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Section 22
Tactical Integration Therapy for DID: The Dilution of Affect Phase

Question 22 | Test | Table of Contents

This phase of the work with DID patients involves the reconnection of the disjointed BASK dimensions; here, each aspect of BASK connected to one experience may be revivified and re-united for one personality or a group of personalities; another formulation would be that several complete BASK experiences are shared and joined for one personality or a set of personalities. The dilution-of-affect phase of the therapy is the abreactive part of the integration work; it is this phase of therapy in which the actual "felt" experiences of the DID patient are more thoroughly "owned" by the patient rather than visited from a distance. The conventional definition of abreactive work emerges from the traditional hypno-analytic perspective where abreaction is considered a release of pent-up affects; the current definition is more suited to a cognitive model where abreaction is thought of as a release of pent-up BASK experiences.

This abreactive phase of the therapy is crucial for the DID patient who needs to differentiate between feeling feelings and doing abreactive work. Many DID patients confuse the passive influence of experiencing the emotion from another personality with "doing abreactions"; in abreactive work, DID patients must tap into the source of their affective or sensory experience, metabolize the various experiences of their lives, and make sense of them in the context of their other past and present life circumstances. The importance of "meaning making" for the personality involved in the abreaction or the group of personalities processing BASKs is essential. Without this, the patient will easily decontextualize and redissociate what was just learned.

Because abreactive work is difficult and "meaning making" essential, it is important to not overwhelm the DID patient. To diminish the likelihood of the abreactive work overpowering the DID patient, four major therapeutic orienting strategies ought to be considered: 1. extensive cognitive restructuring, which has already been described in the suppression-of-affect section of this paper; 2. the use of fractionated, rather than full abreaction; 3. the promotion of the work among personalities that have common affective, sensory, cognitive or behavioral themes, also called like clusters of personalities; 4. the use of temporary blending of personalities to encourage habituation to strong sensations and affects. The three dimensions of stabilization that have not yet been discussed will be considered now.

1. The Use of Fractionated Abreaction rather than Full Abreactions: A fractionated abreaction serves the same overall purpose as a full abreaction. However, from the onset of the revisited episode from the past, it is understood that only a portion of it will be recounted and revisited across as many tolerated BASK dimensions as possible. The dimension from which the partial abreaction will be initiated can be any one of the four BASK components and will be approached in a conservative rather than liberal way. The patient-therapist dyad benefits by erring in the direction of caution and prudence to avoid a domino effect of overpowering feelings and to circumvent affect bridges and sensation bridges that could lead to regression and retraumatization. This fractionated work can be conceptualized as a training program for personalities who like novice mountain climbers do not have to climb the whole affective or sensation mountain at once, but who can purposefully sketch out the landscape, rest on ridges, and planfully negotiate both the complexity of the terrain and the changing climate. Also, like mountain climbers, all personalities are not scaling the same peak, with the same landscape and the same terrain at the same time. Different teams can in parallel conquer their Mount Everest. The host personality may or may not be the overseer of the work, however the therapist-patient dyad benefits if the therapist is an active coach in anticipating crises and cheering personalities on as they get tired or fearful. Fractionated abreactions, though at first blush slower than full abreactions, are more likely to guarantee faster progress. As Richard Kluft suggests: "make haste slowly". Another factor to favor completeness of abreactive work is to advance the work of personalities who share common themes.

2. Work within "Like-Clusters" of Personalities: To continue the sports analogy above, it is helpful that mountain-climbing teams be similarly able and prepared. It is difficult to do a climb when novices are mixed with experts, where some have the appropriate equipment whereas others do not and where some are ready to negotiate the highest snow-covered peaks whereas others (who may have not been listening) thought they were going to the seashore and the peaks were foam on the top of waves. To assure that all personalities are on approximately the same level of affect, of cognition or of sensation, it is essential to review the mapping of personalities for congruence of location on the map and ask the personalities: how similar or dissimilar they are from one another; how and what they feel; and whether the "abreactive team" is well organized, suited, and ready. For example, child personalities who need to abreact an event of being hit with a belt may do well to not be intermixed for the purposes of abreaction with others who have been raped.., even though they may report that their common affective theme is fear. From the perspective of the therapy as a whole, the actual speed of this abreactive paradigm will accelerate as the DID patient develops affect tolerance. Though there are many pathways to integration, with practice, the DID patient may evolve to using EMDR, an automatic information-processing methodology, wreathed into the fractionated abreactive phase. Until EMDR can be introduced, blending of personalities to do abreactive work or to support the partially completed abreactive work may be helpful.

3. Blending of Personalities
The third methodology to build up affect tolerance or bolster abreactive work in progress is the temporary blending of personalities. This reflects a technique in which two or more personalities "step together" and occupy the same space in the DID patient's mind; these personalities line up their BASKs by reviewing where they have commonalities and where they have differences. They are asked to "sit together with" the dissonance; they also could be asked to join to accomplish a task for the system of personalities, to support the host personality's functioning in the world or to directly impact the outside reality of the DID patient. The "instructions" to the blended personalities are that "once their task is accomplished," they are welcome to detach from one another again. This choice option is frequently welcomed by the control-oriented DID patient. As time passes, many of the blended personalities elect to remain blended for longer and longer periods of time. They develop increasing mastery at "group think" and "group feel" until not uncommonly, the blended group spontaneously integrates. This allows for a number of observations by the remaining personalities. The past is different from the present where currently no person will force them to integrate or disintegrate; indeed, the violence and pressures that DID patients have experienced as children created the breakdown of their minds; the current message is that the therapist is not going to "reach in so intrusively and make" the patient change "their minds" in such forceful ways. The central idea in the therapy continues to support the evolution, mastery and self-efficacy of the patient.
- Fine, Catherine G.; The Tactical-integration Model for the Treatment of Dissociative Identity Disorder; American Journal of Psychotherapy; Summer 1999; Vol. 53 Issue 3

Personal Reflection Exercise #8
The preceding section contained information about the dilution of affect phase of Tactical Integration therapy for DID. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Goodwin, B. J., Coyne, A. E., & Constantino, M. J. (2018). Extending the context-responsive psychotherapy integration framework to cultural processes in psychotherapy. Psychotherapy, 55(1), 3–8.

Hardy, K., Meyer-Kalos, P., Adams, C., Elliott-Remes, R., & Gingerich, S. (2021). Brief report describing the integration of two psychotherapy evidence-based practices within coordinated specialty care services for early psychosis. Psychological Services, 18(2), 164–169.

Marsh, R. J., Dorahy, M. J., Verschuere, B., Butler, C., Middleton, W., & Huntjens, R. J. C. (2018). Transfer of episodic self-referential memory across amnesic identities in dissociative identity disorder using the Autobiographical Implicit Association Test. Journal of Abnormal Psychology, 127(8), 751–757.

QUESTION 22
What are the three core concepts in the Dilution of Affect phase of tactical integration therapy? To select and enter your answer go to Test.

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