DID-oriented therapy that elicits alters

1. Introduction

Version followed: DID-oriented therapy that elicits alters, set against two documented positions: the sociocognitive critique (Lilienfeld et al., 1999; Lilienfeld, 2007; Dodier, Otgaar & Lynn, 2022) and the trauma-model, phase-oriented position of the International Society for the Study of Trauma and Dissociation (ISSTD) Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision (Chu et al., 2011) and its defenders (Dalenberg et al., 2012; Brand et al., 2016). The guideline text itself is cited through its published abstract and secondary summaries [uncertain: full guideline text not verified].

This guide concerns a contested question, not a single named therapy. Lilienfeld (2007), in a provisional list of potentially harmful therapies that he called "a work in progress", included "dissociative identity disorder-oriented psychotherapy" [source: Jarrett, BPS The Psychologist, 2008, reporting Lilienfeld 2007]. The concern, as set out by the sociocognitive school, is that therapy which summons, names, maps and repeatedly addresses "alters", especially with hypnosis, can create, legitimise or multiply identity enactments in suggestible clients, and in some 1990s cases was associated with false memories of extreme abuse [source: Lilienfeld et al., 1999; ABA Journal, 2024]. The opposing position holds that dissociative identity disorder (DID) is a trauma-based condition, that the iatrogenesis claim and the belief that treatment is harmful are "myths" unsupported by research, and that DID which is not targeted in treatment does not appear to resolve [source: Brand et al., 2016; Dalenberg et al., 2012].

The psychotherapist's task here is not to choose a camp but to assess carefully, avoid suggestive elicitation of identities or memories, put safety and functioning first, and help clients and families harmed by suggestive practice [synthesis]. Change, in this guide's frame, comes from accurate non-leading assessment, a stable and transparent relationship, safety and emotion regulation, and paced work on trauma and identity that the client directs [synthesis; source: Chu et al., 2011 abstract; TOP DD qualitative study, 2024].

Cross-reference: the Domain III guide 113 covers dissociation-focused treatment as a modality; this guide covers the safety question and the controversy.

2. Framework

Historical phases of the controversy (outline)

1970s-1980s, rapid rise. Reported cases of what was then called multiple personality disorder rose from 79 in 1970 to about 6,000 by 1986, beginning shortly after the book and film Sybil; sociocognitive authors read this as an iatrogenic and cultural "epidemic" [source: Lilienfeld et al., 1999, citing Elzinga et al., 1998].
Late 1980s-1990s, treatment practices and litigation. Critics documented that alters per case rose during treatment, that most patients reportedly knew nothing of their multiplicity before treatment, that a small number of clinicians made most diagnoses, and that hypnosis was associated with more reported abuse and larger alter counts [source: Lilienfeld et al., 1999]. Malpractice suits followed: a Chicago psychiatrist's patients, treated at Rush-Presbyterian-St. Luke's Medical Center, came to believe in satanic ritual abuse memories after hypnosis and medication; the cases settled for $10 million and $7.5 million without admission of wrongdoing, and the Illinois regulator suspended the psychiatrist's licence for two years [source: ABA Journal, 2024].
1994-2011, guideline building. The ISSTD (then ISSD) adopted adult DID treatment guidelines in 1994 and revised them in 1997, 2005 and 2011; the 2011 revision describes itself as a practical guide that does not replace clinical judgment [source: ISSTD Adult Treatment Guidelines page; Chu et al., 2011].
2007-2016, evidence contest. Lilienfeld (2007) listed DID-oriented psychotherapy as potentially harmful; Dalenberg et al. (2012) concluded there is "strong empirical support" that trauma causes dissociation and little support for the fantasy model; Brand et al. (2016) classed iatrogenesis and harmful treatment as myths.
2020s, social media and integration. Clinicians report young people presenting with self-identified DID shaped by TikTok content that diverges from the clinical literature [source: Porter et al., 2023]. Dodier, Otgaar and Lynn (2022) argue the sociocognitive model "neither rejects the existence of DID" nor a trauma link, and propose a multifactorial integrative view.

