THE TREATMENT
OF TRAUMATIC
MEMORIES
IN DID:
INDICATIONS AND
CONTRA-INDICATIONS
Suzette Boon, Ph .D.
Suzette Boon, Ph .D., is a clinical psychologist/psychothera-
pist at both the Regional Institute for Ambulatory Mental
Health Care in Amsterdam South/New West, the Nether-
lands and at the Willem Arntz Hoeve, Den Dolder, The
Netherlands.
For reprints write Suzette Boon, Ph .D., Riagg Z/NW, P .O.
Box 71505, 1008 DA Amsterdam, Netherlands.
This is a revised manuscript of a plenary presentation pre-
sented at the Fifth Annual Spring Conference of the ISSD,
in Amsterdam, on May 10-13, 1995
The author would like to thank Onno van der Hart, Ph .D.,
for his valuable comments on an earlier draft and continu-
ous support as a colleague.
ABSTRACT
A treatment model with a focus on trauma treatment and subse-
quent integration is widely accepted as the most successful among
therapists treatingDID . However, this model may not be the best option
for all DID patients . Lower functioning patients often do not have
the strength or therapeutic potential and/or opportunity to endure
this kind of treatment . This article discusses indications and con-
tra-indications for entering into the second phase in the treatment
of DID patients : the treatment of traumatic memories . A checklist
was developed to evaluate the treatment process and make a well-
founded decision about the transition from phase I, stabilization and
symptom reduction, to phase II, treatment of traumatic memories.
Criteria that influence a decision to focus on phase I only, without
proceeding to phase II, will be discussed
strate the use of the checklist.
The standard of care for the treatment of severe disso-
ciative disorders consists of a stage-oriented treatment model
as first described by Pierre Janet (van der Hart, Brown, &
van der Kolk, 1989) and more recently by contemporary clin-
icians (Brown, Scheflin, & Hammond, 1998 ; Herman, 1992;
Kluft, 1993a ; Horewitz & Loewenstein, 1994) . This model
consists of three stages of treatment : 1) stabilization and symp-
tom reduction (Herman [19921 speaks of establishing safe-
ty) ; 2) treatment of traumatic memories (part of which is
mourning the associated losses) ; and 3) integration and reha-
bilitation . Although controlled outcome studies on the psy-
chotherapy of DID have not yet been conducted, a vast major-
ity of successful treatments have been associated with a model
focusing on integration (Kluft, 1984 ; 1986 and 1993b) . This
approach is also the basis of the official guidelines for the
treatment of MPD/DID of the International Society for the
Study of Dissociation (1994, 1997) .
Effective treatment for DID can never start with exten-
sive exploration of the traumata . On the contrary, as high-
lighted in the works of Kluft, Fine, and many other authors
in the field, trauma-work can only be done after sufficient
groundwork has been completed (Fine, 1991, 1993 ; Kluft,
1986, 1991, 1993a, b & c) . Over the last several years, there
has been a growing realization that not all DID patients are
capable of integrating their traumatic memories (Boon, 1994,
1995 ; Boon & van der Hart, 1995,1996 ; Kluft, 1993a &b ; 1994;
Horewitz & Loewenstein, 1994) . In some cases treatment
techniques focusing on stabilization and symptom reduction
are the only feasible option . The aim is, essentially, to help
the patient to use dissociation as a more effective coping style.
This approach falls into Kluft's category of adaptationalism
(Kluft, 1988b, 1993b) . An important feature of this approach
is pragmatism . The priority is on maintenance and man-
agement of life functions, and improvement of the patients'
functioning . Kluft (1988b) mentions several reasons for ther-
apists to prefer this model : 1) cost containment ; 2) minimi-
zation of the value of psychotherapy ; and 3) burn-out symp-
toms in the therapist . I would like to add another very impor-
tant reason for this stance : a considerable group of patients
is unable to achieve the goal of integration . Severe attach-
ment problems, a lack of ego strength, a lack of the essen-
tial therapeutic potential to proceed due to concomitant psy-
chiatric problems or a lack of motivation maybe among the
reasons that these patients are unable to bear an intensive
treatment geared towards the treatment of traumatic mem-
ories and the achievement of integration.
In this paper I will discuss factors that may influence a
decision toward maintaining a focus on stabilization . I will
present a checklist to evaluate the treatment process and
make a well-founded decision about whether it is appropri-
ate to make a transition from phase I concerns, stabilization
and symptom reduction, to phase II issues, the treatment of
traumatic memories . Clinical examples will illustrate the use
of the checklist .
65
DISSOCIATION, Z'ol . N, No, 2, June 1997
TREATMENT OF TRAUMATIC MEMORIES IN DID
Prognosis and Treatment Goals
Initially there was an optimistic stance among therapists
about treatment prognosis of DID (Kluft, 1984, 1986a).
Although treatment approaches differed with regard to many
aspects (Kluft, 1993a), successful treatment was primarily
focused on integration, a goal that was considered as achiev-
able by most patients . In the pioneering years the literature,
with few exceptions (e .g., Caul, 1988 ; Kluft, 1984), gave
little attention to the complexity of concomitant personali-
ty disorders and severe attachment problems . The indica-
tions or possible contraindications for a treatment approach
focusing on trauma treatment and integration were not dis-
