THE EPIDEMIOLOGY OF DISSOCIATIVE IDENTITY DISORDERS IN RESIDENTIAL DUAL DIAGNOSIS PROGRAMS AND WHY IT IS IMPORTANT.

By Ericha Scott, Ph.D., LPCC917, ATR-BC, REAT, ICRC

Several decades ago, a young woman had been referred to me for treatment for complex trauma and dissociation. I was curious about how she had been diagnosed with a Dissociative Identity Disorder (DID). At the time, DID was referred to as Multiple Personality Disorder (MPD).

When I asked her the question, she smiled slightly, then cocked her head a little bit while she framed her words. Her previous therapist, the referent, had every individual session in her office taped and transcribed. The secretary transcriptionist was feeling confused and frustrated with the tape. Trying to make sense of it she approached the therapist and asked, “So, exactly how many people are in this group?” The therapist responded with, “Group?” As the therapist listened to the tape again, she was shocked by what she heard, yet, had not been able to see. Listening to the tape she was able to hear what had confused the transcriptionist. There were dramatic changes in the client’s quality of voice, as her perceptions and point of view changed, so did the tone, timbre, vernacular/accent, developmental age, and gender of her speech patterns.

There are many reasons why there is mythology around the diagnosis, and unfortunately this is confounded further by what is portrayed in the movies, because it is exaggerated for the audience’s benefit.

One of the myths about the diagnosis of dissociative identity disorder, is that the phenomenon is rare. In fact, according to the DSM-V, “The 12-month prevalence of dissociative identity disorder among adults in a small U.S. community study was 1.5%. The prevalence across genders in that study was 1.6% for males and 1.4% for females”. There are some studies that suggest the percentage of those who qualify for a diagnosis of DID, within the general population, is as high as 3.0 percent. This means that dissociative identity disorders are more common than schizophrenia.

A high-risk population for dissociative identity disorders is substance use disorders.

In four studies, at four different residential substance use disorder programs, 15-39 percent of the client/patient population warranted a diagnosis of Dissociative Identity Disorder. Again, those with substance use disorders in residential treatment are a high-risk population for severe dissociation. Other high-risk adult groups for dissociative disorders include eating disorders, sexual addictions, POWs, those who chronically relapse/overdose/attempt suicide, child soldiers, adult survivors of the child sex trade and organized crime, victims of torture and/or sophisticated forms of coercion/thought control.

If clients or patients experience dissociation to the point of memory problems or amnesia, this means that they are not able to benefit well, or at all, from interventions or treatment for substance abuse/ mental health.

The dissociative client/patient might be the one who appears to be compliant, quiet, spacey and unassuming. Sadly, they may be so internally focused with an ongoing internal dialogue that they are unable to listen sufficiently to lectures and therapist or peer  feedback.

One time, a client returned from rehab and giggled as she told me, “My addict self, did not attend one group”. This is a waste of money and time. The identity, without treatment, remains split, which means that parts of self are able to function with a remarkable amount of autonomy (or even amnesia from consciousness). Generally, the parts of self mimic the dysfunctional family dynamic internally, and in many cases they self-sabotage. I tell my clients, everyone has parts, and all of us have parts of self that mimic our family system. The problem is if your family did not get along.

DID is listed as a diagnosis in the DSM-V, and the etiology is considered to be a result of trauma or a wound in early childhood, generally before the age of six.

One theoretical construct of dissociation is that trauma splits or shatters the personality as a coping mechanism. An alternative concept- structural dissociation suggests that multiple aspects of self are normal and a developmental stage in childhood. Instead of shattering the personality, this theory suggests that trauma prevents the parts of self from integrating fully. In other words, the trauma interferes with child development. How many of us have heard adult women or men speak in a childlike manner, or even baby talk?

Young children experiment with identity. I remember when a friend’s child wore a Santa Claus outfit in the neighborhood to play, and came home very disappointed, with his head down and said, “They knew it was me”.

Dissociation is a trance phenomenon. A normative or common example of trance is “highway hypnosis”. We have all done this at least once. Can you remember driving home, thinking about work or your loved ones and all of a sudden “Voila!”, you are driving up into your driveway wondering how time passed so quickly? You might even wonder if you stopped at the light down the block.

