The Tactical-Integration Model for the Treatment of Dissociative Identity Disorder and Allied Dissociative Disorders

Article excerpt

The ebb and flow of the diagnosis of Dissociative Identity Disorder (DID) and other dissociative conditions has led to the evolution of theories and treatment modalities to resolve the fluctuating and ephemerous symptoms of these conditions. This paper summarizes the structured cognitive-behavioralbased treatment of dissociative disorders that will foster not only symptom relief but also an integration of the personalities and/or ego states into one mainstream of consciousness. This model of DID therapy is called the tactical integration model; it promotes proficiency over posttraumatic and dissociative symptoms, is collaborative and exploratory, and conveys a consistent message of empowerment to the patient.

The diagnosis of Dissociative Identity Disorder (DID), a chronic, complex dissociative psychopathology accompanied by disturbances of identity and memory (1,2), is increasingly acknowledged according to a current survey by Rossel (3). Nonetheless, it remains a controversial diagnosis in the field of psychology. The diagnostic dispute over this trauma-based disorder (4) is neither new, nor readily settled. The phasic nature of the emergence of the diagnosis of DID in the medicopsychological literature spans centuries (5,6). The diagnostic interest of medical professionals and its ebb and flow is as much a function of the rise of new theories and conceptualizations in psychology (magnetic somnambulism, hypnosis, mental disaggregation) as it is a reflection of the sociopolitical climate of the time (feminist movement, Vietnam War, False Memory Syndrome). Each contextualized reemergence of this dissociative diagnosis brings with it a more complete understanding and perhaps a novel perspective on a disorder where the afflicted patients struggle with multiple-reality disorder (7,8) and live under the influence of various self-generated hypnotic realities. It is within these mutable realities that DID patients attempt to problem solve and function.

This malleable psychological background underscores the need for cautious and planful interventions (9,10). A successful therapy will, by intent, bring to the forefront what is hidden, be it conceptualized in terms of personalities, conflicts or alternate realities. DID patients' overwhelming life experiences then need to be metabolized and reabsorbed and reprocessed by them through contextualized abreaction and subsequently processed into their main stream of awareness (10-14). For the DID patient to emerge with a sense of completeness and wholeness requires cautious disequilibrating and frequent restabilizing of the system of mind with sequential and overlapping revisiting of both traumatic and nontraumatic material.

A few models of DID therapy have emerged as facilitating this meticulous process of integration. These are the tactical-integration model (10,13,14), the strategic integration model (15), and a personality-based ego-state model (16). The first two models are geared to promoting the complete integration of the individual as a whole, the latter aims for a functional and satisfactory cohabitation of the various personalities and/or ego states. It is important to recognize that when working with DID, two things stand out with respect to the organizing treatment models: 1. even though the therapist's preferred model of treatment is relevant, particularly to the therapist, the disorder itself will impose the therapeutic interventions (17,18); and 2. the therapists need to be fluent in the traditional psychodynamic and cognitive perspectives (12) aided by a clear understanding of hypnosis and the rules governing trance states to best help this patient population negotiate their own stability@ Attention to the structure and assumptions (10,12) that underlie the tactical-integration model are further elaborated in the following section.

The foundational blueprint from which the tactical-integration model emerges is a modified cognitive-therapy module (10-12,14) where the more structured and purposive the therapy work is, the better it promotes a sense of safety, predictability, and consistency for the patient. …