Phases of the psychotherapist's work

Recognition and assessment. Goal: a careful, non-leading picture of dissociative experience, trauma history, comorbidity, culture and context, including social-media influence. Move on when risk is assessed, a working formulation exists and the client has given informed consent to a plan [synthesis; source: Porter et al., 2023].
Safety and stabilisation. Goal: reduced self-harm and suicide risk, better management of dissociation and emotion, daily functioning. The ISSTD model's first phase is symptom stabilisation [source: Bachrach et al., 2023, summarising Chu et al., 2011]; the TOP DD programme aims to help lower self-harm and suicide risk and manage dissociation and emotions [source: Towson University, Brand faculty page]. Move on only when safety is reasonably stable and the client can ground themselves in session [synthesis].
Paced processing and repair. Goal: work on trauma memories and on any harm from earlier suggestive therapy, without pressing for memories or identities. The ISSTD model's second phase is trauma processing; one schema-therapy team starts trauma processing earlier and found it often destabilised the client at first, so alternated it with other work under a safety plan [source: Bachrach et al., 2023]. Return to phase 2 whenever risk rises [synthesis].
Integration, rehabilitation and follow-up. Goal: a more unified sense of self, functioning, relationships. The third ISSTD phase is identity integration and rehabilitation; Bachrach et al. (2023) report that only 17-33% of patients in earlier studies reached it and that average treatment lasted about 8.4 years, with small or absent effects on core dissociative symptoms in prior studies.

Format and length. Individual outpatient psychotherapy is the documented format; the TOP DD Network was a web-based psychoeducational adjunct to individual therapy [source: TOP DD qualitative study, 2024]. Beyond the averages above, session number and length follow the client's needs and the setting [synthesis].

3. Guiding principles

Hold both documented positions. Practical meaning: you can explain the sociocognitive and trauma models to a client accurately and without contempt for either [source: Lilienfeld et al., 1999; Dalenberg et al., 2012; Dodier et al., 2022].
Do not elicit. Practical meaning: you never summon, name, count, map or invite "alters" to appear, and never use hypnosis or guided imagery to find identities or memories [synthesis, based on the practices criticised in Lilienfeld et al., 1999 and the 1990s cases in ABA Journal, 2024].
Do not dismiss. Practical meaning: you assess dissociation carefully rather than assuming it is iatrogenic or performed; Brand et al. (2016) warn that clinicians who accept the myths are "unlikely to carefully assess for dissociation".
Not fraud, not blame. Practical meaning: even critics state that role enactments are not "conscious deception" and that iatrogenic influence is unintended, so you never accuse a client of faking [source: Lilienfeld et al., 1999].
Safety first, pace always. Practical meaning: risk assessment and stabilisation come before memory work, and you step back when the client destabilises [source: Bachrach et al., 2023; TOP DD qualitative study, 2024, which argues for "carefully paced, phasic treatment that emphasizes safety and stabilization"].
The whole person is the client. Practical meaning: you address and hold the adult person responsible and in relationship, whatever state they are in [synthesis].
Memory humility. Practical meaning: you neither confirm nor refute the historical truth of recovered or emerging memories; you work with their meaning and impact [synthesis; the evidence on memory accuracy is disputed: Dalenberg et al., 2012 versus Lilienfeld et al., 1999].
Context matters. Practical meaning: you consider comorbidity, culture, social background, online communities and informant input before concluding anything [source: Porter et al., 2023].
Transparent consent. Practical meaning: the client knows the diagnosis is debated, what you will and will not do, and what alternatives exist [synthesis].
Function over phenomena. Practical meaning: progress is judged by safety, daily life and relationships, not by the number or vividness of identity states [synthesis].
Never provide, supervise or refer to suggestive elicitation. Practical meaning: you do not refer to practitioners known to work this way and you act when a colleague does [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

