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Journal of Trauma & Dissociation Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjtd20

Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative? a

Bethany Brand PhD & Richard J. Loewenstein MD

b c

a

Psychology Department , Towson University , Towson , Maryland , USA b

Trauma Disorders Program, Sheppard Pratt Health System , Baltimore , Maryland , USA c

Department of Psychiatry , University of Maryland School of Medicine , Baltimore , Maryland , USA Accepted author version posted online: 07 Aug 2013.Published online: 30 Dec 2013.

To cite this article: Bethany Brand PhD & Richard J. Loewenstein MD (2014) Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative?, Journal of Trauma & Dissociation, 15:1, 52-65, DOI: 10.1080/15299732.2013.828150 To link to this article: http://dx.doi.org/10.1080/15299732.2013.828150

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Journal of Trauma & Dissociation, 15:52–65, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2013.828150

Does Phasic Trauma Treatment Make Patients With Dissociative Identity Disorder Treatment More Dissociative? BETHANY BRAND, PhD Downloaded by [Laurentian University] at 09:06 05 October 2014

Psychology Department, Towson University, Towson, Maryland, USA

RICHARD J. LOEWENSTEIN, MD Trauma Disorders Program, Sheppard Pratt Health System, Baltimore, Maryland, USA; and Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA

Proponents of the iatrogenic model of the etiology of dissociative identity disorder (DID) have expressed concern that treatment focused on direct engagement and interaction with dissociated self-states harms DID patients. However, empirical data have shown that this type of DID treatment is beneficial. Analyzing data from the prospective Treatment of Patients With Dissociative Disorders (TOP DD) Study, we test empirically whether DID treatment is associated with clinically adverse manifestations of dissociated self-states: acting so differently that one feels like different people, hearing voices, and dissociative amnesia. We show that, over the course of the study, there were significant decreases in feeling like different people and hearing voices. These results indicate that this form of DID treatment does not lead to symptomatic worsening in these dimensions, as predicted by the iatrogenic model. Indeed, treatment provided by TOP DD therapists reduced, rather than increased, the extent to which patients experienced manifestations of pathological dissociation. Because severe symptomatology and impairment are associated with DID, iatrogenic harm may come from depriving DID patients of treatment that targets DID symptomatology.

Received 8 March 2013; accepted 5 July 2013. Address correspondence to Bethany Brand, PhD, Psychology Department, Towson University, 8000 York Road, Towson, MD 21252. E-mail: [email protected] 52

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KEYWORDS dissociative identity disorder, treatment, sociocognitive, iatrogenic, dissociation There is evidence that psychological treatments can sometimes make patients worse. This observation has led to increased attention to the assessment of potential harm in therapy (Dimidjian & Hollon, 2010; Lilienfeld, 2007; Shimokawa, Laber, & Smart, 2010). Few studies report worsening of symptoms during treatment, and those that do have reported rates of worsening in adults between 5% and 10% (Hansen, Lambert, & Forman, 2002). For example, despite exposure therapy being considered an empirically supported treatment for posttraumatic stress disorder (PTSD; Foa, 2009), in a randomized controlled trial D’Andrea and Pole (2012) found that exposure therapy worsened dissociation among complex trauma survivors, despite some improvements in symptoms of PTSD and depression. Other studies have shown that individuals with complex trauma, high levels of comorbid symptoms, and dissociation require specialized trauma/dissociation-focused treatment to demonstrate reductions in dissociation and other trauma-related difficulties (e.g., Lynch, Forman, Mendelsohn, & Herman, 2008). Some authors claim that dissociative identity disorder (DID) treatment1 is harmful or ineffective at reducing dissociation.2 According to this point of view, referred to in this report as the iatrogenic model (IM) of DID— also known as the fantasy model or sociocognitive model of DID—DID treatment increases the number of dissociated self-states (also known as alters, personalities, parts, and identities, among others), leading to progressive deterioration in the patient that can only be redressed by treatment that attempts to ignore and/or suppress the manifestation of DID self-states (Gee, Allen, & Powell, 2003; Lilienfeld, 2007; Lilienfeld & Lambert, 2007; Lynn, Lilienfeld, Merckelbach, Giesbrecht, & van der Kloet, 2012; McHugh, 1992, 2008; Powell & Gee, 1999). Gee et al. (2003) stated that the most direct way to examine the iatrogenic effects of DID treatment is to measure alternate identity symptoms over treatment time. They speculated that “there will be an increase in symptoms during therapy that coincides with the increased exposure to various forms of social influence concerning DID” (p. 114). These authors posited that what they referred to as “identity enactments” will increase during DID treatment, with deleterious results for the patient. The IM posits that DID is not an authentic psychiatric disorder, nor does it have a salient relationship to antecedent trauma. Rather, it is a condition that only exists because of the influence of naïve therapists on highly “suggestible” patients, in a cultural context that promotes belief in trauma and “identity enactments” (Lilienfeld et al., 1999; Spanos, 1996). According to the IM, this results in a proliferation of “believed in” self-states, factitious identity enactments, and confabulated trauma memories. The goal of this report is to test these hypotheses using data from a longitudinal, prospective study of DID treatment.

