Volume 35/Number 4IOctober 2013/Pages 324-341

RESEARCH

Recovering Identity: A QualitativeInvestigation of a Survivor ofDissociative Identity Disorder

Jesse FoxHope Bell

Lamerial JacobsonGulnora Hundley

This qualitative study investigated the subjective experience of a female survivor of DissociativeIdentity Disorder (DID). The study utilized the narrative method, interviewing the participantthree separate times. Each semi-structured interview reconstructed a particular time in theparticipant's life (past, present, and future) as it related to the disorder. Three themes emergedfrom the participant's experiences with DID: (a) therapeutic outcomes, (h) chronology of DID,and (c) misperceptions of DID.

The Diagnostic and Statistical Mariual of Mental Disorders (DSM-IV-TR;American Psychological Association [APA], 2000) identified DissociativeIdentity Disorder (DID) hy the following four criteria: (a) There must beevidence of two or more distinct and enduring personality states, defined as aunique way of perceiving, relating, and thinking about the environment andself, (b) At least two of the personalit)' states described must repeatedly controlthe individual's behavior, (c) The person experiencing the alter personalitycannot recall information for significant periods of time that are not betterexplained by ordinary memory loss, (d) The first three criteria are not betterexplained by the consumption of a psychoactive chemical or by a generalmedical condition.

With the advent of the DSM-5 in May 2013 (APA, 2013), several of thecriteria for diagnosing DID remain the same, but the DSM-5 DissociativeDisorder Work Group proposed changes that will help clinicians to diagnoseDID more accurately (APA, 2012). The new diagnosis for DID has five cri-

Jesse Fox is associated with bayola University of Maryland. Hope Bell wit the University of Texas at SanAntor}io.and Lamerial jacobson and Culnora Hundley with tie University of Centrat Florida. Corresponderjceabout this article should be addressed to Jesse Fox. Loyola University Maryland Department of PastoralCounseling. 8890 McCaw Road. Suite 380. Columbia, MD 21045. Email: jfoxl@hyoa.edu.

r 1 .324 Journal of Mental Health Counseling

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teria rather than four. The first is a more complete description of personalitystates, defined as "marked discontinuity in sense of self and sense of agency,accompanied by related alterations in affect, behavior, consciousness, memory,perception, cognition, and/or sensory-motor functioning" (APA, 2013, p. 292).Furthermore, these symptoms can be observed by either the person experien-cing possession or by external v/itnesses. The second criterion, consistent withthe current diagnosis, requires a loss of memory not better accounted for bynormal forgeffulness. The third requires the individual to experience clinicallysignificant distress in social, occupational, or other important domains of func-tioning. The fourth prohibits diagnosis if the client's experience is part of anaccepted religious or cultural practice (e.g., imaginary friend in childhood).The fifth requires that the symptoms cannot be ruled out as the result of con-suming psychoactive substances or a preexisting medical condition.

DID falls in the section of dissociative disorders in the DSM-IV-TR; as thesection title suggests, the key clinical feature is dissociation (APA, 2000), whichis defined as "a psychological state in which the individual's level of conscious-ness is altered" and for those who have experienced it, it is described as "beingseparated from their body, 'zoned out,' floating above or apart fr'om the body,detached" (Stickley & Nickeas, 2006, p. 182). More specifically, dissociationis a "disruption of and/or discontinuity in the normal, subjective integration ofone or more aspects of psychological functioning, includingbut not limitedto memory, identity, consciousness, perception, and motor control" (Spiegelet al., 2011, p. 826). Although some degree of dissociation is normal and doesnot contribute to client impairment, it is beyond the scope of this discussionto adequately explain this highly nuanced topic. Cenerally speaking, how-ever, pathological dissociation is typified as "more pervasive, disruptive, and/or distressing than normal psychobiological capacities and their failures (e.g.,ordinary forgeffulness, absorption in imaginative activities, uncertainty whetherone has done something or not, etc.)" (Spiegel et al., 2011, p. 827). For a morethorough discussion of the differences between normal and pathological disso-ciation, see Dalenberg and Paulson (2009).

The number of separate identities reported by those who have statedthey have DID range from 2 to 100, with the average number of evolved altersbeing approximately 10 and the average age for development of separate altersbeginning about 6 (National Alliance on Mental Illness [NAMI], 2000). Alteridentities may exhibit different physical and medical conditions, relationshippreferences, thoughts, feelings, and behaviors. Diagnosis of DID accounts for anestimated 1% of the general population and 1% to 20% of inpatient and outpa-tient psychiatric populations (Brand & Loewenstein, 2010). However, estimatesof the number of alters per individual and the number of individuals with DIDare questionable given the difficulty of diagnosing the disorder and pinpointingalter shift (Spiegel et al., 2011). Trauma is especially prevalent in individuals

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diagnosed with DID; about 71% have experienced childhood physical abuse and74% sexual abuse (Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006).