4.1 Building your own historical and evidence literacy

Purpose / when: before taking on any client with a dissociative presentation, and when a client asks "is DID real?" [synthesis].
Steps: (1) Learn the sociocognitive model's claims and its stated limits: role enactments shaped by cues, media and expectations, not fraud, not wholly iatrogenic, not proven [source: Lilienfeld et al., 1999]. (2) Learn the trauma model's evidence: a consistent, moderate trauma-dissociation association that holds when fantasy proneness is controlled, and no reliable link between dissociation and suggestibility [source: Dalenberg et al., 2012]. (3) Learn the six "myths" Brand et al. (2016) contest, and the integrative reply of Dodier et al. (2022). (4) Learn the 1990s litigation history in outline [source: ABA Journal, 2024]. (5) Summarise both positions in one paragraph you could say aloud [synthesis].
Example language (illustrative): "Researchers disagree about how these experiences develop. Some emphasise trauma, others emphasise how expectations and therapy itself shape them. Many now think several factors combine. Either way, we start with safety and with what you actually experience."
Watch for: a pull to recruit the client into your view; certainty in either direction. Working if you can describe each side in terms its own authors would accept [synthesis].

4.2 Non-leading assessment of dissociative experience

Purpose / when: at intake whenever there are gaps in memory, depersonalisation, derealisation, identity confusion or reports of "parts" [synthesis].
Steps: (1) Ask open questions about experiences in the client's own words before using any technical vocabulary. (2) Use validated self-report screens and structured clinical interviews for dissociative disorders as their manuals direct; describe and score them, do not improvise items [synthesis; instruments not reproduced here]. (3) Record what was spontaneously reported versus what emerged after a question. (4) Ask when experiences began and whether they predated therapy, reading or online content, since critics cite reports that most patients knew nothing of multiplicity before treatment [source: Lilienfeld et al., 1999]. (5) Do not name, number or invite identities; do not use hypnosis for assessment [synthesis].
Example language (illustrative): "Can you tell me about times when you lose track of time, or feel unreal? What is that like, in your own words?"
Watch for: the client adopting your words between sessions; escalating reports right after a question. Working when the history is consistent across sources and over time [synthesis].

4.3 Differential diagnosis and comorbidity review

Purpose / when: before any diagnosis is given or confirmed [synthesis].
Steps: (1) Consider post-traumatic stress, borderline personality features, psychosis, mood and anxiety disorders, substance use, neurological and medical causes; Brand et al. (2016) contest the claim that DID is the same as borderline personality disorder, so assess both on their own criteria. (2) Consider co-occurring conditions, culture, social background and overlapping identities, ideally with input from people who know the client well [source: Porter et al., 2023]. (3) Route possible neurological or medical causes to a physician; never advise on medicines [synthesis].
Example language (illustrative): "Several different things can cause experiences like these. I'd like to understand all of them before we put a name to anything."
Watch for: premature closure on any diagnosis; a diagnosis given mainly because the client requested it. Working when the formulation explains the history without strain [synthesis].

4.4 Assessing social-media-informed self-identification

Purpose / when: an adolescent or young adult arrives already identifying as having DID or a "system", often after online content [source: Porter et al., 2023].
Steps: (1) Learn how DID is presented and discussed on TikTok and similar platforms [source: Porter et al., 2023]. (2) Ask with curiosity what the client has seen and what fitted. (3) Compare the presentation with the established clinical literature, since some presentations "diverge in several respects" from it [source: Porter et al., 2023]. (4) Gather collateral from parents or carers with consent and assent [source: Porter et al., 2023; synthesis for consent]. (5) Neither ridicule the online identity nor confirm a diagnosis on its basis; focus on distress, function and safety [synthesis].
Example language (illustrative): "It sounds like those videos put words to something that felt true for you. Let's look together at what you experience day to day, and what helps."
Watch for: belonging needs met by the online identity; bullying; self-harm content. Working when the client can talk about experiences rather than labels [synthesis].