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According to the IM, the only logical treatment of DID consists of behavioral interventions to ignore and/or suppress manifestations of DID self-states and to discount and/or disregard reported trauma memories (McHugh, 1992, 2008). However, despite the assertions of IM proponents, no systematic evidence in any clinical or research population has demonstrated iatrogenesis as a causal factor in the development of DID or the efficacy (or potential harmfulness) of treatment based on the IM model. On the contrary, a recent comprehensive review comparing the trauma model of dissociation to the iatrogenic/sociocognitive/fantasy model of dissociation, including multiple meta-analyses, found overwhelming support for the role of antecedent trauma in causing dissociation (Dalenberg et al., 2012). However, Dalenberg et al. (2012) did not systematically review treatment outcome data for either the IM or the trauma model for DID or for dissociative disorder not otherwise specified (DDNOS).3 In the present study, outcome data were combined for patients with DID and DDNOS, termed DID patients (American Psychiatric Association, 2000; International Society for the Study of Trauma and Dissociation [ISSTD], 2011). According to expert consensus, effective DID treatment involves a multimodal, phasic, trauma-focused psychotherapy that specifically attends to dissociation, including direct interaction with patients’ self-states (ISSTD, 2011). Both a worldwide survey of DID experts and the ISSTD treatment guidelines have identified interventions recommended as effective at each stage of DID treatment (Brand, Myrick, et al., 2012). Both advocate direct engagement in treatment with DID self-states as essential to definitive, successful treatment of DID. According to a review of published cases and prospective, uncontrolled treatment studies, DID treatment is associated with decreased dissociation, PTSD, depression, anxiety, distress, suicidality, self-destructiveness, and Axis I and II disorders (Brand, Classen, McNary, & Zaveri, 2009). Furthermore, DID treatment is associated with robust decreases in costs to the mental health system over years of follow-up once DID treatment is initiated, even among highly impaired individuals (Fraser & Raine, 1992; Loewenstein, 1994; Ross & Dua, 1993). Brand, Classen, McNary, et al. (2009) were unable to find a single study that provided systematic evidence that DID patients were harmed by DID treatment that focused on direct engagement with self-states. The largest treatment study of DID and DDNOS patients is the Treatment of Patients With Dissociative Disorders (TOP DD) Study. TOP DD is an uncontrolled, prospective, naturalistic study that analyzed treatment outcomes of 280 DID/DDNOS patients at four time points over 30 months of treatment while patients were being treated by therapists from 19 countries, including countries in North America, Europe, South America, and Asia. Most (87%) of the therapists reported having specialized training in treating dissociative disorders, and more than a quarter (26.8%) had

