Case Note
Purpose
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The purpose of today’s session was to develop a level of trust through consistent eye contact, active listening unconditional positive regard, and warm acceptance (Jongsma A. E., 2014). The client began to express feelings more freely as rapport and confidence level have been increased. The client will improve his overall emotional and behavioral functioning by actively participating in the therapeutic process.
Intervention
Today’s clinical contact focused on building the level of trust with the client through consistent eye contact active listening, unconditional positive regard, and warm acceptance (2014). The client was asked to describe the various personalities that take control of him and the circumstances under which this occurs. A functional analysis was conducted with the variables associated with the client’s dissociative states. The customer’s level of insight toward presenting problems was assessed. The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.
Assessment
Psychological testing was administered to assess the presence and strength. The client has been evaluated for evidence of research-based correlated disorders. The severity of the customer’s impairment has been evaluated to determine the appropriate level of care. The feelings and circumstances that tend to trigger the customer’s dissociation state were explored. The customer’s sources of emotional pain/trauma and feelings of fear, rejection, inadequacy, or abuse were explored. The client was assisted in making an insightful connection between his dissociation disorder and the avoidance of facing unresolved emotional conflicts. As the customer stayed focused on reality, rather than escaping through dissociating, he was reinforced. The client was taught several different relaxation techniques to be used to reduce muscle tension and assist in anxiety management.
Treatment Goals and Objectives
Short-term
Kevin will identify each personality and have each one tell its story.
The therapist will actively build the level of trust with the client in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his ability to identify and express feelings.
Kevin will identify the key issues that trigger a dissociative state.
The therapist will explore the feelings and circumstances that trigger the client’s dissociative state. The therapist will assist the customer in accepting a connection between his dissociating and avoidance of facing emotional conflicts/issues.
Kevin will practice relaxation and deep breathing as means of reducing anxiety.
The therapist will train the client in relaxation and deep breathing techniques to be used for anxiety management.
Kevin will verbalize acceptance of brief of dissociation as not being the basis for panic, but only as passing phenomena.
The therapist will teach the client to be calm and matter-of-fact in the face of brief dissociative phenomena so as to not accelerate anxiety symptoms, but to stay focused on reality.
Long-term
Integrate the various personalities.
Reduce the frequency and duration of dissociative episodes.
Resolve the emotional trauma that underlies the dissociative disturbance.
Reduce the level of daily distress caused by dissociative disorders.
Evidence-Based Best Practices (EBBP)
The primary treatment modality for DID is individual outpatient psychotherapy. The best treatment approach includes psychotherapy, group therapy, expressive therapies such as creative art therapy, family therapy, clinical hypnosis, psychoeducation, and pharmacotherapy. The frequency of sessions and interval of treatment may depend on some variables, including the patient’s characteristics, the abilities and preferences of the therapist, and external factors such as insurance and other financial resources and the availability of skilled therapists. DID patients vary widely in their motivation, resources for treatment, and comorbidities, all of which affect the course of therapy (Harper, 2011). Treatment methods depend on the individual and the severity of their symptoms and usually includes some mixture of the previously stated modalities. The minimum frequency of sessions for many DID patients weekly 45- 50-minute session. However, some therapists have found extended sessions (e.g., 75-90 minute) to be beneficial (Dissociation, 2011).
EMDR has many potential benefits in the treatment of DID. EMDR has the ability change trauma based distortions in self-representation, increasing associative linkages to the adaptive material, and facilitating the incorporation of processed traumatic material into alternate identities. Also, EMDR enhances the creation of new behaviors by enabling individuals to process previous traumatic experiences and their current triggers and then develop new patterns of desired skills or behaviors (Dissociation, 2011).
The focus of psychotherapy is to help the customer recognize what may have caused this illness and find new ways of coping with stressful situations that can activate dissociation (Pais, 2009). The primary approach to treatment interventions utilized for DID are phase-oriented (Harper, 2011). There are three phases to the phase-oriented treatment of structural dissociation, and in all phases, it is crucial. The phases do involve periodic returning to earlier phases as an essential component of the treatment is that clients must learn skills to tolerate strong affect, thoughts, and sensations, rather than avoiding them. Phase 1 involves symptom reduction and stabilization which dealing with the phobia of trauma-related mental actions. Overcoming the phobia of trauma-related psychological effects means helping an individual with emotions, thoughts, body sensations, and memories they may have avoided (2011).
