Bethany Brand on the Identification and Treatment of Dissociative Identity Disorder

Bethany Brand: Thank you so much for having me.

BB: It was a number of things. One of the early experiences I had as an undergraduate at the University of Michigan was working in a shelter for women who’d been battered, which is what it was called back then—not interpersonal violence like we call it now. I started hearing about trauma and remember being very interested in it. In my first semester of graduate school, I was doing a psychological testing practicum at Johns Hopkins Hospital on the kids’ unit. This was in the late 80s, so many of the kids had been abused or neglected according to their charts. I asked my supervisor how that experience might be reflected in their psych testing—how would they be different? And there we were at Hopkins, one of the premier institutions in our country, and she did not know.

To her credit, she acknowledged that and asked her supervisor, who later gave us this fascinating off-the-cuff talk about trauma and his experience with traumatized kids. It was so compelling that I decided that was what I wanted to do my master’s thesis on. I was lucky enough at the time that Frank Putnam, one of the legends in the field of dissociation, called my graduate program, asking for students who might be willing to volunteer on his project—a longitudinal study of girls who’d been sexually abused. I was incredibly lucky to be at that right place at the right time, working with a pioneer.

To be honest with you, I wasn’t sure about the whole idea of dissociative identity disorder because we didn’t see that in the lab and that was not what we were studying, even though Frank was studying it at the National Institute of Mental Health. When I later went on internship at George Washington University Hospital, a woman there said she had multiple personality disorder, with whom I had done the testing.

The treatment team was a little skeptical, but my supervisor referred me to Judy Armstrong at Sheppard Pratt Hospital in Baltimore who offered to review the data with me. After she did so, she said, “You know what; you actually might have somebody with MPD.” After that, it was just luck because I got a postdoctoral fellowship at Pratt, where they had just opened up a trauma disorders unit, and where I did my dissertation on trauma. I remained there and began working very heavily with folks with DID, and other serious, complex trauma disorders. Right place, right time, and fortunately, amazing training with amazing clinical supervisors.  

BB: There were a lot of reasons, but just to be very brief; by calling it multiple personality disorder, many clinicians thought it was a personality disorder like borderline personality disorder, and it’s not in that category. The experts in the field wanted to emphasize it was a trauma related disorder connected to dissociation, not a disorder of personality. The name change was an attempt to reflect that.

BB: It’s a terrific start. It’s a foundational start, because it implies that it starts in childhood, which is what developmental disorder means. The research strongly points to very early severe chronic child abuse as the cause. But we also know that there is genetic tendency towards dissociation. And often these clients who end up as individuals who develop DID also have attachment problems because they didn’t have secure attachment. There are multiple things going on, but trauma really has an early childhood foundation.

BB: Yes! We all dissociate to some extent, so normal non-pathological dissociation can occur. It can be going into a state of automatic pilot. For example, when we’re driving down the highway and we’re really thinking about something, and barely remember the drive when we get home. Or we’re driving down the highway and we miss our exit because we’re so preoccupied, not because of traffic, but because of our mental disconnection from what we’re doing.

It can also happen at moments of peak spiritual experiences or athletic experiences when people can disconnect from their bodies or feel out of their bodies and have this incredible experience. But none of these experiences interfere with functioning.  

BB: Exactly. Those are called absorption, and some people are very prone to absorption. We know from research that the more somebody is prone to absorption, they may be more at risk for dissociation. There’s been some debate over whether absorption should be called dissociation or not? For now, it is understood as one of the lower levels, not-so-problematic types of dissociation, which comes from self-report measures.

BB: Yes, I think it is. But I’ll say that with awareness that some people living with DID really resent that, because understandably, this was an adaptation to horrendous, overwhelming circumstances. And so, I completely get it and respect that they had a brilliant way of adapting and getting through what would have been just harrowing experiences. The research actually supports exactly what you said.

As I said earlier, all of us dissociate to some extent. And then when you start studying dissociation and different psychological disorders, there’s a range of scores that people have on the different, self-report questionnaires. And it starts out with people having [scores] a little bit above what might be for people who are not struggling with any emotional disorder.

And then it gets at the highest level is folks with DID. And in between, there might be people with eating disorders and maybe borderline personality disorder, because there’s often a lot of trauma in those people’s background, and then you start getting into PTSD. And then the dissociative disorders indeed are at the end with the highest levels of dissociation.  

BB: Is there some dissociation that goes on during those moments? The answer is yes! Often people are somewhat disconnected from their bodies. An example is a client who, with DID or severe dissociation, may be cutting and not feel it and be kind of fascinated with what they’re seeing under their skin, like really extreme cutting with the detachment. And they don’t feel the pain.

