 This is not a short list of dos and don'ts. The length is due to needing some explanation for the guidelines for those unfamiliar with DID that would not be understood by one sentence e.g. Observe for switching. The uninformed would ask, "What is switching?" not knowing this meant the switch back and forth between different alter personalities/parts within the person who is DID. There is a possibility that amongst patients/clients who enter an Emergency Room/Casualty or Crisis Center there might be a man or woman who could be seeking desperate help for a condition little understood and often denied as existing, in spite of its place in the DSMIV-R diagnoses: Dissociative Identity Disorder. Hereafter, commonly termed DID, and previously named MPD (Multiple Personality Disorder) There is also the possibility of Psychiatric help being called to the ER/Casualty and an attending Physician, RN/SRN or staff responds who does not believe in DID. They may think these patients are Malingerers, Borderline, Schizophrenic or Suicidal, secondary to Major Depression or having a psychotic episode. The danger here is subscribing to any of these diagnoses and prescribing medication for a wild analysis that rather than eliminating the symptoms only serves to aggravate and exacerbate them. This list of guidelines may help to distinguish between the DID sufferer and other conditions and avoid mistreatment. 1. Personality Switching The appearance of alters, other personalities, showing themselves (known as "coming out", in which they take control of the body while present) might take a period of time in a therapist's Office until both Therapist and environment feel safe enough to do so. However, in the case of an emergency or crisis, the DID patient is driven in desperation to seek help, and might come to your Hospital or Center for relief. Because of triggers - which may be people, surroundings, sounds, sights and smells encountered that evoke conscious or unconscious memories of past traumas - alters might come out in an effort to cope with, and protect from what is perceived as potentially dangerous or painful. In actual fact, these fears are founded if there is no understanding of the condition, or belief in the phenomenon and what the patient is telling them. Evidence of switching and the presence of other parts than the person who came into to ER/Casualty or Center may be one or all of the following: Change in handwriting. Forms may be filled out in different writing. Change of names. The patient may insist they are called by a different name than the one first given. This is not a manipulation or deception but is the actual name of the presenting personality. Change of affect. (Mood). Seeing a distraught patient suddenly smile would seem to a mental health professional not only as an inappropriate affect, but that the patient might be hallucinating and responding to some unseen stimulus. Understanding DID one can consider that another alter/part has come out whose role is to comply with authority figures and who needs to smile and be "good" to receive help or attention. There are other reasons that only the part out could explain if they felt safe enough to do so. Voice Change. There may be a complete change of voice ranging from a child's small whisper/cry, to a deep masculine tone or obviously female expression. Age change. Alters can range from young children, some infants, to the elderly who might present as an octogenarian when the body is obviously in the late thirties! Change of sex identity. The patient may insist they are the opposite gender from the person who came in for help. Posture, voice and body language will also accompany this assertion. Stating " I am male" or " I am female" is not a ploy for attention but is the genuine perception of the alter who is out. If asked for a name, one appropriate to gender will be given. Presence of a history of: a. Amnesia for past and present events. b. Headaches that are not relieved by usual medication such a Tylenol, or Tylenol with Codeine, (these headaches are caused by frequent switching or inner chaos such as conflict amongst the alters dialoguing, and are not migraine or other types of head pain). c. Purchase and discovery of articles such as clothes, books, anything of interest that cannot be accounted for as having been bought. d.Hearing voices inside the head that seem to dialogue amongst themselves or with the person (Host) who is most predominantly out. This is diagnostic that the patient might indeed be DID and not schizophrenic, psychotic and suffering from auditory hallucinations. These voices are not coming from outside and giving commands. (Commands can be given by inside voices but this addresses a topic too complex for a guideline list in an Emergency Room or Crisis Center). e.Finding themselves in a strange place with no recollection of getting there. f.Being greeted by total strangers who insist having met and talked with them (these strangers have met and talked to someone - an alter who had control of the body, (also known as executive control), but whom the host, the one most often seen in public really does not know and s/he is telling the truth when saying so. g.Absences from home that might be for a few hours to days long and might include traveling many miles to the other side of the country. h.Loss of time on these occasions occurs as well losing time at home. This lost time, again, which can be short or extended over days, sometimes months and even years, is explained by understanding that other alters have taken executive control of the body and are doing what they either wish to do or have been programmed to do. Recognized symptoms of any abuse victim. a. Fear of being touched. b.Fear of authority figures. c.Inability to say " NO" and this can add do their suffering because of not realizing they have the right to refuse any treatment that feels harmful or has not been clearly explained. d.Hyper vigilance; constantly watching everything that is going on around them as well as what is happening to themselves. e.Fear of closeness. f.Either withdrawal into themselves or exhibiting extroverted behavior or being overtly promiscuous. 