Trance distorts perceptions of time. During trance, one can feel sped up or slowed down. As one young woman in my research study described it, “Do you know what it is like when you are playing outside and it is so much fun, that when your mother calls you can’t believe it is time for dinner because time passed so quickly”, or “Do you know what it is like when your parents are screaming and you are hiding under the piano and you are so scared and time seems to be so long, because it is passing so slowly?”

Most of us know the Queen of Mystery- Agatha Christie, who is considered to be the most widely published author in the world. Her well renowned publications are primarily mystery and crime novels.

Agatha is also well known for what became a dramatic media event in 1926, when she  quietly disappeared from her home for 10-11 days. During this time, she assumed a pseudonym, moved to another city and apparently did not recognize herself in the news reports announcing her disappearance and the ensuing extensive manhunt. Later, after she was found and returned home, two medical doctors diagnosed her with amnesia (“fugue state”). While there are confounding aspects to her story, what remains consistent is that the apparent fugue state was triggered by her husband’s request for a divorce and his admission that he was in love with another woman.

Decades ago, I was referred a woman who had a problem with chronic relapses, contrary to her stated and seemingly sincere wish to stay sober. In fact, her rights for child custody were on the line. She was motivated, yet, there were many confounding issues surrounding her addiction history that did not add up or make sense.

Although it is common for a person who abuses non-prescribed chemical substances to have black outs, it occurred to me to ask, “When are you having black outs?” It was  interesting to watch her face as she reviewed her relapse history – then she asked, “Is it possible that I am blacking out on the way to the liquor store? How is that possible?” It was this question that opened the door to a deeper level of healing and recovery.

Many addiction programs assert that they are trauma informed, yet the large majority of residential or intensive outpatient programs are not adequately educated about how to identify or treat complex trauma and dissociative identity disorders.

Kevin Conners, President of the International Society for the Study of Trauma and Dissociation has found that even in 2018, “Discussions with admissions staff and with clinical directors led to a disturbing realization. Very few people in these essential treatment programs realize the extensive and pervasive nature of complex trauma; what it does to our clients’ sense of self, their ability to build “healthy enough” relationships, and their ability to trust their personal experience with another human being. Even fewer recognize that the quiet, seemingly contemplative client is really emotionally and mentally gone from the room while physically occupying space during a group meeting.

Trying to find a program that would provide sufficient care, adequate structure, and compassionate boundaries even in this time and age of trauma informed care is like finding a needle in a haystack”. At first, when I read Kevin’s statement, I argued with him in my head. I tried to poke holes in his bold assertions and found, after putting my own defensiveness aside, that his points were valid.

As a long-term member of the substance use treatment field, I can say with vehemence that as a field, we can and should do better. Too many addicts are relapsing post  treatment. It is my hypothesis that under-diagnosed complex trauma and dissociation are possible reasons for the high failure treatment rates.

Part of why this topic is so controversial is that there are normative and pathological forms of trance and dissociation. The differential is determined by degrees of functionality regarding identity and memory.

The normal and often rejuvenating experiences of trance are felt during meditation, daydreaming, driving your car, listening to music, writing or creating art, as well as other times of deep thought or flow. During a car wreck, healthy dissociation can help the driver  problem solve more quickly even though the driver’s sense of time has slowed down. Again, it is a question of degree and functionality. For example, even daydreaming can  become pathological depending upon the amount of time it occupies during a day, the level of consequences related to the avoidance of life and responsibilities, and the content of the day dreams such as profound violence or sexual aggression.

DEFINITIONS:

Trance: A half conscious state with a primary internal focus and an exclusion or reduction of attention to external stimuli. There may be a reduction in sensory motor activity and diminished recall as well. Authors Dennis R. Wier and Stephen Wolinski describe addiction as a trance phenomenon.

Ego-state: A consistent pattern of thinking, feeling and behavior, that may function as if autonomous from the self in ways that are ego-dystonic.

Sub-personalities: Ken Wilber identifies subpersonalities as, “functional self-presentations that navigate particular psychosocial situations.” Subpersonalities are considered by some to appear on a short-term basis.

The definition for ego-states and sub-personalities overlap, although they are not quite  synonymous, they are often used as if they are interchangeable.