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completed one of the ISSTD’s specialized dissociative disorders therapy training programs (Brand, Classen, Lanius, et al., 2009). Furthermore, the vast majority of therapists (94%) reported using interventions that specifically addressed dissociation, including directly identifying and working with self-states. Finally, 95% of therapists viewed these interventions as essential to improving internal communication and cooperation among self-states and thus allowing for more integrated and adaptive functioning by the patient (Brand & Stadnik, 2013). In the TOP DD Study, the cross-sectional results (Brand, Classen, Lanius, et al., 2009) as well as the 30-month longitudinal results (Brand, McNary, et al., 2013) showed that DID patients benefited from treatment. Specifically, the longitudinal study found that treatment was associated with significantly decreased dissociation, PTSD, depression, general distress, suicide attempts, self-harm, drug use, physical pain, dangerous behaviors, and hospitalizations, as well as significantly improved functioning as documented by both clinician and patient reports (Brand, McNary, et al., 2012). Even patients with the highest levels of dissociation and depression showed decreases in these symptoms (Brand & Stadnik, 2013; Engelberg & Brand, 2012). More DID patients showed sudden improvement compared to sudden worsening (defined by a 20% increase or decrease in symptoms) at one or more time point(s) (Myrick, Brand, & Putnam, 2013). Patients who suddenly improved had significantly fewer stressors and episodes of revictimization than did those who worsened, indicating that revictimization and/or life stressors, rather than DID treatment itself, were likely to have been factors that contributed to worsening. Sustained worsening over treatment time occurred in only a very small minority (1.1%) of the TOP DD patients. This rate of worsening is similar to or better than rates found in studies of other disorders (Hansen et al., 2002). In this report we examine three outcome variables that, over time in DID treatment, could detect whether DID patients deteriorate during treatment by manifesting more pathological DID symptoms. We hypothesize that patients in DID treatment will report reduced symptoms of pathological dissociation as evidenced by decreases in acting so differently they feel as if they are different people (identity alteration), hearing voices, and dissociative amnesia.

METHOD This brief report relies on unpublished data from the larger TOP DD Study, in which community therapists and their patients were recruited as the participants. The methodology of this study is reviewed in detail in Brand, Classen, Lanius, et al. (2009).

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Participants At intake into the study, participants consisted of 298 therapists and 237 patients, although the number of therapists and patients participating varied over time at each data point. Therapists were recruited from the member register of the ISSTD, from among graduates of the ISSTD’s Dissociative Disorders Psychotherapist Training Program, from mental health professional listservs, at conferences, and by word of mouth. E-mail invitations described the research as a treatment outcome study of DID and DDNOS in which clinicians were invited to ask one DID or DDNOS patient to participate. Exclusion criteria for patients were being younger than 18 and being unable to read English. Therapists completed password-protected, Web-based surveys. Measures for patients were mailed via post to therapists, who distributed the packets of measures to their patients to be completed outside of session time. Patients mailed the packets directly to the researchers. Patient and therapist surveys were matched into pairs by identification codes. The study received institutional review board approval; therapists and patients provided informed consent prior to their participation at each wave of data collection, which occurred at intake into the study and at 6-, 18-, and 30-month follow-up periods. Patient sample sizes at each wave were as follows: Time 1, n = 226; Time 2, n = 171 (76%); Time 3, n = 131 (58%); and Time 4, n = 111 (49%). For more information about reasons for dropping out, see Brand, McNary, et al. (2013).

Measures Dissociative Experiences Scale (DES). The DES (Bernstein & Putnam, 1986) is a 28-item self-report measure in which subjects rate the frequency of dissociative experiences on a scale of 0% to 100% of the time. Cronbach’s alphas for the DES calculated at each follow-up for the current study varied between .95 and .96. The Amnesia scale is a measure of memory loss associated with pathological dissociation and includes DES Items 3, 4, 5, 6, 8, 10, 25, and 26 (Carlson & Putnam, 1993). In addition to the amnesia scores, DES Item 22 was used to assess the percentage of time individuals acted so differently that they felt like different people. Symptom Checklist 90–Revised (SCL-90-R). The 90 items of the SCL-90-R (Derogatis, 1994) measure distress associated with a variety of psychiatric symptoms scaled from 0 (not at all) to 4 (extremely) distressing. Across the four data waves, Cronbach’s alpha coefficients in the current study ranged from .96 to .98 for the Global Severity Index, a summary index for the SCL90-R. The SCL-90-R item about hearing voices was used in this study. Global Assessment of Functioning (GAF). This scale (0–100) is used by clinicians to rate the functioning of adults (American Psychiatric Association, 2000).