cussed widely in the literature, and unfortunately the ISSD
guidelines do not mention this subject, not even in their most
recent revision . Gradually the realization that DID patients
are a very heterogeneous group with different capacities to
undertake definitive treatment has been appreciated (Kluft,
1993 ; Horewitz & Loewenstein, 1994 ; Groenendijk & van der
Hart, 1995).
An overview of the literature shows that several authors
have mentioned factors associated with treatment impasses,
failures or a bad prognosis . Kluft (1984) described 10
patients (out of a study group of 117 treated by the author)
whose treatment failed . These patients had not succeeded
in establishing a therapeutic alliance despite years of effort
and some of the following features were present : They had
severe ego weaknesses, they were often enmeshed with
"traumatizers" ; there was a prolonged "warfare" among the
personalities ; there was substance abuse or sociopathic
behavior . However the vast majority of the patients in this
early study responded very favorably to treatment.
More recently Kluft (1993c, 1994a) compared the
patients he had treated with a patient cohort from an out-
come study described by Coons (1986) . Kluft's patients had
done much better, 75% of his series had rapidly integrated.
Only 25% of the patients from Coons's series responded in
the same positive way to treatment . Patients in the two stud-
ies were from very different backgrounds, however . Kluft's
patients were almost all treated in private practice and had
much more education . Coons's patients were from a state
hospital setting . One of Kluft's conclusions was that MPD/DID
is a very heterogeneous condition with a few subtypes with
different prognostic implications : 1) a group of high-func-
tioning DID patients who respond positively to therapy and
improve quickly ; 2) a group of lower functioning DID
patients with comorbid Axis II conditions whose response
to treatment is less positive (treatment is necessarily much
slower and full integration may not be attained) ; and 3) DID
patients who are unable to make use of a therapeutic rela-
tionship ; they have a dissociative lifestyle and can not change
self-destructive and/or antisocial behaviors . Horewitz and
Loewenstein (1994) also describe three different subtypes
of DID patients comparable to the groups mentioned by Kluft.
The fact that groups of DID patients may differ widely
with regard to treatment setting and level of education is also
confirmed by comparing data from a survey of current treat-
ment practices conducted by Putnam and Loewenstein
(1993) with data of a clinical investigation of 71 Dutch MPD
patients (Boon & Draijer, 1993) . Eighty-one percent of the
patients in Putnam and Loewenstein's cohort [N=305] were
treated in private practice, and 43 .5% had graduate degrees.
Only 12% of the Dutch patient cohort had a degree com-
parable to an American graduate degree . A minority (21%)
was treated in private practice, 54% were treated in an out-
patient psychiatric service, 14% in an inpatient psychiatric
service, and 10% in a psychiatric day hospital . Only 15% of
the Dutch patients were employed . These data suggest that
a majority of this Dutch patient cohort had characteristics
of a "lower functioning " group of patients.
David Caul (1988), one of the first to discuss treatment
prognosis, mentioned a list of factors influencing prognosis
which included : 1) length of (previous) treatment following
DID diagnosis ; 2) number of therapists that have treated the
patient since the diagnosis was made ; 3) narcissistic invest-
ment in the separateness of alters ; 4) preoccupation with
uncovering again and again "new trauma material" instead
of focusing towards resolution ; 5) prolonged presence of a
violent attitude ; 6) the degree of confabulation ; 7) persis-
tence of issues of control or attempts to dominate the course
of therapy ; and 8) little or no emotional commitment to
change.
Putnam (as cited by Comstock &Vickery, 1992) estimated
that one third of DID patients are not treatable . Some of the
reasons that these DID patients were not treatable included
the extent, length, and intensity of the patients' trauma ; their
propensity towards reenactment in adult life ; the coexistence
of medical and psychiatric conditions ; their tendency towards
secondary gain ; their incapacity to attend to stimuli without
cognitive or affective distortion ; their compromised intel-
lectual capacity ; and their lack of motivation to overcome
the past.
It is certain that clinical experience with a low-func-
tioning patient cohort has influenced my thinking about
prognosis, indications, and contraindications for a treatment
model focusing on trauma work and integration . This had
lead to the idea that treatment following the "integration
model" is not always feasible and sometimes an "adapta-
tionalism stance" is the best there is to offer . Not every patient
is best helped following a model of intensive therapy focus-
ing on integration and not every patient has enough
"strength," even after a prolonged stabilization phase, to com-
plete the very demanding stage of the treatment of traumatic
memories, a necessary step in order to move towards inte-
gration . Moreover, sometimes, if intensive treatment has been
started with a patient who is unable to endure this kind of
psychotherapy, he or she can easily deteriorate and more
damage can be done if this type of treatment is continued.
Given the fact that the current "standard of treatment" is
66
 