An ego-state is a set of related behaviors, thoughts, feelings, somatization and energies that make up an aspect of our personality at a given time. Our personalities are not fixed and unchanging. We may have one or more ego-state in conflict with another, often mimicking family of origin dynamics. This is sometimes referred to as a complex.

For decades, I have told my clients we all have an inner or introjected family system, which is wonderful if your family was loving and cooperative. The problem is, if you grew up in a family with conflict, addiction, mental illness, trauma and abuse, then your inner parts will not get along. For those with a dysfunctional inner family system, therapists offer an internal or intra-psychic version of family therapy.

RAPE CULTURE:

When I used to lecture about sexual abuse in the 1980’s, I was naive. I thought that epidemiological information, including education about the long-term consequences and sequela of sexual molestation or assault, would help intervene upon the phenomenon. I truly believed that if adults understood how damaging it is to the psychology, emotional well-being, physical health and spirituality of a child, then adults would quit harming children.
I was wrong.
Thirty years later, the rape culture is not over.

In fact, enabled by generational changes in our culture- retrograde amnesia drugs, the dark web, illicit drugs that enhance sexual arousal and aggression, media (including social media), the fact that sex slavery is part of the second fastest growing illegal industry in the United States, and what I now consider to be the ubiquitousness of all forms of pornography, the problems of sexual assault appear to have increased since my first year  as a case manager in 1985. When I first became a chemical addiction counselor, a newly sober female might report a rape, now, a young adult female recovering addict is likely to report multiple sexual assaults or even multiple gang rapes.

Again, the second fastest growing illegal industry in the United States is human slavery- forced sex and labor trade. A subset of that industry includes: child sex trade and child organ harvesting, facilitated by gangs who are normally territorial, but are collaborating to transport kidnapped children across various city and state territories.

In order to challenge a myth that rape is confined to a class, race or culture, “Among  undergraduate students, 23.1% of females and 5.4% of males experience rape or sexual assault through physical force, violence, or incapacitation”. Sadly, those who experience rape still tend to refrain from reporting their own victimization to authorities. Even if these college campus numbers are low, due to problems of under-reporting, they are still way too high.

This means that now, possibly more than ever, it is important for clinicians to identify, understand, and treat sexual abuse and trauma throughout the life span. Obviously, it is most important to address early childhood trauma because of the impact it has had on shaping or negatively impacting a child’s world view, cognition, learning, physical health, personality, ability to regulate mood, mental health, dissociation, nervous system, addiction potential, resilience, as well as unhealthy patterns of attachment and connection within intimate relationships.

A Partial Solution and a Good Beginning

I highly recommend the work of Richard Schwartz, Ph.D. regarding his Internal Family Systems model to address ego-states in a way that is creative, therapeutic and non-threatening. This model enhances previous work established by Virginia Satir, when she asked people in treatment for addiction to address the conflicts between the addict-self and the recovery-self, or the denier-self.

“Internal Family Systems (IFS) Therapy is a psychotherapeutic modality developed in the mid-1980s, based on the observation that clients sometimes experience subpersonalities that come into internal conflict when dealing with challenges. The IFS model likens these  subpersonalities to an “internal family.” The IFS model uses mindfulness-based and other  strategies to help people resolve internal conflicts in a satisfactory way. During sessions,  therapists actively encourage participants to practice self-compassion toward subpersonalities and an internal dialogue.”

It is the identification and intervention of ungrounded consciousness and the healing of the inner conflicts and power struggles that empowers and enhances long-term sobriety.

Too many people are relapsing post treatment. We are failing the larger majority of those who participate in residential treatment for dual diagnoses. We must not blame our clients/patients or their families. It is time for us to evaluate what our institutions are neglecting. I cannot say that unidentified complex trauma and dissociation are the primary reasons for this shocking health-care failure, but I can assert that it is a significant contributor.

References Provided Upon Request

Dr. Ericha Scott – Licensed as E. Hitchcock Scott, Ph.D. has 33 years of professional experience working with those who have co-occurring addictions, complex trauma and dissociative identity disorders. She has published on topics of addiction, trauma, research on self mutilation by dissociative disordered individuals, and her theory of creative arts therapy. She is a  consultant who trains treatment centers how to address complex trauma and dissociation for those in treatment for addiction. You may call her at 310-880-9761 to book a staff training. www.artspeaksoutloud.org.