Survivors of DID face several challenges, among them (a) media-inducedmisperceptions of DID, (b) decreased functioning, (c) problems with intimaterelationships, and (d) decreased quality of life. To combat these challengesboth mfrd-personally and mier-personally, alters need to communicate witlione another and cooperate on an overall goal for the individual. As a meansfor managing the disorder and promoting a better quality of life, DID survivorsare encouraged to strengthen self-awareness through refiection of intra-per-sonal interaction between alters (Middleton, 2005; Rothschild, 2009). A studyinvestigating the expert practices of clinicians who specialize in DID treatmentfound that therapy with DID clients generally moves in three distinct phasesthat have the following five stages (Brand et al., 2011):

Stages one and two are characterized by a high level of focus on thera-peutic alliance, both establishing and repairing the relationship whenruptures occur, and on emotional regulation.

Experts agreed that stage tliree continues to focus on relational-basedinterventions, but it also incorporates a high level of trauma reprocess-ing, including abreaction and exposure-based interventions.

Stages four and five are typified by the cessation of trauma processing,although experts continue to use relational-based interventions andaddress emotional regulation.

Clinicians who treat dissociative disorders are also faced with challengesbecause these disorders are a symptomatic enigma (Dell, 2009; Cillig, 2009).For instance, individuals with dissociative disorders suffer from a variety ofpsychiatric syndromes that may include post-traumatic stress disorder, depres-sion, anxiety, personality disorders, relational problems, substance abuse, andeating disorders, as well as such at-risk behaviors as suicidality (Brand et al.,2009). Adding confusion to our understanding of the disorder is that studiesdescribing successful treatment of dissociative disorders are primarily clinicalcase studies. Most of the research has investigated clinical, primarily inpatient,populations; relatively few studies have described the lives of individuals withdissociative disorders in natural settings or outpatient counseling. There is alsoa dearth of research using a phenomenological approach that investigates thesubjective experience of survivors of DID who are not currently hospitalizedand howfrom their perspective (rather than the clinician's)their diagnosishas affected their lives. This suggests a gap in the literature in terms of individ-uals who have found effective ways to reduce their distress and manage theirdisorder in their everyday lives, as is the case of the participant in this study.Clearly such individuals may provide significant insight into both the subjec-tive experience of DID and how it can be managed successfully. Furthermore,

Recovering Identity

because understanding and identifying mental disorders is essenfial to ethicalpractice (American Counseling Association [ACA], 2005, Standard A.2.b,Standard E.5; American Mental Health Counselor Association [AMHCA],2010, Standard D.2), counselors need some working knowledge of DID evenif they do not plan to specialize in treatment of this rare disorder, so that theycan capably refer clients to more experienced counselors.

Despite the promise that the narrative method has for informing counsel-ing practice (Creswell, Hanson, Piano Clark, & Morales, 2007), we found onlyone study that had used this method with an individual who had DID (Stickley& Nickeas, 2006). The purpose of the current study was to add to the literatureby exploring the subjective experience of a DID survivor through interviews.The narrative examines the history of the survivor, her present experienee as itrelates to DID, and the meaning she has drawn from her experiences with thedisorder. Two researeh questions guided the investigation: (a) What is the sub-jective experience of a survivor of DID? (b) How does DID affect the qualityof a survivor's life?

METHODOLOGY

This study used a narrative method to extract meaning from the partic-ipant's story (Hays & Wood, 2011). "Narratology" consists of "gathering datathrough collecting [the participant's] stories, reporting individual experiences,and chronologically ordering the meaning of those experiences" (Creswell etal., 2007, p. 240). The form of the narrative (beginning, middle, and end) istherefore essential to the meaning of the participant's story. Furthermore, nar-rative research has promising potenfial to inform the research on and pracficeof counseling, given its similarity to the therapeutic processcounselors helptheir clients by hearing and understanding their stories (Creswell et al , 2007;Hays & Wood, 2011). However, Hays and Wood warned that researchers whouse narratology should exercise caution in determining the climax and con-clusion of the participant's story. Unlike grounded theory, narratology is notguided by saturation, which makes it difficult for researchers to decide whereand when to end their inquiry. To address this challenge, we used Seidman's(2006) three-part, phenomenological-based interviewing strategy to structurethe investigation. Seidman's method is consistent with the philosophy ofnarratology in that it organizes the collection of data on the participant's past,current, and future experience of phenomena being investigated.

