On supervision and treatment teams

Throughout most of my career as a public sector psychologist, working in a variety of settings, I was blessed with good supervision. The few times I either didn’t have a clinical supervisor (as in Jamaica) or didn’t get adequate supervision, I felt like I was walking a tightrope without a net. A good supervisor will listen to you as carefully as you listen to your clients, and give you feedback on how you’re doing.  Positive feedback validates your work and increases your confidence that you’re on the right track, and negative feedback teaches you humility and provides valuable instruction.

As in therapy, a good supervisor asks the right questions. (When the person you’re talking to asks spot-on follow-up questions, you know she’s listening and understands you, whether it’s a friend, therapist, or supervisor.) As your supervisor gets to know you, he will validate your competencies and strengths, be part of your continuing education as a clinician, and insure that you know the appropriate scope of your practice. He will offer constructive criticism when necessary, and may suggest resources for your professional development. He will alert you to possible ethical issues.

At  the beginning of individual supervision, the therapist being supervised might have to staff each case in some detail, until the supervisor gets to know her strengths and limitations. Later in supervision, the therapist might provide brief updates on the progress in cases already staffed and spend more time on new, or challenging, cases. In group supervision, participating clinicians may be asked to prepare case presentations, usually on their most challenging cases.

The other group setting where clinicians might be asked to present cases is in treatment team, which is a kind of group supervision. In community mental health centers (CMHCs) and other treatment facilities, each new case has to be staffed,  and the treatment plan has to be approved by a multidisciplinary treatment team. Not only do treatment teams insure that all treatment is reviewed by colleagues on an ongoing basis, they also serve a professional development function. The ideal treatment team consists of one-or-more psychiatrists, psychiatric nurses (or nurse practitioners), psychologists, social workers, counselors, and possibly specialists such as art therapists or activity therapists. Each discipline represented on a treatment team brings a different area of expertise to the table. In the best treatment teams a kind of cross-pollination of ideas occurs, as treatment plans are generated and reviewed.

I’ve been a treatment team member at CMHCs, juvenile and adult prisons, and hospitals. The smallest, at a rural satellite office of a CMHC, consisted of only a psychiatrist, a psychiatric nurse (my supervisor), and me. The largest consisted of something like fifteen members, with people from all or most of the helping professions listed above. Some treatment teams might give assignments to its members, such as  asking a psychologist to do some psychological testing for a client on someone else’s caseload. In facilities run on the medical model, treatment teams are headed by psychiatrists. In a well-run treatment team, everybody has a voice.

I’ve not only appreciated, but enjoyed most of my treatment team experiences. Working with colleagues from a variety of disciplines has broadened my knowledge and increased my appreciation of the unique contributions offered by each profession. The highest goal of both clinical supervision and treatment team staffing is to insure that clients receive effective treatment, tailored to their unique needs. I have fond memories of interactions I’ve had with a number of my clinical supervisors over the years and – full disclosure – I fell in love with one of them. We’ve been married for almost thirty years.

Maria, a psychiatric nurse, was my third clinical supervisor, and I admired her before I fell in love with her. I had the silly notion – grounded in my own insecurities as a young therapist – that group therapy wasn’t effective with chronically mentally ill clients. She set me straight, telling me that I’d be leading  a weekly group with some of my most challenging clients, and offering to co-lead the group with me until I felt competent to lead it on my own. She was my first role model for doing group therapy.

We felt awkward at first when we started dating, but Maria did the right thing and talked to her supervisor about it. He reassured her: These things happen. You know what you’re doing.

The rest is history.

 

Relapse Prevention, Part 2

In my last post I wrote about triggers for relapse and the importance of having a relapse prevention plan, if you’re trying to establish and maintain a clean-and-sober lifestyle. The relapse prevention curriculum I developed in at the University Hospital of the West Indies in Jamaica included modules on stress  management, anger management, and rational thinking – all topics I’ve covered in previous posts. In this post I’ll be writing about other aspects of recovery from addiction.