BB: There are people in the field that are really pushing for those parts to be called dissociative self-states. In the literature, they’re alternatively called identities, personalities, parts, and alters. We’re really trying to emphasize that whatever they’re called, that they’re all parts of one person. They’re self-states. They’re not different people. That’s why we’re encouraging that name to be adopted in the next DSM.

BB: It depends on what illness you’re talking about. We know that, depending on our emotional state, our blood pressure may change, right? And Frank Putnam, who I referred to earlier, did some of the early research showing that different self-states have different EEG patterns.

Simone Reinders in the Netherlands has done a bunch of research studying neurobiological differences among some self-states. She’s tried having professional actors impersonate self-states while they were hooked up with all kinds of biological markers, including brain scans. They could not emulate different self-states.

It’s remarkable. It’s not magic. It’s a disorder that is linked to neurobiological changes and differences. And of course, these different self-states are going to include the traumatized self state, the one that remembers trauma and has all the symptoms that go with that PTSD. When they’re scanned, of course you might expect their heart rate to be much faster and for them to have more activity in their limbic system, versus a part that’s very detached and doesn’t recall that trauma. The heart rate of that self-state is not going to be as elevated. And they’re not going to have the intense amygdala activation.  

BB: Yes. There are studies about that, talking about how animals go into survival mode and, you know, like the faint mode or the feigning death mode. There are some animals that have that response of total disconnection from their bottom up to allow them to survive attack. Well, there’s some parallels with humans that have been horrendously abused repeatedly. Their brains shift into dissociation as a survival mechanism.

Their access to memory can be quite different as well. One of the diagnostic requirements is that there be amnesia for some of their life experiences, that are not due to drugs, alcohol, or head injury. Or they may not remember key autobiographical events, like their own wedding. We call that dissociative amnesia.  

BB: There are a lot, unfortunately. One is that DID is exceptionally rare. On and across different prevalence studies, at least 1% of the general population meets criteria for DID. That’s the same prevalence rate roughly as bipolar disorder and schizophrenia. So, it’s not rare, but there have been some critics.

Critics of the whole notion of dissociation and DID have been putting it out for a long time in articles that are published in journals. And that has found its way into psychology textbooks that undergrads and grad students read that put forward that myth so that unfortunately, many people, even mental health clinicians, think it’s rare. Another myth put forward by the critics is that DID folks exaggerate their symptoms or are prone to create false memories of abuse.

When you actually compare people with DID to people with PTSD to what are called healthy controls, people who don’t have any emotional problem, and professional actors who try and emulate all of this stuff, there are some studies we’ve done that show that people with DID

are no more likely than people with PTSD to develop false memories.

The important thing that most mental health clinicians have not been trained to know is that they are highly symptomatic across a bunch of different domains. They don’t just have amnesia and different dissociative self-states. They also have PTSD. And we know PTSD is a complicated disorder with 17 potential symptoms. And so, at times they’re flooded with traumatic intrusions, pictures, awful memories, awful nightmares. And then there’s periods where they’re shut down and avoid it because it’s so awful to remember and feel that stuff.

And then there can be incredible periods of irritability and sleeplessness and feeling like they’re an awful person and different from the rest of the world. There’s a lot of research showing that dissociation is very common among people with PTSD. They also have major depression and because living with all these symptoms is so brutally difficult, many of them have substance use problems.

They try to knock out the memories by drinking too much or using drugs. They often also have eating disorders because they have a very difficult time tolerating their bodies. They blame their bodies for their abuse, and so they try and get really big so that nobody’s ever attracted to them or—and they often go back and forth, or they get really anorexic and starve themselves hoping to die or to look unappealing that way.

All of that is shown in the literature. And with regard to feigning DID, one of the ways that you look for malingering is when somebody is reporting too many symptoms or reporting exceedingly severe symptoms. They are much more likely to be classified as potentially malingering on some of the evidence-based measures and interviews for malingering. I’ve developed research that helps mental health clinicians and forensic experts know how to differentiate when somebody has true DID and when somebody is attempting to simulate it.

The critics also don’t really understand complex trauma. They are typically not clinicians or academics. But because so few mental health folks are getting trained in the evidence-based information about DID, they come away with these stereotypes out of textbooks that are just wrong. They’re just flat wrong. And myths.   

BB: Back when I was trained, I was taught that if you hear voices, you are psychotic. But more than 75% of people who have DID hear voices.