Next, Phase 2: treatment of traumatic memories This step that involves overcoming the phobia of traumatic memories is complicated and full of potential pitfalls. The actual treatment of traumatic memory includes both guided synthesis and guided realization. Guided synthesis involves controlled exposure to the traumatic memory so that it is not experienced as overwhelming.
Then Phase 3: Integration and rehabilitation involes the final phase begins when the majority of a survivor’s traumatic memories have become autobiographical narratives. The survivor is encouraged to let go of unhelpful beliefs and behaviors and to engage in the world with new coping skills.
For the treatment of DID and other dissociative disorders, the most well-known CBT intervention is the Tactical-Integration model which has a foundational blueprint which is a modified cognitive therapy module
Patients with DID do poorly in unspecified treatment groups that include individuals with complex diagnoses and clinical problems. Many DID patients have difficulty tolerating the strong effects elicited by traditional process-oriented psychotherapy groups or those that encourage dialogue, even in a limited way, of participants’ traumatic experiences. Some such therapy groups have resulted in symptom exacerbation and dysfunctional relationships among group members.
Medication
Currently, there are no listed drugs to treat dissociative disorders individually. However, individuals with dissociative disorders, particularly those with associated depression and anxiety, may benefit from treatment with antidepressant or anti-anxiety medications. According to (Gentile, 2013), the following are Pharmacologic Treatment of DID:
Antidepressants/anxiolytics (e.g., selective serotonin reuptake inhibitors, non-selective reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors) treat comorbid symptoms, stabilize mood, and reduce unpleasant symptoms, hyperarousal, and anxiety. For example, sertraline is a SSRI used for depression. The usual adult dose of Sertraline initial dose: 50 mg orally once a day and maintenance dose: 50 to 200 mg orally once a day. According to Drug.com, list the following commonly reported side effects of sertraline include: diarrhea, dizziness, drowsiness, dyspepsia, fatigue, insomnia, loose stools, nausea, tremor, headache, paresthesia, anorexia, decreased libido, delayed ejaculation, diaphoresis, ejaculation failure, and xerostomia (Publications, 2016).
Benzodiazepines use with caution to decrease anxiety; this medication class may exacerbate dissociation. Xanax XR is a common drug used to treat anxiety disorders. (Publications, 2016), list the following as common side effects of Xanax XR include: depression, diarrhea, drowsiness, dysarthria, headache, insomnia, memory impairment, nervousness, sedation, and tremor.
Beta-blockers, clonidine stabilize mood and reduce intrusive symptoms, hyperarousal, and anxiety.
Atypical (second generation) antipsychotics stabilize mood and reduce overwhelming anxiety and intrusive symptoms.
Prazosin is effective in reduction of nightmares.
Carbamazepine and other mood stabilizers can be helpful to reduce aggression, intrusive symptoms, hyperarousal.
Naltrexone used to reduce self-injurious behavior
References
Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (5th Ed). Washington DC: American Psychiatric Association.
Dissociation, I. S. (2011). Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, 115-187.
Gentile, J. D. (2013). Psychotherapy and pharmacotherapy for patients with dissociative identity disorder. Clinical Neuroscience, (10) 22-29.
Harper, S. (2011). An examination of structural dissociation of the personality and the implications for cognitive behavioural therapy. The Cognitive Behaviour Therapist, 4:53-67.
Jongsma, A. E. (2006). The complete adult psychotherapy treatment planner. New Jersy: John Wiley and Sons, Inc.
Jongsma, A. E. (2014). The adult psychotherapy progress notes planner. New Jersy: Wiley.
Pais, S. (2009). A systemic approach to the treatment of dissociative identity disorder. Journal of Family Psychotherapy, 20:72-88.
Publications, H. H. (2016). Drugs.com. Retrieved from Drugs.com: www.drugs.com
