In the September/October
1999 issue of the ISSD (International Society for the
Study of Dissociation ) newsletter, ISSD president
Peter Barach lists 10 changes in the treatment of DID
that have occurred in the past 10 years. Number 3 is
"Focusing on the dissociative patient as a whole."
He writes, "Along these lines, I have found that
referring to DID as the 'not to know strategy' can
facilitate this shift in focus."
Some of my patients
and I like this and find it useful in treatment
because it is non-pathological, describing a strategy
rather than a disorder. DID in adulthood is, of
course, a disorder, causing much difficulty and
dysfunction in daily living. It should stay in the
DSM and should be treated as a psychological problem.
But the etiology of DID in childhood, engendered in
experiences of abuse, suggests that it arose
originally as a strategy, as a way to avoid full
conscious experiencing of something intolerable.
Calling it the
"not to know strategy" emphasizes the
functionality of the dissociative splits. They were,
in effect, a way not to know everything all at once.
"Not to know" includes not knowing actual
events, and also their attendant emotions, cognitions
and behaviors. Blocking all or part of this knowing
allows a child to function.
This title also
puts less emphasis on the separateness of the parts,
and more on the functionality and reason for the
separateness. Along these lines, I am sometimes
calling parts "knowing areas." I talk about
them more as areas of knowing certain things rather
than as separate entities. For instance, one knowing
area can know part of what happened, and others can
know other parts. This is helpful for some patients
who have a sense of wholeness at times -- it doesn't
imply that they aren't whole.
When I think this
way, I don't use the term integration as much, when
referring to processes of unification or removal of
the dissociative barriers. While I do believe that
integration should be the goal of treatment, I think
of it more as a gradual process of increasing the
sharing of knowing among parts, than as a discrete
event. I am substituting "increasing self
knowing and self tolerance" for the term "integration."
When I work this way, the work often feels more fluid
and gentle, and there is more empowerment for the
patient. If it serves them, they can choose to share
knowing between areas. I notice that more of the work
of therapy is done with co-consciousness when we
think this way.
Example: A patient
I will call Jody had been feeling very anxious for a
week, and could not discover the reason, no matter
how much we explored it. The anxiety was becoming
intolerable. Using the "not to know"
framework, I asked if the knowledge about the source
of the anxiety was located in a knowing area, and
asked if she wanted to increase knowing between
herself and this area, in order to decrease her
anxiety. She agreed. She simply asked herself where
the knowing about the anxiety was, and if that "knowing
area" was willing to share with her. She became
aware of hearing the information being shared within
her, and, by understanding the reasons for the
anxiety, was able to take steps to diminish it.
In summary, I
propose that thinking and talking about DID in
treatment (not in terms of the DSM) can be helpful in
focusing on the wholeness of the patient, de-pathologizing
the origin of DID, and facilitating improved daily
life through increased co-consciousness.