Anna (mid 20s) was admitted to our challenging behaviour service in Stoke in 2011 from another independent mental health hospital. She had been in contact with mental health services since her early adolescence and had numerous admissions to NHS services. Anna had an existing diagnosis of Dissociative Identity Disorder upon her admission, as well as a history of serious self-harm, substance misuse, an atypical eating disorder, and destructive interpersonal relationships. As a mother of two young children, maintaining family relationships was extremely important to her.
Upon admission, Anna presented with disordered eating alongside the associated low weight and required feeding via an NG tube. In addition, she manifested high levels of distress and disturbance characterized by severe dissociative states. Following initial assessment and a multidisciplinary formulation process, it was identified that Anna required specific intervention for her primary diagnosis of Dissociative Identity Disorder.
Working within a paradigm of structural dissociation, a primary goal of psychological therapy was to enhance Anna’s awareness of the different parts of her internal system and to negotiate and resolve the conflicts of different parts/alter identities. Treatment followed a phase-oriented approach, with the initial phase comprising of establishing safety, stabilisation, and symptom reduction. A primary component of this was the development of a positive and constructive behavioural repertoire, i.e. reducing deliberate self-harm.
Subsequent phases of resolving past trauma have involved the sharing of information and co-operation between different parts/alter identities and applying therapeutic techniques including reprocessing and re-scripting to reduce symptoms associated with this. The final phase of Integration of the internal system of parts has involved enhancing and facilitating communication and collaboration amongst them, so as to increase motivation and hope, reduce episodes of dissociative amnesia, develop positive behaviours and work towards shared goals.
Anna has attended twice weekly psychological therapy with our Clinical Psychologist throughout her admission. She engaged well with Art Psychotherapy for a period of at least 12 months, during which she worked upon developing an overall conceptualization of her internal system of alters using a specialized creative process.
A consistent multidisciplinary approach has been integral to Anna’s treatment and psychologically informed care plans were developed to identify appropriate responses to different dissociative states in order to manage them more effectively. Anna was initially admitted to Horton ward as the nature of her behaviour was severe and challenging and she required adequate support. However, after several months, she was able to be moved to High Ash, which was a more suitable environment for her, conducive to positive engagement and progress.
During her admission, Anna has worked with the clinical team within the approach outlined above and has made considerable progress. The incidence and severity of her self-harm has gradually decreased over time, resulting in her observations reducing from 2:1 to standard. Anna was able to modify her eating patterns over time, such that she no longer required the NG tube and has maintained a healthy weight. Her family relationships, particularly those with her children, have been substantially strengthened and they have represented significant protective factors for her.
Within her psychological therapy, Anna has been able to process past trauma and achieve a high degree of integration within her internal system of alters. She was discharged from our psychiatric rehabilitation hospital and from her Section 3 and has been participating in leave away from the hospital in preparation for her discharge to supported living in the community.