By Rachel Downing, L.C.S.W.-C.
© 2003 Sidran Institute. This article may not be reproduced without express permission of the publisher. Contact email@example.com.
The purpose of writing this article is to provide survivors with DID and therapists who treat DID with a greater understanding of integration and life after integration. One of the least understood aspects of the treatment of Dissociative Identity Disorder (DID) is the concept of integration. Information on this topic for professionals or individuals with DID is limited. Therapists may have difficulty explaining what integration means and how it will benefit their clients. Individuals with DID often express fear of integration. Sometimes survivors feel that the integration of personalities is disrespectful of the important role they have played in their survival.
In material written by DID survivors, integration has been referred to as the "I" word. In a recently published book for survivors with DID, therapists are advised not to discuss integration with clients until the latter stages of therapy, when the issue of what to do about the personalities needs to be faced. Survivors write (and talk on TV) about their right to remain DID and not have integration forced on them by therapists.
One recently published book about recovery from DID written by several individuals supposedly recovered/integrated did not live up to its billing. Some of the authors acknowledge that they still are dissociative, yet they consider themselves healed. I attended a workshop held by two individuals integrated/recovered from DID. When asked whether integration was a necessary part of healing, they considered it a personal choice. They were unable to articulate the advantages of integration and non-dissociative coping.
When I read material written by individuals who fear integration and choose to stay dissociative, I sense that the decision is based on inadequate understanding. It is very human to fear things we do not understand. Fear of the unknown holds people back, whether DID or non-DID. Without more information about integration and trauma recovery, how can individuals with DID be informed consumers and make knowledgeable choices?
As a fully integrated person (formerly DID) and a trained therapist, I decided it was important to speak out about the naturalness of integration, the benefits of integration, and the peace that comes with full acceptance and ownership of all parts of oneself. I want survivors to understand integration as a friend, not a foe. To see integration as a goal not set by therapists, but sought after by survivors who want normal lives as whole people.
In 1990, I experienced my final integration after 11 years of DID therapy. When I was going through the process of integration I searched for information about the process and what to expect. I was disappointed that practically nothing had been written either for therapists or for clients.
When I reviewed the literature on integration this year for this article, I discovered how minimally the issue of integration and post-integration therapy has been addressed even now. Given that integration and post-integration therapy is estimated to require one-fourth to one-third of the total treatment, this lack of information is surprising. Overall I was disappointed with the lack of usable information for survivors and therapists about integration. For a current review of the literature and websites on this topic see the appendix to this article.
At the most basic level, integration simply means acceptance/ownership of all thoughts, feelings, fears, beliefs, experiences and memories (often labeled as personalities) as me/mine. It means giving up the split(s) that says something is "not me." Integration is more than about personalities. It is about full acceptance of all dissociated aspects of oneself. Integration is a process not an event. It occurs throughout therapy (and outside of therapy) as dissociated aspects of one's self become known, accepted and integrated into normal awareness. It is a natural process in the recovery from trauma. It brings a kind of peace that comes with fully accepting and loving yourself.
During the course of my therapy, I accepted/integrated many new awarenesses about myself. I accepted the core accounts of trauma and my feelings about this. It was hard for me to face the fact that my father had hurt me. I had kept the memories of his abuse separate from my everyday belief that my father loved me and wanted what was best for me. Having to rewrite my life story taking into account the abuse was one aspect of the integration for me.
Integration occurs when I accept a dissociated personality, part, or aspect of myself and bring it into normal awareness. It is not about getting rid of or killing off a part of myself. When I maintain the split and say it is "not me," I am implicitly rejecting that part of myself. Essentially, integration is fully embracing each and every part/aspect of myself.
Full acceptance allows greater self-control and choices. This is true not just for individuals with DID, but for non-DID as well. For example, when I deny, reject or dissociate that I have a problem with binge eating, I am not able to work on the problem. When I admit/accept that I have the problem, I can take action to deal with my feelings and choose new ways to handle the problem. With DID, when I deny/reject a part of myself that wants to cut/hurt me, I can't control that part of myself. When I incorporate that part of myself I gain control and choices.
REASONS TO INTEGRATE
I feel sad when I read accounts by individuals with DID who choose to stay dissociative. I fear they do not understand integration as a natural part of the healing process. I remember after I integrated all of the personalities, I was surprised that I still had all of the thoughts and feelings that had been labeled as personalities. I came to realize that the personalities were always and only a collection of thoughts, feelings, experiences and memories that had been separated from normal awareness and from other collections of thoughts, feelings, experiences and memories. Personalities are not real people. They are aspects of one person that have been separated from normal awareness. After my final integration, I realized that the personalities were a way to describe my internal experience. With therapy, I changed my internal experience and learned new ways to describe my inner thoughts and feelings.
