instruction to forget raised the overall (conscious and nonconscious) memory performance of the patients. An alternative construction hypothesis is proposed that identifies dissociative style with enhanced skills of constructing conscious experiences.

Fine, C. G. (1999). The tactical-integration model for the treatment of dissociative identity disorder and allied dissociative disorders. American Journal of Psychotherapy, 53, 361-376. ABSTRACT: The ebb and flow of the diagnosis of Dissociative Identity Disorder (DID) and other dissociative conditions has led to the evolution of theories and treatment modalities to resolve the fluctuating and ephemerous symptoms of these conditions. This paper summarizes the structured cognitive-behavioral based treatment of dissociative disorders that will foster not only symptom relief but also an integration of the personalities and/or ego states into 1 mainstream of consciousness. This model of DID therapy is called the tactical integration model; it promotes proficiency over posttraumatic and dissociative symptoms, is collaborative and exploratory, and conveys a consistent message of empowerment to the patient.

Bonanno, G. A., Znoj, H., Siddique, H. I. & Horowitz, M. J. (1999). Verbal-autonomic dissociation and adaptation to midlife conjugal loss: A follow-up at 25 months. Cognitive Therapy & Research. 23,) 605-624. ABSTRACT: Individuals who fail to "work through" the emotional significance of a loss have traditionally been assumed to suffer increased grief. G. A. Bonanno et al (1995) tested this assumption by operationally defining emotional avoidance as a verbal-autonomic response dissociation, or the reduced experience of negative emotion coupled with relatively high levels of autonomic responsivity. In contrast to the traditional assumption, individuals who at 6 mo had shown verbal-autonomic dissociation had the mildest grief course through 14 mo. Verbal-autonomic dissociation was linked to initially high levels of somatic symptoms, but to low somatic symptoms at 14 mo. In the current investigation, the authors collected follow-up data on 36 of the same Ss (aged 21-55 yrs) through 25 mo postloss and assessed additional health-related variables. Verbal-autonomic dissociation was again linked to the mildest grief course with no evidence of delayed grief. This predictive relationship remained significant even when initial levels of grief were controlled. Further, no evidence was found for enduring or delayed health difficulties in association with verbal-autonomic dissociation. Implications for future bereavement research are discussed.

Michelson, L., June, K., Vives, A., Testa, S. & Marchione, . (1998) The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia. Behaviour Research & Therapy, 36, 1011-1050. ABSTRACT: Investigated the relationship between traumatic experiences and dissociation with pretreatment psychopathology and rates of recovery, relapse and maintenance for patients receiving cognitive-behavioral treatments for panic disorder with agoraphobia. 89 21-64 yr old Ss who met Mental Disorders-III (DSM-III) criteria for agoraphobia with panic attacks completed packets containing measures to assess history of trauma, victimization, and dissociation. It was hypothesized that a variety of trauma-related variables (e.g., history of traumatic experience, type of trauma, age at which the trauma first occurred, perceived responsibility, social supports available, self-perceived severity, level of violence, and whether or not the traumatic event was followed by self-injurious or suicidal thoughts and/or behaviors) and dissociative symptomatology would be predictive of (1) greater psychopathology at pretreatment, (2) poorer treatment response and (3) higher relapse rates and poorer maintenance over a 1 yr longitudinal followup. These hypotheses were supported by the findings and the theoretical, empirical and clinical implications are discussed.

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