I’ve met people with serious substance abuse problems who were too  proud to admit that they needed help in their recovery. (“I’m man enough to do it on my own!”) I’ve also known drug abusers who couldn’t imagine talking to other people – especially strangers – about addiction-related things they’d done and were ashamed of. But I’ve never met a recovering addict who got and stayed clean-and-sober without help from others, either in the form of professional help, or peer support groups such as AA. The road to recovery isn’t a road to walk alone.

Although I never saw him staggering drunk, my own father was an alcoholic. A military man who prided himself on his self-control, he once went for a year without drinking, to “prove” his ability to control his drinking. He went for exactly 365 days without a drink, but he hated every day of his self-imposed sobriety. It’s a condition known in the recovery community as “dry drunk.” As planned, on Day 366 he resumed drinking, moderately at first. But within weeks he was back to hiding bottles and drinking at the level he’d been drinking before his year of “white knuckle” sobriety.

There are individuals, I’m told, who’ve regained control of their excessive drinking and become moderate “social drinkers” – but I’ve never met one. “Someday I’ll be able to drink again” is a dangerous thought for people in recovery. Addicts are notorious for irrational thinking and self-deception. Many a relapse starts with thoughts like “I’ll allow myself one beer on my birthday” or “I can still shoot pool with my drinking buddies at the bar, and just drink sodas.” One of the arguments for attending Twelve Step meetings is that in time you’ll come to recognize your own rationalizations, by listening to other addicts who’ve come to recognize their own bullshit. Twelve Step meetings are all about getting real with other addicts who they know won’t judge them, because they’ve been there, done that, themselves.

Some friends and family of addicts don’t want to support their recovery, for a variety of reasons. Other well-meaning people who care about an addicted friend of family member become enablers. With the best of intentions, they try to shield their friends or  loved ones from the natural consequences of their addictions. They think they’re being helpful, but they’re simply enabling the person to continue drinking or using. In order to truly help, enablers need to learn to practice tough love – to stop attempting to rescue the person, and to let them suffer the natural consequences of their substance abuse. A mother practicing tough love won’t bail her son out of jail, because she knows from experience that if she does, he’ll be shooting up again within hours of his release.

Most recovering addicts come to the realization at some point in their recovery that they not only have to stop their drug-of-choice, but all intoxicating substances. I’ve known a number of crack and opioid addicts who initially believed that they could substitute alcohol and/or cannabis for their drug-of-choice, only to find that it was just a bridge back to their preferred drug. Cravings are one of the most common triggers for relapse, and getting high or intoxicated doesn’t improve anyone’s judgment or ability to resist cravings.

In my last post I mentioned euphoric recall (addicts dwelling on memories of the good times they’d had drinking and drugging, before getting addicted) as a trigger. This is one form of rumination, but addicts can also ruminate about how much they’d like to get high right now. This kind of thinking activates cravings that lead to relapses.

I’ve had some personal experience with this, as a recovering nicotine addict. What I found was that when I ruminated on how good it would feel to light up a cigarette, I relapsed time and again. Eventually I was able to identify my ruminations as a predictable relapse trigger, and to stop dwelling on thoughts about how I’d like to have a smoke. I still have occasional situation-specific cravings for tobacco, but I no longer feed the initial thought with more thoughts, and the cravings only last for a few seconds. After years of being  nicotine-free, the long-term rewards of being a non-smoker outweigh any momentary cravings I might have to light up again.

Relapse prevention, Part 1

I’ve written about my two years (1991-93) as a ward psychologist on the fledgling Detox/Rehab Ward of the University Hospital of the West Indies (UHWI), in Kingston Jamaica. When I started my Peace Corps tour of service, the ward had no treatment model other than the medical model, supported by Twelve Step meetings (Alcoholics Anonymous, Narcotics Anonymous). I introduced a relapse prevention curriculum that was adopted by the ward staff. When I recently checked out the UHWI Detox/Rehab Ward (now called the Addiction Treatment Services Unit) online, I was delighted to see that it’s still using a relapse prevention model. My Peace Corps legacy was a relapse prevention manual that I wrote for use on the ward. A Returned Peace Corps Volunteer who’d served at UHWI years after my departure told me that the manual had still been in use  when he was there.