DISSOCIATION, Vol . 2, June 1997
BOON
intensive psychotherapy with "a minimum recommended fre-
quency of sessions twice a week" (ISSD Guidelines, 1994,
1997), it is not so easy to change the focus of treatment (or
frequency of sessions) without inevitable feelings of aban-
donment, anger, and of "being a treatment failure " on the
side of the patient, and strong countertransferential feelings
on the side of the therapist.
With a considerable group of low-functioning patients
the focus of therapy should be, as a rule, limited to crisis man-
agement, stabilization, and symptom reduction .The aim is
essentially to help the patient to use dissociation as a more
effective coping style . Boon and van der Hart (1994, 1995,
1996) described eight types of interventions aimed at stabi-
lization and symptom-reduction in the first treatment phase
of DID and five factors important in making the choice to
remain focused on these treatment goals only . Electing lim-
ited treatment goals for those patients who seem to be unable
to work toward processing trauma and integration has the
disadvantage that there will be always an unstable equilibri-
um easily disturbed by stressful situations or other difficult
life events . However the cost of treatment with a focus on
trauma may be too high emotionally and may lead to chron-
ic decompensation or worse.
CRITERIA THAT INFLUENCE A DECISION FOR
A LIMITED TREATMENT FOCUS
The first phase in the treatment of DID is always focused
on stabilization, establishing personal safety, and self-care.
Moreover it is very important to work on the establishment
of a therapeutic alliance . The length of this first phase may
differ considerably from patient to patient . Pacing the ther-
apy is essential (Fine, 1991 ; Kluft, 1993b) . During this phase,
the following treatment strategies are applied (Boon & van
'der Hart, 1994, 1995):
a. General applicable supportive interventions, useful
in the care of many other clients in crisis as well;
b. Psychoeducation with regard to dissociation, DID,
and PTSD, which may heighten a sense of control
and which lower feelings of anxiety and shame ; also
psychoeducation also with regard to attachment
problems;
c. Teaching coping and containment techniques with
regard to traumatic memories (Brown & Fromm,
1986 ; van der Hart, Boon & van Everdingen, 1990) ;
i.e ., teaching a constructive use of dissociative abil-
ities;
d. Teaching cooperation between various identities, in
particular between those adult identities which are
unaware of the traumatic past and who function
mainly in daily life (Kluft, 1993c) ;
e. Developing positive contact between the therapist
and identities which are aggressive or self-destruc-
tive (often so-called "perpetrator-introjects "), and
subsequently between these identities and other
identities;
f. Cognitive therapy, aimed at correcting faulty cog-
nitions and basic assumptions of various identities
(Fine, 1988, 1992 ; Ross, 1989);
g   Marital or family therapy with the patient, her/hispartner, and the current family (Panos, Panos &
Alfred, 1990 ; Sachs, Frischholz & Wood, 1988);
h . Developing a protocol for crisis intervention, includ-
ing short-term inpatient treatment.
It is my clinical experience that mapping all personalities
during the first treatment phase is not desirable, because that
may trigger traumatic material and overwhelming feelings
the patient can not (yet) tolerate . For an alternative per-
spective see Fine (1991) and Kluft (1991) . During this phase
I prefer to work with identities which actively participate in
daily life, cognitive observer identities and, if possible, the
so-called "perpetrator-introjects ." They are often responsi-
ble for a lot of chaos and self-destruction but may become
very good therapeutic allies once they decide that therapy
is not going to harm them or other identities and that they
will not lose their "function ."
When working with lower functioning patients it is not
always easy to make a decision whether or/and when to pro-
ceed to the second treatment phase, the treatment of trau-
matic memories.
In my clinical approach to the decision for a treatment
focusing on stabilization only or a more encompassing treat-
ment approach, the following factors are taken into account
(Boon & van der Hart, 1994, 1995, 1996 ; van der Hart, van
der Kolk, & Boon, 1997):
I . The Patient's Current Personal and Professional Functioning
DID patients differ widely in their ways of function-
ing in daily life . Some patients are able to maintain jobs;
some study, have hobbies, friends, and a good social sup-
port system . Others, however, have not had much edu-
cation and/or are unable to do any kind of work . Some
have long psychiatric histories ; they are unable to main-
tain stable relationships or do not seem to succeed in
eliciting any support at all from external sources . Often
there are other Axis I diagnoses, such as episodes of
severe depression or anorexia that need to be addressed.
In the first treatment phase, one of the goals should
be the improvement of personal functioning . This may
include helping the patient : 1) to find meaningful activ-
ities during the day ; 2) to form supportive relationships
with significant others ; 3) to learn to abide by contrac-
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DISSOCIATION, WI. No. 2, June 1997
TREATMENT OF TRAUMATIC MEMORIES IN DID
tual arrangements with respect to the therapy ; 4) to con-
trol impulses ; and 5) to improve his or her general capac-
ity for self-care.
In general high functioning patients do not have
many problems in the above-mentioned areas . Never-the-
less, their treatment should proceed very slowly (Kluft,
1986h, 1993a) . Early exploration and treatment of trau-
matic memories, without having first established the
capacity for re-stabilization, can seriously disrupt the
patient 's functioning . Some of the lower functioning
patients manage to improve gradually with respect to per-
sonal functioning during the first stage of therapy ; oth-
ers do not . If there is not any improvement in functioning
over time and the patient remains isolated, unable to
undertake any kind of daily activities, unable to organize
some social support, unable to learn to relate to others
(including the therapist) in a more stable way, a thera-
py focusing on treatment of the treatment of traumatic
memories is not feasible.
2. The Presence of an Axis II Disorder
Many DID patients have concomitant axis-II disor-
ders . Often they meet criteria on a descriptive level for
one or even more DSM-N personality disorders . Research
among 71 Dutch patients has shown that 38% met full
(five or more out of nine) criteria for borderline per-
sonality disorder (BPD) and 65% met four or more cri-
teria (Boon & Draijer, 1993) . However some of the so-
called personality disorder criteria may be misunderstood
posttraumatic symptoms and disappear during treat-
ment . On the other hand if all personalities of the DID
patient have the same rather rigid behavior pattern asso-
ciated with a certain personality disorder then treatment
may be seriously complicated . Patients with comorbid
Axis II conditions have much more difficulty forming
an attachment to the therapist . They often engage in
pathological self-soothing behaviors, have poor judgment
in their interpersonal relationships, and tend to reen-
act former traumatic attachments . Testing and some act-
ing-out behavior in the beginning of therapy with DID
patients can be considered "normal," but if it is impos-
sible to control this in the course of the stabilization phase
it is not wise to proceed with the treatment of traumat-
ic memories.
Severe Axis II problems may also cause a lack of moti-
vation or a lack of willingness to take the responsibility