I now understand that the personalities developed in my childhood before a clear sense of self-identity was established. Being able to develop personalities and compartmentalize the trauma was necessary for survival. Early trauma is an essential part of the development of DID. Trauma later in life -- even ongoing intense trauma such as war -- does not result in the development of DID.
After I became an adult and no longer lived in violent, abusive or unsafe circumstances, I had the freedom to choose new coping methods. I had the freedom to let go of my childhood defenses. I no longer needed survival as the guiding principle for my life. Remaining dissociative maintains survival based thinking. Integration is a choice to do more than just survive.
When I still had DID and wanting to be integrated more than anything else, I didn't fully understand what integration would mean to my functioning and my life. I just knew I wanted to have full access to my whole self without having to dissociate. I wanted a stable sense of identity. I didn't want who I was shifting, based on triggers or the environment. I wanted what had been taken from me by the abuse -- a stable sense of self, consistent functioning and normal awareness. I felt like a person might feel who was abused/assaulted resulting in being crippled in a wheelchair. If that happened I would want my full functioning back. Yes, I could adjust to life in a wheelchair, but why accept the limitations if I could have full recovery and run again? I felt the same way about my recovery from trauma. I didn't want it continuing to determine my sense of self and functioning. I wanted to run again.
Now that I have had twelve years of being integrated, I am better able to describe the positive impact of integration on my life. There are four dimensions of how integration has changed me.
1. Relationship to Myself. It is my experience that integration represents a statement of self-love. Claiming all aspects of myself as ME is incredibly freeing. It is a way of embracing my humanness and realizing the capacity for healing. I now have a full range of feelings available to me. In general I can choose how I want to act in the present moment and not have my actions determined by my trauma history. I am fully open to my whole self. Nothing is excluded. This full acceptance of myself allows me to have a new life. How I felt after my integration is expressed in the words from the country song, "Unbroken":
You held me up to the sunlight. Now it feels like -- No one ever left me out in the rain, Cold words remain unspoken and I never got lost, spent years in the dark... and I'm unbroken.
2. Relationship to Others. One of the most rewarding aspects of being integrated is the positive change in my relationship with others. Before my integration I had many faithful and long-term friends. They hung in with me through the years of struggle. They were there for me. And now after my integration I can be there for them. There is real adult mutuality in our relationships. Instead of saying to a friend in crisis, "I will call and check on you this weekend" -- I can say, "I know you're having a hard time, call me any time. Here is my cell phone number." The old way I kept control of the relationship so I could call when I was functional/adult. Now I am always adult and able to really be present for my friends and family.
Integration means I can finally be a consistently available parent for my son. Even when I was a functional/working DID he never knew when it/I would change. In a way having a DID parent is similar to having an alcoholic parent. The child never knows what the parent will be like when the child comes home from school. Because I had a "good mom" personality, I minimized in my mind the extent of the impact of my DID on my son. I can now put my son's needs first instead of having to choose for my survival over his needs. Becoming a real/whole mom is one of the best aspects of being integrated.
3. Relationship to Life. Being integrated gives me the opportunity to be fully present to life and better able to handle life crisis. I am open to new experiences, including a fantastic vacation spent swimming with dolphins. I am better able to handle it when life throws me a curve as it did when I was diagnosed with cancer in 1995. As I face the inevitable changes and losses that come with aging, I do so as a whole person with a full range of coping skills.
4. Relationship to Death. This may seem strange to put in here, but it is a relevant factor for me. As a gerontological social worker in the first fifteen years of my professional career, I worked with and learned from older people. I always asked myself what made the difference between older people who faced the end of their lives/losses/death with dignity and peace and older people who were bitter and in despair. I could see it wasn't life circumstances alone that made the difference. Older people at peace with themselves were satisfied with their life choices and accepted the difficulties of their lives.
Often when I made significant choices about my life -- such as moving across the country to follow my DID therapist -- I would ask myself, "How will I view this when I am an old woman in a nursing home?" I am at peace with the choices I have made in my life, including the choice to integrate, accept, and claim my whole self, and I accept the reality of my traumatic and abusive past. I am ok with aging and facing the end of life. I don't believe this acceptance of my life history and of my inevitable death would be possible from a dissociated/DID/PTSD frame.
LESSONS LEARNED FROM THE RECOVERY OF CHILDREN WITH DID
My understanding and beliefs about the importance of recovery from trauma and DID has been influenced by my knowledge about treatment of children with DID. I found it quite interesting that children with DID recover quickly (optimum length of treatment 12-24 months) once placed in safe environments, provided appropriate treatment, and given good parenting. Given other options children seem to be able to let go of personalities/dissociation and continue with normal development.