A relapse prevention approach to recovery works well within the medical model, which – like Twelve Step programs – regards addiction as a disease. I introduced the patients on the ward to the relapse prevention model in my psycho-educational groups. Addiction, I said, is a chronic, progressive, relapsing disease that is ultimately fatal, if the disease progression isn’t arrested. Chronic means it doesn’t just go away at some point. Progressive means it gets worse over time. Relapsing means that most addicts will relapse multiple times before establishing long-term sobriety – if they ever succeed in doing that.

One of the advantages of the medical (or disease) model of addiction is that it helps some alcoholics/addicts to understand why they can’t control their drinking and/or drugging: they have a disease. Guilt and self-blame don’t generally help people to come to terms with their addiction. The medical model tells addicts that while they can never be “cured” of their chronic disease, they can halt its progression and stay in long-term recovery. This is why alcoholics in AA programs still refer to themselves as alcoholics, even if they haven’t had a drink in many years. They’re not ex-alcoholics, they’re in recovery. They may have stopped the disease progression, but they remain at risk of relapse. As any recovering addict will tell you, recovery happens one day at a time.

If you’re an addict, relapse prevention means learning what puts you at risk of relapsing. There are myriad ways that people who are struggling to stay in recovery unconsciously set themselves up for relapse. The first step in creating a personalized relapse prevention plan is to identify your triggers for relapse. Triggers can be people, places, things, activities, attitudes, emotions or thoughts. Different people have different triggers.

Recovering alcoholics may have to sever relationships with their old drinking buddies and stay away from bars and parties where alcohol is served, at least in early recovery, possibly permanently. If a lover is still drinking/using, a person in recovery may have to end the relationship. A recovering crack cocaine addict may need to stay away from the places he used to score and use, and might be triggered by the sight of a crack pipe or the smell of cocaine being smoked. Stress, anger, anxiety and depression might trigger a relapse. Thoughts like, “I’ll never drink again unless ________” can be a set-up for relapse, as can euphoric recall – dwelling on thoughts about the good times you used to have getting high, before you became addicted.

The second step in creating a relapse prevention plan is knowing in advance what you’re going to do instead of using, once you’ve been triggered. That might be going to a Twelve Step meeting, calling your sponsor, or checking yourself into Rehab. If you don’t have a plan for what you’ll do when you’re triggered, you’re probably going to relapse. A slip – defined as a single episode using your drug of choice or a bridge drug – need not become a relapse, if you have a plan and act on it. All too often, when an alcoholic gives in to temptation and drinks a six-pack after an extended period of sobriety, she thinks “I blew my recovery! I may as well go to the liquor store.” If, instead, she goes to an AA meeting or calls her sponsor, and admits what she’s done, she may prevent the slip from becoming a full-blown relapse. I used to quote an African proverb I’d heard somewhere: “If you want to avoid falling where you have fallen before, don’t examine where you fell, but where you slipped.”

I don’t mean to suggest that everyone with an addiction problem has to join a Twelve Step program and go to meetings for the rest of their lives, although for  some that may be exactly what they need to do. I’m convinced that there’s more than one road to recovery. I’ll write more about relapse prevention in another post.

Psychological learning theory

I briefly covered behavior modification in a prior post. In this post I’ll explain classical and operant conditioning in more detail, with examples to illustrate the concepts. The principles of behaviorism, or learning theory, are fundamental to the science of psychology. Two of the names most commonly associated with behavioral psychology are J. B. Watson and B.F. Skinner. Two key words in learning theory are stimulus and response.

