A huge barrier for survivors of abuse, especially child abuse, is the issue of trust. How do you ever establish trust with a therapist, friends and family, and how do you repair it when it falters? Since trust is the first cornerstone of therapy, lack of trust leaves the individual stalled in making therapeutic progress.

Turns out the cycle of trust and lack of trust is normal in DID. Here are my research findings with ties to my own experiences.

Barriers to trust – fear of rejection and the protective wall

Inside us we all have walls. With DID, some are very thick, having been built and reinforced over many years. Trauma in childhood prevents the child from “establishing trust and form attachment to others.” Trust has been violated. This continues throughout life, and the individual develops fear and mistrust in future relationships. [Hunter] If we don’t let anyone in, then they can’t really hurt the fragile person inside us. While it helped us survive, that protectionism now prevents true, long-lasting trust in relationships.

In my quest to possibly change therapists, I have identified trust as the main issue. But I have also acknowledged that I have difficulty with trusting anyone, including family and friends. Best friends.

Hand in hand with trust (for my anyway) is fear of rejection. As a child, I never really allowed myself to fully be included because I didn’t want to be rejected. Hung on the sidelines. Easily hurt, I felt terrible if I hurt someone but didn’t have the tools to reach out to them.

Trust is also exacerbated by the presence of alters – these parts of the personality have protected the child and the adult, and can be resistant to “coming out” in a controlled manner, even though they may have “popped out” in response to triggers, with or without the individual’s knowledge. [Hunter]

And now I realize have a very angry alter who has hurt people without my knowledge, which makes that shame in hurting people even worse.

On the flip side, I am also very easily hurt. Overly sensitive. At one time or another, those I wanted to trust have hurt me. Even now, my therapist says that they support me completely 90% of the time, but all I remember is the 10%.

Like many other survivors, I am hypersensitive to words, actions, and motivations. I have read in many places that individuals with PTSD/DID or DDNOS are very attuned to detecting lies and rejections, having been lied to many times. If I feel someone is not being completely honest, or is hiding something (whether related to me or not), I go on yellow alert and the wall begins to rise.

The added effects of amnesia

Part of the problem is memory. That declarative and emotional/trauma memories are stored in different places, often disconnected. Is this why I can’t trust? If I get triggered by the thought that I am being rejected because it brings out feelings of the past, am I literally separating my memories of friend/family’s support from my hypersensitive traumatic memories of their rejection?

But then why can’t I hold on to the good stuff – the times my friends have helped me? The negative memories are stronger?

I know my memory is broken. Long term memory filled with periods of amnesia, sometimes years long. Short term memory with gaps -missing chunks of both good times and bad.

Is it that my method to protect myself, by broken memories, and my fear of rejection are the reason why I can’t let down the wall to trust?

From what I read, yup. Again girl, within the realm of DID, you are “normal.” Man I love that word.

Fleeting versus permanent trust

I know I have trusted – I know I have the ability. In pockets of very open and honest conversation with friends and family, I have trusted completely. Cried at the strength of the connection. Conveyed that I fully intended to maintain the connection. But then later I run from the support, unable to return phone calls. The renewed fear of rejection.

I know this is my issue, and a result of my trauma. After 25-30 years, I understand FINALLY why I have these fears and difficulty trusting. It’s all the trauma and DID, and my “problem” is common. Some parts of me trust easily and want to maintain these relationships. Other parts of me are always cautious and on alert for future abuse and rejection.

A dear friend said to me, “Our friendship will not fail because of me. It will fail because you ran away from it.”

And I knew she was right. Because part of me trusted her completely, but other parts could not. I have not been able to establish complete trust. My husband says I can trust her, I know intellectually I can trust her. But why do I feel that hesitation? Have I sensed a lie? Was there one so long ago that I can’t let go of?

And with nine parts in your system, achieving COMPLETE trust requires lot of agreements to get!

So what is trust and why is it related to therapy?

I found a wonderful website that discusses research study results of patient’s concerns in DID treatment by Gudrun Frerichs, and entitled DID: Overview of Research Findings. Her blog is at http://gfrerichs.typepad.com/my_weblog/.

She finds that patients are mainly concerned with “connecting” – with three distinct stages – “Reaching out for therapy,” “Coming together,” and “Making human contact.” She identifies the issues and implications for both patients and therapists. These just resonate SO STRONGLY in me as MY PROBLEM! Right from the mouths of other individuals with DID!

“CONNECTING is a process in which DID clients who have been disconnected from themselves, from people, and from the world, gradually re-established relationships with others. It occurs because they decided to reach out for therapy, to bring all the personality parts together, and finally to make contact with other people.

“Connecting reflects the essence of the solution DID clients seek to reverse their internal dividedness.

