Journal of Trauma & Dissociation, 14:84–96, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1529-9732 print/1529-9740 online DOI: 10.1080/15299732.2012.710185
Dissociative Identity Disorder and the Process of Couple Therapy HEATHER B. MACINTOSH, PhD, CPsych McGill University School of Social Work, Montreal, Quebec, Canada
Couple therapy in the context of dissociative identity disorder (DID) has been neglected as an area of exploration and development in the couple therapy and trauma literature. What little discussion exists focuses primarily on couple therapy as an adjunct to individual therapy rather than as a primary treatment for couple distress and trauma. Couple therapy researchers have begun to develop adaptations to provide effective support to couples dealing with the impact of childhood trauma in their relationships, but little attention has been paid to the specific and complex needs of DID patients in couple therapy (H. B. MacIntosh & S. Johnson, 2008). This review and case presentation explores the case of “Lisa,” a woman diagnosed with DID, and “Don,” her partner, and illustrates the themes of learning to communicate, handling conflicting needs, responding to child alters, and addressing sexuality and education through their therapy process. It is the hope of the author that this discussion will renew interest in the field of couple therapy in the context of DID, with the eventual goal of developing an empirically testable model of treatment for couples. KEYWORDS dissociative identity disorder, trauma, couple therapy, marital therapy
Received 28 December 2011; accepted 18 May 2012. Portions of this article were presented in 2011 at the 28th Annual Conference of the International Society for the Study of Trauma and Dissociation, Montreal, Quebec, Canada. Address correspondence to Heather B. MacIntosh, PhD, CPsych, McGill University School of Social Work, 3506 University Street, Room 300, Montreal, Quebec, H3A2A7, Canada. E-mail:
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INTRODUCTION Up to now, the literature on couple therapy and trauma has neglected the topic of dissociative identity disorder (DID) as an area of exploration and development. The few existing references focus on couple therapy as an adjunct to individual therapy rather than as a primary treatment for couple distress and trauma. Couples dealing with the DID of one member may experience significant challenges, but the literature is virtually silent on the characteristics and clinical needs of these couples. Some inferences may be drawn from the literature on childhood sexual abuse (CSA) survivors, an overlapping population that has also experienced considerable psychological trauma. While interpersonal relationships are strong moderators and mediators of the relationship between childhood trauma and long-term distress (Runtz & Schallow, 1997; Whiffen, Judd, & Aube, 1999), CSA survivors report more current relationship problems, high levels of couple distress and dissatisfaction, sexual difficulties, and challenges with trust and intimacy (Davis & Petretic-Jackson, 2000; DiLillo, 2001; Rumstein-McKean & Hunsley, 2001). In addition, a history of CSA in one partner in a couple impacts the other partner, who often reports isolation, pain, anger, frustration, dissatisfaction, and communication problems (Reid, Wampler, & Taylor, 1996). Couple therapy researchers have begun to develop modified practices to provide effective support to couples dealing with the impact of childhood trauma in their relationships, but little attention has been paid to the specific and complex needs of DID patients in couple therapy (MacIntosh & Johnson, 2008). This review and case study is intended to renew interest in the field of couple therapy in the context of DID and to explore themes related to treatment.
LITERATURE REVIEW In the limited literature on DID and couple therapy, there is some consensus that couple therapy should serve as an adjunct to individual therapy or even be restricted to use after integration (Panos, Panos, & Allred, 1990; Sachs, Frischholz, & Wood, 1988). However, the impact of developmental trauma on later couple relationships is well documented and can only be amplified by the presence of DID. Putnam (1989) indicated that persons with DID “often marry spouses with a significant amount of psychopathology.” Being exposed to the unspeakable traumatic experiences of their partner may further compound these challenges, so that vicarious traumatization may impact their belief systems, their sense of trust and safety, and their capacity for intimacy. Benjamin and Benjamin characterized the married life of those with DID as chaotic and painful. A high level of stress in these relationships was demonstrated in the impact of direct trauma symptoms such as flashbacks, intrusive thoughts, and dreams (Benjamin & Benjamin, 1994b, 1994c).