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RESULTS Analyses of variance were used to compare means over time. Descriptive statistics can be found in Table 1. The patients reported a significant decrease in the frequency of acting so differently in various situations that they felt “almost as if they were two different people” over time (i.e., identity alteration), F(3, 647) = 6.21, p < .001 (see Figure 1). The patients reported hearing the voices of their dissociated self-states less frequently over the course of treatment, F(3, 649) = 3.40, p = .02 (see Figure 2). The mean amnesia scores did not decrease significantly over time, yet there was no increase in dissociative amnesia during the study; in fact, the means were lower at each stage of treatment, albeit not at a statistically significant level (see Figure 1). The patients became more functional over the course of treatment, as reported by the therapists using the GAF (American Psychiatric Association, 2000), F(3, 776) = 6.24, p < .001 (see Figure 3).

DISCUSSION IM proponents concerned about the harmfulness of DID treatment opine that what they call “identity enactments” increase during DID treatment, indicating to them that substantial clinical worsening is occurring. Contrary to these concerns, this study found that subjective self-division decreased over time in DID treatment. TOP DD patients showed a significant decline in feeling that they act so differently that they experience themselves as almost two different people They showed a significant decrease in hearing the voices of dissociated self-states. Although the mean ratings for dissociative amnesia were lower at each follow-up, these changes were not statistically significant. However, dissociative amnesia certainly did not increase with DID treatment, as predicted by Gee et al. (2003), who argued that amnesia is “the easiest symptom to ‘discover’ by suggestion” (p. 115), that is, that amnesia reports should increase because of iatrogenic influence. Furthermore, the patients became more functional over time in treatment, as assessed by therapist reports of GAF scores. This is consistent with the longitudinal regression data presented in Brand, McNary, et al. (2013), shown here in Figure 1, showing improvement in functioning over time in DID treatment. DID patients may have a variety of deficits due to dissociation, including lack of recall of behavior in different self-states. In DID treatment, therapists help DID patients develop more continuous memory across dissociative barriers and control over state shifts by encouraging more communication, collaboration, and cooperation among self-states. This results in better management of behavior across all self-states, with an increased sense of control over switching and/or shifting of dissociative states, and a gradual development of an increasingly integrated sense of self. This is accompanied

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30.68 1.89 20.53 56.26

M 20.63 1.61 20.66 31.99

SD 277 223 223 222

Valid N

Notes: GAF = Global Assessment of Functioning.

GAF Hearing voices Amnesia Identity alteration

Variable

1

32.42 1.63 18.22 48.98

M 21.56 1.57 19.51 34.46

SD

2

184 167 167 167

Valid N M 35.52 1.49 17.00 43.56

Time

22.82 1.51 19.93 34.20

SD

3

174 133 135 132

Valid N

M 39.79 1.39 16.34 42.85

TABLE 1 Descriptive Statistics for GAF, Hearing Voices, and Acting Like Different People Over Four Time Periods

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22.12 1.51 17.49 32.48

SD

4

145 130 131 130

Valid N

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FIGURE 1 Mean amnesia and identity alteration scores over four assessments in Treatment of Patients With Dissociative Disorders Study participants (color figure available online).

by improvement in continuity of memory for life history and contemporary experience. As these analyses show, in DID treatment, DID patients gradually experienced less division into self-states and were less frequently affected by hearing self-states’ voices. These findings are consistent with the TOP DD Study participants developing greater integration among self-states, contributing to better control over dissociative symptoms, accompanied by improved functioning in daily life. These data from the largest and longest longitudinal treatment study with DID/DDNOS patients did not show evidence that DID treatment creates or worsens subjective self-division/perception of dissociated self-states. Nor did treatment exacerbate the intrusion of dissociative voices of self-states, nor was it accompanied by an increase in dissociative amnesia. On the contrary, according to their therapists’ reports, DID patients in the TOP DD Study experienced improved functioning, while dissociative symptoms declined. In our view, IM theorists conflate increased awareness of dissociated selfstates in DID treatment with the iatrogenic creation of self-states. Thus, they view DID treatment as harmful because it “creates” self-states (Lilienfeld,

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FIGURE 2 Frequency of hearing voices in Treatment of Patients With Dissociative Disorders Study participants. CI = confidence interval (color figure available online).