Children when provided the opportunity naturally move towards healing and integration. The treatment goal when working with children is always the return to normal awareness and normal development. Knowing about treatment for children with DID reinforced my belief that full recovery is natural. When working with children the idea of "going together" is addressed from the very first session. There is no debate about remaining dissociative. Integration is discussed and treated as a natural event. When it is handled this way children spontaneously move toward full recovery.
PHASES OF INTEGRATION
Integration is a process. It is not a single event. It occurs throughout the therapy. In this section and the one that follows, the process is described in several ways. First, the phases of integration are explored, two examples of integration are given, my concerns about integration are discussed, how I learned to give up dissociation is described, and core aspects of my final integration are shared. In the next section, experiences after my final integration are presented. This includes the joy of a new life as an integrated person, dealing with a serious illness, and changes after my integration.
I went through many phases as I integrated the personalities (thoughts, feelings, experiences, and memories). My first integration in 1987 was an exhilarating experience. It was also quite interesting. I lost my voice. It was as if I didn't know what voice to use without the dissociated parts speaking. With that integration I gained freedom from PTSD, flashbacks, and inconsistent adult functioning. I began to have more normal relationships with my family and friends. I had hope for a full recovery from the trauma.
All of this changed when external traumatic events overwhelmed me and the integrated personalities became separate again. I was devastated. I had had a taste of freedom and peace and I couldn't hold on to it. My therapist was reassuring and saw no reason why I couldn't regain the lost ground. I had simply gone back to my familiar defenses in the face of new trauma.
As I continued in therapy I had many experiences of integration followed by disintegration. With the help of my therapist, I learned to view this as a natural process, not a series of failures. I needed practice at being integrated and learning to use new defenses. I stayed determined to achieve stability and freedom through permanent integration.
One of the things I did that helped me access and integrate the personalities was to put together a collection of songs I called my "integration tape." All of the songs, such as "Ain't No Mountain High Enough" and "Kentucky Rain," focused on reaching out to lost or distant loved ones. I listened to the tape over and over for years. In my thinking, playing this music told my mind what I expected -- that all parts of myself were to be found, known, accepted, and integrated.
During the course of my therapy the personalities grew and changed. At first I saw them as being fixed in time. As the personalities interacted in therapy and learned more about each other and life, a natural process of change and growth occurred. The personality that was integrated/accepted was different than the raw traumatized personality that first presented in therapy. This transformation made for easier integrations. As I observed/experienced this, I developed the belief that the mind is always working toward healing. I gained confidence in the therapy process
There is a school of therapy called "Re-Decision Therapy." The basic concept is that we (DID and non-DID) make psychological choices as children to adapt to the needs of our family situation. As adults we need to rethink and re-decide about how we want to cope/adapt. I found this concept quite helpful in my healing. I could respect my choice as a child to dissociate and survive in the face of overwhelming and ongoing trauma. But I could, as an adult, choose how I wanted to cope now as I remembered the trauma and faced life as a free adult. I COULD CHOOSE AGAIN.
Integration of a Personality Fragment
One example of accepting and integrating a dissociated part of myself was my experience with the part of me I called "the cooking girl." She was formed in my childhood to preserve everyday functioning. It was her job to cook and bake. She did not have awareness of the trauma events and was able to do things with enjoyment. I needed her to be separate when I was a child and could not escape the ongoing trauma. As an adult she helped the personality system by providing relief from intense feelings and memories. When she was in the kitchen baking, I felt at ease and did not experience fear, PTSD, or trauma memories.
During my therapy, as I worked on the trauma issues, I realized that I no longer needed to continue my dissociative coping because I was no longer in a trauma/abuse situation. This speaks to the importance of establishing safety as a necessary condition to be free to choose new coping. I respected the historical importance of this part of me but slowly came to realize that keeping a separate/dissociated part was based on the old trauma-based belief that dissociation/personalities was the only safe way to function. I no longer needed to maintain a "not-me" frame.
With my new understanding I was able to accept/integrate the "cooking girl." I accepted all of the thoughts and feelings of this part of me, let go of the protective dissociative barrier that kept "her" separate, and brought her into normal awareness. I was still able to enjoy cooking and I learned to handle the PTSD/memories in new ways. I did not experience this as a death or banishment. I experienced it as full acceptance of her/me.
Integration of a "Dangerous Personality"
I had a personality that protected the child ones by being aggressive and assaultive towards others. She also protected others from having to deal with the memories and the feelings because so much time was spent trying to control her and stay safe. When her role as protector was respected and she was shown more constructive ways to protect the child personalities, she was transformed from an out-of-control, violent, and hurtful personality to a positive helper personality.
When this "dangerous personality" turned constructive helper was integrated, her primary concern was how others would handle the knowledge of the trauma memories and feelings that she held in her awareness. As the other personalities (child ones) got to know her, they wanted the integration, because they did not want her to be alone with the memories any more. The process of integration/acceptance addressed all these issues.