to get better.
3. Patient's Life Cycle Phase And/Or External Life C r
Sometimes the patient's life cycle phase seriously lim-
its therapeutic possibilities . For female DID patients, preg-
nancy and the raising of very small children can be very
demanding . In general the focus of therapy should be
on stabilization, in particular when the patient has little
68
support from a partner and/or significant others . With
older patients the factor of age may also play a role in
determining the focus of therapy . Many older people
show diminished ego strength . Subsequently it is more
difficult for them to endure demanding therapy . Kluft
(1988c) stressed the importance of going very slowly with
the older DID patient . I think that in many cases older
DID patients may be helped best by a therapy focusing
on stabilization only.
External life crises also limit the possibility of doing
trauma work . These crises may differ widely, but always
need to be addressed first . Finally, factors such as severe
physical infirmity or terminal illness in the patient or a
close family member are contraindications for pro-
ceeding to the next phase.
4. Substance Abuse
Many DID patients have personalities in their system
that are alcohol and/or substance abusers . Generally this
behavior is considered as a form of self-medication asso-
ciated with the management of painful traumatic mem-
ories and feelings . Some clinicians argue that the addic-
tion of alcohol and/or drugs will disappear after trauma
work has been done . Others stress the importance of
addressing alcohol and/ or substance abuse as a separate
problem . I think that alcohol or drug addiction should
be addressed in the initial stages of the treatment.
Patients (or specific personalities) need to learn new cop-
ing techniques to replace harming the body through alco-
hol, drugs, or excessive amounts of medication . If they
have not learned other coping techniques there is a risk
that they will abuse substances even more in the second
phase, when confronted with feelings that they can not
tolerate . If there is no motivation to give up alcohol or
drug abuse, I consider the treatment of traumatic mem-
ories to be premature.
5. Ongoing Abuse
It is clear that in cases where there is ongoing abuse,
the only focus of the treatment can be to help the patient
to stop or remove himself/herself from the abuse . It is
my experience that in some cases a prolonged episode
in a psychiatric hospital has enabled the patient to end
an abusive relationship . In many parts of the world, this
option is not available.
In conclusion, it is usually not one of these factors,
but a combination of these factors that may lead to the
decision for therapy focusing on stabilization only . It is
often impossible to make a well-founded decision early
in treatment . In some cases, treatment of traumatic mem-
ories becomes possible after a prolonged stabilization
phase or when the patient has entered another life phase.
DISSOCIATION, Vol, X . 2, toe 1997
BOON
Checklist for the Evaluation of the Treatment Process
Kluft (1994 a&b) was the first to develop an instrument,
the Dimensions of Therapeutic Movement Instrument
(DTMI) , to measure therapeutic progress of DID patients . This
instrument was specifically designed for use in treatments
that work towards integration (Kluft, 1994h) and addresses
12 dimensions of therapeutic progress . Kluft has described
three different groups of patients based on DTMI scores
achieved by different DID patients : High, Middle and Low
Trajectory patients . Although the instrument can be used in
adaptational treatments, it is clearly designed for a treatment
trajectory with a focus on integration . For instance, a scale
to describe function (Dimension 13), is optional.
Because my personal experience -both with most of the
patients I have treated as well as in many consultations and
supervisions - has been primarily with middle or low-func-
tioning patients, I felt a need to develop a checklist which
may enable the clinician to make a well-founded decision
either for phase I only, or for a more encompassing treat-
ment model . This checklist differs from the DTMI in that is
has been designed from an adaptationalist stance . The focus
is primarily on the first phase of treatment ; there is no dimen-
sion concerned with integration . Using this checklist, the fol-
lowing areas can be systematically evaluated : diagnostic
assessment ; psychiatric history and prior treatment ; trauma
history ; ongoing abusive relationships ; acceptance of diag-
nosis ; current functioning ; life-cycle phase and interaction
with current functioning ; other problem areas interacting
with current functioning (for instance, financial problems;
general health problems) ; acceptance of treatment frame
and boundaries ; extent of cooperation with the therapist;
specific problem areas in therapeutic relationship ; and
crises during treatment.
The therapist evaluates each area at the beginning of
treatment . Further evaluations can be done as often as nec-
essary ; I prefer to evaluate once every half year . Most areas
can be scored in the following way : 1) absent ; 2) present ; 3)
seldom (present) 4) recurrently (present) 5) frequently (pre-
sent) 8) not clear . There are no "subscores " for the differ-
ent parts of the list nor a "total score ." The instrument was
designed for clinical practice, not as a research instrument.
Decisions based on the checklist may also vary from patient
to patient and from therapist to therapist depending on the
personal experience and the therapeutic skills of the thera-
pist . However, in general I believe that the transition from
phase Ito phase II can only be made if a patient is functioning
without major problems in the areas VI -XIV and if there are
no major somatic or psychiatric comorbid conditions that
complicate the situation.
I have used this checklist in the following ways : 1) to eval-
uate my own patients and discuss patients with colleagues,
in order to make a decision based on the checklist whether
a transition towards the next phase is appropriate at that time;
2) to motivate individual patients, particularly when the
patient wanted "more and faster" therapy or was not taking
enough responsibility for her own treatment . In those cases,
using the checklist in the session was helpful to motivate the
patient to make necessary changes in phase I of the treat-
ment . In other cases it did help the patient to accept the fact
that "more and faster" was not a wise treatment strategy at
that point in time . Moreover, psychoeducation about the
problems of comorbid conditions and attachment problems
helped these patients to understand that they were not "treat-
ment failures," and needed their own time and pace to get
further in therapy . It is also useful 3) as an instrument dur-
ing supervision or consultations.
To illustrate the use of this checklist the therapy process
of several patients will be described.
Patient One
Agnes was 28 years old when she was referred to our psy-
chiatric department in an acute crisis . After her boyfriend
had left her, she smashed her apartment to pieces, took her
one-and-a-half year old son, and went to her mother's house.
There she barricaded herself in her old bedroom . The fire
brigade had to break in through a window . She refused food
and water, and a request was made to hospitalize her against
her will . This did not occur, because by the time a second
psychiatrist had come to judge her situation she was eating
again . She did not want to speak or make any contact, how-
ever . After a few days, all of a sudden she left her mother 's
home with her child and went back to her apartment.
She was referred to the author for outpatient therapy.