BB: Yes, schizophrenia or maybe the psychotic phase of bipolar disorder. I would encourage therapists to not automatically assume that hearing voices means psychosis. There’s a whole bunch of research, including people who don’t have DID, experience voice hearing, and this is strongly associated with trauma exposure. There have been meta-analyses that support this, so I suggest that clinicians always ask every client, no matter the setting, if they have been exposed to trauma. So, learn how to do a good trauma assessment.

If somebody endorses having experienced trauma, then ask about PTSD symptoms and dissociative symptoms. Ask about the different types of dissociative symptoms. Ask about depersonalization. Does the person ever feel numb when they should have feeling? Does the person ever feel like their body doesn’t belong to them? Do they ever see themselves at a distance, like outside of themselves, like they’re watching a movie? Those are three common symptoms of depersonalization, and there’s a range of other symptoms they can ask about, like do you sometimes feel like you’re younger or not your own biological age. Ask about voice hearing.  

BB: It does sound farfetched, right? But that’s because people are misunderstanding the disorder. It is impossible for people to have multiple people inside themselves. It is impossible. Right. But, Lawrence, you don’t have a little Lawrence running around in your brain, and I don’t have a little Bethany running around in my brain. How do you know you’re not me? 

BB: I stump my students when I ask that question. You know who you are because you know that you have a cat and that you’ve been married and lived in Michigan, and that you like Hello Kitty, and that you like certain kinds of music and food, and you have knowledge and memory of family and life experiences. But people with DID don’t always feel like all that.

First of all, they have periods of time missing. And so, they’re confused about who they are and what’s happened in their lives. But they’re not different people inside. Now, I’m going to say that, and some of the readers who have the idea are going to object to what I just said, because some people with DID do feel like they are different people.

That is their perceived experience, but people with DID don’t literally have little people running in their heads either. Our personalities are based on the neural firing of networks in our brains. And like we were saying earlier, there’s a neurobiological pattern that is characteristic for trauma related self-states versus ones that are very detached and don’t remember the trauma.

So, I think a lot of mental health people are mistaken and don’t understand what they have heard. It’s rare and I’ve been told this so many times, “Doctor Brand, I’ve been in the field for 30 or 40 years, and I’ve never seen a DID patient.” But I guarantee you, if they’ve really seen a lot of clients, they actually have, but missed it because perhaps they’re looking for dramatic presentations like Sybil. If it was that obvious, then when people switched states, it would be easy to diagnose. But that’s what movies do to make it look right to the audiences. That is not actually what DID really looks like.  

BB: It means that clinicians who work with DID and other serious dissociative disorders are realizing that there needs to be three stages of treatment. When somebody comes into treatment with complex trauma, and especially if it’s very serious, there needs to be an initial stage of stabilization of their symptoms. At this early stage, they may be suicidal, self-harming, drinking and using drugs, or engaging in some other kind of addictive behavior.

They often have really high levels of hospitalization, so they need to learn other ways of regulating themselves that are safe and that they can do out of the hospital. If and when they get stabilized, they begin learning how to regulate emotions in ways that ground them, which is the opposite of dissociation.

Once they’re stable and want to go on to stage two work, we are talking about trauma processing. That’s where they may then talk about some of the trauma so that gradually they can heal from that and not have so many intrusions of nightmares and flashbacks and horrible memories or feeling numb to it.

It’s an awful thing to feel like you’re deadened inside. That would be stage two work, which can take a very long time. So can stage one, by the way. And then comes stage three. For complex trauma—and I’m not just talking DID now—but in general, the person works more on developing their life, their friendships, their career goals; they’re no longer so focused on the past and trauma, but integrating into whatever kind of life and relationships they want. 

BB: Yes. The program I’ve created with colleagues called “Finding Solid Ground” is a staged stabilization approach where we help clients learn about, first of all, grounding. But it’s not just for people with DID, but also for people with complex PTSD, and what in the United States is called the dissociative subtype of PTSD.

Our research is showing it helps all these folks, not just DID, but they learn to be more present to their emotions and deal with emotions in healthier ways. They learn about how to deal with PTSD so it’s more contained and not so intrusive so they can sleep better so that they're not having these awful images pop into their mind and interrupt their functioning all day.

We help them learn to separate past and present. When somebody has very bad PTSD, the brain cannot really distinguish the difference between a flashback and the present moment. It feels to the person it is happening now. So, we teach them how to catch their warning signs that they may start being close to being at risk for intrusions of PTSD, that they might start dissociating, that they might start drifting towards self-harm, and then find ways to get out of that cycle. Among other things, we teach them a little bit about the neurobiology of trauma and that it’s not their fault.  