It was not an easy integration. The hardest part was letting go of the innocence contained in the child personalities. No longer did I have an innocent part that did not know of the trauma. I cried for days, not because of the integration, but because I had to let go of the fantasy that there was a part of me that had not been abused.
Integration of Trauma Memories
In many cases integration of certain personalities automatically resulted in the integration of the memories they held. Other memories were recalled in PTSD flashbacks, without a personality frame. The therapy work of processing and healing the memories was done before the integration of these memories. They were not integrated in their raw and intense form. The memories were then integrated as historical realities, which is normal awareness for memories.
My Concerns About Integration
One of the fears I faced before my final integration was that if I integrated I would not be able to deal with new trauma memories. I was afraid that I could not access or process trauma memories without being dissociative. My therapist assured me that I didn't need to remain DID to uncover or process trauma memories. He pointed out that many people with childhood trauma histories access and process trauma memories without personalities. I accepted what my therapist said and continued my goal of integration.
I had other worries about my capacity to integrate. I was concerned that I wouldn't be able to integrate because I had so many personalities. (I had hundreds of personalities and fragments.) At one point I was so dissociated that the idea of integration seemed ludicrous. My therapist assured me that numbers of personalities did not matter.
I was also worried that I wouldn't be able to integrate because of the extent of the abuse. It had been very violent and sadistic. I also was forced to abuse others and had horrible shame and guilt. The abuse included what is called ritual abuse. I wondered if maybe it was too much to integrate? Here again my therapist assured me that the extent and type of abuse would not necessarily prevent me from integrating.
Another worry I had was that I wouldn't be able to integrate because of my age. I was in my mid-40s and feared I was too adjusted to dissociation to move past it. I was concerned that a lifetime of dissociative coping would be too hard to overcome. I don't believe I ever discussed this fear with my therapist.
My experience points out the importance of therapists' being informed about integration and able to answer questions posed by DID clients. Clients need accurate information. I had read things that were not true about integration. For example, I had read that poly-fragmented DID ritually abused individuals (like myself) could not integrate. Having a well-informed therapist made a difference to my recovery.
Learning to Give Up Dissociation
Learning to give up dissociation as a coping mechanism was difficult for me. After all, I had been using it to cope since I was three years old. (My final integration took place when I was 46 years old.) In many ways I had become addicted to dissociative coping. It was easy and I was good at it. I used it to cope with trauma and to cope with everyday life stress. It had become automatic.
I knew that to continue using it as an adult when there was no trauma present was to live with a survivalist view of the world. Dissociation was based on the old reality that the world was not safe and there was no escape. This was true for me as a child in an abusive household but no longer true as an adult. I was no longer trapped and I could choose healthy environments, adult coping skills, and nourishing relationships.
I didn't want to have to switch between personalities to have access to all parts of myself. I wanted to have normal awareness and full everyday access to my whole self. Yet letting go of the dissociation that had taken care of me for so long was an emotional process. I cried and I grieved. I was letting go of an old friend so that I could move forward in my life.
I worked with an art therapist and drew pictures of a child letting go of balloons that flew into the sky. I used the twelve-step program to overcome my addiction to dissociation. I had to admit that being dissociative had made my life unmanageable. I worked with my therapist to learn new coping. It was scary to reach out into the unknown but I wanted my whole self back. I didn't want the trauma to continue to define me.
I now understand that this process of giving up coping learned in childhood and learning new adult coping skills is a process that most individuals face in therapy. For the non-DID individual this may mean giving up reliance on anger or reliance on staying busy and taking care of others rather than facing yourself. Learning to choose new coping as an adult is often a primary therapy task for Adult Children of Alcoholics. It is an essential goal for individuals addicted to alcohol and drugs. The addict/alcoholic has to learn to cope without drinking or taking drugs just as the person with DID learn to cope without dissociation. The issues for the person with DID may be more intense and dramatic but the process is similar.
My Final Integration
Before I could achieve a permanent and stable integration I had to make some major changes in my therapy and in my life. I agreed to take psychiatric medication that I had refused for years. I admitted I was an alcoholic/addict and participated in twelve-step recovery. I became willing to try new therapy approaches. I dealt with and gave up the feeling of being special as a person with DID. My therapist used to joke that my treatment goal was to become boring, average, and normal. I agreed as long as he defined normal by California standards (I am from California and a California girl at heart).
My final integration took place over three months in the spring of 1990. I did not participate in any ceremonies or rituals when the personalities merged. I did not experience a sense of the personalities blending into the host personality or into each other. The integration/full acceptance of all parts of myself was based on a series of decisions and shift in therapeutic tasks.
