Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Sunday, November 1, 2009

Disturbed patient, disturbing therapy by St. Cloud psychologist |

Somebody on Twitter alerted me to this story. Briefly, a therapist got over-involved with two of her clients and was disciplined for it. The problem, at least as it is framed by the local newspaper, is that she has poor boundaries and poorer reality testing: As they so cutely put it, she believed the client's delusions more than the client did.

The line between a memory and a delusion is a fine one, especially in Dissociative Identity Disorder (DID). DID occurs in people who have suffered especially severe and often bizarre, but quite real, abuses while at the same time there is an unreal quality to the disorder itself. Real memories, in other words, quite commonly exist side-by-side with unrealistic beliefs in DID.

Therapists are not, and cannot be, in the business of validating clients' memories. However, when a client questions her/his own memories, we can encourage reality-testing by the client. In doing so we must not forget that perpetrators of abuse quite naturally go to great lengths to hide what they are doing, so that validating a specific memory may simply not be possible. We also need to caution clients against attempts to validate that may be dangerous, such as directly confronting perpetrators.

Sometimes the only validation available is indirect: We are working on a dysfunctional behavior in therapy, a memory surfaces, and the behavior “spontaneously” clears up. Other examples of indirect validation that come to mind include addicted and sexually-acting-out siblings (possible co-victims) and an arrest of a relative for a related crime. None of these things proves the validity of a specific memory, but it does lend credence to the client’s family portrait.

It is a myth, by the way, that a person has to remember in order to heal. Or that survivors have to remember more: To quote the late Ann D. McAllister, Ph.D., "What [they] already remember is more than enough." Digging for additional memories runs the risk of (a) producing "memories" that aren't, and (b) completely unraveling the client's ability to function in the present.

Since disbelieving real abuse can be as harmful as becoming part of a delusional system, the therapist serves the client best by focusing on current functioning. The focus of treatment becomes teaching the client to manage flashbacks, switching between alters, emotions, appropriate boundaries, insomnia, self-harm, addictions, self-image, etc. And the key phrase here is “teaching the client to manage,” not managing it for the client. Treatment for DID is emotionally intense, and it’s not going to happen without a degree of dependency developing. But throughout the therapy, the therapist maintains the boundaries of the working relationship and encourages the client’s independence.


Anonymous said...

I just got this book. I wonder how childhood sexual abuse intersects with DID. I wonder how it affects development of sexual orientation.

Virginia S. Wood, PsyD said...

I am not familiar with the book, but it looks interesting and I plan to check it out. Thanks for the link.

As for DID, by definition it's a trauma response and among traumas experienced by children, particularly female children, incest is a relatively frequent type. Virtually all persons exhibiting DID have in their backgrounds sexual abuse from the extreme end of the traumatic spectrum.

As for sexual orientation, childhood sexual abuse and orientation per se do not appear to be related. Persons with DID, for example, will have alternate personalities of all genders, ages, and orientations. What is universally affected, as one might expect, is adult sexual functioning.