WORKING WITH
DISSOCIATIVE IDENTITY
DISORDER IN
STAVANGER, NORWAY
Ingunn Move, Psy
Tone Sem Langfeldt, Psy.D.
Tor Boe, Psy.D.
Jan Haslerud, M.D.
Francoise Stoerseth, M.D.
Ingunn Hove, Psy .D., Tone Sem Langfeldt, Psy .D., Tor Boe,
Psy.D., Jan Haslerud, M .D., and Francoise Stoerseth, M .D .,
are all working as clinicians at Rogaland Psychiatric Hospital
in Stavanger, Norway.
For reprints write Ingunn Hove, Psy .D., Department of
Psychiatry and Drug Addiction, Rogaland Psykiatriske
Sykehus, P .b. 1163 Hillevag, 4004 Stavanger, Norway.
ABSTRACT
The article gives a short review of how knowledge and competence
on dissociative disorders have developed in Stavanger, Norway . The
main part of the article describes two patients with dissociative dis-
orders. The first of these cases describes a middle-aged female patient
with a long psychiatric history with different psychiatric diagnoses.
She was the first among our patients to get the MPD diagnosis in
1992 . The other case presents a young man diagnosed with DDNOS
during his first stay in the psychiatric department in 1993 . The diag-
nosis later on was changed to MPD . Their treatments within the
Norwegian mental health system are illustrated.
INTRODUCTION
Interest in the role of trauma in psychopathology has
grown in Norway since the 1980s . Well-known psychiatrists
have, for many years, researched the symptoms found in the
concentration camps in the second world war, and described
the KZ (concentration camp) syndrome (Eitinger, 1964).
The Alexander Kielland disaster in 1980, in which an oil-rig
that housed many oil workers overturned, killing over 100
people, also alerted Norwegian psychiatrists and psycholo-
gists to the importance of research in traumatology . Finally,
the extent and importance of childhood trauma and incest
became more widely known in the 1980s . In spite of this,
nothing was written about dissociative disorders in the
Norwegian professional medical and psychological journals
before the 1990s, although the D.SM-III (American Psychiatric
Association, 1980) , which described them in detail, was wide-
ly used in Norway over this period of time.
A group of clinicians at the psychiatric hospital in the
County of Rogaland (RPS), which is situated in Stavanger,
were intrigued by inpatients diagnosed as psychotic or schiz-
ophrenic who did not present typical clinical symptoms and
who did not respond to antipsychotic medication . By search-
ing the literature and databases, important and clarifying arti-
cles were found, suggesting the possibility that some of these
patients might be dissociative . Specialists from Holland
(Onno van der Hart, Ph .D., Suzette Boon, Ph .D., and Nel
Draijer, Ph .D.) and the United States (Richard Loewenstein,
M.D., Bessel Van Der Kolk, M .D., and Glen Gabbard, M .D.)
were contacted . Through participation in ISSD conferences,
their knowledge and understanding of traumatized patients
grew .
When the Stavanger group published their first article
(Boe, Knudsen, & Haslerud, 1993) in the Norwegian Medical
Journal on "Multiple personality, also a Norwegian phe-
nomenon?" the journal's editor regarded this as very con-
troversial and added a critical commentary in which it was
claimed that multiple personality disorder (MPD) was iatro-
genic and that the MPD diagnosis was superfluous (Goetes-
tam, 1993) .
The Dissociative Experiences Scale (DES) of Bernstein
and Putnam (1986) was translated into Swedish in 1992 by
Ulla Karilampi, then a Swedish student of psychology, and
into Norwegian in 1993 by Tor Boe, Jan Haslerud, and Helge
Knudsen . The Structured Clinical Interview for the Diagnosis
ofDSM-IVDissociative Disorders SCID-D, devised by Marlene
Steinberg, M .D . (Steinberg, Rounsaville, & Cicchetti, 1990),
was translated into Norwegian by the Stavanger group, and
used in the first study of the frequency of dissociative disor-
ders in a Norwegian inpatient clinic (Knudsen, Draijer,
Haslerud, Boe, & Boon, 1995).