2. HOW TO RESPOND. Tell your name as many times as is necessary with any new personality who might come out. Remember that each one who comes out has not met you and you are a total stranger to them. Each needs to be treated with respect. Speak clearly and move slowly. This is hard sometimes in a crisis and emergency setting, but these people are instantly terrified by any sudden movement that will be perceived as potential pain or punishment. Rapid, unpredicted behavior might silence them from being able to say what they need to say, and for you to gather important data. Respect the boundaries of closeness and personal space. Do not intrude further than you see is comfortable for the patient. Allow whoever accompanies them, if there is obvious rapport between them, to stay with the patient at all times. It is likely to be a friend, relative, or even therapist or crisis counselor who knows the patient and their alters, and whose input and aid can be invaluable to both you and the patient. Where you think the alter who is out is a child, treat them as you would any frightened child. Speak softly, be gentle and reassure them of your desire to help as best you can. Use simple words they can understand, explain everything to them and allow them to draw if they cannot put into words what they are trying to say. Whatever procedure needs to be carried out, ask permission to do so and explain everything that will take place and why it is being done. When you see a strong, or any reaction to surroundings such as noise, smells, equipment, presence of new authority figures, doctors etc. explain who or what they are. (See above mention of triggers and explanations below). Be aware that when you have met a person suffering with DID they have become so as a result of tremendous and often unimaginable abuse, especially if sustained in a cult setting, religious or otherwise. Thus, what might be a normal every day occurrence for you can be a reminder of hideous experiences in which medical instruments and procedures have been used literally, or are symbolic of what has been used to torture and abuse your patient. So much so,that their mind has fragmented into parts that hold experiences too overwhelming for one person to survive and not go insane. Dissociating into these fragmented parts, and with the split off part of the mind creating alters to take what one person cannot handle, is why you might encounter more than one personality in the patient who comes seeking your help and understanding. 3. Triggering Procedures Undressing. Abuse victims were made to undress and remain naked for child pornography, prostitution, bestiality, molestation and sexual violations at home or in cult rituals. Undressing, therefore, can arouse memories of any of these traumas and PRIVACY is of utmost importance throughout ANY procedures ordered. Accompanying friends or relatives should also be allowed to stay with the patient at all times. You are much more likely to obtain cooperation with this in place. 4.Intrusive Procedures a) Abuse victims, especially cult survivors, often known as SRA (satanic ritual abuse) survivors have been forced to endure needles inserted under finger or toe nails and in other body parts. Hence, a nurse or doctor coming to draw blood can cause recall of such memories associated with needle experiences. Blood, in and of itself, for cult survivors who are DID, even without a procedure, is a reminder of rituals involving sacrifice of humans and animals, cannibalism, and other ritual events. The sight and smell of blood can be terrifying to such a patient and may also remind them of being forced to drink blood along with other body fluids, or drugs. b) Images of the insertion of objects such as crucifixes, guns, knives, or other foreign objects into their anus, vagina or mouth will be evoked by gynecological examinations, enemas (some cults give enemas to force diarrhea then force ingestion of the feces and urine as punishment), suppositories and catheters. Drugged food and drink will be remembered when the patient is told to take oral medication, have a throat examination or offered food and drink, however kindly motivated, by the staff. Do not take it personally if a patient is refusing to eat or drink as it is not because of you, or that they are trying to be difficult. Their reasons for refusal are legitimate and are associated with horrors you cannot assimilate without knowledge of their true histories. c) The generalized incidence of rape by men, women and animals will be cause for extreme reactions to gynecological procedures and may also bring up memories of abortions experienced or observed. d) EEG’s, electro encephalograms, can trigger conscious or unconscious associations to stun guns, electrical shocks, insertions of wires and chips into the brain for