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In the one published quasi-empirical assessment of the impact of complex developmental trauma on the process of couple therapy, numerous adaptations to the couple therapy process were required to assist trauma survivors. In particular, the therapeutic process and therapist behaviors were modified to manage overwhelming affect dysregulation, challenges with perspective taking, and difficulties engaging in therapeutic tasks such as affective heightening and enactments. For a full review of the impact of complex trauma on the couple therapy process, see MacIntosh and Johnson (2008). The present discussion concentrates on the unique impact of DID on the couple therapy process. In spite of these challenges, trauma survivors desire intimacy and closeness, and the failure to provide couple therapy when a couple presents with distress may result in the failure of a potentially viable relationship and deprive a DID patient of what could be one of the most important supports in his or her healing process (MacIntosh & Johnson, 2008). The existing literature on DID and couple therapy consists entirely of theoretical explorations of couples dealing with DID and one thematic analysis of five couple therapy cases. These authors identified a number of themes for the couple therapist to consider (Levenson & Berry, 1983; Panos et al., 1990; Sachs et al., 1988; Williams, 1991), including learning to communicate, focusing on the here and now, preventing the sabotage of individual therapy, dealing with disruptions in the couple system, understanding affective pervasion, handling conflicting demands and needs, responding to child alters, supporting the sexual relationship, incorporating education, adjusting to integration, dealing with impatience with therapy, and not losing sight of a partner’s challenges that might become lost with the focus on the DID patient. The case of “Lisa” and “Don” described here illustrates some of these themes as they arose in their couple therapy process.
THE CASE OF LISA AND DON Lisa and Don responded to an advertisement seeking distressed couples, of which one member had a history of CSA, to engage in a study examining the process of couple therapy in the context of CSA. Lisa withheld her previous diagnosis of DID from the principal investigator (this author), because of her belief that she was no longer dealing with issues related to dissociation. This diagnosis was not evident from the administration of standardized measures of trauma symptoms. Had Lisa disclosed her diagnosis of DID, the couple would have been excluded from the study. Lisa and Don provided informed consent for the taping of all sessions and for the eventual publication of process material arising from the couple therapy sessions.
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Background Lisa and Don met when they were in their early 40s. Lisa had never had a romantic relationship before, whereas Don had been married with two children, and his wife had left him after more than 15 years of marriage. Lisa had experienced early, severe, and prolonged sexual abuse by her father and older brother. She described her ability to dissociate as her “lifesaver” and credited her alter personalities with helping her to escape. Lisa had previously undergone 10 years of intensive individual therapy that had ended 2 years prior to the onset of this study. She reported that this therapy was focused on helping her process and integrate traumatic memories. As therapy unfolded and Lisa’s alters began emerging in the context of couple therapy, she was able to acknowledge that she continued to experience an internalized child state (Katie) that curled up inside her stomach and needed a great deal of quiet and nurturance; an unnamed adolescent “rebel” state that used food, fast driving, and excessive exercise to cope with overwhelming affect; other self states that held memories and feelings related to her trauma; a “spiritual” part (Maeve) who helped ground her through prayer and spiritual music; and other “angry” parts that she did not like to talk about. Lisa considered this ongoing state of fragmentation to be “integration,” as she was able to live in a state of cooperative co-consciousness. Don had been abandoned by his mother for a prolonged period when he was 5 years old. She reappeared after a year with no explanation. Don was left feeling that people might suddenly disappear for no reason and demonstrated heightened vigilance for attachment figures that was only further accentuated when his first wife left him for a woman seemingly “out of nowhere.” Don denied a history of overt trauma but showed a significantly limited capacity to adopt another’s perspective and to empathize. He also demonstrated what Lisa and Don described as a “codependent” style of interpersonal relationships, a pattern associated with the avoidance of one’s own issues when one’s partner has DID (Benjamin & Benjamin, 1994c). Don had not received any prior form of mental health treatment and expressed significant anxiety about letting an “outsider” into their lives.