Data CollectionThe Seidman (2006) method gives participants an opportunity to recon-

struct their experiences with phenomena under investigation and is not limitedby topic. It is also philosophically consistent with the purpose of narratol-

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ogythe chronological collection and ordering of the subject's experiencesin order to derive meaning from the form of the story (Hays & Wood, 2011).Three of us interviewed the subject separately in secure locations within alarge southeastern research university. Gonsistent with the Seidman (2006)method, the interviews took place at one-week intervals to allow the partici-pant ample time to reflect upon her disclosures, thereby adding depth to eachsubsequent interview without losing the story line. The interviews focused onthe following domains in chronological succession: (a) detailing the context ofthe participant's history with DID, (b) reconstructing the details of her presentexperience with DID, and (c) reflecting on the future and the meaning of herexperience as they relate to DID. Since the purpose of each interview was toinvestigate a different aspect of the participant's experience with DID, we drewup a semi-structured interview protocol to ensure that questions asked werenot redundant between interviews. All three interviews were audiotaped andtranscribed for detailed analysis.

ParticipantThe participant was a 35-year-old Gaucasian female with a history of DID.

She was recruited by a member of the research team who had previously part-nered with her to advocate for survivors of DID. Because of this long-standingrelationship with the participant, we were able to verify the authenticity of herexperiences with the disorder and obtain reliable interview data. We obtainedinformed consent from the participant and approval from the InstitutionalReview Board to conduct the interviews and publish the findings.

Data AnalysisThe three-step data analysis consisted of deriving codes, categories, and

themes from the interview transcriptions. This procedure is common to manyapproaches to analyzing qualitative data (Greswell, 2007). As a validity check,each interview was analyzed by researchers other than the one who conductedit, and initial codes were entered into three separate coding documents. Aftereach transcript was coded, code documents were compared and redundantcodes combined. From the final list of codes, we created the categories thatemerged by clustering codes under new category names. From this list, weidentified themes that tied the categories together. The final themes identifiedwere therapeutic outcomes, chronology of DID, and misperceptions of DID.

Researcher ReflexivityThrough reflexivity, researchers can position themselves in relation to the

study they are implementing by becoming aware of their subjectivity and har-nessing its power to contribute to rather than detract from the research findings(Greswell, 2007; Glesne, 2006). As a group that has collaborated on previous

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investigations of the experiences of survivors with DID, we are heavily investedin both the research and the practice of helping people with this rare disorder.We acknowledge a possible bias that may be a source of both great strengthand potential weakness in terms of this study's findings. The narrative researchmethodology we used corresponds well to previous therapeutic training, whichallows us to generalize our skills as practitioners into the interview process.Since each researcher was first a practitioner, for instance, there was potentialfor each of us to experience a blurring of roles and act as counselor rather thanresearcher. Therefore, we acknowledge the potential that our bias to help theclient could have overshadowed our desire to represent the data authentically.

We also have diverse backgrounds of age, gender identity, ethnicity, sexualorientation, geographical origin, education, and family upbringing. Our diver-sity allowed us to bring in-depth perspectives to the process of data collection,analysis, and understanding our findings. However, the potential for personalbias was ever-present. Although each researcher has had extensive trainingin understanding and owning personal values, experiences, and perspectives,these may still have influenced this study's findings at some point.

Threats to Validity, Verification Strategies, and Ethical IssuesBoth Creswell (2007) and Clesne (2006) suggested strategies that can

be used in qualitative research to counteract personal biases and bolster theauthenticity of data collection, analysis, and findings. For purposes of validityand verification, we employed researcher reflexivity, investigator triangulation,and an external auditor. We used reflexivity by articulaUng individual positionsand confinuing to reflect on personal biases throughout data collection andinterpretation.