When Onno van der Hart, Ph .D., visited Stavanger, Henk
Otten, M .D., a Dutch physician who had specialized in psy-
chiatry in Stavanger, was asked to come from the Norwegian
Lappland as a translator . He became interested in dissocia-
tive disorders and qualified as a hypnotherapist after study-
ing in Holland . Otten returned to Stavanger and is active in
the dissociation group, teaching hypnotherapy and dis-
cussing the treatment of patients with a dissociative identi-
ty disorder (DID) diagnosis . The Lappland group, including
Henk Otten, M .D ., and Karl Y . Dale, Psy .D., has also trans-
lated the Dissociation Questionnaire (DIS-Q) (Vanderlinden,
Van Dyck, Vandereycken, Vertommen, & Verkes 1993).
Recently, the Dutch Somatoform Dissociation Questionnaire
(SDQ-20) (Nijenhuis, 1997) has been translated by Francoise
Stoerseth and colleagues in Stavanger, and research on
somatic dissociation has started.
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Trond Diseth, a child psychiatrist at the National Hospital
in Oslo (Rikshospitalet) has translated and introduced the
Adolescent Dissociative Experiences Scale (A-DES) developed
by Armstrong, Putnam, and Carlson in 1993 (Armstrong,
Putnam, & Carlson, 1997).
In Stavanger, we are now in contact with professionals
throughout Norway . Lars Weiseth and specialists from
Holland and the United States have held lectures here
(Richard Loewenstein, M .D., in 1995 ; Bessel van der Kolk.
M.D., and Glen Gabbard, M .D., in 1996 ) . The Stavanger
group has been actively lecturing in Norway on dissociative
disorders, self-mutilation and the use of the SC:ID-D . The
Psychiatric Educational Fund in Stavanger produced a book-
let on DID and dissociative disorders in 1993 that has sold
thousands of copies throughout Norway . They have also pro-
duced and distributed a video of an interview with Onno van
der Hart, Ph .D., on multiple personality disorder in 1993.
Interest in dissociative disorders is growing in Norway
and we are receiving more and more requests for informa-
tion from colleagues in other parts of the country . There is
still a saying among our more skeptical colleagues, howev-
er, that "the DID seems to be a strange US and Stavanger phe-
nomenon, because nobody else in the country seems to find
any of these patients ."In 1995, a group of skeptical colleagues
at our clinic invited Professor H . Merskey, a member of the
False Memory Syndrome Foundation advisory board, to give
a speech on "The production of Multiple Personality
Disorder" without managing to diminish the still growing
interest and engagement in the field of dissociation among
the local clinicians.
In Stavanger, a well-established research and study
group has been doing diagnostic and therapeutic work on
inpatients and outpatients with dissociative disorders .The fol-
lowing two cases will serve to illustrate some of this work.
CASE ONE
(CONTRIBUTED BY T .S. LANGFELDT, PSY .D.)
A year ago, I was asked to take over the therapy of a 48-
year-old woman, Mrs . A, who had the diagnosis of DID . She
had been hospitalized for eight years and was about to leave
the hospital to live in an apartment in a health service cen-
tre . She had initially been diagnosed as schizophrenic but
later was understood to have dissociative identity disorder.
Mrs . A had told the staff about hearing voices from the
first day of her hospitalization, but the voices had been inter-
preted as a psychotic symptom . When she told the staff that
she was going to be punished by one of the voices, they pro-
tected her . When she actually began to hurt herself, the staff
stopped her . It became very difficult to prevent self-inflict-
ed skin burns.
Mrs . A has a history of severe abuse from her mother
and sexual abuse from her father extending from her early
life through adolescence to adulthood . She escaped by mov-
ing to another country when she was 20 years old . She mar-
ried and had two children . Mrs . A was an only child and was
kept isolated from friends . She was constantly afraid and was
in constant pain due to the iron-burns and cigarette-burns
inflicted on her by her mother . She never took off her clothes
at school and nobody knew about her suffering . She cannot
remember any single moment of happiness with her moth-
er, but in spite of regular sexual abuse, she has some good
feelings for her father . She remembers her first dissociative
episode when she was seven years old . She felt that a girl some
years older took control of her body in situations of extreme
loneliness . New alters came along as she grew older, when
she was in situations that aroused extreme anxiety . She has
suffered from severe amnesia and still has hours and days
that just disappear . She believes that there are alters that she
does not know of, which take control from time to time . As
of today, 92 alters have been identified . Some have names,
others are named by their function ("the filter") or charac-
teristics (the Homosexual).
Mrs . A says that she shifts identities very fast in almost
any situation that is threatening or that provokes anxiety.