“Having survived childhood experiences of neglect, sexual, physical, and emotional abuse, DID clients face the formidable task of overcoming their ingrained automatic protective responses of withdrawal and avoidance in order to connect with their therapist, with themselves, and finally with others in the community.

“Psychotherapists face the formidable task of connecting with a highly suspicious, highly protected, and highly crisis prone client. They have to establish a therapeutic environment in which trust and safety can be developed.

“Investigating the three stages of Connecting, we notice that in each stage DID clients have to overcome isolation and separateness by developing trust. Yet, in each stage this central task had a different emphasis as discussed in the first part of this chapter under the three stages ‘Reaching out’, ‘Coming together’, and ‘Making contact’.” [Frerich]

Wow – here I am beating myself up over my inability to trust, and Frerichs found that this is a major issue in all phases of therapy for those with DID. Cool – again, I am NORMAL! (smile).

The Three States of Connecting:

Because Frerich’s site is SO COMPREHENSIVE, I may review it in a later post. For this post, I’d like to focus just on the trust issue I am struggling with. While trust is important throughout the process, initially establishing that trust, and then being able recover lost trust, are critical in the first stage. The three states expanded a bit here for reference:

1) Reaching Out: The Symbol for Hope: Frerichs echoes available research – the first stage of healing is establishing trust and safety with a therapist.

2) Coming Together: the main task was re-connecting with the different parts of one’s personality as well as re-connecting emotionally and cognitively with one’s experiences of past abuse and trauma.

3. Connecting: This was a main concern of DID clients in the therapy process, which required that clients MAKE HUMAN CONTACT. For that they needed to overcome their fear of other people, to develop trust, and to learn how to relate. Again, fear becomes a large factor.

Barriers to trust

Reaching out for therapy symbolizes the hope and the longing for healing, for being well, and for functioning effectively in every day situations.

In order to succeed in therapy, the survivor must begin letting down the defenses of avoidance and dissociation. Therapists need to recognize these defenses or protective mechanisms, and know how to intervene while establishing new methods of coping. This is pivotal to treatment. [Frerich]

Establishing this safety and trust is the cornerstone of a successful therapeutic relationship. However, there are many factors that work against this from both the survivor’s and the therapist’s side.

Frerichs interviewed many individuals with DID and found several barriers to healing. Whether these issues exist in each therapeutic relationship, or the degree to which they exist, they are important common issues for individuals with DID and should be considered by client and therapist like.

The largest barrier to healing was lack of understanding by the therapist. A doubt that the therapist was in it “for the long haul,” or that they could feel a connection with the therapists.

Clients want therapists to suspend their ideas of what they think of is real, and try to see through the multiple eyes of the client. To convey the sense of empathy, of connection. Giving guidance and support for connectiveness – making the “human connection.” With that connection comes trust.

This [seeing through the client's eyes, making the human contact] is seen by DID clients as pivotal for understanding their actions, their thinking, and their ways of operating.

Clients also face frustration of clinicians who don’t believe the diagnosis. Clients often keep the diagnosis hidden from friends and co-workers due to the stigma associated with it. Therapists who do not deal directly with alters can also lead the client to conclude that the therapist does not believe in the diagnosis. However, DID patients of therapists who did not work with alters all showed DID on followup. [Dissociative] However, using techniques such as hypnosis, therapists can engage in lengthy conversations with alters to understand their role in the system, and make agreements on cooperation with others in the system, and to help them with their own issues. [Piper]

Clients also want to believe that their therapist can deal with whatever comes up - trauma details, etc. They could only allow themselves to believe the safety of the therapeutic relationship if they believed the therapist could support them at the same time “they were grappling for control themselves.” This is especially important over time because patients feel “lost” without understanding the symptoms. [Frerich]

Another aspect of developing trust is feeling that the therapist is knowledgeable in the area of dissociation and DID. I found a very interesting item that I can somewhat identify with. Clients feel increased control by doing their own research to understand DID. However, sometimes these same clients feel exploited by their therapists because they feel they have to educate their therapist on DID. [Frerich]

On one hand, that sharing of information is positive and shows the client’s interest in understanding the condition. On the other hand, having to educate the therapists can exacerbate the childhood feelings of exploitation and feeling used. “…I was there to educate my therapist. I know that I know more about DID than most therapists but please, I want someone to be there for me.” [Frerich]

Client’s roles and struggles that the therapist should be aware of

Trust can be easily destroyed in the early phases of therapy. Patients report that the biggest struggle was to stay motivated through therapy. Changing therapists (usually involuntarily) caused patients to become “trapped in that building trust and safety stage.”

Part of establishing safety is to develop a plan with the therapist on how to recognize that a crisis is eminent and the steps that should be taken to protect the safety of the client. What the therapist will offer, what services will be sought, etc. At that point, patients often need someone else to take control – to give them the sense that they are not just floating in the middle of the abreaction and crisis.