In the first session she said she did not need therapy for her
past problems ; that she only wanted to talk about the pre-
sent . However, it became clear that she had severe dissocia-
tive symptoms (for instance, almost total amnesia for the past
crisis) . The diagnosis DDNOS was made, and DID was sus-
pected.
Using the checklist, the following picture of her base-
line presentation during the first months of therapy can be
given . Agnes presented with a "classical" (see Kluft, 1985)
DID picture, i .e., a depressed host, very defensive and secre-
tive about the dissociative symptoms . She did not present with
other psychiatric problems on Axis I ; the diagnosis on Axis
II was not clear . There had been some prior outpatient ther-
apy, but no hospitalizations . Apart from recurrent severe
headaches, she did not mention other somatic complaints.
Her current functioning was very problematic . She was a
nurse, but did not have a job because she had to take care
of her young child . She had financial problems ; the rent of
her house was too high for her to afford without the support
of her former boyfriend . After he had left her, he did not
take any responsibility for their child . She had no social sup-
port system and had a very ambivalent relationship with her
mother and half-brothers and sisters . At times she had prob-
lems with proper self-care and with the care of her child.
Although she felt sometimes very suicidal, she was able to
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DISSOCIATION, Vol . 2, June 1997
TREATMENT OF TRAUMATIC MEMORIES IN DID
control her feelings and not act upon them . She reported
some eating problems, mainly bingeing and vomiting . There
was no alcohol or substance abuse . Although several other
personalities had written letters to the therapist in the
course of the year and DID was confirmed, Agnes was
ambivalent about this diagnosis.
However, she did accept the treatment frame and
boundaries, and she showed willingness to cooperate with
the therapist to improve her situation . She was motivated to
learn techniques of self-hypnosis for containment of reacti-
vated traumatic memories, building ego strength, etc . After
one year Agnes was functioning much better . She had found
a day-care center for her child, she passed exams and
entered university, and she found a cheaper apartment . Also,
she had become more open about her dissociative symptoms
and had accepted the diagnosis of DID . However, she was
still without social support . She often engaged in rather
destructive interactions with her former boyfriend and with
her mother, which at times severely threatened her stabili-
ty. Now her attachment problems became a main focus of
therapy . By the end of the third year of therapy, she began
to learn to keep more distance and disengage (most of the
time) from destructive interactions . At the same time she
made some new friends . She functioned much better in all
areas of the checklist and a sufficiently strong therapeutic
alliance was built . It was then that the therapist and Agnes
could make a decision about making the transition to phase
II, the treatment of traumatic memories . This choice has
proven the right one . Agnes is now, about five years later,
fully integrated.
Patient Two
Marianne, when referred for a first diagnostic consul-
tation, was a 34-year-old woman, who had been in psychi-
atric care for the past five years, after her divorce . She did
not have children . The first treatment setting was a psy-
chotherapeutic clinic for patients with severe personality dis-
orders, with group therapy treatment focusing on exploration
and the past . In response to this treatment regime she total-
ly decompensated and rapidly became worse . She then was
referred to an inpatient setting for more chronic, lower-func-
tioning patients, with an individual treatment focus on the
here and now . During her stay there DID was suspected . A
consultation by the author confirmed the diagnosis and a
treatment plan was made to help this patient to get out of
the hospital and live on her own again . Four years after this
consultation she was referred to the first author again for a
supportive therapy . She then lived in a "half-way" home for
chronic patients . Her profile on the checklist was as follows:
In addition to the Axis I diagnosis of DID, she received an
Axis II diagnosis, Borderline Personality Disorder . She had
reported a history of severe abuse by an organized perpe-
trator network . Although she did not report enmeshment
with the original perpetrator network, she was constantly
reenacting the trauma by letting herself get picked up, beat-
en up, and abused . She was very self-destructive in other ways
as well, such as recurrent deep cutting and other suicidal
behaviors leading to many visits to emergency rooms . She
was frequently hospitalized and demanded lots of medica-
tion . During hospitalizations she regressed into child-alters
or other dissociative states which had resulted in her getting
hours of attention by staff nurses to "get her back" to the
here and now . She had very few daily activities and no sup-
port system . She had many difficulties in accepting the treat-
ment frame and boundaries . There were frequent crises . She
was able to involve and split many different therapists, and
agencies became conflicted and argued heatedly about her
treatment . In her individual therapy sessions she switched
rapidly from one alter into another, which made therapeu-
tic work difficult . Although she claimed that she was willing
to do therapeutic work, she in fact undermined any attempt
of the therapist to help her achieve more stabilization . She
constantly tried to bring traumatic material into the session
and she stopped this behavior only after she was explicitly
told that therapy would end if she were to continue doing
this . It took two years- with very severe limit-setting - to edu-
cate Marianne how to take minimal responsibility for her own
treatment . At the end of these two years, I decided to show
her the checklist and score it together . I explained to her
what work had to be done before she ever could get to the
next phase of therapy, which she claimed she wanted to enter.
There were very few positive scores in most of the areas of
the checklist at that time . After this confrontation, Marianne
suddenly and amazingly started to change her behavior . She
stopped the cutting, the "emergency calls and visits " dimin-
ished greatly, and she found herself a job . She also started
to learn new strategies to cope with her feelings, flashbacks,
etc . Marianne is currently in her fourth year of therapy and
is now making plans to leave the "half-way home" and live
on her own again . She has managed to keep her job in the
last year and is starting to make some friends . She also has
achieved much more control over her self-destructive behav-
iors, except for the overeating . In the therapy, her attach-
ment problems were addressed . Marianne has done better
after an extensive period of tough and continuous limit-set-
ting (which had not been done before she was referred to
me), a lot of psychoeducation, and finally a "confrontation"
with the checklist . Although the work is still in phase I and
more time is needed to work through attachment problems
before proceeding to the phase of treatment of traumatic
memories, this option now can be considered.
Patient Three
Sandra is an attractive 30- year-old woman, who had had
previous psychotherapeutic treatment for six years . During
this therapy the diagnosis of DID was made . She was referred
to me after she moved to another city . After her divorce, she
lived alone and had a job as an administrator . Every week-
70
 