She is afraid of taking the bus from the hospital to her new
flat . She is afraid that the bus driver will take her away some
place and hurt her . One of her alters called Boris takes over
in this situation . He is an irritating, hostile, and strong per-
son . Mrs . A feels ashamed and embarrassed about him but
she manages to take the bus . There may also be situations
where there is a fight "inside of her " about what to do, say
or mean, and this fight makes her feel confused and very
depressed.
Building a Relationship
Mrs . A was very afraid of me in the beginning . Once, she
walked out of the office . She has asked me several times in
a serious/humorous way if I was sent by her mother to spy
on her, and has suggested that I had microphones in my
office . After we established some degree of relatedness she
gave me a set of drawings that was a representation of her
life story . We used some of the drawings as a starting point
in our relationship, thus finding a way of communication
that reflected the understanding she wanted to convey . Of
course, she tested me in the beginning of treatment . I tried
very hard to understand the total loneliness, pain, and grief
that she had suffered from her childhood through her adult
life, and as an adult, and how she had managed to survive.
Building a Relationship With Her Other Alters
Slowly, I came to meet the other alters . She told me that
some of them were noisy and laughing and that she would
be punished if she told me about the abuse and about her
alters . It was especially Boris who insisted that everybody is
a potential abuser, and that Mrs . A should never trust any-
one . Mrs . A had to listen to him as long as he was the one
who was the most helpful in everyday life and protected her
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WORKING WITH DID IN STAVANGER, NORWAY
from real danger . In addition, she was very disturbed by
thoughts that she was a nasty person who deserved all the
punishment she had endured as a child . It was Boris who
never had doubted her innocence ; he was therefore very
important to her . Boris was also very shy and afraid and
refused to talk directly to me . He agreed to talk to me through
Mrs . A . I told him about my respect for him, about never
doubting Mrs . A's innocence, and his lifelong struggle to keep
her away from potential danger . Mrs . A told me that he
accepted my view and that he would be present in the ther-
apy sessions without laughing or quarreling . Mrs. A also had
one female identity called Mona who was most often pre-
sent in daily life in the hospital . She was a likeable, obedi-
ent and nice woman . She was always present in dialogues
with the doctors and nurses when discussing medication.
Only in short periods had Mrs . A been herself, mostly with
her primary nurse, whom she had known for seven years.
She also trusted me enough to be herself in my presence.
She felt relaxed being herself and did not want to leave my
office . She wanted a part of her to stay there constantly and
she asked humorously if an alter could sit on a chair in my
office all week . We both knew that this was a cognitive way
of her making an emotional link to a place where she felt
well . She told me about a personality named Jens who was a
homosexual and who was in love with a male patient . She
often found herself outside his door, feeling foolish and
ashamed . She could feel an enormous struggle inside her-
self when this happened, and she could also imagine the
excitement Jens felt.
Discussing the Alters' Way of Helping Her in Daily Life
By describing the different alters and how they behaved,
we were able to start planning how they could help her in
given situations . Once, she wanted to visit her mother, whom
she had not seen for eight years and who was in an old peo-
ple 's home . She was really afraid of losing control, fearful
that her aggressive alter would do something violent . We dis-
cussed which and how many alters could help control and
support the aggressive alter so that he would not do anything
brutal . We also discussed the possibility of the aggressive alter
"staying at home," but she decided that she wanted all the
alters to come along . She made arrangements within her sys-
tem as to who would protect the aggressive alter . She visit-
ed her mother and no harm was done . Feeling so much
aggression was so frightening that Mrs . A felt she had to "keep
her feelings in separate boxes ." This prevented her from feel-
ing that she was a whole person and depressed her.
Dealing With Aggression
Mrs. A was becoming more and more worried by the
aggressive feelings . She had never been violent in any way,
but she often felt she might lose control and hurt somebody.
She had injured herself seriously some years before by burn-
ing and cutting herself, and had starved herself for days . She
became afraid of herself because she felt such a strong inner
pressure of anger .We discussed the many different ways of
expressing aggressive feelings in a positive way . She was very
good at drawing and she had written a lot of poems . We also
decided to try music therapy . She was very afraid of making
any form of noise because she had always been punished
when she made noise as a child . Mrs . A was willing to try play-
ing drums, and we started working on sounds as a way of
expressing emotions, including aggression . We are still not
sure if this is helping her . She remains very afraid, and she
often sees the piano which the music therapist is playing as
a whale with big teeth that can eat us all . The main thing is
that she manages to hold on to herself in these exciting ten
minute music sessions, together with two other people, an
accomplishment that makes her very proud . She continues
to be very afraid of her aggressive feelings, and she has late-
ly started to talk more specifically about feeling aggressive
when she was a child, and when she looked after her chil-
dren . She is afraid that she might have hurt her children in
some way when they were young.