programming purposes. Thus, terror is evoked around ECG’s. Scans or like procedures which need to be explained, permission granted, and the procedure canceled if the patient is obviously retraumatised by the sight and thought of it. e) It is a tragedy to see that patients who act out violently in some settings are still being placed in four point restraints or even tied with poseys (a soft canvas like cloth restraint). ANY restrictions of this kind will trigger victims who have been bound by ropes, tape, or chains by abusers for rape or torture, especially around the wrists, neck, chest, and ankles. All the points, please note, that are immobilized by restraints. At one time I volunteered to be put into the restraints so I could feel how it is, and I was not even acting out ! ... thus did not know the stress of patients who are restrained for their violent acting out. Acting out for them being a violent terror-based reaction to feeling trapped, in which restraints only compound the terror.OR, the acting out can be rage that needs to be recognized for what it is and asked its cause rather than immediately turning to physical force as a solution. Multiples are all too familiar with forced bondage. Final note. Whether DID or some other condition your patient may come in presenting, there are essential components to your attitude and behavior, especially to DID patients, that will enable optimum cooperation, further understanding of what is the real underlying problem(s,and in turn, advance a more accurate diagnosis. These include: 1. Treat them with respect. Whether it is an adult or child you are faced with. 2. Listen, (don’t just hear and ignore) to what is being told. Look for the message in the message that body language can tell you when the words are not enough. Especially with child alters. 3. Explain everything that is happening, will, or may happen. 4. Honor Personal Space. Move slowly - and ask permission before touching or starting any intrusive procedure. 5. With DID patients, continually orient and reorient when needed, especially if different alters come out. 6.If you see any of the above indications that your patient might be DID, believe what they are telling you and try to find an accepting milieu or Therapist where they will receive treatment appropriate for the condition. 7. If you, yourself, have little or no knowledge of DID go to workshops, read as many books and articles that you can find on the subject. Decry the assertion that what Multiples tell you are all false memories. I am not discounting that there are those who use false memories for mercenary or malingering purposes, but there are too much data from men, women and children, who have no knowledge of each other and who are separated by age, ethnic, demographic, educational and economic differences all presenting the same symptoms and histories, for this phenomenon to be the fabrication or fantasy of so many minds. As a number of my DID friends and clients have asked me, "Who would want to make up such stories that make me live in constant fear, with night terrors and suffering physical pain from past abuse. To say nothing of the emotional and psychological anguish I struggle with all the time?" People who are blind cannot see the sun and might deny its existence but they cannot deny feeling its influence - the warmth that flows from it. The uninformed about DID, or the abusers whose actions and behavior have resulted in children dissociating, or adults dissociating and becoming multiple, deny its existence. The former deny it because of ignorance, unbelief that such horrors could be true, or they have never encountered anyone who is DID. The latter, the abusers, deny the stories of DID survivors because they have programmed their victims to silence, and denial protects their identity as perpetrating evil. Mental Health professionals, Medical staff, friends and relatives of Multiples, like all who feel the influence of the sun, feel what radiates from these survivors seeking healing, and for those of you working in Emergency Rooms/Casualty Departments and Crisis Centers, you are often the first to encounter and hear their cry for help. Work with open minds and hearts, there are malingerers out there, manipulators and hysterics, but there are also DID men and women whose truth may seem incredible but whose story and symptomatic presentation reflect that truth. Please don't MISS it! Medicine balances its skills with money. We have a LIFE on one side of the scale and our skills on the other. Let us keep the latter picture firmly in mind. Goessoftly Retired Therapist www.goesoftlyishere.com (permission for reprints required)   | Normalizing and Demystifying DID | DID and Littles.(Child/Young Alters) | ISOLATION | Mono's Disbelief | Distortion: Good and Evil | ASPECTS OF BODY CHANGES | Relationships | Across The Board | Across The Board | FORGIVENESS | I am BAD | Headaches | LYING AND DECEPTION | LOST and LOSS | EYES | Controversy. Research projects. | Feeling is Healing | Alone and Aloneness | VICTIM or VICTOR ? | TEARS | Medication and DID | DID Emergency Room/Casualty and Crisis Center Guid | Acknowledging The Inside Community | The NO TALK Rule. Silencing. | | THE HEALING PROCESS | DISSOCIATIVE IDENTITY DISORDER | POETRY | Biographical Entries | THE OTHER SIDE OF LIFE | STORIES FOR LITTLES (Pigmus and friends) | SEEDLING THOUGHTS TO WATER | | Return Home | Great Links | Sign/View Guestbook | |
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