In terms of triangulation, three different researchers conducted the inter-views. Seidman (2006) stated, 'Though [ interviewers] may be disciplined anddedicated to keeping the interviews as part of the participant's meaning-makingprocess, interviewers are also a part of that process" (p. 22). Having differentinterviewers afforded each of us the opportunity to have first-hand experiencewith the participant and her story. Furthermore, after collecting the interviewdata, we traded transcripts and analyzed interviews we had not personally con-ducted. The combination of personal experience in interviewing and analyzingan interview by someone else helped to balance each researcher's perspectiveson the participant's process of making meaning. Although we have alreadysuggested that having three interviewers helped to add a layer of investigatortriangulation to the study, we acknowledge this strategy introduces a potentialfor discontinuity between inter\'iews. Interviewing relies on the strength of therelationship between interviewer and participant to foster self-disclosure andobtain rich qualitative data for analysis (Seidman, 2006). Using different inter-viewers may have limited the depth of disclosure by causing our participant

to spend more time warming up in interviews two and three than if there hadbeen only one interviewer.

Last, our research team included an external auditor who is an expert inDID treatment with three doc to ral-level degrees, one of them a medical degreein psychiatry. The auditor's tasks were adapted fi^om Consensual QualitativeResearch Methodology (CQR; Hill et al., 2005): review of both the threetranscribed interviews and the findings and suggestions for revisions when ourinterpretation of the data seemed inaccurate. The auditor provided feedbackand recommended changes related to the accuracy of the codes and codingsystem and suggested collapsing certain subcategories and using different termsfor certain words to try to better capture the essence of the codes.

A potential ethical concern of this study was protection of the participant'sidentity during presentation of the findings; since the purpose of the narrativedesign is to capture the significant details of the participant's life as it relatesto DID, there is a danger of publishing information unique to the individual.To protect against that we gave the participant a fictitious name, Sophia, andwill generalize otherwise specific details of her disclosures that could threatenconfidentiality.

RESULTS

The coding process of the interviews resulted in three overarchingthemes: outcomes, chronology of DID, and misperceptions of DID. Eachcontains categories with codes embedded from all interviews conducted withSophia. As noted, lists of the initial codes, categories, and themes were createdafter reviewing and analyzing the data against a small list of codes drawn fromprevious studies. The results are presented thematically and the categories thatcomprise each theme are described in detail.

Therapeutic OutcomesThe outcomes theme had two categories, positive and negative.Positive outcomes. Although DID was a difficult disorder for Sophia to

cope with and stemmed firom negative childhood events, the data revealedmany positive outcomes, such as self-efficacy, empowerment, and positive rela-tionships (see Table 1 for the full code list). With regard to self-esteem, Sophiamentioned, "I think a lot of that helped me to have better self-esteem and abetter outlook on myself in general," which indicates that her self-confidenceincreased over time during therapy.

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Table I. Themes, Categories, and Codes

Outcomes

Positive Outcomes

Empowerment

Self-efficacy

Increased communication

Positive relationships

High intelligence

Hope

Empoviiering others

Normalization

Negative Outcomes

Fear of disclosure

Relationship difficulties

Suicidal ideation

Defense mechanism

Desperation to be believed and understood

False recovery

Isolation

Undefined Spiritua/ity

Chronology of DID

Abuse History

History of childhood abuse

Characteristics

Decision making

Dissociation

Situational triggers

Alter roles

Depersonalization

Alters present

Confusion over symptoms

Therapeutic /mp/ications

Effective therapy

Ineffective therapy

Pivota/ Moments

Diagnosis as life-changing

Misperceptions of D ID

Inaccurate Media Portrayal

Sophia reframed many of the symptoms she currently experiences aschallenges, stating "I don't know if I have symptoms anymore because ...that just implies that you have an issue. But I don't think I have symptoms, Ijust have my challenges." Learning to normalize her symptoms as challengeshelped Sophia to see her experiences with DID as something to be organizedand dealt with rather than as a sickness to be cured. She further emphasized,"Those challenges, I know what they are, so it's not like a symptom, it's just apart of living with DID."

Strong relafionships were another positive outcome of DID for Sophia.Through the process of finding her own healing through counseling, Sophiahas been able to share her story with other people. She found that after reveal-ing her diagnosis and experiences to people they sometimes told her secrets oftheir own, including their personal struggles with mental illness. As a result,Sophia began to experience a level of intimacy in her relationships that sur-prised her. She stated:

I know so many of my friends' secrets that I never thought I wouldhave ever known or care to know, but it just made them feel thatmuch more connected to me, which is why I think I have the strongrelationships that I have.

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By sharing her story with other people Sophia was able to not only maintainpositive relationships, which had been a major difficulty for her after thetrauma and dissociation she experienced, but was also able to empower othersto find resolutions to their own life circumstances and difficulties. In addition,after telling her closest friends about her life with DID, she noticed that she nolonger had to explain some of her idiosyncrasies to them because they alreadyunderstood them, and added, "That's why it's so much easier that she knows Ihave DID because she absolutely understood what was going on."

