When creating a treatment plan for DID, it's important to consider the symptoms of your client, their current state and readiness for treatment, the individualized goals of the plan, and treatment approaches to be applied.
Comprehensive assessment and differential diagnosis
Aim to gather comprehensive information to get a clear picture of a client’s DID. It's important to distinguish DID from other mental health, neurological, and medical health disorders through differential diagnosis. Consider including a trauma-informed inquiry into dissociative symptoms in congruence with the DSM-V-TR.
Behavioral observations are useful, as well as research-validated assessments such as the SCID-D and DES that can be applied initially and over time as well. Multiple assessments can be valuable to give a clearer diagnostic picture. It is generally recommended that assessments be applied at a consistent cadence (i.e. 3 months), but can also be applied if there are any notable changes, such as moving to a different phase of treatment, or significant shifts in life circumstances or symptoms. If there's a signed release of information for a close loved one, that can also provide useful information.
Once you have an initial clinical conceptualization, it will be important to diagnose the correct ICD-10 code for documentation and billing purposes.
Understanding the client’s internal system
Mapping out the client’s internal world with them should be part of the treatment plan. Understanding the unique identities, or “alters,” of the client is essential for working with them. Over time, through discussion, assessment, and observation, you will start to see the unique memories, experiences, roles, emotions, and physiological responses tied to each identity. These identities carry different responsibilities, such as self-protection or carrying traumatic memories from childhood. Exploring each different identity with understanding and respect can lead to developing trust with clients and their system.
Goal setting with the system
Goal-setting with a DID client should be a compassionate and collaborative process. It can be helpful to incorporate the different parts into the planning process. Treatment plans, especially if treatment is being paid for by insurance, need to include SMART objectives that are specific, measurable, achievable, relevant, and time-bound. However, since DID clients are often affected by trauma and internal experiences, it can be helpful to have some flexibility for goals and objectives. Tracking progress should be measurable, and not overly harsh. It's important to exude compassion for the often non-linear nature of client change.
According to the ISSTD Journal of Trauma and Dissociation, some common overarching goals for DID include: fusion, where the client integrates into one identity, or integration (also known as functional multiplicity), in which multiple identities are maintained but life is lived with greater collaboration, stability, and well-being. The ISSTD emphasizes that fusion is the most complete resolution, however some clients may not be able to achieve this or desire to achieve this goal and thus opt for integration. As with all treatment, the ultimate goals should be determined by the client.
Building a multidisciplinary support plan
Multiple angles of support are typically the most effective approach to DID. Creating a multidisciplinary team, each with their own role, can provide the necessary support. Psychotherapy, psychiatric medication management, case management, support services, medical evaluation, and a safety plan are all components that can be included in the plan if it's necessary and the resources are available. The collaboration should be documented in the plan.
Developing a support team depends on the client’s goals, their current support already in place, and their capacity to initiate a search. If the client has existing people on their treatment team, such as a psychiatrist or case manager, it's important to get the client’s consent to interact with them and start collaborating. Clients without providers, but with motivation and knowledge of where to find them, may benefit from encouragement and accountability with their progress. Clients with no provider and no knowledge of where to find them, may benefit from assistance identifying suitable resources, such as local organizations or reputable online directories.
Regular check-ins and plan flexibility
Part of building trust over time is consistent check-ins with the client. These discussions can help to understand the progress so far and the response to the treatment plan. Flexibility is needed based on what the check-ins reveal. Changes in the treatment plan can be made based on client choices, preferences, and mitigation of the risk of overwhelming or retraumatizing the client. There should be room to view setbacks with the treatment plan not as failures, but as opportunities for growth and resilience.