Themes in Treatment Learning to communicate. Learning how to communicate about issues that arise as a result of the unique impact of DID in one partner is essential to the couple relationship. The complex trauma and couple therapy study found communication and openness to be significantly hindered. These challenges are caused notably by deficits in affect regulation and in mentalizing capacity, such as perspective-taking skills and empathy (MacIntosh & Johnson, 2008). In addition, individuals with DID often experience significant shame about their dissociative processes and hide their many selves, which can lead to confusion and conflict in a couple (Loewenstein & Ross, 1992).
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The therapy process encouraged Lisa and Don to talk about Lisa’s internal system of dissociated self states and helped Don to process this previously unknown information. Don also learned how to talk about the impact of Lisa’s DID on his sense of safety and intimacy in the relationship. The following is a transcript of a session helping the couple communicate about the impact of trauma and DID on their relationship. Don was struggling to understand why Lisa “checks out” when they are having conversations, why she gets overwhelmed, and why she seems to “switch off” and to forget things. Therapist (T): Lisa (L):
T: L: Don (D): L: T: L: T: L: T: D: L: T: D: T: D:
How much of you is integrated in the whole relationship? You talked about these compartments. Depending on my stress level, the higher stressed I am, the less I am available, the more compartmentalized I become. That’s a pattern that’s never bothered me before because I can live with it but now, when I’m in a relationship I’ve got someone feeding me back things and it’s like, I see it more clearly. You’ve become more aware of the extent of the compartments. Yeah. She seems to turn off parts of herself when overwhelmed. I just can’t tolerate long arguments . . . I turn off. When you do go into a more compartmentalized place, for you that’s trying to lower the level, to calm yourself? Yes. To soothe yourself? Yes. And Don, you experience that as disconnection and “I don’t care”? Yeah. It isn’t that I don’t care, I am trying to settle myself inside. (to Don) And you experience that as “I don’t care, leave me alone”? Yeah. And for Lisa it’s “I need to stop, too much.” How does that feel for you Don? I’m disappointed that we can’t talk about things . . .
Many similar discussions ensued throughout the course of therapy to help Don and Lisa talk about the impact that they had on each other and their challenges in meeting their conflicting needs. As Don became more aware of the different parts of Lisa, it became easier for him to understand her “checking out” in the context of switching, internal self-regulation, and managing distressed internal dialogue. Although he continued to struggle
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to understand her times of dissociative disconnection, he was more able to regulate his own anxiety and attachment distress. Handling conflicting needs. In the case of Lisa and Don, the potential is high that the DID partner will want and need more than one thing at the same time, as is likely with any couple dealing with one partner’s DID. Previous authors have highlighted the importance of communication in couples dealing with DID so that they may learn how to express this dilemma openly and resolve conflicts through compromise (Benjamin & Benjamin, 1994a, 1994b, 1994c; Panos et al., 1990). Although the DID partner may be experiencing the needs, longings, and struggles of many alters, the couple relationship is a relationship between two adults. Couples need to learn how to balance childlike needs with the respect for boundaries, reciprocity, and responsibilities that inevitably come with mature, adult relationships while continuing to acknowledge issues specific to DID. By facilitating the couple’s growth in the areas of healthy communication and negotiating compromise, a therapist can support the couple through this challenge. For Lisa and Don, the primary conflict over mismatched needs arose over Lisa’s need for processing and quiet time following her busy day at work or any intense conversations; she required this so that she could selfregulate internally and respond to the needs of her alters. Don’s needs for intimacy, closeness, reassurance, and almost constant contact conflicted with these needs. It is important that the therapist not focus narrowly on the “pathology” of the DID partner; rather, the valid and important needs of both partners are to be expressed. The following is a transcript from a session with Lisa and Don in which Lisa’s conflicting needs for her internal self-regulation of alters and spending time together were explored. L:
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I just need some quiet time to go inside and sit with Katie and Maeve and that is just so foreign to him but I need time . . . you know. And the more he would push the farther I would go away. The farther away you got from yourself? Yeah, I lose myself. The closer he got, the farther you backed up. I have a lot of fears about how I am going to keep things okay inside and have the time I need to be able to give to him because I know he requires a lot more energy than I do. That I’m aware of . . . Well, because of that compartmentalization that you talked about, there may be some parts of you that haven’t come into the world in terms of feeling safe, yet to open up to those needs. No. It sounds like you’ve been really on alert territorially around making sure that you can take care of yourself. There hasn’t been enough room for you to really look at what your needs might be in the relationship as an emotional person. Yeah, I guess I’m just trying to learn about this. I don’t know how to be in a relationship.