Such a plan can offer comfort, safety and containment to DID clients and treats them as equal partners in the therapeutic process. [Frerich]

The bottom line

This is the stage I am stuck at. Maybe I need to be reassured a hundred times, I don’t know. But the fact that Frerichs identified this as critical, I am beating myself up less for being stuck in this stage.

Only when the client was able to trust that the therapist knew what she was doing, and that the treatment would help her to recover, was she able to overcome her fear of the traumatic material and start the next phase of the healing journey. [Frerich]

Repairing broken trust

The need for control can sabotage therapy, and therapists need to be aware of this and act in way that conveys they understand the behavior is a result of the need to protect, rather than acting in a punitive manner. The breakdown in trust must be reestablished before therapeutic work can continue.

Clients often test therapists to make sure the therapist will not turn on them. That the therapist can handle it. Clients have been abused and betrayed, and may transfer that experience to the therapist and test him/her to make sure they will not do it as well. [Frerichs]

Control is a big issue – clients want to feel that they have some sense of control in the management of their therapy, since control was taken from them during the trauma. Having control over all selves is central to recovery. This need for self-control, and the client’s asking questions and challenging treatment, may be interpreted as resistance to therapy. [Frerichs]

Apparent resistance to therapy may also be caused by transference – the client pushes back with anger for seeming trivial issues can be viewed as “a demonstration of fledging selfhood.” [Dissociative]

Transference is a major impediment to trust and intensifies the sense of isolation. If the client has a negative reaction to the therapist based on past feelings of abuse, being hurt, or abandonment, a common reaction is to stop therapy. [Frerechs] This may be exacerbated if the client has difficulty being oriented to the current place and time. [Dissociative]

Transference issues are more complicated with DID patients. Each alter may develop different transference issues with the therapist – young alters may need more reassurance and nurturing. Angry alters may respond to the therapist as the abusive father or abandoning mother figure, and resist further treatment. The most common issues involve angry alters who attempt to provoke a similar response from the therapist. Responding to the transference issues of one alter while another is manifesting can cause greater problems. [Wilber] But if these issues can be worked through, that the relationship can be improved. Frerichs stresses the need to address the “holistic of the client.” [Wilber]

Faith in the process

To foster trust, the patient has to have faith in the process, which can be difficult to maintain over the long course of therapy.

The development of faith was an ongoing process during the early stages of therapy and depended to a large extent on the therapist’s ability to convey that healing was possible, that the process would produce healing, and that the client had the ability to manage the process. [Frereichs]

This also includes faith in the different personality parts – understanding that the little girl inside is actually the client, and that connections included addressing the conflicting needs of the system.

Another aspect of trust is that the different personality parts trusted different people, which can completely confuse the issue. This can become easier in the later phases of connecting when integration begins to occur, but it should be recognized as a real impediment to complete trust in the early phases of therapy.

A closing thought

My therapist said that I am in a “major setback” in my therapy. That makes me feel terrible – does that mean I am not only NOT making progress, but going backwards? I feel alone, abandoned, and in a deep hole trying to dig myself out.

I am trying to go forward – I just hitting this wall. I know part of it is my inability to trust. Please help me address this – I know the problem – please help me with the solution!

Then I read something that makes me feel much better. Trauma theory has identified isolation and difficulty establishing human connection as major issues. Therapy is fraught with cycling ability to trust, and it is normal to have to readdress trust at several times during the course of therapy. And that this is NORMAL!

“Multiples seem to teeter continuously on the brink of total disaster. Every improvement is followed by a relapse. Hostile alters threaten suicide, internal or external homicide, and assorted other catastrophes” (Putnam, 1989, p. 160).

On the edge, even little triggers can lead to “losing it” and sliding down the slope of loss of control. As recognizing and understanding triggers is a major part of therapy, constantly “losing it” and climbing back up that slope becomes a theme of therapy, and not a negative setback.

References

Dissociative Identity Disorder: Ethically unsplitting the split personality, accessed from http://mentalhealthedce.com/courses/contentDID/trkDID10.html The entire course is located at http://mentalhealthedce.com/courses/contentDID/contentsDID.html

Frerichs G. (2007). DID: Overview of Research Findings, accessed from . http://gfrerichs.typepad.com/my_weblog/301_connecting_the_overview_of_did_treatment/index.html

Hunter DM. (???). Dissociative Identity Disorder, accessed from http://www.global-therapy.com/dissociativeidentitydisorder.htm

Piper Jr. A (1998).Multiple Personality Disorder: Witchcraft Survives in the Twentieth Century, Skeptical Inquirer magazine, accessed from http://www.csicop.org/si/9805/witch.html

Wilber C. (1988). Multiple personality disorder and transference. Dissociation 1:1, March 1988, accessed from https://scholarsbank.uoregon.edu/dspace/bitstream/1794/1334/3/diss_1_1_9_OCR_rev.pdf