Negative outcomes. Coping with DID did create many obstacles forSophia, among them desperation to be believed by others, especially therapists.Sophia mentioned the feeling of hopelessness, for example: "I think throughmost of the trauma therapyfrom the time I was diagnosed, the stabilization,and the trauma processingI think through that whole time I was in anentirely hopeless state." Another problem was the difficulty of establishing rela-tionships, especially after beginning therapy. She stated that becoming "physi-cally and emotionally intimate is when the floodgates opened," often resultingin her own retraumatization and distancing herself from possible relationships.

One of the greatest fears Sophia dealt with during her experiences withDID was of being rejected by other people because of her diagnosis, especiallyby friends, family, and her profession. She recounted morose visions in whichshe would be told that she could no longer be a teacher because her conditionmade her unstable and therefore unsuitable to work with minors. That fearwas sometimes agitated when parents from her class would ask her for moreinformation about her diagnosis, believing "they would not allow me to teachtheir children and they would have these preconceived notions and they wouldtake their children out of my class."

Chronology of DID ThemeThe chronology of DID theme covered four categories: abuse history,

characteristics, therapeutic implications, and pivotal moments.Abuse history. From the age of 2 on Sophia had a difficult and abusive

childhood, with repeated sexual, physical, and emotional abuse by differentfamily members. Her DID symptoms appeared during this time as a protectivefunction that allowed her to "run away both physically and mentally." Whendiscussing memory of the abuse, she stated "I don't experience them as my ownexperiences ... I know that they happened, but they happened in different partsof me." The abuse continued until Sophia attempted suicide and disclosed herabuse to a mental health worker. She was then placed in the household of anon-offending family member, where the quiet atmosphere facilitated her rec-ognition of the different voices occurring within her, periods of time that weremissing, and mood swings.

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Gharacteristics. The characteristics of Sophia's DID reflect her symp-toms, such as alter presence and roles, decision-making, and co-occurringsymptoms. These run chronologically, with past symptoms and characteristicsdiscussed first, flowing into current characteristics. Discussing the origin of heralters, she stated, "I always remember the main alters that I have. I can remem-ber them forever. ... I can clearly remember talking to them before I was inkindergarten," and "I don't remember not hearing them I didn't know whatit was, of course." Sophia felt her symptoms were largely unnoticed by others,with a few exceptions; "People thought I was very moody because my emo-tions were so random and off the wall and constantly changing," and "peoplethought I was a little spacey."

Sophia's symptoms were dominated by blurred time and feelings of forget-fulness: "I was the sticky note queen because I couldn't remember anything."Sophia also discussed feeling shame and isolation, having "a lot of the 'what'swrong with me' kind of feelings, like I must be flawed or I must be crazy, orwhy am I acting this way." The DID symptoms were accompanied by suchconditions as an eating disorder, drug and alcohol abuse, and suicidal ideation.

Although the alters most likely always had roles, once in therapy Sophiawas able to delegate and organize alters to keep track of different jobs: "Thecaretaker made sure that we remembered to brush our teeth, and that we atebreakfast and brushed our hair." Furthermore, the genders of the alters com-plement their unique personas. For instance, Sophia explained that the altershe assigned the role of "protector" is known for his intense anger. Sometimeshis anger will break into consciousness, as when she is having a minor conflictwith her partner or when she perceives a danger in a given social circumstance.

Gurrently, Sophia described herself as being "eo-conscious," meaning sheis able to communicate with her alters without dissociating from the here andnow, although this was not always the case. Moreover, it was only after counsel-ing that Sophia became able to recognize her alters' distinct personas. Throughthe course of her therapy, Sophia was able to identify seven alters. With thehelp of her counselor, she integrated the seven into five, only to discover twomore later. Sophia mentioned that one of the greatest difficulties for her is tonegotiate the competing interests of each alter. This is most prevalent whenshe needs to make a decision and it can make even the simplest task complex.She explained:

There is technically still seven of me and trying to make a decisionwith seven people is hard. So everything just takes longer, like whatto wear in the morning, what to make for lunch, and what we'regonna get at the store, what we're gonna get at the restaurant.