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Don struggled to hear Lisa and went on to discuss his need for closeness and his challenges in understanding Lisa’s needs. This was a frequent source of distress that was mediated within the couple therapy environment to assist them in learning how to negotiate, take on the perspective of the other, and have empathy for the other’s needs. As Don became more familiar with Lisa’s alters, he became more able to regulate his own distress and include her multiple needs in his understanding of her. However, given the somewhat invisible nature of Lisa’s alter system, Don continued to experience anxiety and attachment hypervigilance. Responding to child alters. Within the context of couple therapy it is important to give space to child alters that hold different affective experiences of the couple relationship given the significant impact that these parts may have on the couple system. Finding balance between hearing the distress of child alters and attending to their needs while remaining focused on present tense functioning in an adult relationship is a significant challenge in the treatment of a couple dealing with DID. The following segment illustrates some of the therapist’s attempts to engage with child alters that emerged within couple therapy sessions. Katie discussed how she was the part of Lisa who “went away” during the abuse; she was still the part of Lisa that “goes away,” that was afraid of Don, for example. In spite of education, Don did not understand the fear because he struggled to mentalize: How can she experience me that way when I am not that man? L: T: L: T: L: T: L: T: L:
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I know there is a part of me, um, that is a very young part. Hmm. Yeah. Katie; she has a name, you know? (tentative) How old does that part of you feel? I don’t know. I’d say under 10. This is a part of you that has a lot of vulnerability and longing? Yeah, but she’s also the one that goes away when things get threatening. She gets scared. When the abuse happened, she’d be the one sitting up on the ceiling watching and so, I’m just coming to understand that she goes away a lot and I know he’s safe but that’s a coping pattern that she goes away and then I’m not emotionally present to him at all. It doesn’t seem to matter if he’s safe or not, Katie is primed to fear and she hasn’t learned another way, and that takes time. I think he doesn’t understand sometimes about the fear or that’s hard for him so when I say I’m afraid he’s like, you don’t need to be afraid of me. It’s not you I’m afraid of; it’s just an old pattern for her. Right. Then it got so stressful between us and she was just gone most of the time. How was that for you, Don?
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It was really tough. I’ve never been exposed to any of this before. No one in healing? No, that was the hardest thing to understand. I think I still don’t 100% understand all of it but I always took it so personally. I’d want to be with her and I’d walk up behind her to give her a big hug and she’d be like, get away. You know, she didn’t want me touching her, how come? You felt hurt. Yeah. And that happened a lot, every time I’d try to get close to her she kept backing up and I’d keep walking forward, closer to her and I couldn’t help but think that it’s something about me, something I did wrong, I had a million questions that never really got answered. (in small child voice; Katie) When he gets angry it’s scary. I’m afraid he will hurt me. I know he won’t hurt me but I’m afraid that he will. Building up the repertoire of who is safe and not safe in the world will take time. Lisa you are shaking, what’s going on? Are you present? Um, yeah. (little voice) He gets an angry face, he scares me. You see that face and you can’t tell that he isn’t going to hurt you? Right. (shaking) When he comes toward you looking angry you get scared and hide? Yeah. That sounds really scary for you. When you were little, people who looked angry did hurt you. Is there anything that Don could do to help you when he is feeling angry and you get scared? I don’t know. You don’t know that when someone gets an angry face that they aren’t going to hurt you? When Don says to you, it’s okay, I’m not going to hurt you, do you believe him? Yes, I just get so scared. When he gets mad I can feel this big energy in him and I’m sure he’s going to hurt me. It was very helpful to you to absorb all of that energy when you were little, you know when the lightning was going to strike. You could brace yourself, you knew.