DISSOCIATION, Vol. X, To . 2, June 1997
BOON
end she uses hard drugs and after this lets herself get abused
by men . She is constantly at high risk for HIV-AIDS or other
sexually-transmitted diseases . In her therapy sessions she is
punctual, always present, polite, and at times very seductive.
Superficially, she is very cooperative, but in truth, nothing
changes whatever I try . When she came to treatment Sandra
had very little memory at all about her childhood, but at times
she had very bad dreams or flashback-like experiences about
abuse by both her parents and a network of other people.
Although she reports these experiences, she is very reluc-
tant to consider the possibility that things like that might have
happened in the past . She is unable or unwilling to work to
achieve more control with regard to the drug abuse . She
promises herself week after week to stop the drug abuse and
the abuse by many different men, but is unable to give tip
these behaviors . She does not allow access to the alters that
are involved in the drugs and abusive relationships . So far it
has not been possible to teach Sandra either other coping
mechanisms or any containment techniques . Sandra scores
very low in many areas of the checklist and after many years
of therapy it has been very difficult to achieve any changes.
In this situation a transition to another phase cannot be con-
sidered at all . The major goal is to preserve current func-
tioning and to try to prevent deterioration (for instance the
possibility that she might lose her job).
Patient Four
Grace is a 44-year-old woman, married with grown-up
children . She came with her therapist for a consultation . She
wanted to move on towards phase II and do trauma work,
but her therapist was not sure whether that would be the
right decision . Grace had been in therapy with her current
therapist for about four years with the diagnosis DID . Before
that she had had outpatient therapy for several years . During
this earlier therapy the diagnosis DID had been made . This
treatment was broken off after a crisis and admission to a
psychiatric hospital . In the previous years Grace had man-
aged to pickup her life again and she functioned rather well.
She worked in the business of her husband, whom she
described as very supportive . She .had a good supportive net-
work and there were no problems in most areas of the check-
list except one major and important one . Although Grace
had allowed access to many alters and had worked very hard
and successfully with hypnotic techniques for containment
and safe places, she was still phobic for "inside communica-
tion" and terrified of the "angry ones," in particular a part
she called "the father ." During the consultation she dissoci-
ated into an alter who told me that "he ['the father'] had to
disappear ." I used the checklist and explained to Grace and
her therapist that I thought that trauma work would be pos-
sible in the future provided that she would allow contact with
the "angry ones ." I could also explain that trauma work with-
out the permission and cooperation of the "angry ones " was
impossible and bound to fail, because those parts had kept
the angry feelings . Finally I was able to "talk through " and
relabel the "angry parts" as helpers . Grace could accept this
explanation, and both she and her therapist made a plan to
try to improve communication with those parts that had not
yet participated in the treatment.
DISCUSSION
I have described several cases to illustrate the use of the
checklist and the considerations that are important when
making a decision for a transition from phase I to phase II,
the treatment of traumatic memories . All four patients were
treated in a psychiatric outpatient department and were prob-
ably, in Kluft's terms, "middle" or "low trajectory" patients.
The first patient achieved stable integration after about eight
years of treatment . The others have been in treatment for
DID for between four and eight years, and a transition to
phase II cannot yet be considered because of the complex-
ity of their pathology . Although low-functioning DID patients
clearly follow a different pathway, another factor that may
determine their treatment progress should be considered.
In addition to patient factors, there are also therapist
factors that influence t reatment outcome . In the Netherlands
the diagnosis and treatment of DID have received consider-
able attention compared to other European countries in the
past ten years (van der Hart & Boon, 1990), but there are
still very few "experienced " therapists . Although intensive
training has been made available in the past years, many ther-
apists are treating their first DID patient . Moreover, the ther-
apists are often from very different backgrounds, some with
considerable basic psychotherapeutic training, others with
less extensive training . Therefore, in most of the consulta-
tions I did in the past years there was a combination of fac-
tors that influenced the treatment situation of a given
patient . Almost all patients were complex, with substantial
Axis II problems, many of the therapists were inexperienced
with regard to the treatment of severe personality disorders
and attachment problems, as well as with regard to specific
DID treatment techniques (for instance, how to address "the
angry ones," and how to help a patient overcome a phobia
for these parts, as was the case in the last vignette).
Treatment frame problems were very common with
patients deteriorating in regressive dependency, in need of
hospitalization, and while working with burned-out, over-
involved therapists struggling with strong countertransfer-
ential feelings . Patients with powerful attachment problems
were seen two or three times a week by therapists who had
problems setting limits in the treatment frame and difficul-
ty in handling transference/countertransference issues . Do
we have to blame these therapists? Is this a typical Dutch prob-
lem? I do not think so at all . I think this a typical pitfall in
the treatment of DID, in particular with complex, lower-func-
tioning patients . A great deal of experience is necessary to
set firm boundaries and handle strong transference and coun-
71
DISSOCI .AT10N, Vol . X. No. 2, June 1997
TREATMENT OF TRAUMATIC MEMORIES IN DID
tertransference issues and to prevent deterioration in low-
functioning DID patients . From that point of view, too much
emphasis on intensive treatment (with sessions twice aweek)
and a focus on integration as "the only (and best) treatment
pathway" can create unrealistic expectations in both patients
and therapists, and eventually can do harm . In my opinion,
future revisions of the ISSD treatment guidelines should
address these problems and pay more attention to consid-
ering alternative treatment pathways . This may prevent
extra traumatization in patients (and their therapists) who
believe that they are treatment failures, because they are
unable to follow the pathway toward integration.
In training and supervision, I currently advise therapists
to start with a weekly session, in particular when the patient
has complex Axis II problems and the therapist is relatively
inexperienced . It is easier to change the frequency of ses-
sions from once a week to twice a week than the other way
around . In cases where a focus on stabilization clearly seems
to be the only realistic pathway from the beginning, the fre-
quency of sessions may be even fewer than once a week to
prevent regressive dependency.
When working with patients I have found the checklist
very helpful in explaining to them different pathways and
reasons why a focus on stabilization was the best current
option at that time . Kluft (1994) has described his reasons
for not sharing the scores of the DTMI with his patients . He
was mainly worried about a negative effect on those patients
that did not do well . I think that there could be such an effect
when the only way is a pathway towards treatment of trau-
matic memories and integration . I have had very different
experiences . When scoring the checklist with a patient I
always give a great deal of explanation and psychoeducation
about the problems we encounter . I have found that if I can
explain with empathy the reasons for a focus on stabiliza-
tion, patients ' reactions were positive, and their feelings of
being a "bad patient" or "a treatment failure" could be pre-
vented . Sometimes, if I think that a patient clearly can do
better and should take more responsibility, the confronta-
tion with the checklist is helpful to motivate a patient . But
even then the timing of when to score the list with the patient
is very important . This is illustrated by the second case his-
tory . Marianne was a very complicated patient who had pre-
vious treatment that had fostered major regression . It took
several years to correct the impact of the previous treatment
and set limits, a task that would have been difficult for a ther-
apist without experience with complex DID . But once these
boundaries were established, the use of the checklist was help-
ful in motivating her to make further steps.
CONCLUDING REMARKS
DID patients differ widely with respect to ego strengths
and therapeutic potential . Although recent approaches in
the treatment of DID pay much more attention to pacing the
therapy, building ego strengths and assessing the individu-
al vulnerability of DID patients, integration can not be
achieved in the treatment of many patients . Prognosis
should get more attention and controlled treatment studies
are needed to enable us to make better decisions about what
kind of treatment is best when and for which patients.
The exploration and treatment of traumatic events
should only start when certain conditions are met : some sta-
bilization and symptom reduction must be reached ; patients
must master certain skills such as functioning in daily life,
maintaining some supportive relationships, and having
some control on self-destructive behaviors ; patients must have
established some cooperation among alter personalities
and have established a firm working alliance with the ther-
apist . This also includes a working alliance with the inner
perpetrators . Unless these conditions are fulfilled, attempts
at trauma work should be discouraged.
The checklist I presented can be seen as a preliminary
contribution to the clinical decisions concerning a transi-
tion from phase I to phase II in the treatment of complex
dissociative disorders . With a focus on phase I and the
patient's current functioning, it may be a supplement to
Kluft's DTMI . a73
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TREATMENT OF TRAUMATIC MEMORIES IN DID
APPENDIX I
Checklist for the Evaluation of Treatment Process of DID
I. BIOGRAPHICAL DATA
Age
Sex
Marital status
Children
Education
Employment status
II. DSMIVDIAGNOSES Baseline After (Fill in time)
AXIS I
AXIS II
AXIS Ill
SCID-D symptom profile
DES score
III . PSYCHIATRIC HISTORY Baseline After . . .
Prior treatment
Inpatient treatment
Suicide attempts
Scoring : 1 = absent, 2 = present, 3 = seldom, 4 = recurrent, 5 = frequent, 8 = unclear
74
 