Classical conditioning is also known as Pavlovian conditioning, based on Ivan Pavlov’s famous experiments with drooling dogs. Salivation is what behaviorists call an unconditioned response to an unconditioned stimulus – the presentation of food. In other words, neither dogs nor humans have to be taught to salivate when we see and smell food that appeals to us. A bell is initially a neutral stimulus, having nothing to do with food or salivation. But when a bell is rung every time food is presented, it becomes a conditioning stimulus, as the brain learns to associate it with mealtime. Eventually the ringing of the bell alone, without the presentation of food, will stimulate salivation – a conditioned response.

Classical conditioning is one of the most powerful tools used by marketers and advertisers to condition behavior on a mass scale, through the popular media. They systematically condition consumers to associate pleasant or desirable things with symbols such as McDonalds’ golden arches, logos, slogans, jingles, and attractive people giving sales pitches. They use it because it works. You see bikini-clad babes posing at car and boat shows because it increases the sales of the cars and boats  they’re posing in front of.

Where classical conditioning is a passive mode of learning, involving the creation of unconscious associations, operant conditioning involves systematic responses that shape a target behavior, making it occur either more frequently or less frequently. The process starts with recording the baseline frequency of the target behavior, i.e. how frequently it naturally occurs without systematic reinforcements being applied. Things that happen consistently as a consequence of the target behavior will tend to make it occur more frequently, if followed by a rewarding – or positively reinforcing – response (e.g. praise, money, candy, affection, etc.). If an expected reward is withheld – negative reinforcement – or the behavior is somehow punished – aversive reinforcement – the behavior tends to occur less frequently. Negative reinforcement is also used to increase the frequency of the behavior, when an aversive consequence (e.g. pain, shaming) is removed/avoided.

We might go to work even if we don’t really want to, because we know that our behavior will be reinforced by a paycheck. We know that if we stop going to work, the reinforcer will be withheld. Operant conditioning is the way we shape the behavior of our children, and train animals to obey our commands or to learn tricks. It explains the motivation athletes have to spend long hours exercising and practicing their skills.

The other principle to understand about operant conditioning is ratios of reinforcement, which can determine how lasting a conditioned behavior is. A hungry, caged rat can be taught to press a lever relatively quickly, if it’s rewarded with a food pellet every time the lever is pressed – a 1:1 ratio of reinforcement. But if you stop reinforcing the learned behavior with food, it won’t persist. In order to make the new behavior more persistent, you gradually “thin out” the frequency of reinforcement, perhaps starting with a 1:2 ratio. Now the rat only gets food every second time it presses the lever. Then you can go to other fixed ratios (1:3, 1:4); but if the ratio becomes too thin or if the food pellets stop coming, the learned behavior ceases, or in behavioral terms is extinguished.

If you really want a target behavior to persist without reinforcing it at a fixed interval, you move to a variable ratio: you vary the ratio, so the rat doesn’t know how many times it will have to press the lever (1:2, then 1:5, then 1:3, then 1:6, then 1:2, etc.) in order to get the food pellet. A hungry rat will keep pressing the bar, having learned that it will eventually get rewarded with a pellet. A well-fed rat will find better things to do with its time.

To take this to the level of human conditioning, think of the difference between a vending machine (with a 1:1 ratio of reinforcement) and a slot machine (with a variable rate of reinforcement). Every time you feed the required amount of money into a soda machine and press a button, you expect to get a soda. If you don’t and you’re very thirsty, you might try a second time. But if your behavior isn’t reinforced the second time, you certainly won’t keep feeding money to the machine.

But if you’re sitting at a slot machine, you don’t expect to be reinforced every time you put in a quarter and pull the lever. You might  get a sequence like this: nothing, $2, nothing, nothing, $5, nothing, nothing, nothing, $3, nothing, nothing, etc.. The behavior of feeding money to the machine and pulling the lever might persist until you’re out of money. Gambling machines have been called “addictive” because when we get money back from the machine, we get a jolt of the neurotransmitter serotonin ( a positive reinforcer) and persist, anticipating the next jolt – much like a hungry rat conditioned to persist in pressing a lever, knowing it will eventually get a food pellet.