Working With "Black Holes"
Mrs . A was suffering from severe amnesia . She lost a few
hours every day, and often whole days at a time . The nurses
said she would behave differently and often change the name
on the door of her room . She was behaving well and the nurs-
es could talk to her . Despite her concerns, she was never
aggressive . She always became frightened when she realized
that she had been "away ." She believed that there were one
or more other alters other than the 92 that she knew to be
present and this scared her . She was afraid that these alters
knew of more traumatic events than she was aware of, and
she believed that the reason they were unknown was that she
could not bear more pain by acquiring their knowledge . She
is now afraid that she has been aggressive to somebody . It
became clear that there was one alter (the Philosopher) with
very religious and philosophic interests who knew of these
other persons . She would not tell about them unless Mrs . A
was ready . The Philosopher started to write letters to me about
God and Creation and about the meaning of life and about
life and death.
As of today we do not know what the Philosopher knows.
But we believe we can use the Philosopher to lead us to the
unknown alters when time is right and Mrs . A feels safe
enough.
Using Hypnosis in Treatment
Mrs . A was very willing to try hypnosis in order to get
into contact with the alters she did not know . She entered
into a state of relaxation very easily . She also managed to
find a safe place to concentrate . The other alters also found
safe places . When all the alters were safe, it became possible
to get in contact with an alter who had travelled to another
city some weeks earlier . The alter could talk about the trip
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and why he did not want Mrs . A to know about it . After the
hypnosis, Mrs . A felt very strange and empty . She said that
she had been in the safe place all the time and did not know
anything about the alter that had been talking to me . As we
have only just begun with this promising method, we do not
know if it can be used to recall more of her traumatic expe-
riences . We are aware of concerns that have been raised about
the veracity of recalled material, but this is not a focus of this
report.
Nightmares and Dreams
Mrs . A had a lot of nightmares and dreams . In one repet-
itive dream she was standing with many adults in a circle
around her . The adults wore dark cloths . She was crying . She
needed some help to see if she was pregnant, but nobody
responded . She used to wake up feeling very lonely and afraid,
and could not go to sleep again . It was clear that none of the
other alters knew of this dream . We decided to look at the
dream again as if it were a movie . I asked her to see if all the
people were in dark clothes . She could see two women who
had dresses with flowers on . I asked her to focus on the women
and look for any signs of contact . Mrs . A then said that when
one of the women turned around, it was her school teach-
er . She then asked me if I thought that the school teacher
would have helped her if she had known about the abuse,
and I said that I thought she would have tried . The next week
she told me that she had had the same dream, but that the
school teacher this time had turned around and given her
a gift . The gift was a therapist . She did not have the dream
again . I think this dream was about hope . Today Mrs . A says
she knows more about being herself in relation to other peo-
ple . She trusts some people in the hospital . Her goal is to
remain herself in relationships to other people outside the
hospital and to get in contact with the alters she does not
know of . She is interested in the world outside and she wants
to know her son and daughter better . She is hoping for a
better life, but gets ironic about the matter of managing her
life better, and says it is a bit late to start living at the age
of forty-eight!
CASE TWO
(CONTRIBUTED BY I . HOVE, PSY .D.)
I work as a psychologist in an outpatient clinic for psy-
chiatric patients who abuse drugs (dual diagnosis patients).
This clinic is a part of Rogaland Psychiatric Hospital (RPS).
I started working with John in September of 1992 . He later
told me he had tried psychiatric treatment twice before, but
he was treated by male therapists . He was afraid of men and
had dropped out of treatment.
Background
When he was a week old, John was placed in an orphan-
age because his mother did not want him . He visited his moth-
er on weekends, but does not remember how often . He was
physically abused by her, and was abused both physically and
sexually by her different male partners and other visitors.
When he was nine years old he moved from the orphan-
age to live with his mother and a stepfather . This came as a
shock for which he was not prepared . He asked to move back
to his former home where he felt safe, but this was refused.
From then on he had nightmares . He started stealing,
smoking, and drinking . Later he started using illicit drugs.