2007; Piper, 1997), rather than recognizing that clinical strategies designed to increase the awareness of self-states, and the promotion of collaboration, cooperation, and communication among self-states, actually increases adaptive and more integrated functioning. In addition to the consistent finding that DID treatment is beneficial, the treatment costs and suffering of DID individuals have also been shown to decline with DID treatment. Indeed, several studies showed substantial cost savings once DID treatment was initiated compared to costs prior to the commencement of DID treatment (Fraser & Raine, 1992; Loewenstein, 1994; Ross & Dua, 1993). For example, the annual cost of mental health treatment for a British woman with previously undiagnosed DID decreased from £29,492 ($47,187) to £10,695 ($17,112) following diagnosis and treatment for DID, indicating an annual savings of £18,797 ($30,075; Lloyd, 2011). Similar savings have been found in all studies that have examined this question (Loewenstein, 1994). In summary, the current study is consistent with the literature documenting that DID treatment is beneficial. We found that the TOP DD participants showed reductions in manifestations of dissociated self-states, including subjective self-division, and hearing voices of self-states. Contrary

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FIGURE 3 Global Assessment of Functioning over time in Treatment of Patients With Dissociative Disorders Study participants.

to the concern—stridently advocated by IM proponents—that DID treatment is harmful, this study, as well as every empirical study of DID treatment published in English to date, finds that DID patients benefit from the type of treatment based on the ISSTD (2011) guidelines and further delineated by expert survey (Brand, Myrick, et al., 2012). Thus, proponents of the IM need to conduct studies comparable to the TOP DD Study showing that their treatment model is efficacious and that, in fact, the behavioral suppression model favored by the IM proponents does not cause harm to patients. Finally, IM proponents have criticized the data on DID treatment as not having been acquired in randomized controlled trials (Paris, 2012). Randomized controlled trials have not been conducted on DID patients, in part because of the difficulty of standardizing treatment for such a severe, disabling disorder with a variety of clinical presentations and a range of symptoms, disability, and high rates of suicidal and self-destructive behavior (Brand, Loewenstein, & Spiegel, 2013; Johnson, Cohena, Kasena, & Brook, 2006; Loewenstein, 1994; Mueller-Pfeiffer et al., 2012). However, evidence from this and other studies is consistent with DID treatment being responsible for improvements in DID patients’ symptoms and functioning.

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Multiple studies have shown that DID is a serious mental illness with significant disability, symptoms, and dysfunction and with high rates of suicidal and self-destructive behavior, often requiring treatment in more restrictive levels of care, leading to high costs to the mental health system (Brand, McNary, et al., 2013; Johnson et al., 2006; Loewenstein, 1994; Mueller-Pfeiffer et al., 2012). DID has been shown to have a substantial burden of disease for individuals who suffer from it and for society (Spiegel et al., 2011). In addition, studies have demonstrated major costs to the health care system for these patients, with significant reductions in cost with appropriate DID treatment (Brand, Classen, Lanius, et al., 2009; Brand, Lanius, et al., 2012; Loewenstein, 1994; Mansfield et al., 2010). Indeed, there are data that iatrogenic harm may result from depriving DID patients of appropriate treatment (Brand, McNary, et al., 2013; Spiegel et al., 2011). In particular, iatrogenic damage may befall DID patients if clinicians believe the unsubstantiated notion that DID treatment is harmful, do not obtain appropriate training in DID treatment, and then provide “treatment” consisting of ignoring and/or suppressing DID self-states. Based on the current state of the evidence, we conclude that treatment based on the IM falls below the current standard of care.

NOTES 1. For the purpose of this article, DID treatment is used to mean the phasic trauma treatment model described in the Guidelines for Treating Dissociative Identity Disorder in Adults (International Society for the Study of Trauma and Dissociation, 2011). 2. Dissociation refers to many phenomena. Because iatrogenic model theorists are specifically concerned about the creation and manifestation of dissociated self-states (e.g., feeling as if one has multiple self-states, acting like different people, hearing voices of self-states, dissociative amnesia), we confine our definition of dissociation to be consistent with this notion. However, we believe that this reflects an overly simplified understanding of dissociation and the phenomenology of DID, overlooking other crucial aspects of dissociative phenomena and symptoms in DID (e.g., Dell, 2006). 3. DID and the most common forms of DDNOS are currently viewed as essentially the same disorder, especially with regard to treatment (Spiegel et al., 2011).

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Does phasic trauma treatment make patients with dissociative identity disorder treatment more dissociative?

Proponents of the iatrogenic model of the etiology of dissociative identity disorder (DID) have expressed concern that treatment focused on direct eng...
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