4.5 Informed consent about a contested diagnosis

Purpose / when: before any treatment plan; again before trauma processing [synthesis].
Steps: (1) Explain that the condition and its treatment are debated, in plain terms (see 4.1). (2) Explain what you will do (safety, stabilisation, paced trauma work) and will not do (summon or map identities, hypnosis to retrieve memories). (3) Explain the evidence limits: uncontrolled studies and few trials [source: Bachrach et al., 2023]. (4) Record consent; for minors, obtain parental consent and the young person's assent [synthesis].
Example language (illustrative): "I won't be trying to bring out different parts or dig for hidden memories. We'll work on safety and on what you already know, at a pace you set."
Watch for: a client who wants identities explored as a goal in itself. Working when the client can restate the plan in their own words [synthesis].

4.6 Monitoring your own cues (anti-suggestion self-check)

Purpose / when: every session with a dissociative presentation; in supervision [synthesis].
Steps: (1) After sessions, note any question, label or reinforcement you gave to identity displays. (2) Check against the practices critics link to iatrogenesis: summoning, naming and mapping alters, hypnosis, and preferential attention to multiplicity [source: Lilienfeld et al., 1999]. (3) Check whether you repeatedly ask about specific kinds of abuse that the client has not raised [synthesis; cf. ABA Journal, 2024]. (4) Bring recordings or process notes to supervision where consent allows [synthesis].
Example language (illustrative, to self or supervisor): "Did I ask about that before the client mentioned it? Did I give more warmth to the identity than to the person?"
Watch for: session content growing more dramatic while functioning worsens, which critics associate with reinforcement [source: Lilienfeld et al., 1999 on alter counts rising during treatment]. Working when phenomena are stable or settling and function improves [synthesis].

4.7 Responding when an identity state appears spontaneously

Purpose / when: a client switches presentation, uses another name, or speaks as a "part" without prompting [synthesis].
Steps: (1) Stay calm and orient to time, place and the room. (2) Speak to the whole person and keep the session's task in view. (3) Acknowledge what is said without asking for more identities, names or descriptions; one schema-therapy team reframed identities as modes and did not press the client to share all of them [source: Bachrach et al., 2023]. (4) Help the client ground and return to the adult conversation. (5) Afterward, review what happened together and what helped [synthesis].
Example language (illustrative): "I hear that this feels very young and frightened right now. You're here in my office, it's Tuesday afternoon, and you're safe. Let's notice your feet on the floor together."
Watch for: your own fascination; repeated switching when difficult topics arise. Working when the client returns to presence more quickly over time [synthesis].

4.8 Suicide and self-harm risk assessment

Purpose / when: at intake and whenever distress rises; self-harm and suicide risk is a stated target of the TOP DD programme [source: Towson University, Brand faculty page].
Steps: (1) Ask directly about suicidal thoughts, intent, plans, past attempts and self-harm, following your service's standard risk-assessment practice. (2) Include risks reported in any state or "part" as risks to the person. (3) Build a written safety plan with warning signs, coping steps, people and services; Bachrach et al. (2023) used one when trauma work destabilised a client. (4) Lethal-means counselling covers safe storage and removal only. (5) Give crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland) [synthesis for steps; resources standard].
Example language (illustrative): "Sometimes when people feel this overwhelmed they think about ending their life. Has that been happening for you?"
Watch for: risk rising after trauma-focused sessions; amnesia for self-harm. Working when the client uses the plan and risk falls [synthesis].

4.9 Stabilisation: grounding and emotion regulation skills

Purpose / when: phase 2, before and alongside any trauma processing [source: Bachrach et al., 2023 on the ISSTD phase model; TOP DD aims].
Steps: (1) Teach simple grounding (orienting to the senses and the present) and identify the client's early signs of dissociating. (2) Teach emotion-naming and tolerance skills appropriate to the client. (3) Practise in session, then between sessions. (4) Consider an evidence-informed psychoeducational adjunct of the kind TOP DD Network offered online; its later refined version is the Finding Solid Ground programme [source: TOP DD qualitative study, 2024] [synthesis for steps 1-3].
Example language (illustrative): "When you feel yourself drifting, try naming five things you can see. Let's practise it now while things are calm."
Watch for: skills used only in session; overwhelm. Working when the client reports catching dissociation earlier and recovering faster [synthesis].