The family moved a lot, and he attended five different
schools . John was a good pupil before moving back to his
mother, but after the move he started having behavior prob-
lems . He was sent to a special school and later to a treat-
ment-collective for young drug addicts . He was there twice,
the last time voluntarily . There he met a girl with whom he
lived for several years ; they had two daughters together . They
both used drugs most of this time . Shortly before he came
to treatment she had thrown him out . John had been vio-
lent towards her on several occasions, once seriously . He
was later convicted for this.
The Diagnostic Process
When we started treatment John admitted that he was
not in touch with his feelings and was often misunderstood
by others . He complained about loss of control over his
thoughts, and that he heard a voice in his head that told him
what to say and do . He had amnestic periods and he cut him-
self . He was violent without provocation and used ampheta-
mines to regain control . He had no recollection of his vio-
lent acts . He wanted to kill his mother, and he told me about
these wishes without visible feelings of guilt . He told me that
it felt as if another person controlled him when he was vio-
lent, and he had no way of stopping it . He also told me he
was lucky never to have killed anybody . He described how
he in a way left his body when he was abused, and we dis-
cussed the possibility that the same thing happened when
he was violent, since he had amnesia for the violent acts . He
had explained his forgetting of his violent acts as due to his
drug abuse, although he often had been totally sober when
the act actually happened.
Some months later, he admitted having "out of the body"
experiences every day . He often felt invaded by another per-
son and observed himself from the outside.
In March of 1993, he came to an appointment and told
me he was not John . He said he was "the other person ." He
heard more voices and they were aggressive . He was afraid
he would hurt somebody and felt out of control . He saw
images like a film before his eyes, in which he killed people.
I hospitalized him on a voluntary basis and gave him a diag-
nosis of dissociative disorder not otherwise specified
(DDNOS) . He stayed in the hospital for two weeks . After the
hospitalization period he was unstable in his contact with
me for several months . He used drugs heavily and I made
strenuous efforts to keep in touch with him .
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WORKING WITH DID IN STAVANGER, NORWAY
On December 24, 1993, he was hospitalized again . He
was confused but not psychotic . He said he had walked
around for a week without sleep, food or drugs . He did not
know where he had been or what had happened . He talked
about a servant who told him what to do . He said that he was
to be sacrificed on Christmas Eve, and was waiting for instruc-
tions . He was terrified . The diagnosis of multiple personal-
ity disorder (MPD) was made over the following three to four
weeks . It became clear that he had at least two alters.
Throughout this process John and I had discussed his
condition openly . I had told him that the symptoms could
be either psychotic or dissociative . From the start 1 actually
believed they were a dissociative phenomena, but I knew lit-
tle about these myself at that time . I explained to him some
of the dynamics of dissociation, and he confirmed that much
of this was familiar to him . He has seemed relieved by my
explanations and was really surprised that a diagnosis exist-
ed that included his symptoms . At the same time this also
frightened him . I could see how anxious he was when he
revealed his symptoms to me . I felt I was being tested a long
time before he was able to trust me . I have not promised him
that I will not make mistakes, but I have promised I will always
be able to tell him why I do what I do . I also have been very
conscious about being totally honest with him and never use
even the smallest white lie . 1 think he would detect such lies
before I had finished talking.
Early Stages in the Treatment Process
The diagnosis was confirmed during the first four weeks
of hospitalization . He had nightmares every night . These
nightmares appeared to be spontaneous abreactions which
were extremely frightening . He told me about the content
of some of them.
Over the next six weeks he self-mutilated frequently . He
needed to see blood . We regarded him as suicidal and the
people around him were afraid . Twice he cut himself so
deeply that he needed surgery to repair his wounds.
Our strategy has been consistent to make him respon-
sible for his own safety . John had to ask for help if he felt he
was losing control . He could have someone in his room or
outside of his room when he felt the need . He left the hos-
pital several times . We were concerned and afraid he would
kill himself, but we permitted him to go . Instead of battling
for control, I tried to negotiate and make agreements with
him about his safety when he wanted to leave . We worked
with control, and I tried to make alliances with the angry
alters . At this time 1 did not know how many alters I was relat-
ing to . We also talked about my safety, and he took the respon-
sibility for addressing this . I suggested several different means
of increasing safety, such as having an extra person present
in our sessions . I let him decide whether that was necessary.
He thought it over and found out that his dangerous alters
were not dangerous to inc.
The period of self-mutilation culminated in a very dra-
matic episode in which he came to my office drunk after hav-
ing cut his arm . He brought the knife with him, and sever-
al different alters came forward and were angry . After an
intense internal struggle he stabbed the knife in my table.