DISSOCIATION, Vol . X. No. 2 . June 1997
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APPENDIX I
Checklist for the Evaluation of Treatment Process of DID, Continued
IV. MEDICAL . HISTORY Baseline After (Fill in time)
Somatic complaints
Neurological complaints
Neurological examination
Other
VI. TRAUMA HISTORY Baseline After . . .
Memories of abuse
Abuse reported above age 12
Sexual abuse
Physical abuse
Other abuse/trauma
Between ages 6-12
Sexual abuse
Physical abuse
Other abuse/trauma
Under age 6
Sexual abuse
Physical abuse
Other abuse/trauma
No memories of abuse
No memories of other traumatic events
Scoring : 1 = absent, 2 = present, 3 = seldom, 4 = recurrent, 5 = frequent, 8 = unclear
75
DISSOCIATION, Vot, X, No. 2, June199i
TREATMENT OF TRAUMATIC MEMORIES IN DID
APPENDIX I
Checklist for the Evaluation of Treatment Process of DID, Continued
VII . CURRENT FUNCTIONING Baseline After . . .
1.
 
Daily activities
work/study/school
volunteer job
taking care of children, household
hobbies/sports
2 .
 
Support system
contact with partner
contact with children
contact with friends
contact with colleagues
other significant relationships
3 .
 
