Assimilation of Alters in a Case of Dissociative Identity Disorder

Home , Attachment disorder, Beat (charity), Tourette syndrome

MIAMI UNIVERSITY The Graduate School

Certificate for Approving the Dissertation

We hereby approve the Dissertation

Carol Lee Bentall Humphreys

Candidate for the Degree:

Doctor of Philosophy

______Chair William B. Stiles, Ph.D.

______Reader Roger M. Knudson, Ph.D.

______Reader Larry M. Leitner, Ph.D.

______Graduate School Representative Paul V. Anderson, Ph.D.

ABSTRACT

FROM FRAGMENTATION TO NEGOTIATION: ASSIMILATION OF ALTERS IN A CASE OF DISSOCIATIVE IDENTITY DISORDER

By Carol Lee Bentall Humphreys

This case study examined the psychological changes shown by Kristen, a female client diagnosed with Dissociative Identity Disorder, across four years of psychotherapy. A team of eight (six coinvestigators, myself as the primary investigator and former therapist, as well as my dissertation advisor) tracked Kristen and her alters’ shift in experience from internal fragmentation at therapy intake to dramatically increased communication among her alters at termination. This change process included the gradual reduction of Kristen’s internal amnesic barriers as she actively engaged in therapy. Her experience of “pulling one brick out at a time” was examined using the assimilation model, a theory of psychological change. We analyzed therapy notes, psychological reports, audio-tapes, video-tapes, transcribed therapy sessions, client-produced emails, drawings, and letters to further an understanding as to how change occurs in therapy for those who experience fragmentation. This was a theory-building study, informing the assimilation model as well as evaluating its account of Kristen’s extreme experiences of internal multiplicity.

FROM FRAGMENTATION TO NEGOTIATION:

ASSIMILATION OF ALTERS IN A CASE OF

DISSOCIATIVE IDENTITY DISORDER

A DISSERTATION

Submitted to the Faculty of

Miami University in partial

fulfillment of the requirements

for the degree of

Doctor of Philosophy

Department of Psychology

Carol Lee Bentall Humphreys

Miami University

Oxford, Ohio

2009

Dissertation Chair: William B. Stiles, Ph.D.

Carol Lee Bentall Humphreys

2009

Table of Contents

List of Tables ...... viii Dedication ...... ix Acknowledgements ...... x

Introduction ...... 1

Current Study ...... 1 Dissociation ...... 2 Dissociative Identity Disorder ...... 4 The Assimilation Model ...... 6 Assimilation and DID ...... 8 Assimilation of Problematic Experiences Sequence ...... 9 Case Study Methodology ...... 10 The Client ...... 12 Kristen’s Worlds and the Alters ...... 14 Why I Chose This Case ...... 17 Design ...... 17

Method ...... 18

Participants ...... 18 Measures ...... 21 Procedure ...... 21 The Rounds of Analyses ...... 23

Results ...... 25

Elaborated Concepts ...... 25 Organization of Results ...... 26 Data Packet # 1: Historical Documents ...... 27 Why I Chose This Data Packet...... 27 What We Learned ...... 28 Clinical Observations ...... 28 Assimilation Constructs ...... 31 Data Packet # 2: Beginning Therapy Sessions ...... 36 Why I Chose This Data Packet ...... 36 What We Learned ...... 36 Clinical Observations ...... 37 Assimilation Constructs ...... 45 Data Packet #3: Early Sand Tray Work ...... 47 Why I Chose This Data Packet ...... 47 What We Learned ...... 48 Clinical Observations ...... 48 Assimilation Constructs ...... 51

iii

Data Packet #4: Home Visit ...... 53 Why I Chose This Data Packet ...... 53 What We Learned ...... 53 Clinical Observations ...... 54 Assimilation Constructs ...... 60 Data Packet #5: Client Notes to Therapist and Self ...... 63 Why I Chose This Data Packet ...... 64 What We Learned ...... 64 Clinical Observations ...... 65 Assimilation Constructs ...... 67 Data Packet #6: Semester Summary and Emails ...... 69 Why I Chose This Data Packet ...... 69 What We Learned ...... 69 Clinical Observations ...... 70 Assimilation Constructs ...... 78 Data Packet #7: Therapy Summary, MMPI-A Reports ...... 80 Why I Chose This Data Packet ...... 80 What We Learned ...... 81 Clinical Observations ...... 81 Assimilation Constructs ...... 85 Data Packet #8: The Alters Speak ...... 88 Why I Chose This Data Set ...... 88 What We Learned ...... 88 Clinical Observations ...... 88 Assimilation Constructs ...... 94 Data packet #9: Identity Confusion ...... 97 Why I Chose This Data Packet ...... 97 What We Learned ...... 98 Clinical Observations ...... 98 Assimilation Constructs ...... 100 Data Packet # 10: Tay Visits Therapy ...... 101 Why I Chose This Data Packet ...... 102 What We Learned ...... 102 Clinical Observations ...... 102 Assimilation Constructs ...... 111 Data Packet #11: Zac’s Perspective ...... 112 Why I Chose This Data Packet ...... 112 What We Learned ...... 112 Clinical Observations ...... 112 Assimilation Constructs ...... 116 Data Packet #12: Zac Meets the Parents ...... 117 Why I Chose This Data Packet ...... 117 What We Learned ...... 117 Clinical Observations ...... 118 Assimilation Constructs ...... 127