He did not threaten me in this episode, but I was frightened
he would hurt me or himself . The next day he had total amne-
sia for what had happened . I asked for an alter who could
give me information . The next session I met the one I had
asked for . He told me he was "the boss," and he revealed to
me a system of eight alters . I introduced a communicative
system of finger signals for communicating with alters and
made a contract with the system against violence toward him-
self or others . This contract was renewed in every session for
the next seven weeks . Usually there was no negotiation about
this ; he told me that the alters often discussed this arrange-
ment before the sessions . When he revealed the system, the
nightmares stopped for a while.
We had sessions twice a week ; during this period they
lasted up to two hours . In the sessions that followed the Boss
telling me about the system, I realized that he had also
informed the other alters about the system and amnestic gaps
were filled.
The Alters
The Angel, created between two and three years of age,
was abused until the body was seven years old . The Quiet
One (age seven) took over this role after age seven . Together
with the Support (age nine) they help the Boss (age 13) to
keep order . The Boss is literally the boss - he is the strongest
alter . He gave me and the other alters the information about
the system . The Innocent (age nine) and the Support (age
nine) have been present much of the time . They are both
socialized and easy to relate to . The Innocent belongs to the
"angry" side and helps the others to be aggressive when nec-
essary . The Wild One (age 11) is a protector of the body,
and he can be dangerous to others . He reacts to real threats
from outside and to flashbacks, which often resulting in
unprovoked violence . The Hotheaded One (age 12) is a per-
secutor . He is responsible for the self-mutilation and has a
need to see blood . He can also be dangerous to others . Satan
(age 12) is the leader of the aggressive alters . He is the most
powerful of these, but has a hard time controlling the
Hotheaded and the Wild Ones . Usually he lets the others
come forward to do what he wants them to do, but some-
times he has to do "the jobs " himself . Satan competes with
the Boss for control . John (age 31) is the host person . In the
beginning he knew nothing about the others.
John and the aggressive alters are drug addicts, while
the others are not . The Innocent likes alcohol, and prefers
sweet liquors . The Wild One uses alcohol and amphetamines.
The Hotheaded One uses cannabis, heroin, and benzodi-
azepines . Satan uses everything available, including LSD . John
prefers amphetamines.
During three sessions, I met the Innocent . This was
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allowed due to a compromise between the Boss and Satan.
They both listened to what happened in the sessions and
informed the other alters about what they found appropri-
ate . I always had in mind that the other alters may hear what
I said to whichever alter was out, and I was careful to talk in
positive ways about all the alters, including the aggressive one,
claiming that every one had had an important role in the
survival of trauma, and that every one will also be important
in the future . I explained to him that the alters together have
the qualities he normally would have developed in one per-
son, if he had not experienced all the tremendous trauma
that caused his dissociation.
I told John I would like to meet the alters directly . In
response to this, I met all the other alters except the Angel
during the following sessions, a new one in every session . We
started with the angry ones, and Satan decided the succes-
sion : the Wild One, the Hotheaded One, and Satan . They
were all suspicious, angry, and frightened and accused me
of creating chaos in the system . I negotiated hard with every
alter and managed to make a contract about cooperation
with the rest of the system . Satan told me he was very angry
with me, but he had accepted an agreement not to hurt me.
In the next sessions I met the Quiet One, the Support
and at last the Boss again . The same arrangements were made
with them . The Boss decided I did not need to talk directly
to the Angel, and we agreed he would inform the Angel about
what was going on.
I suggested the Boss and Satan could try to cooperate
instead of fight each other . I advised that they could try to
use their strength together to protect the other alters and
the body, and create a leader team . The following days they
tried to do so, and the system had several positive experi-
ences of this kind . This was not easy for them ; they were sus-
picious of each other and often managed to cooperate only
for short periods of time.
The Following Years
Later another system of five alters appeared . These knew
nothing about the others . In addition to these, another two
were revealed later, one at a time . One of these is female.
