3. Establishing communication and understanding between the dissociated self-states as the Therapeutic goal
There are many discussions as regard to the purpose of the treatment of
dissociative disorders. In days when dissociative disorder began gathering
attention from clinicians in 1970s ~ 80s, getting parts of personality together
to achieve a whole personality tended to be considered as a goal for the
treatment of those with DID. Richard Kluft asserted that to establish“integration”and“fusion”is the final goal of the treatment. He states as follows.
It usually becomes essential to replace dividedness with unity, at least for
the purpose and motivation, for any treatment to succeed. Work toward this goal
and possible integration of all personalities distinguishes the treatment of
MPD (1984, p.11)
In his study Kluft reported that among
171 DID patients during his study, 83 of them reached fusion (Kluft, 1984). Following
his clinical report and suggestions, many analysts consider that the integration
of personalities as the long-term outcome of DID. However, fusion or
integration were not altogether promoted blindly. Although it is supposed to be
the goal, Kluft himself admonished the “premature overemphasis on pursuit of fusion”which can cause its failure.(p.11). Van der Hart (2006) noted
that “there is the persistent myth that merely integrating experiences is
sufficient for overcoming traumatization” (Howell,182~183), implying that there is more than just integration.
The idea that fusion and integration as a goal can relatively
smoothly merge with traditional analytic thinking. Although psychoanalysis
“analyzes” human mind, Freud acknowledged that the integration that he calls “psycho-synthesis”
is thus achieved in analytic treatment as the final result.
As we analyze...the great unity which
we call his ego fits into itself all the instinctual impulses which before had
been split off and held apart from it. The psycho-synthesis is thus achieved in
analytic treatment without our intervention, automatically and inevitably. (Freud,
1918, 161).
However, recently more diverse ideas
have been proposed in the analytic community. Itzkowitz indicated as follows:
The goal of the working
through process is not necessarily the consolidation of self-states into a
single, integrated individual … [But to help] the person understand and
negotiate meaningful forms of relatedness with these heretofore unknown parts
of herself.（p.152）”.
He thus indicates that both integration and relatedness
among parts can be a therapeutic goal. In the guideline for the treatment of
DID issued by the International Society for the Study of Trauma and
Dissociation (ISSTD) has a much less stress on the fusion/integration as a
treatment goal:
A desirable treatment
outcome is a workable form of integration or harmony among alternate
identities. (ISSTD, 2011, p.133).
Thus, although the term integration
is still used as a treatment outcome, its nuance is changed and is now paraphrased
as a harmony among identities. The term integration itself gained its duality
and ambiguousness.
International Society for the Study of Trauma and Dissociation (2011) Guidelines
for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal
of Trauma & Dissociation, 12:115–187.
Kluft, R (1984) Treatment of Multiple Personality Disorder. A Study of 33
Cases. Psychiatric Clinic of North America p.9~30.
The current therapeutic
approach for the dissociative disorder tends not to discuss whether integration
is the goal or not, but to take a phase-oriented approach where the therapist responds
to the patient's condition in a contextual way. They are often described as
follows (Howell, 2011, p.168).
・Establishing safety
・ remembrance and mourning
・reconnection with ordinary
life
It is noteworthy that there is no particular remarks
about fusion or integration. Howell discusses coconsciousness and co-participation
where she stresses the importance of dissociative parts cooperating and helping
each other to run their life in a peaceful way. She states that the purpose of
the treatment is that “more information essential to healing and enhanced
functioning is shared among dissociative parts” so that “dissociative barriers
are lessened.” Howell states that integration is a “one-person concept” (p.143).”
She promotes the notion of contextual interdependence which avoids the problem
in the often implied opposition between dissociation versus unity.”
Modern analyst Bromberg speaks in a very
similar tone. He promotes respect for the uniqueness of each
personality and the attitude of “finding and directly engaging the patient's
dissociated voices as discontinuous but individually authentic expressions of
selfhood” instead of resorting to the promotion of premature integration
(Bromberg, 1998, p.199).
To summarize, what Itzkowitz stated as
a goal for the treatment suggests us as a “turn” to an even handed approach beyond
“opposition between
dissociation versus unity” (Howell, as above). Again it is not “either or” but
somewhere between, or both, depending on the clinical context.