BB: When I first accepted that postdoc at Sheppard Pratt in 1993, the emphasis in the field was integration of personality states. And yet that’s not what I was hearing and seeing was happening very often. I was the leader of a study where we asked experts around the world how many patients had they integrated in their careers. It was small numbers.

That may not sound like a jolt of lightning to readers, but it did lead us to rethink whether that was very achievable for most patients or not?

At the same time, many people living with DID do not want to integrate their parts because they have lived often for decades with these parts. And that helps them function from their perspective. That is who they are. They value their parts, or eventually you hope that therapy can help them learn to respect and value their parts rather than be at war. Some of the self-harm and suicide attempts are about one part trying to kill off another. At the time, they don’t recognize they will all die if they commit suicide. So now I have a different perspective and I think there are different options. I think clients should have the right to choose what they want their endpoint to be.

And that may change over treatment. In the beginning, some clients absolutely say get rid of these parts, but they don’t understand. They can’t. I use the metaphor that you can’t live by cutting out your heart or your liver. And it’s the same thing with self-states. You have survived because of the self-state. You can’t get rid of one. You can learn to work as a coherent collaborative group like a business or a healthy family rather than being at war. 

BB: Of course, as a therapist, I’m teaching them, but I don’t want their spouse or partner to be doing therapeutic things. Right! But it gets really messy. If they have children who see them switch, and mom or dad doesn’t seem to remember things they’ve said or done, I find ways to explain DID to the kids in an age-appropriate way.

It is incredibly important that they’re not switching a lot in front of their children. Parents should be consistent no matter what, no matter who they are, whether they have DID, bipolar disorder, or PTSD. Children need consistency. So I would work with a client to help them develop the parenting parts and having them learn to look similarly and act similarly with the kids, so they’re not confusing the kids.  

BB: Yes. So that might be something that we’d work on, to go back to that last example, when they’re around their children. You would want them to work towards having parts that can be very supportive, caring, loving, consistent parents. And the parts that are little, that feel as if they are young children, terrorized, traumatized themselves, would be in the back of the mind.

All this is metaphor, however, right? There are no little people, right? But metaphorically, those self-states are taken care of internally so that they are consistent. Same thing with work, same thing when they’re driving.  

BB: Really good question. Some of the same symptoms that later develop and become more severe in adulthood can be seen in little children with the beginning stages of a dissociative disorder. One thing I haven’t mentioned is that adults with DID can go into trance states where they’re not responsive to the outer world.

Little kids start showing attention and zoning out. They’re often misdiagnosed as having ADHD. So again, we need all clinicians to be trauma-informed and trained. Not that they’re expecting to see a dissociative kid, but they might, especially if they have symptoms of PTSD like nightmares and flashbacks, or report having imaginary friends. Some talk about that for a second.

Developmentally, it’s normal for children to have imaginary friends. But if imaginary friends start to be frightening, or upsetting, or tell the child to hurt their sibling or a pet, or to destroy their toys, that’s not a “normal” kind of scenario. Little kids usually stop talking about imaginary friends around age seven. But people with DID report that they never went away. Those actually linger as parts of their dissociative self-states.   

BB: It might be! During medical training, students commonly think they have all the different disorders. The same thing may be happening in our field. For 26 years, I taught a course on differential diagnosis and interviewing. At the beginning of the class, I warned the students that they were going to be tempted to diagnose themselves along with everybody they loved or hated. It is a normal phase of learning the DSM but I asked them to be respectful and stick to the diagnostic criteria, so they don’t go telling people they’ve got borderline personality disorder.

There is a normal stage of training in which, at least for a while, we may overuse certain concepts as we’re learning them. But again, if clinicians are well-trained in differential diagnosis they will be less likely to overdiagnose certain symptoms and disorders—in this case, dissociation and DID. This is one of my research streams.

There is a lot of research out there, and I’ve written a book about how to assess dissociation and how to distinguish it from other symptoms and disorders. Here is where training is critical. The ways you treat schizophrenia and bipolar disorder are very different from the way you treat DID. Schizophrenia and bipolar are the two disorders that people with DID are most often misdiagnosed with.

People with DID don’t need mood stabilizers or heavy-duty antipsychotics. Instead, you do a trauma-informed stabilization approach. Two of my earliest DID clients were misdiagnosed with schizophrenia and treated accordingly for years. One passed away and gave me permission to share her story. By the time I saw her, she had horrible tardive dyskinesia. She had been disfigured by the treatment for schizophrenia that she didn’t have. Once we started working together, she got a lot better— not cured, but a lot better, and she was much more functional. She had dropped out of school and midway through high school, she went back and became a minister in her community.  