What it takes to be a psychotherapist

These are just my opinions, based on my thirty-plus years as a psychotherapist. I suspect that the first thing it takes to be an effective therapist is to feel a calling to the profession, as in a religious calling, or vocation.  I may be wrong in this belief, but I don’t think many people enter the profession with the goal of becoming wealthy or famous. (I think the same is true of the best teachers.) A basic qualification is that you’re a compassionate person by nature. I grew up thinking I was going to be a career Army officer, like my father and his father; but at the end of my service obligation I resigned my commission and decided to study psychology on the GI Bill. I knew I wanted to be a healer, not a soldier.

One factor in my calling to be a therapist was the gratitude I felt for having been raised by loving parents, in a loving family. I had a happy childhood, and the older I became, the more aware I was of my good fortune. My father felt called to lead men in combat; I felt called to help people who hadn’t been blessed as I had been, to heal and grow.

That’s not to say that a happy childhood is a prerequisite for being a good therapist. Sometimes the compassionate nature that’s a basic requirement for the profession comes from painful personal experience, and empathy for others. Dialectical Behavior Therapy (DBT), a highly effective therapy for people diagnosed with Borderline Personality Disorder, was the brainchild of Dr. Marsha Linehan. It was born from her own struggles with mental illness, and her own painful road to recovery. I’ve known a number of good therapists who were themselves in treatment for a mental illness.

Therapists are flawed human beings, like everyone else, and I’m not saying that your life has to be in anything-like-perfect order for you to be an effective therapist. But in order to be able to separate your own needs from those of your clients, you need to have the kind of self-awareness and insight that come from leading a balanced life, in which your own basic needs are being met. Any blind spots about your own personality and needs will be blind spots in your understanding of your clients’ personalities and needs. (In my opinion all therapists have blind spots; it’s a matter of how many and how big. That’s where good supervision – and an openness to being supervised – comes in.) If you  have significant unresolved conflicts in your own life, you probably need to be in therapy, yourself. Having the experience of being in therapy (some therapist training programs require it) will surely help you to be a better therapist.

You have to have the ability to be present and caring with many people who are in pain, without becoming functionally depressed. This is another reason why you’ll need to have your own psychic house in order, if you’re going to be able to help other people. In most clinical settings, being a psychotherapist carries a lot of responsibility with it. It’s a very stressful profession. If you work with clinically depressed people, you have to be prepared for the possibility that one of your clients may commit suicide. Especially if you work in the public sector, you may also have to work with violent people.

If you have a tendency to be judgmental, you can’t be a good therapist. You’re bound to encounter clients whose values are very different from your own. You have to accept the client as he is in order to help him change. Carl Rogers called this “unconditional positive regard,” and maintaining this radical acceptance may call for frequent attitude adjustments on your part. This requires self-awareness and emotional stability. It’s okay for a therapist to be a flawed human being, as long as you have some awareness of your flaws.

You need to enter the profession with an awareness of your limitations as a helping professional. You’re not there to fix people or to solve their problems. There are people entering therapy who are looking for a rescuer, because they think they need to be rescued and nobody in their social support network has been able to rescue them. (The “rescuer” is a role played by certain people in many dysfunctional families.) All you can do as a therapist is to try your best to establish a helpful relationship with your client(s) and to work with them in good faith on goals that were mutually agreed-upon. Among the appropriate roles you may play as a therapist are teacher, facilitator, coach, and even cheerleader. But you aren’t going to rescue anyone.

Sometimes you’ll fail to be helpful, despite your best efforts. Sometimes a client you thought you had a good relationship with, and were helping, will abruptly drop out of therapy; and you’ll never discover why. Sometimes you’ll feel “in over your head” with a client, not knowing what you should say or do next in your efforts to facilitate positive change. That’s when you need to appreciate the limits of your abilities to help alleviate suffering in a person you’ve come to care about. You may find that you’re not able to help someone you really, really want to help. These are humbling experiences. These are times when you need a good supervisor.