4.10 Balanced psychoeducation about dissociation

Purpose / when: early in work and whenever the client asks what is happening to them [synthesis].
Steps: (1) Explain dissociation as a range of experiences many people have under stress. (2) Present the debated questions honestly (4.1) without telling the client which camp they belong to. (3) Avoid vocabulary that treats identities as separate people, while respecting the client's own words. (4) Link understanding to safety and daily life [synthesis]. Participants in the TOP DD Network study described insight, hope and self-compassion as outcomes of psychoeducation [source: TOP DD qualitative study, 2024].
Example language (illustrative): "Dissociation is the mind's way of putting distance between you and something that feels too much. Learning to notice it gives you more choice."
Watch for: psychoeducation becoming a new script the client performs. Working when the client applies ideas to their own life [synthesis].

4.11 Holding emerging trauma memories with humility

Purpose / when: a client reports new or recovered memories of abuse, especially extreme or ritual abuse [synthesis].
Steps: (1) Listen and respond to the distress without confirming or disputing the historical detail. (2) Note the context in which the memory emerged (session, reading, online content, another therapy). (3) Do not use hypnosis, guided imagery or repeated questioning to fill gaps; such methods featured in the 1990s cases [source: ABA Journal, 2024; Lilienfeld et al., 1999]. (4) Explain that research disagrees about memory accuracy in dissociative clients: Dalenberg et al. (2012) found no evidence that recovered memories are more inaccurate, while sociocognitive authors stress suggestion and confabulation [source: Dodier et al., 2022]. (5) Discuss any legal or family action as the client's own decision, made outside therapy pressure [synthesis].
Example language (illustrative): "What you're remembering is clearly very painful. I can't know exactly what happened, and I won't push you to remember more. We can work with how this is affecting you now."
Watch for: pressure (from you, groups or online communities) toward more detail; memories expanding to implausible scale. Working when distress lessens without the narrative escalating [synthesis].

4.12 Pacing trauma processing

Purpose / when: phase 3, once safety is reasonably stable [source: Bachrach et al., 2023 on the ISSTD phase model].
Steps: (1) Agree with the client what will be worked on, in small portions. (2) Use a trauma-processing method you are trained in and that the client consented to; do not improvise. (3) Check grounding at the start and end of each session. (4) Alternate processing with stabilising work if the client destabilises, as Bachrach et al. (2023) describe. (5) Return to safety planning if self-harm or suicidal behaviour rises [source: Bachrach et al., 2023].
Example language (illustrative): "We'll go only as far as you can stay present. If you start to lose touch with the room, we'll pause and come back to the here and now."
Watch for: sessions leaving the client unsafe for days; switching to avoid content. Working when the client can tolerate the material and functioning holds or improves [synthesis].

4.13 Working with a client who doubts memories or a diagnosis formed in earlier therapy

Purpose / when: a former patient of suggestive therapy now believes some memories or identities were shaped by it, as in the 1990s retractor cases [source: ABA Journal, 2024].
Steps: (1) Validate the confusion and grief without telling the client which memories are true. (2) Map what they now believe, what they are unsure of and what they still hold to. (3) Address shame, anger and loss of trust in therapy. (4) Address losses: relationships, years of life, custody or reputation [synthesis; family consequences in ABA Journal, 2024]. (5) Offer information on complaint and legal routes if asked (4.18) [synthesis].
Example language (illustrative): "You trusted someone who was supposed to help, and now you're not sure what is real. That's a terrible position to be in, and we can take it slowly."
Watch for: swinging from one certainty to the opposite; suicidal risk during reappraisal. Working when the client tolerates uncertainty and rebuilds a coherent life story [synthesis].

4.14 Repairing harm and trust in therapy itself

Purpose / when: the client was harmed in prior treatment and fears repetition with you [synthesis].
Steps: (1) Name openly that therapy can cause harm, citing the field's own literature where useful (Lilienfeld, 2007). (2) Make your boundaries explicit: no elicitation of identities, no memory-recovery techniques, the right to stop any activity. (3) Invite feedback each session. (4) When you make a mistake, acknowledge it promptly and specifically [synthesis].
Example language (illustrative): "If anything I do reminds you of what happened before, please tell me straight away. You can stop anything we're doing at any time."
Watch for: compliance masking distrust. Working when the client disagrees with you safely [synthesis].