Most of the time since September, 1992, we have usually
worked intensively twice aweek, but have met less frequently
in some periods . At times, John is tired of therapy and wants
to escape from it . He has been hospitalized a number of times
in the last years, but these are shorter admissions, at times
when the anxiety is too unbearable and the alters are afraid
and aggressive . Our relationship is very strong and I regard
this alliance as an extremely important factor in the thera-
peutic process . John is also very dependent on me, and my
summer vacation is a problem every year . He also has had
problems in the course of shorter absences . Contrary to my
usual practice, I have sent him postcards, which he has appre-
ciated . During the last three years I also have taught him a
hypnotic technique he can use during my absences . John
has described safe places where he liked to stay when he was
small, and we have "placed" the small alters in safe places
and told them not to have the experience of time passing.
In addition to his safe places, I have described different fan-
tasy pictures of pleasant surroundings which he can use . This
has been useful to him . He has had the experience of the
small alters remaining safe and untroubled by my absence.
We also have worked out an organization of his alters,
in which all four alters have executive responsibility in addi-
tion to John . They have an internal arrangement of respon-
sibility and power, and they relieve each other in order to
make sure every one of them has enough control, but also
has the opportunity to rest . These leaders are responsible
for the comfort of the other alters . This cooperation model
works well most of the time . However, when John is exposed
to external stress which especially triggers flashbacks of early
trauma, the system is not strong enough.
John has refused to work towards integration . He does
not believe that is possible and does not want to work direct-
ly with his traumatic experiences . He wants to forget the trau-
ma, but he knows this is impossible . In difficult periods he
has terrible nightmares or no sleep at all, and he wanders
around outside or listens to music in order not to hear all
the voices in his head.
During the therapeutic process he obviously has disso-
ciated a lot . He often reveals that he does not remember his
sessions . For a long period of time I recorded the sessions,
and he kept the tapes so that he could listen to what we had
talked about afterwards, and he found this helpful.
I have also recorded three different tapes with hypnot-
ic suggestions about relaxation and fantasies about a pleas-
ant and safe place, which he can use whenever he likes . The
tapes have been very useful for him . He listens to the tapes
every night during difficult periods, and tells me that this
calms him down.
The contracts about violence against himself or others
have been repeated through the whole therapeutic process,
but are made for longer and longer intervals . He has not
self-mutilated since we made that agreement, and he has
admitted that this contract has prevented him from using
violence both against himself and others in stressful cir-
cumstances.
On one occasion I was afraid of him . Early in the treat-
ment process I came back from vacation and met a little
(probably psychotic) two- to three-year-old alter which I had
never met before . The alter was terrified and aggressive . He
did not know me and had not been forward since the body
was at that age . I interpreted this among other things as a
punishment against me for having been away . I completed
this session with two male nurses present . The next time I
talked to John, I was really angry with him for having risked
destroying our relationship . He admitted the system knew
what happened, apologized, and promised never to behave
like this again . He never has .
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DISSOCIATION, Vol . X, No. 3. September 1997
WORKING WITH DID IN STAVANGER, NORWAY
During these years John has been hospitalized several
times on a general psychiatric ward . He also has spent near-
ly a year in a special section of our hospital where drug addicts
with psychiatric problems are treated, and was in the reha-
bilitation department for a few months . I have been his ther-
apist throughout all these stays in hospital, and I visit him
wherever he is, in addition to his coming to my office . In the
past year, he has lived alone in an apartment outside town.
He is socially totally isolated, but he is not using drugs . He
manages the apartment quite well, although this varies with
his condition . He eats when he is hungry, about once a day,
but he has learned to make sure he always has food avail-
able .
He is visited by a psychiatric nurse once every two weeks.
This contact is also very important . I feel a need to include
more persons in his life in order to make him less depen-
dent on me . He has no contact with his own family . His bio-
logical father died many years ago, and his mother died
recently . He had not talked to her for a couple of years prior
to her death, and did not want to attend the funeral . He has
no contact with his daughters now . They live in another town.
He has tried to establish contact with them in the course of
treatment, but he has problems with keeping telephone
appointments . He has realized that he must concentrate on
himself.
He manages his own finances . Sometimes he has spent
money without remembering how, or he has lost money on
the way home, or has taken a taxi and not remembered after-
wards . This happens less frequently now, and I think he uses
a lot of energy in order to manage keeping order . He has
a stable income from disability benefits.
My wish for him is that he could live in a house togeth-
er with two or three other psychiatric patients, where each
of them has their own part of the house, in addition to a liv-
ing room and kitchen where they can be together . John needs
contact with other people, but most of the time he is not
able to approach others . Ideally, social contact should be eas-
ily available for him . He can not live together with other
patients with a drug problem . This would be too risky.
In such a house psychiatric staff would be needed to look
after the patients every day or every other day depending on
their condition.