In discussing, more overtly, Katie’s experiences in childhood and now, with Don, Don was more able to acknowledge Lisa’s distress in the present tense. Don’s distress about being betrayed had been focused externally on the risk that Lisa would have an affair, and he was slowly coming to realize that her distress and distractions were internally driven. This was a very slow process, as the unique dyadic contribution of the impact of Don’s history of abandonment butted up against Lisa’s history of severe and violent abuse. Sexuality. Normalizing sexual needs while understanding the impact of trauma and finding safe ways to touch and express these needs has been identified as an important goal for couples dealing with DID (Benjamin & Benjamin, 1994c; Panos et al., 1990). Issues of sex and sexuality are
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particularly challenging for child alters. Katie enjoyed cuddling with Don, whom she experienced as a safe male adult. Meanwhile, Don found this cuddling confusing and interpreted Katie’s desire for cuddles as initiation of sex. Lisa felt caught in between. Don could not figure out how to initiate sex without triggering Katie/Lisa; each time she tried to tell him about her discomfort, he became angry that he could not express himself sexually to Lisa however he wanted, whether verbally or by touch. He felt that he was being told what to do because of Lisa’s traumas. He believed that her issues were in the past and that Lisa should be able to just get over them and be sexually open with him. Sessions explored how to protect child parts during sexual intimacy. Learning how Katie could go away for sex and how all of the parts of Lisa could learn the difference between different kinds of touch—when in her childhood touch had always been about sex—was an important process in the couple therapy. L:
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It takes me off guard even when I know that he’s around, it’s just like (switch to Katie) it’s my body you know and Don doesn’t have a right to touch me that way at all. There’s a process you need to go through to move into that space and when you’re not in it, these other thoughts and feelings come up. What happens on the inside of you, the different parts of you about this? (sighs; pauses) What does Katie have to say about all of this? I don’t like it. I don’t like being touched. He scares me. How does it feel when Don touches you when you aren’t expecting it? It’s scary, he might hurt me. You’re afraid, something bad might happen? Yeah, I don’t know what he’s doing. It makes me scared and I think all of the bad things that used to happen. It makes you remember all of the bad things that used to happen when you were little? Yeah. When Don touches you it’s hard for you to know that it’s Don and he’s not going to hurt you. You’re still scared. He won’t not touch me. What could happen? (recounts sexual abuse dynamics) Can you tell Don how you feel about him touching you when you don’t want him to? Sometimes it feels like he doesn’t understand. How much of the time are you and Lisa hanging out together inside? A lot. Sometimes it’s me and not Lisa. So you are out more than maybe Don knows? Yes.
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So sometimes for things like touch or cuddling you might be there more than Lisa? Yes, I like cuddling. How do you feel about the sex? That scares me. I don’t want to be there for that. How do you know when there’s sex, to go away so that you aren’t a part of that? I don’t know, Lisa tells me but sometimes it’s too late. Does Don know when you are around? I don’t know, probably not. It sounds like it might be hard for Don to know whether it would be okay to touch or to initiate sexual things with Lisa. Yeah. I don’t want him to touch my private parts; I just want cuddling. He just thinks he can touch me. You want to cuddle but you don’t want him to touch your private parts. Yeah. Don, do you know when Katie is around, can you tell? No, I don’t always know. Most of the time when I touch her private parts it’s just because I’m trying to be affectionate, I’m not trying to hurt her or tell her that we have to have sex. It’s affection and not sexual necessarily? Yeah. Lisa and Katie have had so much violation of sexual, of any kind of touch, it’s hard for her to tell the difference. Yeah, sometimes I’ll just be trying to give her a hug and she backs up and I’m like, okay, and I back up too. (Lisa comes back) You can tell. You just touch me wherever you want. No I don’t, what do you mean? I might go to give you a kiss or something and pat you or something. It feels like Lisa is saying, “I don’t want you” instead of “I’m scared”? Yeah. I do love you. Sometimes it’s hard to remember that? Sometimes she just gives me a look or something and I just feel lost. It sounds like you two aren’t alone in those moments, the monsters are still there too, those horrible memories and you both feel alone, lost and afraid. Yeah, I understand that, but there must be a difference between how I try to give her a hug, to an abuser coming up and forcing to have sex. There has to be a difference. Lisa do you feel a difference, does it feel different inside? Yes, it feels different, it is warmer.