Data Packet #13: A Second Parent Meeting ...... 128 Why I Chose This Data Packet ...... 128 What We Learned ...... 128 Clinical Observations ...... 128 Assimilation Constructs ...... 131 Data Packet #14: School Visit ...... 132 Why I Chose This Data Packet ...... 132 What We Learned ...... 133 Clinical Observations ...... 133 Assimilation Constructs ...... 137 Data Packet #15: Facing Loss and the Group Meeting ...... 138 Why I Chose This Data Packet ...... 138 What We Learned ...... 139 Clinical Observations ...... 139 Assimilation Constructs ...... 142 Data Packet #16: Hanson ...... 144 Why I Chose this Data Packet ...... 144 What We Learned ...... 145 Clinical Observations ...... 145 Assimilation Constructs ...... 147 Data Packet #17: Hanson and Pictures ...... 148 Why I Chose This Data Packet ...... 148 What We Learned ...... 148 Clinical Observations ...... 149 Assimilation Constructs ...... 152 Data Packet #18: Termination, Co-consciousness, and Jessie...... 153 Why I Chose This Data Packet ...... 153 What We Learned ...... 154 Clinical Observations ...... 154 Assimilation Constructs ...... 158 Data Packet #19: Similarities and Differences in Termination Work ...... 159 Why I Chose This Data Packet ...... 159 What We Learned ...... 159 Clinical Observations ...... 160 Assimilation Constructs ...... 164 Data Packet #20: Meeting the New Therapist and Wrapping Up ...... 165 Why I Chose This Data Packet ...... 165 What We Learned ...... 165 Clinical Observations ...... 165 Assimilation Constructs ...... 168 Data Packet #21: Kristen’s Farewell Scrapbook ...... 169 Why I Chose This Data Packet ...... 169 What We Learned ...... 169 Clinical Observations ...... 170 Assimilation Constructs ...... 173

Discussion ...... 175

Our Conceptualization of Kristen’s Change Process ...... 176 Assimilation: Overview of Kristen’s Change Sequence ...... 178 The Assimilation of Alters: Contrasting Zac and Hanson ...... 181 Theoretical Innovations and Issues ...... 185 Alters as Subcommunities ...... 185 Increased Access Reflects Increased Assimilation...... 185 Asymmetric Access between Host and Alters ...... 186 Zone of Proximal Development...... 187 The Process and the Relationship ...... 189 Successful Intervention Strategies ...... 192 Limitations and Methodological Issues ...... 193 And, Finally… ...... 195

References ...... 197

Appendix A Releases ...... 205

Appendix B POC Form ...... 211

Appendix C Example of a Completed POC ...... 212

Appendix D Coinvestigators Instructions ...... 213

Appendix E Syllabus...... 216

Appendix F Kristen as Drawn by Zac...... 218

Appendix G Zac as Drawn by Zac ...... 219

Appendix H Madonna as Drawn by Zac...... 220

Appendix I Hanson as Drawn by Zac ...... 221

Appendix J Ike as Drawn by Zac ...... 222

Appendix K Tay as Drawn by Zac ...... 223

Appendix L Jessie as Drawn by Jessie ...... 224

Appendix M Megan as Drawn by Zac ...... 225

Appendix N Max as Drawn by Zac ...... 226

Appendix O Ive by Zac ...... 227

Appendix P Real World Sand Tray at Start of Therapy ...... 228

Appendix Q Real World Sand Tray at Termination ...... 229

Appendix R Imaginal World Sand Tray at Start of Therapy ...... 230

Appendix S Imaginal World Sand Tray at Termination ...... 231

Appendix T Kristen’s MMPI-A ...... 232

Appendix U Zac’s MMPI-A ...... 233

vii

List of Tables

Table 1 Assimilation of Problematic Experiences Sequence ...... 10

viii

Dedication

To Kristen for courageously engaging in change and for trusting me to tell her story.