The decision to stop talking about myself in the third person
The first decision was to stop talking in the third person or referring to any thoughts, feelings, or fears as "not me." By this time, I was mostly co-conscious for the personalities. I was maintaining the dissociative buffer out of habit and fear. I verbally made myself claim everything as me. For example, I might be thinking, "she is afraid of living alone." But I said, "It feels uncomfortable to admit this but I am afraid of living alone." The idea and choice to work this way was mine. Somehow I sensed that this linguistic process would move me toward healing and integration. This shift in how I talked was a critical element in my final integration.
Early in this process I sometimes needed to say things like "It doesn't feel like my feelings but I am angry at you." Talking this way meant I had to acknowledge my feelings. This process of claiming my feelings, thoughts, and experiences resulted in a natural process of acceptance/integration. It was difficult at first but with time became easier and easier. It felt freeing to claim my whole self. Eventually referring to myself in the third person felt strange and uncomfortable.
As things shifted inside, I discovered that it was OK and manageable to accept/integrate the thoughts, feelings, experiences, and memories. In a way integration is like learning to swim. I had to get in the water to do it. For me the only way to cope with integration was to integrate.
The decision to directly experience internal conflict
Another decision that I made was to allow myself to directly experience internal conflict. Previously different personalities handled different points of view. It was necessary to negotiate between personalities to handle different preferences and opinions. When I consciously claimed the diverse thoughts as mine I discovered that it was OK to have different thoughts and feelings. I could have different viewpoints and still choose how I wanted to act in the present.
When I was dissociated, I had parts of me that believed in God and went to church. Other parts of me didn't have any connection to God and never went to church. It seemed my attending church and going on spiritual retreats was dependent on which personality was strongest at the time. After I accepted my mixed feelings about God and going to church I was able to choose to regularly attend church while still recognizing and respecting the different feelings.
The examination of trauma-based beliefs
Part of the process of integrating was examining beliefs I had acquired growing up with the ongoing abuse. As a child I learned that having feelings was bad. I learned to hide my feelings in different personalities and fragments. Before I could integrate a wide variety of feelings I had to change my beliefs about having feelings. I came to understand that feelings are a natural aspect of being human. I came to recognize we are born with the innate capacity for feelings. I learned to modulate my feelings and choose how I wanted to handle them. Claiming my feelings was one more way of not letting the abuse control my life.
Acceptance of negative aspects of myself
One of the hardest aspects of integrating/accepting the whole was accepting the parts of me that wanted to hurt others. Because I found these thoughts unacceptable they had to stay dissociated. I made a conscious decision to accept negative, hostile, and hurtful thoughts as one aspect of being human. By this time in the therapy the dangerous and violent personalities had changed. They no longer acted on thoughts and feelings. They were able to separate the past from the present.
The therapeutic task was to integrate/accept my hurtful thoughts toward others. The integration was made possible by learning non-dissociative coping for handling the thoughts. For example, I learned to self-talk my way through the feelings. I could say to myself, "It is human to have hurtful thoughts. It is understandable after all the abuse I suffered that I occasionally think of hurting others." I discovered that the hateful thoughts often were a way to avoid feeling vulnerable. When I allowed myself to feel a wide range of feelings the angry/hurtful thoughts would recede and pass.
The realization that nothing is lost
When people ask if you lose parts of yourself when you integrate, I often want to chuckle. I would have been glad to lose the angry/hurtful/hateful parts of myself. I would have liked to not have negative feelings. But integration is accepting the whole me. Even as I integrated/accepted the positive parts of me, I also accepted the negative parts of me. It's all there. Nothing is lost.
There is a kind of paradox with integration. One of the fears expressed by individuals with DID who choose not to integrate is that parts of the self will be lost, disappear, or die. The reality is that after integration the parts of the self are actually closer and more real than ever. The dissociative barrier is gone and the aspects of the self are now experienced directly.
LIFE AFTER MY FINAL INTEGRATION
Since my integration twelve years ago I have faced many challenges, including cancer, the death of my mother, loss of employment, a cross-country move, and an ongoing struggle with recurrent clinical depression. I have also handled triggers that previously would have caused me to dissociate. I have uncovered new memories of abuse. I don't believe I could have handled these memories until I was whole and had non-dissociative coping.
None of these events have caused me to go back to dissociation. This stability did not happen magically. I actively worked on problem solving and handling my feelings. I understood that if I went back to denial and avoidance it would leave me vulnerable to returning to dissociation.
Integration of dissociated aspects of self did not mean the end of therapy. My final integration was in the spring of 1990 but my therapy did not end until the December of 1994. There were still many therapeutic tasks to attend to. I needed support for the new coping. It was painful to grieve my lost childhood and the years of adulthood devoted to recovery, but it was an important component of post-integration therapy. In addition, I reprocessed some of the trauma memories from an integrated frame. This reprocessing included sorting out the mixed validity of my memories. I took time to make decisions about my future as an integrated person. It was only after I was integrated that I was able to work through the transference issues.