Therapeutic implications. Sophia searched several years to find a coun-selor who understood her symptoms. This resulted in codes for ineffective and

effective therapy. Due to the variety of her symptoms, accurate diagnosis puz-zled not only her but also the practitioners from whom she sought help. Forexample, in college, "I had this same depression and same, like, confusion andhearing things, and people saying I did things that I didn't do and all those samepanic attacks and nightmares and random things." The symptomatic confusionwas clear in the plethora of diagnostic labels she encountered as she soughthelp: "I was diagnosed with everything. I was schizophrenic, schizoaffective,borderline, bi-polar, ADHD." Clinicians perceived her unwillingness to acceptthese labels as evidence of denial; one clinician said she was simply "diagnosisshopping." Although finding a counselor with the appropriate knowledge fortreating DID resulted in the recovery she is currently experiencing, Sophiacategorized the bulk of her therapeutic experiences negatively. For instance,"One counselor told me 1 would grow out of it. Not to worry about it, I'll ustgrow out of it." After multiple misdiagnoses, incorrect medication prescriptions,and a general lack of understanding of dissociative disorders, Sophia becamedesperate to be believed and understood.

Once Sophia found an effective counselor, things began to change forher. This counselor had experience with dissociative disorders and set up atreatment that began with organizing her alters:

Figuring out who the voices were ... helped so much, because it justmade everything calmer, because it wasn't just this ... ball of mess.We had names for everybody; we knew what everyone's job was ...we created guidelines so that it wasn't just everyone screaming allthe time.

Once Sophia had a calmer inner environment, the counselor began process-ing her childhood trauma by, e.g., "looking at each alter, and what memoriesit had, and what experiences they had." This intensive process consisted ofthree-hour sessions twice a week for a month. Sophia described this part ofthe counseling as going "back into the valley of the emotion ... to wrestlewith all the pain that in some ways you have dissociated your entire life." Afterthis therapy she came to the realization that she is particularly susceptible todissociation from certain situational triggers, such as seeing a scary movie thatinvolves violence.

Sophia's counselor played a pivotal role in her recovery not only by beingthe "right fit" but also through support and reassurance. Sophia stated that hercounselor reassured her with statements such as "I believe in you" and "Don'tgive up" when the trauma processing became extremely difficult. AlthoughSophia is currently stable in her diagnosis, she retains five alters: "The remain-ing five of us are still present ... but we function as one unit, so we're coexist-ing." She described her current therapy as a continual process where "there'sa constant revisiting."

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Pivotal moments. The predominant pivotal moment Sophia identifiedrepeatedly was finding a counselor who understood her condition: "The defin-ing moment of my life was [the counselor] giving me that diagnosis [DID]."She went on to say, "No one ever thought to ask those questionsI didn'teven know that people knew to ask those quesfions ... I really felt like 'Oh mygod, this woman actually understands everything I'm saying.'" The feelings ofunderstanding and acceptance facilitated Sophia's healing so much that "It wasthe first time that I felt hope that I could get better "

Misperceptions of DID ThemeThe misperceptions of DID theme has only one category: media portrayal.

Though it had only one category, we chose to give the theme its own designa-tion because of its influence in societal stigmatization and misunderstandingof survivors of DID, which Sophia emphasized during her interviews. Shementioned, "If I can get one message, it's ... erase whatever you've seen on TVbecause that's not what it is." She explained that media portrayals of DID areprimarily for entertainment value. For instance, even when her symptoms wereat their worst, most people could not tell that she had a disorder. Sophia said.

The media is portraying an image. But they're portraying the imagethat we give them. Because people like me, other people who haveDID, are too afraid to come forward and say that they have DIDbecause they are afraid of the repercussions. So the media is onlyleft with the exploitation of the people who like 15 minutes of fame,I'll do anything you want, parade my altersthose are the kind ofpeople they're showing because those are the people they're getting.And it's creating this vicious circle.

She cited depictions of DID, including movies and television shows, as propa-gating myths about the disorder. She contended that, contrary to many of thesepopular depicfions, most people with DID are not unemployed or unstableand do not rapidly switch between "crazy" alters. On the contrary, she stated,"People with DID work full-time, they're married, they have children, they'rejust regular people. Who also happen to have DID."