BB: Only 8% of APA-approved doctoral programs require a course in trauma. That’s gotta change. Information about trauma should be a required part of graduate training in psychology, social work, and related fields. As part of that training, they also need to learn about dissociation and the range of dissociative disorders, and how you assess for dissociative disorders, and how you do differential diagnosis. And, of course, something about evidence-supported treatment. There’s only one program so far based on randomized controlled trial data that shows it helps people with profound dissociative disorders. But they should hear about that. That should be in the textbooks.

BB: A group of us have been pushing for different guidelines about working with complex trauma that finally got approved by the APA this last summer. But there is pushback. And a lot of us think there’s a political issue. Let’s just think about what PTSD means. The required criteria center around avoidance. You nailed it there!

Even people who’ve been traumatized don’t want to think about it. It’s human nature not to want to know, think, and talk about trauma. Believe me, it’s a hard part of my job. I do it, and of course I know how to do it. But hearing the stories of what has happened to little children is incredibly difficult.

And there’s some real doubters out there when it comes to thinking about child abuse. Maybe they should read a little bit about child pornography and child trafficking and how rampant they are, because we’ve got plenty of evidence that that happens. Some individuals report that part of their abuse was being the victims of child pornographers.

So, I think we don’t want to think about that stuff!  

BB: Avoidance. You nailed that.

BB: I’m sure that’s some of it, but not-unshockingly, it likely goes back to financial issues.

BB: At this point, the National Institute of Mental Health has never once funded a study of the treatment of DID. So, I have literally had to get donations to fund my studies. Do you think cancer researchers do that? Do you think researchers of any other disorder must have bake sales and pass the plate at college?

Where is the money in trauma right now? It’s in the Veterans Administration. I’ve heard this from various people who work there. They do not recognize DID, and they don’t want anybody in the VA system being diagnosed with DID, because that’s a real problem for our military, right? Everybody there has a dissociative disorder. Although believe me, I have assessed people in that system and helped them get honorary discharge. Anyway, there’s a huge amount of funding that goes to VA research and they emphasize working with adults. They want to keep the soldiers “strong” and ready to go or whatever the branches to ready to fight. Yeah. The childhood trauma.  

BB: I do, and I think many, many researchers are very concerned about funding for new science research in general. But then when you get into groups like research on women, research on children, research on traumatized people, research on any kind of minorities, but especially LGBTQ groups, people are very worried. My funding has always been a problem. But I do have many generous donors.

BB: So, we’ll have some hot chocolate sales and some coffee. Yes, There is a group called the International Society for the Study of Trauma and Dissociation (ISSTD). They do lots of multi-level, face-to-face and online training for dissociation and children, adolescents, and adults. They also supported RCT studies for our Finding Solid Ground program.

I’m strongly urging clinicians to learn about that program. We’ve got two books out there. One for people living with the disorder, and one for therapists. Our research shows that the Finding Solid Ground program works best when the therapist knows the program and the clients working with the therapist who knows the program.  

BB: For anybody working with complex trauma, there is going to be countertransference and traumatic countertransference. And the client will experience transference. There’ve been times I felt like I wanted to rescue somebody because they’ve had such a hard life. But you’ve got to keep the boundaries strong. I consult with a lot of therapists. One of the mistakes I hear from therapists is they do try and rescue, or they go too far. It’s not uncommon that therapists will see a DID client for free and become very burned out. I don’t ever advise that.

The psychotherapy research shows that people benefit from treatment more if they’re paying something. It’s also common for therapists to alternate between feeling helpless, like the child was back during trauma time, and at other times harsh and mean which the client may experience as harsh and mean, almost like the perpetrator or a non-protective bystander. Those three roles are extremely common in the treatment, so I teach a therapists to watch for that, to work on that, and to make that understood. Something they actually talk about with their clients so neither get stuck in those spaces and can learn from it. It’s part of the healing, rather than becoming the point where the treatment comes off the rails.  

BB: Yes. There are people out there who have died because of this disorder, but there is hope, even despite the tremendous suffering. It’s important that these people know that they are not alone, and neither are their therapists. It’s important that therapists convey that they’re not alone, it’s not their fault, and that they are not weak or dumb. They don’t have to suffer endlessly, and neither do therapists need to feel powerless. There's hope. 

BB: Thank you!