Dissociative Identity Disorder: Using the Countertransference

I have to start by taking you back to the mid Eighties, when I began my Psychoanalytic training in London. My recollection is that countertransference (CT) was treated as a negative phenomenon, an assiduous inescapable bi product of therapy that required vigilance and supervision to avoid the potential for destructive consequences for the patient and the therapy. Countertransference was generally viewed as having to do with unresolved issues in us as therapists that would need ongoing analysis, or as resulting from the avoidant projections from our patients.

I have noticed a welcome shift over the years. A more empathic approach now fosters the exploration of both the positive aspects and the inevitable challenges to our unresolved personal psychic experiences.

DID – A way of dealing with the impossible

DID is the consequence of extreme life threatening (generally early) childhood trauma, where the physical and psychological survival necessitates the unconscious splitting of the mind to deal with the impossible. The emotional impact is separated from the functional need to keep connected to the world and people around you through amnesic barriers.

The catastrophic consequences all apply to someone with DID but will be present in some form with any significant adverse childhood development. They include:

• Loss of Curiosity – a child’s innate sense of curiosity and excitement gets shut down in the face of an adult’s disinterest or punitive response.
• Abandonment – resulting in periods of hypo-arousal, where a child’s disconnection from an adult attachment leads to a place of pointlessness, fragmentation of self and loss of the life instinct.
• Attachment to an abusive adult – very often the only counterbalance to this sense of annihilation is through the attachment to an abusive adult and often through dangerous life-threatening behaviour. This state of hyper-arousal is the only connection to feeling alive, however destructive the consequences.
• No notion of normality – a child in such situations has surviving by watching the distorted world around them, copying and internalising that experience.
• No integrated self – there is consequently no timeline of experience, only living from moment to moment.

The unique role of the therapist in DID work

When working with adults who are living with a dissociative disorder, we, as therapists, have a unique role. Alongside our core therapeutic training, we need to incorporate an inquisitive and proactive dialogue by seeing the person we are working with as both client and partner to their own recovery. Our countertransference and our client’s countertransference are the key to change.

Here is a clinical vignette to illustrate how this works in practice:

Elaine, who has DID, is describing in graphic details a time as a six year old when she was physically abused by her father. She tells me this in a calm and detached manner as though reporting someone else’s experience. Meanwhile, I find myself feeling enraged and harbouring thoughts of wanting to get hold of this man and express this displaced anger to his face.

With non-dissociative clients I might explore where their anger was as they seemed so calm about it. But with DID clients, I have to be much more explicit. My response might go something like this:

Elaine, I am really struck by the calm way you are telling me about what happened with your father. I just wanted to share with you that I found myself having strong feelings listening to you, feelings of anger and aware that my heart was beating faster. I just wondered if I was feeling what parts of you inside might quite rightly feel about what happened then.

Here, I am trying to find the right words to help reactivate Elaine’s curiosity. This allows her to develop a normal reaction to outrage and, in so doing, helps the lowering of the amnesia wall and the slow emergence of a more integrated self.