The Joy of a New Life
After my integration I was free to enjoy things I couldn't before. I could go out at night. I could travel and take vacations (when I was dissociative I couldn't do this because new environments triggered me). So when I wanted to celebrate my fiftieth birthday, I was able to fulfill a dream and spend a week with dolphins in Florida. I swam with them, petted them, fed them, and worked with the trainers and trained them. I have a picture in my bathroom of myself swimming with the dolphins. It always brings a smile to my face.
I could not have taken the trip when I had DID. I would have been too terrified to fly on the eight-passenger plane that took me to the island where the dolphin center was located. I would have been too afraid to travel to a new place alone. I would have worried about the sleeping arrangements and food at the dorm where I stayed. I couldn't have trusted that I would stay an adult for the whole trip (one week).
Instead, I was able to joke that my biggest worry was which camera to use for the pictures and whether I had enough sunscreen on. I felt free and happy inside. I viewed my dolphin vacation as a celebration of the new life I had gained through integration and recovery from trauma. One of the best parts of the vacation was coming back and spending a whole therapy session recounting my trip and watching the vacation videotape with my therapist. It was quite a contrast to years of chaotic and difficult sessions.
Dealing with a Serious Illness
One example of new coping after integration occurred when I was diagnosed with cancer in 1995. I was afraid that being physically sick and facing the possibility of dying (old issues for me) might bring back my old ways of coping. I was afraid it might trigger feelings about my body being vulnerable. Since I understood that historically dissociation came to help me when I was scared and overwhelmed, I knew I needed to face my feelings and fears head on.
I talked with my friends openly about my fears and my feelings. I discussed how unfair it felt to again be facing a life-threatening illness. I expressed my fear and anger that I might die and be prevented from enjoying a lifetime of normal living. I talked about my feelings about my body being cut open and the cancer taken out. (This was especially difficult given my background of ritual abuse.) I had to remind myself that having surgery was not abuse. I had to reassure myself that surgery was not a punishment and I had done nothing wrong to deserve having cancer.
Because I was integrated and stable when I had the cancer, I was able to be proactive in my care. When I had my first symptom of possible cancer I immediately sought medical care. Since it was discovered early, the cancer was only at Stage I and had not spread. If the cancer had occurred during the time I was dissociative -- afraid of doctors, shots, surgery, and medical hospitals -- I doubt I would have been able to take care of myself so rapidly. I would have delayed seeking medical care while the inside ones debated about my symptoms and what action to take. I would have had trouble sorting out whether the symptom was physical or psychological.
Since I had already resolved the internal conflict about God, I was able to go to healing services, ask people to pray for me, and pray for myself. This brought me comfort and helped me face the cancer. If I had still been dissociative, I don't think I could have turned to God for comfort. I had a personality that wanted nothing to do with God or spiritual activities. At one time she loudly pronounced to my therapist "If I have to get religious to get well it will never happen."
Because I had faced the abuse done to my body I was able to keep the historical feelings about my body and the trauma experiences in check. I no longer had to reassure child personalities that it was safe and that medical treatment was not abuse or a violation of the body. I no longer had to switch to arrange for adult ones to come out and talk to the doctor. I no longer had to explain to the doctor that I had DID and needed extra time to explain medical procedures to other parts of myself. I did not have to bring a friend with me to my medical appointments. I no longer had to fear that the little ones would be triggered, come out, and be re-traumatized. I had thoughts about past things that were done to my body but they were manageable memories not flashbacks. I was grateful that I was facing the cancer as an integrated whole person.
Getting through the surgery and the recovery without dissociating was quite an achievement for me. When I had DID, I was terrified of all medical procedures. I put off medical and dental care because it triggered and dissociated me. I was once hospitalized for three days in a psychiatric hospital to cope with receiving a tetanus shot.
Even though I had been out of therapy about a year and integrated for five years at the time of my illness, I went back to my DID therapist for short-term therapy (six-eight weeks). I was able to process the meaning of having cancer and the surgery in the context of my life experiences. By acknowledging my trauma-based fears and reprocessing some trauma memories, I was able to prevent a return to dissociation.
Experiencing Physical Pain
Another thing that changed for me after my final integration was my response to physical pain. When I had DID, I was able to dissociate physical pain. I had learned this as a child to cope with physical abuse. When I was dissociative, I had my dental work done without Novocaine and felt no pain. Once I had a window slam down on my fingers -- breaking one and damaging the others. I felt pain for an instant at the moment when the window slammed down but immediately dissociated the pain. During the months of recovery from this accident I felt no pain.