SOPHIA'S STORY AND DID RESEARCH

We found several consistencies between the themes in Sophia's story(e.g., outcomes, chronology of DID, and misperceptions of DID) and priorresearch. In line with the traumegenic theory of DID (Cohen, 2004; Cleaves,May, & Crdena, 2001), Sophia's symptoms (amnesia and alter presence)manifested affer she experienced severe physical, sexual, and emotional abusein early childhood. Like many others with DID (see NAMI, 2000), Sophia's

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Symptoms also began ata relatively young age, before she entered kindergarten.Her experiences of successful counseling closely resembled tlie report of whatexpert clinicians of DID treatment have found effective (Brand et al., 2011).Most notably, both Sophia's story and expert responses suggest that early intreatment it is important to focus on establishing a strong therapeutic allianceand repairing any ruptures that may occur. On the other hand, the bizarresymptomatic presentation of DID confounds some clinicians and, consistentwith Sophia's experiences of misunderstanding by mental health professionals,can lead some to question the validity of the client's experiences (Cillig, 2009).In Sophia's case, misunderstanding from the mental health community was anobstacle to resolution of her distress.

LIMITATIONS

tion:Two important limitations to this study require explanati*

Qualitative research is host to many strategies for collecting data, suchas interviews, field observations, and documentary and visual data(Polkinghorne, 2005). The strategy this study used was transcribedinterviews. Without other forms of collecting data, this study is limitedto the self-disclosure of the participant. Furthermore, the depth ofdisclosure by participants is limited to the trust they have in the rela-tionship with the interviewer (Seidman, 2006). We may have missedpotentially valuable information that could have been supplementedthrough another form of data collection. To account for this limitation,we used a rigorous interviewing technique (see Seidman, 2006) to bothprovide researcher triangulation and obtain contextualized data fromwithin the participant's life story.

The purpose of this narratology was to understand the subjectiveexperience of one survivor of DID. We caution against generalizingthese findings to other individuals with DID. It is not the purpose ofqualitative research, especially narratology with one participant, togeneralize findings to the population sampled. Moreover, the manifes-tation of DID within each individual is unique, rendering any attemptto generalize its manifestation in one person to other clients with DIDpotentially misleading. However, we believe readers will find common-alities between prior research and Sophia's story, along with those ofother individuals with DID they may encounter. Also, we believe thatSophia's narrative can serve as a stimulus for counselors to pursue thetopic further as part of their professional development.

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IMPLICATIONS FOR MENTAL HEALTH COUNSELING PRACTICE

Taking the limitafions into consideration, the findings suggest thatSophia's journey from childhood trauma, the emergence of dissociative symp-toms, and her later recovery were a mixture of pain, confusion, fear, and even-tually hope. She endured many trials as she sought help for a disorder she didnot understandand, to her disappointment, neither did many of her mentalhealth professionals. However, after finding a counselor who understood herexperience, Sophia was able to find a sense of stability in her life that helpedher to not only survive but also thrive. Sophia's narrative has numerous impli-cafions for counselors: (a) being a knowledgeable and caring counselor is ofutmost importance when dealing with DID; (b) sharing experiences of DIDwith a counselor and later with trusted ftiends may help clients resolve DIDsymptomology; and (c) counselors may have an integral role in promotingaccurate percepfions of clients v/ith DID in contrast to media portrayals.

For Sophia, finding a knov/ledgeable, empathie counselor was pivotal toher healing. Sophia described her story as a tesfimony to how effective therapycan make a difference in a person's life. Consistent with expert descriptions ofeffecfive DID treatment (Brand et al., 2011), Sophia's successful experiencewith counseling seemed to follow three distinct phases: stabilizafion, traumaprocessing, and promofing daily function. Sophia's level of distress stabilizedin part with the organizafion of her alters. Working with her counselor, Sophiaassigned roles and tasks to gain control over the manifestation of her alteridenfifies. This seems to be a paradox, but giving the alters control over certaintasks (note-taking, to-do lists, deciding where to eat, etc.) actually underminedtheir ability to subvert her consciousness during fimes of distress. As she stated,giving her alters guidelines for communicafion helped to smooth out eachalter's chaotic clamoring for attention. After organizing the role of each, Sophiaprocessed with her counselor the dissociated trauma that each retained. Sophiadescribed the trauma-reprocessing phase of counseling as the most difficultbecause she had to accept the repressed emofion that each alter possessed andincorporate it into her core idenfity. These sessions were consistently threehours long. However, after progressing through the proverbial valley of her pastabuse experiences, Sophia found significant relief and turned to daily mainte-nance of her disorder.