4.15 Family work after allegations or estrangement

Purpose / when: families divided by abuse allegations that emerged in therapy, whether the client still holds them or has retracted [source: ABA Journal, 2024 for the documented family impact; synthesis for steps].
Steps: (1) Work with the client's consent and goals; you are not an investigator. (2) Separate the questions of what happened from what each person needs now. (3) If children are involved, follow child-protection duties first (4.17). (4) Refer family members to their own therapist where conflicts of interest arise [synthesis].
Example language (illustrative): "My role isn't to decide what happened. It's to help you think about what you want your relationships to look like now."
Watch for: being drawn into adjudicating; risk to children. Working when contact, distance or repair is chosen deliberately rather than under pressure [synthesis].

4.16 Working with a client drawn to alter-focused practice

Purpose / when: a client wants a practitioner, group or online community to find, name or "meet" more identities, or to recover hidden memories [synthesis].
Steps: (1) Explore what the client hopes this will give them (understanding, belonging, relief). (2) Share the documented concerns from both positions (4.1), including the 1990s cases. (3) Offer what you can provide instead: safety, stabilisation, paced trauma work. (4) Respect autonomy; document the discussion [synthesis].
Example language (illustrative): "I can hear how much you want to understand yourself. Some methods that go looking for parts or memories have led people into more distress. Here's what I'd suggest instead."
Watch for: isolation in online communities; escalating identity claims. Working when the client's goals shift toward daily-life functioning [synthesis].

4.17 Safeguarding minors and vulnerable adults

Purpose / when: disclosures of current abuse; minors presenting with dissociation; a vulnerable adult at risk [synthesis].
Steps: (1) Know your jurisdiction's mandatory reporting and child-protection routes. (2) Report current risk to children as required, regardless of uncertainty about older memories. (3) With minors, obtain parental consent and the young person's assent, and involve carers in safety planning [synthesis; collateral input per Porter et al., 2023]. (4) Do not interview children about abuse in ways that could contaminate later investigations; leave forensic interviews to trained services [synthesis].
Example language (illustrative): "Because you've told me someone may be hurting a child now, I have to share that with the people whose job is to keep children safe. I'll tell you what I'm doing."
Watch for: delay because memories are uncertain. Working when risk is reported and the therapeutic relationship survives [synthesis].

4.18 When a colleague or institution uses suggestive elicitation

Purpose / when: you learn that a colleague, supervisor or service routinely summons or maps identities, uses hypnosis to recover memories, or pressures clients toward abuse narratives [synthesis].
Steps: (1) Document what you observed. (2) Raise it with the colleague or through supervision where safe. (3) If concerns persist or a client is at risk, use your service's governance route and your licensing board or professional body's complaint process; the Illinois regulator's action in the 1990s case shows regulators act in this area [source: ABA Journal, 2024]. (4) Never refer clients to, or supervise, such practice. (5) Consult your professional ethics code, for psychologists the APA Ethics Code [synthesis].
Example language (illustrative, to a colleague): "I'm worried that asking clients to bring out named parts could be shaping what they report. Can we talk about how you decide when to do that?"
Watch for: retaliation; client harm continuing during delay. Working when practice changes or the concern is formally reviewed [synthesis].

4.19 Outcome monitoring, documentation and supervision

Purpose / when: throughout [synthesis].
Steps: (1) Track safety (self-harm, suicidality), functioning, relationships and dissociative symptoms with standard measures. (2) Note any increase in identity states, names or memory content and whether it followed your input. (3) Review the plan with the client at set points. (4) Seek specialist consultation for complex cases; the evidence base is mostly uncontrolled studies with modest effects on core symptoms [source: Bachrach et al., 2023] [synthesis for steps 1-3].
Example language (illustrative): "Let's look at how the last few months have gone: safety, work, sleep, relationships. What's better, what's harder?"
Watch for: years of therapy with growing phenomena and no functional gain, the pattern critics warn about [source: Lilienfeld et al., 1999]. Working when function improves and phenomena settle [synthesis].

