THE TREATMENT OF TRAUMATIC MEMORIES IN DID : INDICATIONS AND CONTRAINDICATIONS

A treatment model with a focus on trauma treatment and subsequent integration is widely accepted as the most successful among therapists treatingDID. However, this model may not be the best option for all DID patients . Lower functioning patients often do not have the strength or therapeutic potential and/or opportunity to endure this kind of treatment. This article discusses indications and contra-indications for entering into the second phase in the treatment of DID patients: the treatment of traumatic memories. A checklist was developed to evaluate the treatment process and make a wellfounded decision about the transition from phase I, stabilization and symptom reduction, to phase II, treatment of traumatic memories. Criteria that influence a decision to focus on phase I only, without proceeding to phase II, will be discussed . Clinical examples will demonstrate the use of the checklist. The standard of care for the treatment of severe dissociative disorders consists of a stage-oriented treatment model as first described by Pierre Janet (van der Hart, Brown, & van der Kolk, 1989) and more recently by contemporary clinicians (Brown, Scheflin, & Hammond, 1998 ; Herman, 1992; Kluft, 1993a; Horewitz & Loewenstein, 1994) . This model consists of three stages of treatment : 1) stabilization and symptom reduction (Herman [19921 speaks of establishing safety) ; 2) treatment of traumatic memories (part of which is mourning the associated losses) ; and 3) integration and rehabilitation . Although controlled outcome studies on the psychotherapy of DID have not yet been conducted, a vast majority of successful treatments have been associated with a model focusing on integration (Kluft, 1984; 1986 and 1993b) . This approach is also the basis of the official guidelines for the treatment of MPD/DID of the International Society for the Study of Dissociation (1994, 1997) . Effective treatment for DID can never start with extensive exploration of the traumata. On the contrary, as highlighted in the works of Kluft, Fine, and many other authors in the field, trauma-work can only be done after sufficient groundwork has been completed (Fine, 1991, 1993 ; Kluft, 1986, 1991, 1993a, b & c) . Over the last several years, there has been a growing realization that not all DID patients are capable of integrating their traumatic memories (Boon, 1994, 1995; Boon & van der Hart, 1995,1996; Kluft, 1993a &b ; 1994; Horewitz & Loewenstein, 1994) . In some cases treatment techniques focusing on stabilization and symptom reduction are the only feasible option . The aim is, essentially, to help the patient to use dissociation as a more effective coping style. This approach falls into Kluft's category of adaptationalism (Kluft, 1988b, 1993b) . An important feature of this approach is pragmatism . The priority is on maintenance and management of life functions, and improvement of the patients' functioning . Kluft (1988b) mentions several reasons for therapists to prefer this model: 1) cost containment; 2) minimization of the value of psychotherapy ; and 3) burn-out symptoms in the therapist . I would like to add another very important reason for this stance : a considerable group of patients is unable to achieve the goal of integration . Severe attachment problems, a lack of ego strength, a lack of the essential therapeutic potential to proceed due to concomitant psychiatric problems or a lack of motivation maybe among the reasons that these patients are unable to bear an intensive treatment geared towards the treatment of traumatic memories and the achievement of integration. In this paper I will discuss factors that may influence a decision toward maintaining a focus on stabilization . I will present a checklist to evaluate the treatment process and make a well-founded decision about whether it is appropriate to make a transition from phase I concerns, stabilization and symptom reduction, to phase II issues, the treatment of traumatic memories . Clinical examples will illustrate the use of the checklist.