Survivors of sexual abuse often struggle with developing healthy sexual relationships. Those with DID and their partners are doubly challenged to
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find ways to manage child parts who might emerge during sex. This process of untangling and exploring continued throughout the couple therapy process, as both partners came to understand each other more deeply. Don began to distinguish between Lisa and Katie, to be more clear about sexual touch, and to give Lisa more notice before shifting into a sexual stance. Education. As the therapy process continued, it became more and more clear that Don’s experiences of attachment betrayal and trauma, in childhood and in his first marriage, were severely compromising his capacity for perspective taking and empathy; he simply could not see the impact of Lisa’s trauma from her perspective and rather continued to see her behaviors in the context of his feared abandonment. As a result of these challenges, the therapist tried an educational approach to help Don understand explicitly the impact of sexual trauma and DID, in the hope that this would enable him to see Lisa more clearly. Specific sessions were set aside for education, with the goal of helping Don understand why certain activities and actions—such as grabbing Lisa from behind or grabbing her genitals—might be distressing and challenging for her. Don’s own struggles made it very difficult for him to understand, without feeling resentful, that he needed to incorporate an understanding of her triggers and trauma history into his ways of interacting with Lisa. Long discussions were scheduled about the psychobiology of trauma, the limbic system, and the impact of trauma on a person’s need for selfprotection and the impact this has on adult life. The nature of dissociative fragmentation and the neurobiology of trauma were explored, and Don listened very carefully and was very engaged in this process. It appeared, over time, to help contain his distress over what he believed to be Lisa’s intentional withdrawal and avoidance of intimacy and closeness with him.
CONCLUSION AND FUTURE DIRECTIONS The study of the couple therapy process for couples dealing with DID is in its infancy. Early theoretical explorations did not lead to further study, and, in fact, the literature in this area ceased to evolve. In addition, this literature suggested that couple therapy serve as an adjunct to individual therapy rather than as a primary treatment for couple distress. This tendency can lead to a focus on the trauma of the DID partner and an expectation that the nontraumatized partner will set aside his or her own needs. However, a primary focus on the here-and-now processing, rather than the “there and then” as it is enacted in the couple, can lead to a failure to integrate important aspects of the couple distress specifically related to the trauma and DID into the therapy. This can further lead to challenges in identifying relational patterns when different self states respond to the partner in different ways. These relational patterns must be untangled, explored, and understood.
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The case of Lisa and Don demonstrates the importance of focusing on the needs of both partners to acknowledge the impact of the nontraumatized partner on the couple system and to see the couple therapy process as a primary treatment. The focus of sessions frequently shifted from couple work to explore the unique histories and sequelae that both Lisa and Don brought to the relationship. In addition to the specific issues posed by Lisa’s DID, Don’s distress, his limited perspective-taking capacity, and his severe attachment vigilance played a significant role in the couple distress and therapy process. Working through the therapeutic process in an effort to assist Lisa and Don as they learned to regulate their affect individually and mutually, to adopt another’s perspective, and to empathize was a challenge. Only slow and inconsistent improvement was achieved over the course of therapy. Identifying the mechanism of change to help DID patients and their partners develop these capacities, in the context of couple therapy, will be an important theme to explore in future studies. Couples in which one partner is struggling with DID can experience severe distress and particular challenges related to the DID, and they require effective and tolerable treatment. It will be imperative to continue documenting cases to replicate themes from this early work and identify other unarticulated themes, with the goal of developing a strong model for the treatment of couple distress in the context of DID and then assessing this model empirically. Future studies of couple therapy with trauma survivors could consider including participants with a diagnosis of DID to begin to build a base of data from which to build this model for treatment. Developing and validating an evidence-based protocol for treating couple distress, in the context of DID, is a project that faces significant challenges. This is labor-intensive work, referrals are limited because of the ongoing debate about providing treatment to couples in which one member evidences DID, and there is a dearth of trained therapists available. In spite of these and other challenges, the benefits of providing a safe, secure, and loving haven for trauma survivors in their couple relationships are immeasurable.