Sophia attributed the origin of her disorder to significantly traumaficchildhood experiences, which is consistent with epidemiological studies ofdissociafive disorders (Sar, 2011), saying, "I think it was just a perfect combi-nafion of my age, being sexually abused, and my personality type." As a resultof her DID, she experienced significant interpersonal isolation. It was particu-larly difficult to listen to Sophia's description of the lack of understanding andignorance of the mental health professionals ftom whom she had sought help

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earlier. After treatment from counselors who labeled her with a wide range ofdiagnostic syndromes, including one who accused her of diagnosis shopping,she finally found a counselor who could understand her experience and pro-vide her with hope. With an accurate diagnosis of her disorder, with counselingSophia experienced significant resolution. However, her experiences of mis-diagnosis should motivate counselors to educate themselves about the subtlenuances of DID, given its complex symptomatic presentation (Gillig, 2009)and provide more effective services to clients who may suffer from the disorder.In particular, effective help could be a matter of identifying the disorder andreferring clients to clinicians who specialize in DID treatment.

Although DID constitutes a small percentage of the general and psy-chiatric inpatient populations (Brand & Loewenstein, 2010), facilitating theconnection behveen survivors of DID through support groups or group therapymay help with the resolution of distress. It is significant that after achievingpartial healing from the trauma of her childhood, Sophia was able to share herpersonal story of triumph with other people in her life. As a result, she begannoticing that people often reciprocated and told her secrets about themselvesshe never foresaw knowing. Gurrently, Sophia derives a great sense of purposeand fulfillment in helping other people like her who struggle to come to termswith DID. Gounselors who work with individuals who have DID should rec-ognize the empowering effect that sharing their stories can have on clients, thepeople in their lives, and others with who may suffer from DID. This wouldimply that counselors help their clients research resources that relate to DIDwhere clients can find social support when they are ready to reengage in rela-tionships outside of counseling.

Sophia's sense of shame stemming from the social misrepresentation ofDID is particularly troublesome. She attributed a significant portion of DID'ssocial stigmatization to popular and misleading depictions of DID in entertain-ment media. She cited television shows and motion pictures that misconstruethe often-ordinary lives of those with DID. Much like reality television shows,Sophia stated that such portrayals draw individuals seeking attention from soci-ety who use the disorder as a gimmick. Dell (2009) suggested that exaggerateddepictions of DID also mislead clinicians into believing that it is easy to identifythe disorder based on alter shift. The reality is that rapid switching betweenidentities is subtler and less common than is portrayed by the entertainmentindustry. In most cases, in only a small minority of cases does the disorderpresent so extremely. The unfortunate side effect is that Sophia has felt thestigmatization of such depictions and worries that people in her life will equateher experiences with exaggerated and often fictitious media representations ofDID. Counselors and other mental health professionals are in an ideal positionto educate and advocate for greater understanding of individuals with DIDduring individual, couples, and family therapy.

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GONGLUSION

DID is a rare and complicated disorder, with prevalence estimated at1% to 20% of psychiatric inpatient and outpafient populations, that oftenconfounds clinicians because of its highly nuanced presentation (Brand et al.,2009; Brand & Loewenstein, 2010; Dell, 2009; Swartz, 2001). Although it isdifficult to estimate precisely how many people suffer from DID, it seems clearthat some individuals diagnosed with DID have experienced significant child-hood physical and sexual abuse (Foote et al., 2006). DID also poses uniquechallenges for any sufferer, most notably intrapersonal and interpersonal dis-tress or impairment Furthermore, DID represents a challenge to any clinicianbecause its symptoms are so complex and need specialized treatment.

To help answer our research questions, we used Seidman's (2006) three-part, phenomenologically based interviewing. The participant we recruitedwas a 35-year-old Caucasian female with a history of DID, whom we namedSophia to maintain confidentiality. After the interviews, we used a variety ofverification strategies to refine our interpretation of the data; where appropri-ate we attempted to let Sophia speak for herself during the presentation of thefindings. Sophia's experiences with DID were complex; often we found clearcorrelations between her experiences and past DID research. Sophia's storycomprises three primary themes: (a) outcomes, (b) chronology of DID, and (c)misperceptions of DID.

We identified three implications of the study for the practice of mentalhealth counseling. First, both true earing and specialized knowledge of DIDwere essential to helping Sophia find resolufion. Professional counselors whodesire to work with these clients can learn from Sophia's history of misdiagnosisand seek addifional training in order to work effectively with this disorder, orat least recognize when to refer clients to counselors who are more familiarwith DID. Second, sharing her story with a caring professional helped heropen up to people who she felt were trustworthy and as a result helped her todevelop relationships and enhance her level of funcfioning. Finally, counselorscan help their clients during individual, couples, and family counseling bydemystifying media portrayals of the disorder, which are often inaccurate andexaggerated.

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