While at first this might sound appealing -- not having the physical pain -- it was a problem during my recovery from this injury. I needed physical therapy to regain the use of my right hand. A basic treatment principle in physical therapy for regaining lost motion is to move the injured body part to the point of discomfort. Since I did not have discomfort or pain I could not tell the physical therapist what was too much pressure. I couldn't guide the intensity of the physical reconditioning based on what hurt. It was frustrating for both the physical therapist and for me. I never gained full use of my fingers on the injured hand.
After my final integration I faced a situation where I was injured and experienced physical pain. I had been climbing in an attic to retrieve stored Christmas decorations when I fell through the insulation. I caught myself on the wooden beams so I did not go all the way through the ceiling.
I was bruised and scraped up and it hurt. I remember my surprise at feeling the physical pain. I thought, "so this is what it feels like." I had mixed feelings -- something you get used to after integration -- about my physical pain. I felt sad that I had lost the "magic" of dissociating. Yet I was glad to know I was at last like other people. I was relieved to discover that I could cope with the physical pain.
After my final integration and leaving DID therapy, I did access and process both new trauma and new everyday memories. One trauma memory was triggered by external events. First, I had strong feelings and reactions that did not make sense. Then the memory of the trauma event came into my awareness. It was painful to face but I was able to handle it with non-dissociative coping. It was actually easier to cope with it as an integrated person. I was able to put the memory in context of all my life experiences rather than view it in a narrow dissociated space. I was able to use a variety of coping skills rather than rely on dissociation/personalities.
One thing that surprised me about memories recovered after integration was the recovery of positive memories and positive feelings. I was able to access positive feelings toward my mother and acknowledge that she did have positive feelings toward me. It allowed me to make peace with her and say good-bye to her before she died. And it contributed to my ability to grieve and cope with her death.
Maintaining the Integration Over the Years
It has not been an easy twelve years facing "life on life's terms" as they say in AA. I have discovered that integration is an ongoing process. I still sometimes gain new awareness of the impact of my trauma background. Recently I had diabetic nerve pain in my toes. It was an uncomfortable burning feeling. Just for a moment, I thought, "maybe it's punishment." Then I thought, "There it is -- your trauma history." Then I moved on to the rest of my day. I have learned I don't have to hold on to those fleeting thoughts.
Maintaining long-term integration takes work just as maintaining long-term sobriety takes work. I try to stay on top of my feelings and not push any of them aside. Hidden feelings are the fodder for dissociation. I do this primarily by talking with friends. Sometimes, I write in my journal or write poetry. I ask for help when I need it and have returned for therapy depending on the issues that have come up. I invest in my relationships and send birthday cards and thank you notes. I make certain my life doesn't get too busy. I schedule down time, ranging from all day in my nightgown to a weekend of spiritual retreat. This is important since I have discovered exhaustion or over stimulation leaves me vulnerable to intense feelings. I try to eat sensibly and exercise regularly. I see my medical doctor when I have symptoms that need evaluation. I still don't watch violent movies. I respect my past and try to live in the present.
Integration of all aspects of oneself is a natural part of recovery from trauma. Facing trauma-based defenses and choosing new non-trauma-based defenses is a way to take control of life and live in the present. It is a difficult therapeutic journey but worth the effort. The reward of a normal non-dissociative life with full self-acceptance is an immeasurable treasure.
Integration of the whole self is a statement of self-love. I had a part of me that was instrumental to my learning to accept my whole self. She said she was a shepherd and the personalities were the sheep. It was her job to bring everyone forward for help and healing. She was not afraid of any of the personalities. She knew them all and she loved them all. She wanted all to be integrated. She was respected by the personalities and guided many of the practice integrations. After her job was done she had no investment in staying separate. The spirit of acceptance she represented still lives inside me as I accept and love all aspects of myself on an ongoing basis.
If you are a DID survivor, I hope more knowledge and understanding about integration will enable you to see integration as a natural part of healing. If you are a therapist, I hope I have helped you realize how important you are to the integration process. Clients need neutral and objective information about integration to be provided throughout therapy. DID survivors need support for the feelings about accepting dissociated aspects of themselves. Pacing and timing the integration work is critical to successful outcome.
I realize more than ever that the best way to honor the personalities is to incorporate them into the whole self. It is not a matter of parts dying on the behalf of the host personality. Integration benefits all personalities/the whole person. There is no death of personalities. All the previously separated ones now exist as thoughts, feelings, and memories inside me. Integration is a choice to move past trauma-based coping and thinking. We honor the past when we put it in its proper place and live fully in the present.
DID Integration: Review of the Literature and Web Sites (6/03/02)
Compiled by Rachel Downing, L.C.S.W.-C.
