Review of Dr. Richard Loewestein’s presentation of

“Treating Dissociative Disorders: Lessons Learned” on September 29, 2007

By Tracey McHugh, LICSW

   Dr. Richard Loewenstein presented on the treatment of Dissociative Disorders in a unique format.  The morning consisted of him being asked questions by NESTTD members Denise Gelinas, Janina Fisher, and Rina Dubin.  The questions were generated by NESTTD members, Program Committee member Wendy Forbush, as well as Denise, Janina, and Rina.  Dr. Loewenstein then shared his wisdom with us in a more formal presentation in the afternoon.

Shame

     Shame was an important topic that was woven into various areas during the program.  Loewenstein gave a strong recommendation that we read “Shame and Pride” by Donald Nathanson.  He also encouraged us to read Richard Kluft’s work on shame.  He sees shame as a significant issue in the work with DID clients for many reasons, including the fact that it causes the therapist to back away.  Loewenstein cautioned us to be aware that our own shame can impact our clinical relationships.  And, he noted that shame is often the source of the patient’s withdrawal from the world.  Avoidance of life activities that may appear to be because of depression or anxiety are often actually due to shame.  He stated that there are four aspects to shame.  These are: 1. Attack self (“I’m a loser, I’m not good enough”) – this part of shame impacts a person’s ability to do things, to engage in life, their sexuality, etc., 2. Attack other – when someone wants to get back at those who have “made” them feel badly (most of our clients weren’t able to fight back, they are good people who can’t attack mother, father, etc. so the shame goes back into the self and alters), 3. Avoidance – we avoid what makes us feel badly and, finally, 4. Withdrawal (which is a chronic form of avoidance.)  Loewenstein observed that alters can be understood as these different sides of shame.

     Loewenstein stated that in order to work effectively with shame the therapist must identify it and identify its patterns in the patient’s life, as well as learn how to talk about it with patients.  For example, it’s not unusual to find that our clients are often unable to accept praise.  What the therapist must remember, before even approaching praise, is that it’s important for us to tie praise to specific accomplishments.  He cautioned us to be careful in the traumatic transference because the patient may have been praised during abuse.  Ask, “Is it okay if I tell you that I’m proud of you for ____ achievement?”

Transferential and Counter-transferential Pitfalls

     Transference and counter-transference were also issues that we heard about throughout the day.  It’s important to be attentive to the traumatic transference.  Relationships, even therapeutic relationships, are dangerous for DID patients; they are filled with traps to be navigated.  Patients often think we are treating them for our own narcissistic fulfillment.  They keep us at a distance, often hiding alters from us so that we cannot call on those alters.  We become bystanders, helpless to stop the violence of the patient’s self-injury, or other violence they might experience during our work with them, and leave them to wonder if we are going to be helpful, or harmful.  Many persecutory personalities are failed protectors.  (We also see this in the shame dynamic when an alter says, “Why couldn’t I protect her? You’re saying I screwed up!”)  And when a patient/alter become aggressive, where does the therapist fall in the victim-abuser-bystander triad?  For this reason it’s critical that we remain aware of our role and possible trauma re-enactments, including those that threaten safety.

     When a patient is unable to commit to safety, and the therapist admits him/her to an inpatient psychiatric unit that has no idea how to work with DID patients, is this a re-enactment?  Ask the client, “What does this remind us of?”  Say, “In order to protect you, I send you somewhere to be protected, yet they are unable to do that.”  “Is there another strategy we can come up with to keep you safe enough?”  If the patient agrees to commit to safety after this, ask, “What’s changed?”  It is critical to do thorough safety evaluations under these circumstances. Loewenstein stressed the importance of being consistent around patients’ safety issues.  Do NOT have variable boundaries around safety.  

     Loewenstein encouraged us to not step away from working with the “bad guy” or difficult parts.  They were, after all, created to protect our clients when they were vulnerable.  If a patient has lived a life of avoidance, as discussed earlier, and then comes to therapy, it makes sense that they feel more vulnerable in the therapy than in most parts of their current lives, so work with the challenging parts and recognize the role they play in the client’s functioning.  Utilize all that you have available to you in this work.  DBT’s Behavioral Chain Analysis form can be helpful in working with these parts.

Anticipation

     The third theme woven through this informative and thought-provoking day was anticipation.  Loewenstein stressed the importance of DID therapists anticipating every possibility that could come up in treatment.  He told us to always gather information about a patient’s functioning in an ongoing and consistent way.   Planning your work with DID patient’s is critical no matter what stage you are working on.  Have an overview of what you are working on and the direction you are going.  Consistency is important regardless of which alter you’re working with.  Don’t lose sight that you’re dealing with a complex system of selves as well as a whole human being. 

Stage Two Treatment

     Loewenstein said that done correctly Stage Two trauma processing can be a very important and powerful process for some of our patients.  He noted that it helps patients, for whom it is indicated, become more integrated and get much better.  Yet, he emphasized the need for lengthy, obsessively careful, and extensive planning in order to manage this phase of treatment successfully.  Furthermore he reminded us that many patients will not have the capacity to move beyond the stabilization phase.

     The reasons NOT to go forward with Stage Two work include: fear of pain associated with the process; fear of punishment for disclosure (internal or external); fear of life disruption; not wanting to know that which could disrupt important relationships; fear of making false accusations; fear of integration as “death” of alters; fear of losing dissociation/switching as defenses; unwillingness of alters to give up each others’ “companionship,” and patient prioritizing uncovering over improvement. 

     I found this to be a rich, informative, and thoughtful program that covered a large array of topics in a sensitive and non-judgemental manner.  Although I have been able to touch on some of the learning from the day, this simple overview of some of the highlights does not do it justice.=

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