REFERENCES Benjamin, L. R., & Benjamin, R. (1994a). A group for partners and parents of MPD clients: II. Themes and responses. Dissociation: Progress in the Dissociative Disorders, 7(2), 104–111. Benjamin, L. R., & Benjamin, R. (1994b). A group for partners and parents of MPD clients: III. Marital types and dynamics. Dissociation: Progress in the Dissociative Disorders, 7(3), 191–196. Benjamin, L. R., & Benjamin, R. (1994c). Issues in the treatment of dissociative couples. Dissociation: Progress in the Dissociative Disorders, 7(4), 229–238.
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Davis, J. L., & Petretic-Jackson, P. A. (2000). The impact of child sexual abuse on adult interpersonal functioning: A review and synthesis of the empirical literature. Aggression and Violent Behavior, 5(3), 291–328. doi:http://dx.doi.org/10. 1016/S1359-1789%2899%2900010-5 DiLillo, D. (2001). Interpersonal functioning among women reporting a history of childhood sexual abuse: Empirical findings and methodological issues. Clinical Psychology Review, 21, 553–576. doi:http://dx.doi.org/10.1016/S02727358%2899%2900072-0 Levenson, J., & Berry, S. L. (1983). Family intervention in a case of multiple personality. Journal of Marital and Family Therapy, 9, 73–80. Loewenstein, R. J., & Ross, D. R. (1992). Multiple personality and psychoanalysis: An introduction. Psychoanalytic Inquiry, 12(1), 3–48. doi:10.1080/ 07351699209533881 MacIntosh, H. B., & Johnson, S. (2008). Emotionally focused therapy for couples and childhood sexual abuse survivors. Journal of Marital and Family Therapy, 34(3), 298–315. doi:http://dx.doi.org/10.1111/j.1752-0606.2008.00074.x Panos, P. T., Panos, A., & Allred, G. (1990). The need for marriage therapy in the treatment of multiple personality disorder. Dissociation: Progress in the Dissociative Disorders, 3(1), 10–14. Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York, NY: The Guilford Press. Reid, K. S., Wampler, R. S., & Taylor, D. K. (1996). The “alienated” partner: Responses to traditional therapies for adult sex abuse survivors. Journal of Marital and Family Therapy, 22, 443–453. doi:http://dx.doi.org/10.1111/j.1752-0606.1996. tb00219.x Rumstein-McKean, O., & Hunsley, J. (2001). Interpersonal and family functioning of female survivors of childhood sexual abuse. Clinical Psychology Review, 21, 471–490. doi:http://dx.doi.org/10.1016/S0272-7358%2899%2900069-0 Runtz, M. G., & Schallow, J. R. (1997). Social support and coping strategies as mediators of adult adjustment following childhood maltreatment. Child Abuse & Neglect, 21(2), 211–226. Sachs, R. G., Frischholz, E. J., & Wood, J. I. (1988). Marital and family therapy in the treatment of multiple personality disorder. Journal of Marital and Family Therapy, 14(3), 249–259. doi:http://dx.doi.org/10.1111/j.1752-0606.1988. tb00744.x Whiffen, V. E., Judd, M. E., & Aube, J. A. (1999). Intimate relationships moderate the association between childhood sexual abuse and depression. Journal of Interpersonal Violence, 14, 940–954. doi:http://dx.doi.org/10.1177/ 088626099014009002 Williams, M. B. (1991). Clinical work with families of MPD patients: Assessment and issues for practice. Dissociation: Progress in the Dissociative Disorders, 4(2), 92–98.
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