Even though it is customary to list references by the author's last name, this collection is arranged by date of publication. The emphasis on chronology shows the progression of printed material on this topic and emphasizes the lack of publications in this area. This is particularly interesting because it is estimated that integration and post-integration work constitute 20 to 25 percent of the treatment time. Publications by both professionals and mental health consumers are included.
Books and Articles
Kluft, Richard P., and Fine, Catherine G., eds. Clinical Perspectives on Multiple Personality Disorder. American Psychiatric Press: Washington D.C.
Two chapters in this book focus on integration. "Clinical Approaches to the Integration of Personalities," by Richard P. Kluft, and "A Tactical Integrationalist Perspective on the Treatment of Multiple Personality Disorder," by Catherine G. Fine. The article by Kluft represents the mainstream view of the process of integration and importance of integration.
W., Lynn. Mending Ourselves: Expressions of Healing & Self-Integration. Many Voices Press: Cincinnati, OH
This book published by Many Voices consists of a variety of material: stories, poems, drawings, and accounts of healing and integration written by the readers of the newsletter Many Voices.
Whitman, Tammy, and Shore, Susan C. The Multiple's Guide to Harmonized Family Living: A Healthy Alternative (or Prelude) to Integration. Artistic Endeavors Publishing: Marina Del Rey, CA
The authors are a client with DID and a psychotherapist who question the necessity of integration as well as the reality of successful integration. It is clearly one-sided even though they say it is okay if people choose to integrate.
Phillips, Maggie, and Fredrick, Claire. Healing the Divided Self: Clinical and Ericksonian Hypnotherapy for Post-traumatic and Dissociative Conditions. W.W. Norton & Company: New York
The authors provide one of the best descriptions of the "integration continuum" in the chapter titled "Integration and New Identity During Later Stages of Treatment." It is an excellent presentation of the issues that need to be addressed in treatment. This material would be helpful to therapists whether they used hypnotherapy or not.
Bryant, Doris, and Kessler, Judy. Beyond Integration: One Multiple's Journey. W.W. Norton & Company: New York
This book provides the most thorough account of therapy after integration available today. Co-authored by the client and therapist, it is well written and includes sections on
"Lost Developmental Stages" and "Developing New Patterns of Coping."
Silberg, Joyanna L. (ed.) The Dissociative Child: Diagnosis, Treatment, and Management. The Sidran Press: Baltimore, MD
This excellent book has a chapter titled, "Promoting Integration in Dissociative Children."
Shirar, Lynda. Dissociative Children: Bridging the Inner and Outer Worlds. W.W. Norton & Company: New York
The relevant part of this book is the last chapter, titled, "The DID Child: Integration and Follow-Up" which has a section called "The Child's Experience of Integration."
Hocking, Phoenix J. 37 to One: Living as an Integrated Multiple. The Safer Society Press: Brandon, VT
Even though her vehicle for integration is probably totally unique -- she spontaneously integrated during a body massage -- her account of life after the integration is interesting and non-threatening.
Ross, Colin A., and Ellason, Joan W. "Two-Year Follow-Up of Inpatients with Dissociative Identity Disorder" American Journal of Psychiatry, 154:832-839 (Available at http://www.rossinst.com/2yr_study.htm.)
This is an excellent study that evaluates changes for individuals with DID on many standard psychometric instruments. It compares individuals who have integrated vs. those who have not integrated.
Siegle, Daniel J. The Developing Mind: Toward a Neurobiology of Interpersonal Experience. The Guilford Press: New York
This book does not focus on DID treatment but speaks of "self-states" and multiple selves. It has an excellent chapter on "Integration." It directly address key questions: Why not live as a collection of self-states? Is integration necessary? The author looks at these issues from both a neurobiological and interpersonal perspective and presents a very thoughtful discussion.
This site describes itself as offering "words of hope for people recovering from trauma and dissociation." It has a section titled "Feeling Good" that focuses on recovery and integration.
This site managed by social worker Patricia D. McClendon answers the question "Do you happen to know of any books or journals on integration?"
Contains an article titled "Thoughts on Integration" by a multiple who describes herself as pro-choice. However she has decided to stay multiple.
This web site has a series of articles describing various phases of the author's integration. At first she decided not to integrate but "loved the inside people enough…they didn't need to be separate anymore."
This site contains an article, "Thoughts on Integration," from an individual who reports it took her fifteen years to finally integrate ten personalities.
About the Author
Rachel Downing received her Master's Degree in Social Work in 1973 from San Diego State University. She is currently employed full time as a clinician at Behavioral Health Partners in Frederick, Maryland. She has been on the Advisory Board of the Sidran Institute for years as a Mental Health Educator and Consumer/Survivor Advocate. Her 34-page handwritten booklet with drawings and thoughts about the early process of recovery from DID entitled Can I Look Now? is available from the Sidran Press.
© Sidran Institute, 2003. This article may not be reproduced without express permission of the publisher.