Self-care
care for the body
food
sleep
Scoring : 1 = absent, 2 = present, 3 = seldom, 4 = recurrent, 5 = frequent, 8 = unclear
VI . ONGOING/CURRENT ABUSE
 
Baseline
 
After (Fill in time)
Enmeshment with original perpetrators
Ongoing abuse reported
Enmeshment with new perpetrators
Abuse reported
Reenactment of the trauma
Prostitution
Destructive relationships with significant others
76
 
DISSOCRTION, VoL X, No
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APPENDIX I
Checklist for the Evaluation of Treatment Process of DID, Continued
VIII . LIFE-CYCLE PHASE/INTERACTION WITH
CURRENT FUNCTIONING Baseline After (Fill in time)
IX . OTHER PROBLEMS INFLUENCING
CURRENT FUNCTIONING Baseline After ..
Financial problems
Health problems
Housing problems
Substance Abuse
Alcohol
Drugs
Medication
X . SPECIFIC PROBLEMS Baseline After . . .
Self-destructive behavior
Compulsive behaviors
Eating problems
Antisocial behavior
Contact with the law
Other problems
XL ACCEPTANCE OF DID DIAGNOSIS Baseline After . . .
Scoring : 1 = absent, 2 = present, 3 = seldom, 4 = recurrent, 5 = frequent, 8 = unclear
77
DISSOCIATION, Vol. X. No. 2, June 1997
11~K1I .
 
If 1. LI
  IN
APPENDIX I
Checklist for the Evaluation of Treatment Process of DID, Continued
XII . EXTENT OF COOPERATION WITH
THERAPIST Baseline After .
 
.
Willingness to allow contact with alters
Willingness to allow contact with perpetrator
parts/"inner leaders"
Willingness to learn (or increase) internal communication/
cooperation among alters
Willingness to be taught (hypnotic) techniques for:
1.
 
Building ego-strength
2.
 
Coping with reactivated traumatic memories/
containment techniques
3.
 
Self-soothing
4.
 
Coping with and regulating intense feelings
5.
 
Willingness to do homework assignments
Scoring : 1 = absent, 2 = present, 3 = seldom, 4 = recurrent, 5 = frequent, 8 = unclear
78
XI . ACCEPTANCE OF TREATMENT FRAME
AND BOUNDARIES
 
Baseline After (Fill in time)
DISSOCIATION, Vol
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APPENDIX I
Checklist for the Evaluation of Treatment Process of DID, Continued
XIV . CRISIS DURING TREATMENT Baseline After . . .
Phone calls with therapist
Admitted in psychiatric hospital
Suicide attempts
Severe self-mutilation
Severe (life-threatening) loss of weight
Other crises
Scoring : 1 = absent, 2 = present, 3 = seldom, 4 = recurrent, 5 = frequent, 8 = unclear
XIII . SPECIFIC PROBLEMS IN THERAPEUTIC
RELATIONSHIP
 
Baseline
Severe attachment problems
Unable to engage in an intense therapeutic relationship
Constant "testing"
(Very) controlling
(Very) manipulating
(Very) demanding
Continuous suicidal threats
Regressive dependency (strong wishes for nurture)
Attention-seeking between sessions
Aggressive behavior towards therapist
Unable to take responsibility "to get well"
(others have to do the work)
After (Fill in time)
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DISSOCIATION, Vol . X, No . 2, Jwie 199;