5. Handling problems

The number of identities, names or memories keeps growing. Critics report that alters per case rose during treatment while counts at diagnosis stayed constant [source: Lilienfeld et al., 1999]. Response: review your own cues (4.6) in supervision, stop any practice that gives identity displays special attention, refocus sessions on safety and daily function, and track whether growth slows [synthesis].
The client insists you "meet" or work with each part. Response: explore the wish (4.16), explain your approach and its reasons from both positions (4.5), offer to work with the whole person's experience of inner conflict, and document the discussion. If the client chooses a practitioner who elicits identities, do not refer or supervise; leave the door open [synthesis].
The client feels disbelieved. Brand et al. (2016) warn that clinicians who accept the "myths" may under-assess dissociation. Response: separate your stance on causes from your belief in the client's suffering; say plainly that you take the experiences seriously and repair any rupture openly (4.14) [synthesis].
The client feels pathologised or reduced to a label. Response: shift language to experiences and goals; review whether the label helps or harms function [synthesis].
Overwhelm and destabilisation after trauma work. Bachrach et al. (2023) report early trauma processing often destabilised their client, sometimes with suicidal behaviour, and alternated it with other work under a safety plan. Response: pause processing, return to grounding and safety planning (4.8, 4.9), reassess risk, and resume only by agreement [source: Bachrach et al., 2023; synthesis].
Suicidal crisis. Response: follow standard risk assessment and the safety plan; give 988 (US) or Samaritans 116 123 (UK and Ireland); arrange urgent services where risk is imminent. Discuss suicide without method detail [synthesis].
Stuck clients: years in therapy, little change. Bachrach et al. (2023) report long average treatment and small or absent effects on core symptoms in earlier studies. Response: review goals and formulation, seek specialist consultation, consider whether comorbid conditions are untreated, and consider a time-limited, function-focused plan [synthesis].
Non-adherence to stabilisation work. Response: find out what the client gets from crisis or from talking about identities, simplify skills, and link practice to the client's own goals [synthesis].
Amnesia between sessions. Response: use brief written session summaries the client keeps, agreed with the client; repeat key points without adding interpretations [synthesis].
A client brings memories of ritual or organised abuse. Response: follow 4.11 and 4.17; respond to distress, avoid confirming or refuting detail, report current risk to children, and avoid memory-recovery methods given the documented 1990s cases where no supporting evidence was found [source: ABA Journal, 2024; synthesis].
Online community conflict or influence. Porter et al. (2023) describe young people getting most of their mental health information from social media. Response: discuss online content openly and without contempt, assess bullying and self-harm exposure, and involve carers for minors [source: Porter et al., 2023; synthesis].
A previous or concurrent therapist uses alter-eliciting methods. Response: with consent, consult the other clinician; avoid parallel treatments with opposing methods; follow 4.18 if harm is evident [synthesis].
A colleague treats Lilienfeld's list as settled, or dismisses it entirely. Lilienfeld called the list provisional, "a work in progress" [source: Jarrett, BPS, 2008]. A 2021 re-analysis of evidence for therapies on that list judged critical incident stress debriefing and Scared Straight likely harmful; its published summary reports no verdict on DID-oriented therapy [source: KU News on Williams et al., 2021] [uncertain: full paper not verified]. Response: present the evidence as each side states it [synthesis].
Your own fascination or scepticism. Response: name it in supervision; both can shape what clients report or withhold [synthesis].
Legal involvement (records requests, litigation, recovered-memory claims). Response: keep contemporaneous, factual notes that separate what the client said from your interpretations; seek legal and professional-body advice before releasing records [synthesis].
Physical or neurological symptoms. Response: refer to a physician; never present psychotherapy as treating physical disease and never advise on medicines [synthesis].

Sources

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