Those are the human qualities I think you need in order to become a psychotherapist. In terms of academic requirements, generally you need to have a graduate degree in psychology, sociology/social work, nursing, counseling, or a related field. If you work in the public sector, you may be “credentialed” to deliver specified clinical services, without having to be licensed in your profession. If you want to work in the private sector or have your own private practice, you’ll have to be licensed.

What you’re “supposed to feel”

No matter what kind of family or culture we were born into, we got instructed on what we should feel under this or that circumstance. Some of the instructions came in the form of admonitions (“Of course you love him, he’s your father!”) and some in the form of role modeling. As children, we learn a lot from the behaviors we observe being demonstrated by those around us.

Real love is rooted in a naturally-occurring feeling we have for another person, but love is institutionalized in a variety of ways. New mothers are “supposed to” love their babies, but this isn’t always the case. It may be a hormonal thing, as with post-partum depression, or it might be that the child was conceived by rape; but a mother who doesn’t spontaneously feel love for her newborn is usually judged or blamed. Children are “supposed to” love their parents, but not all parents are worthy of their children’s love.

We all have feelings about our feelings. We may feel ashamed for having been afraid, or angry at ourselves for being depressed. A number of people I worked with over the course of my career felt terribly guilty for not loving a parent or other close relative who had neglected and/or abused them. We can’t choose what we authentically feel about anyone, and nobody has the authority to tell you what you’re “supposed to” feel. Real loving feelings either arise spontaneously, or they don’t. It’s not something we owe someone just because we’re blood relatives.

Gestalt guru Fritz Perls said that most people are socialized to be phony. Ideally, a kiss is a genuine expression of affection or love. But many times in some families, children are told to hug and kiss a relative because (s)he’s kin, whether or not the child feels affection or love for that person. Kissing may become a hollow social ritual, performed because it’s expected. In some family situations, a child may be expected to kiss someone who has abused or neglected them, or whom they find “creepy.” In some cultures a child may be required to kiss a dead relative at a funeral. This sort of thing can be a traumatic experience. It can be a perversion of what a kiss is meant to express. You can’t make yourself love someone any more than you can make someone love you. But you might be put in a position where you feel you have to fake it. When Perls called a behavior phony, he wasn’t judging the client; he was observing that the behavior wasn’t an authentic expression of feeling.

I’ve worked with couples in loveless marriages who reflexively claim to love one another, because that’s what’s expected, when they haven’t felt love for their partner in a long time. It’s not always black and white, however. Observing my father’s parents as a youth, I came to understand the term “love/hate relationship.” Love and hate can be closely allied, and it’s been suggested that the opposite of love isn’t hate, but indifference.

Relationships can be emotionally nourishing or, at the other end of the continuum, they can be toxic. People can change, and family systems can change. Often the goal of family therapy is to change the family system and to promote reconciliation between family members. But this isn’t always possible. Bad marriages can be terminated by divorce, but your parents will always be your parents – for better or for worse. I’ve worked with people who’ve tried time and again to reconcile with family members, only to find that the relationship remains toxic to them despite their best efforts. If a client had gotten to the point where they’d concluded that a family relationship would never be anything but painful for them, I’d suggest that she had the option to “divorce” that relative. It’s a sad happenstance, but it’s sometimes necessary for healing to begin.

I’ve also suggested that not all “kinfolk” need be blood-related, that you might have brothers and sisters you haven’t met yet. There are several people in my life that I consider “found” brothers and sisters. Someone who was abused or neglected by a parent might later find a nourishing relationship with an “other mother” or with a man who feels like the father he wishes he’d had. I’ve seen it happen. The mere fact of blood relationships doesn’t necessarily confer lifelong obligations, and certainly not the obligation to feel a certain way about a member of your birth family. We feel what we feel, and there’s no “should.” Rational thinking can free us from the tyranny of “shoulds.”

Multiple personalities?

“Multiple personality disorder,” now known as dissociative identity disorder (DID), is one of the most controversial diagnoses in the field of psychiatry. While dissociation – feeling like you’re not in your body or that you’re not “yourself” – is a recognized psychiatric symptom, some mental health professionals have questioned whether a person can truly experience themselves as having multiple identities. While only a few colleagues in my thirty-plus years as a psychologist have had a client that they believed had DID, I’ve known other clinicians who’d diagnosed it in several clients they’d worked with. Psychodiagnosis, as I’ve said before, isn’t rocket science.