It would also be helpful if John had an opportunity to
work on the days he feels able to do so.
The therapy will continue, with different content and
goals depending on his condition and wishes . He is not ready
to finish the therapy, but I doubt we will get much further
as long as he refuses to work toward integration . Stabilization
and higher quality of life have been the key words in our
work the last year of treatment .
CONCLUDING REMARKS
To work with dissociative identity disorder patients is a
challenge in many ways . First it is important to know the symp-
toms in order to make the correct diagnosis.
Building a therapeutic alliance is also crucial for these
patients (Kluft, 1996) . As they have a history of betrayal and
abuse, absolute honesty and reliability from the therapist is
essential . As long as the basic relationship is established, one
can use fantasy techniques and try different interventions.
One of the first important tasks is to create structure and
control where this is needed.
It is important to avoid a struggle over power . The patient
will always win this kind of struggle, which may accelerate
self-mutilation . The patient should have as much power and
responsibility for him or herself as possible . These patients
are survivors, and it is important not to be overwhelmed by
their helplessness and regression . Staff members can easily
find themselves doing things for these patients which they
find hard to admit afterwards . Another pitfall is to be so fas-
cinated by the exotic symptoms that the investigation of the
symptoms becomes the dominant goal, instead of focusing
on therapy . This kind of approach may lead to even more
fragmentation.
Our experience with communicating directly with the
alters is positive . It is also important to remember when talk-
ing to the patient that all the alters may be listening to what
the therapist says . In building relations with the patient and
the alters it can be wise to talk in positive ways to the patient
about all the alters, including the persecutors, and show an
understanding of their roles and functions in the survival of
trauma . a73
REFERENCES
Armstrong, J .G., Putnam, F.W., & Carlson, E.P. (1997) . Development
and validation of a measure of adolescent dissociation : The
Adolescent Dissociative Experinces Scale . Journal of Nervous and
Mental Disease, 185(8), 491-497.
Bernstein, E .M., & Putnam, F .W. (1986) . Development, reliability
and validity of a dissociation scale . journal of Nervous and Mental
Disease, 174, 727-735.
Boe, T., Knudsen, H., & Haslerud, J. (1993). Multippel personlighet,
et fcnomen ogsa i Norge? (Multiple personality - also a Norwegian
phenomenon?) Tidskr Nor Laegeforen, 113,3230-3232.
Eitinger, L . (1964) . Concentration camp survivors Norway and Israel.
Oslo : University Press.
Goetestam, K.G. (1993) . Er multippel personlighet en psykiatrisk
lidelse? (Is multiple personality a psychiatric disorder?) Tidskr Nor
Laegeforen, 113,3224.
Kluft, R.P. (1996) . Treating the traumatic memories of patients with
dissociative identity disorder . American Journal of Psychiatry, 1996
(Festscript Supplement), 153(7), 103-110.
172
 
DISSOCIATION, Vol, X, I\ o
HOVE/LANGFELDT/BOE/HASLERUD/STOERSETH
Knudsen, H ., Draijer, N ., Haslerud,_J ., Boe,T., & Boon, S . (1995).
Prevalence of dissociative disorders in a Norwegian general psy-
chiatric department . In O. van der Hart, S. Boon, & N. Draijer (Eds.),
Proceedings of the Fifth Annual Spring Meeting of the International Society
for the Study of Dissociation (79)Amsterdam : International Society
of the Study of Dissociation.
Nijenhuis, E . (1997) . The development of the somatoform disso-
ciation questionnaire (SDQ-5) as a screening instrument for dis-
sociative disorders . Acta Psychiatrica Scandinavica, 96,311-318.
Steinberg, M ., Rounsaville, B ., & C icchetti, D.V. (1990) . The struc-
tured clinical interview for DSM-III-R dissociative disorders:
Preliminary report on a new diagnostic instrument . American
journal of Psychiatry, 147, 76-82.
Van der Hart,O. (1993) . Multiple Personality Disorder . Video inter-
view with Onno van der Hart, Ph .D. by Psychiatric Educational Fund,
Stavanger.
Vanderlinden, J ., Van Dyck, R., Vandereycken, W., Vertommen, H .,
& Verkes, J .R . (1993) . The Dissociation Questionnaire:
Development and characteristics of a new self-reporting question-
naire . Clinical Psychology & Psychotherapy, .
173
DISSOCIATION, Vol. September 1997