In my opinion, multiple personality disorder was a “fad diagnosis” for a while, influenced by the popular book and movie, The Three Faces of Eve (Joanne Woodward won an Oscar for her portrayal of Eve), and subsequently the TV movie Sybil, with Sally Fields as a woman with multiple personalities. In my career I only had one client that I treated for DID. Some of my colleagues had doubts about my diagnostic impression, because they were skeptical about “multiplicity” as a phenomenological state. But my clinical supervisor validated the diagnosis and helped me to work strategically in my treatment.

My one client with DID – I’ll call her Susan – had corresponded with Chris Sizemore in her quest to understand her experiences of blackouts, and subsequently finding evidence of having done things she had no recollection of doing. Chris was the “Eve” of The Three Faces of Eve, and she’d written a book titled I’m Eve in which she revealed that the psychiatrist who’d written the book about her hadn’t, in fact, cured her of the disorder as he’d claimed. She’d discovered that she had more than the three personalities described in the book, and it took her years of additional therapy with another therapist to resolve the issue and experience herself as a single, integrated person.

With Susan’s permission, I initiated a correspondence with Chris, who validated the therapeutic strategy I’d described to her. Each of Susan’s personalities served a distinct function in her life, and she’d come to unconsciously rely on “them” to do things she didn’t think she was capable of doing, herself. Her “core personality” wasn’t initially aware of all the other personalities, and didn’t grasp that she’d unconsciously created them. Once she understood what was happening, she was terrified at the prospect of facing the world as a single, integrated person, but deeply troubled by her frequent dissociative episodes. She knew she couldn’t go on living that way.

The primary metaphor I used in therapy was that people are like oranges. We all have different aspects of our personalities, just as an orange has multiple sections. (I’ve labeled some of mine: the lieutenant, the teacher, the player, the host, etc.) Most of us, I said, have permeable boundaries between our sections. Each section is aware of the other sections, and is aware that it’s part of a single entity – an orange. I suggested to Susan that people with DID have impermeable boundaries between (at least some of) the sections. Each “personality” was aware of the core personality, but not necessarily aware of all the others, or the complex web of selective interactions among personalities. Some of the personalities that “came out” in sessions seemed open to the notion of eventually integrating with the core personality; others feared extinction. The method of integration was to make the boundaries between the sections permeable: to help each personality to be aware of the others, the function that each served, and the fact that they were all part of the whole person that was Susan.

Over time Susan gained the insight she needed, comprehending that DID wasn’t something that had happened to her, but rather something she was unconsciously doing – and could stop doing. But first she needed to learn to trust that her core personality had all of the capabilities that she’d attributed/distributed to the “others.” She eventually achieved her goal of integrating the splintered parts of herself. We kept in touch for a while after I was transferred to another satellite office of the regional mental health center, and she maintained her awareness of herself as a single personality with multiple facets. Like the rest of us. When she tried to give me credit for her breakthrough, I said what I always said in that circumstance: “You did the work; I just helped.”

I later met Chris Sizemore, who had become an active mental health advocate and public speaker. I saw her again a few years later and got to spend some time with her. She remembered me from our first meeting and “hugged my neck,” as we say in the South, when we met for the second time and when we parted. She was a highly intelligent, warm and generous person, and did a lot to promote awareness of mental illness. I feel privileged to have encountered her.

I still believe DID is a valid diagnosis, but think it’s very rare. I never worked with another person with the diagnosis again. My therapy with Susan was one of the most complex in my career, and I never needed good supervision more than then. I felt like I was walking a tightrope between not invalidating Susan’s experience of having more than one personality, while not validating her belief that the “others” were truly separate from her core personality. I think that my study of phenomenology in grad school really helped me to help Susan to integrate her “split personality.”