Acknowledgements Lately, on more than one occasion, my friends and family have heard me say, “It has taken a community to get Carol through graduate school.” In that spirit, I would like to offer my deep appreciation to all those who have supported me on this 20 year life journey! I would like to begin by thanking my volunteer coinvestigators and dear friends, Hugo Schielke, Jonathan Fishman, Brendon Smith, Julie Swanson, Chris Reiger and Kathy Conaway for the many late nights they spent analyzing this extensive data. Extra thanks go to Jonathan for formatting assistance! Thank you all for your generosity of spirit and your willingness to add more to your already very busy schedules! This psychotherapy research would not have been possible without the excellent clinical supervision and support that I received during Kristen’s four years of therapy. I thank Julie Rubin, my primary supervisor, for serving as a wonderful role model who taught me ways to navigate both academia and clinical work. Learning from you and with you has been a joy! I would also like to thank Roger Knudson, the original supervisor, and later, a consulting supervisor on this case. You consistently challenged me to grow as a clinician and as a thinker. I thank my honorable committee members, Larry Leitner, Bill Stiles, Roger Knudson, and Paul Anderson for their thoughtful readings, suggestions, and editing on this dissertation. Over the years, these gentlemen have generously served in various capacities as my professors, advisors, collaborators, coauthors, and committee members on my thesis and comprehensive exams. I owe a very special thanks to my advisor and dissertation chair, Bill Stiles, a man who was willing to build many meaning bridges with me on this amazing, dialogical journey. I thank my best friend Julie (and Tim) for many moments too numerous to mention, but especially, for believing in me! To my best graduate school friends, Meredith, Jill, and Amberly, who welcomed me to Miami and lamented or celebrated each step with me, thanks for your help and friendship! I thank my book club, a group of fantastic ladies who have supported my journey with good food, great wine, intelligent discussion, moral support, and sisterhood. I offer a special toast to Noga and Dave for their warm hospitality during my numerous visits to Oxford. Thanks to my brother, Robert, and his family, Karen, Nia and Gareth for their steady faith. Thanks to my parents, Adella and Stan Bentall for their love and support in sunny Santa Fe! And finally, a round of applause goes to my favorite people on earth, my two intelligent and vibrant children, Tynel and Tyler Humphreys, for patiently and lovingly sharing this life journey with me.

From Fragmentation to Negotiation: Assimilation of Alters in a Case of Dissociative Identity Disorder In successful therapies, some type of positive change occurs for clients. Whether it is resolution of a problem, deeper understanding, amplified sensitivity, increased skills, or an improved sense of self, clients who benefit from therapy leave changed. Those who struggle with dissociative disorders and, in particular, Dissociative Identity Disorder (DID, formerly known as Multiple Personality Disorder), present to therapy with chronic problems in daily living that include struggles with memory, identity, perception, and consciousness (American Psychiatric Association, 2000). When those who experience DID initially choose to enter therapy, they are generally seeking relief of symptoms or improvement in their lives. Yet, their experiences of internal fragmentation are often difficult for them to understand and communicate. Such struggles are thought to reflect the construction of various alternative personalities (alters) and the amnesic barriers that surround and isolate some of their experiences. These barriers limit their internal communication—the collaboration or negotiation among alters. Part of the process of change in therapy for these clients includes the breaking down of the amnesic barriers. Current Study In this study, the breaking down of amnesic barriers in the case of Kristen, a pseudonym, was examined. Kristen, a female therapy client diagnosed with DID, moved from internal fragmentation to negotiation between her alters during four years of therapy. She came to therapy reporting that she felt “out of control.” Unable to cohesively articulate her struggles, she reported a significant loss of memory, time and sense of self. She described feeling like she was “standing outside my body watching it all happen.” Her initial narrative was, at times, illogical and difficult to follow as she frequently switched topics in mid-sentence. She repeatedly said “I don’t know what is happening to me.” Yet, she insisted “I want to understand myself” and “I am trying to get it all out.” Kristen was committed to therapy and was an active agent of the change process (Bohart, 2000, Bohart & Tallman, 1999). She likened the work to “pulling one brick out at a time.” Despite moments of intense distress, Kristen was never hospitalized and never received psychotropic medication. During the four years of therapy, Kristen successfully graduated from

high school, applied to college, initiated friendships, sought and sustained employment with increasing responsibilities, committed to a romantic relationship, and faced many of her fears. At the time of termination, Kristen demonstrated significant improvement both behaviorally and psychologically. Her parents reported that she appeared to be feeling better and coping with life more successfully. Kristen, herself, said that she was happier and felt like therapy had “saved” her. She imagined that she “would have been dead without therapy.” Clinical colleagues and supervisors also observed and commented on Kristen’s improvement. Clearly, Kristen had made significant change, but what really happened and how did it occur? These questions plagued me, Kristen’s therapist and a psychotherapy researcher. With her and her parent’s informed consent, I presented papers on Kristen’s change process and our work in therapy at various psychology conferences. I wrote one article about Kristen and her primary alter’s (Zac) assimilation of anger (Humphreys, Rubin, Knudson, & Stiles. 2005) and another about the way Experiential Personal Construct Psychotherapy (EPCP; Humphreys & Leitner, 2007) assisted me in using drawings of her alters’ as a means for eliciting Kristen’s deeply-held, non-verbal constructs. I wrote about Kristen’s change process in my Masters thesis, where I provided an EPCP alternative diagnosis (Humphreys, 2005). As a student of the assimilation model, a model of psychological change (Stiles et. al., 1990; Stiles, 2002), I had also framed my understanding of many of her changes in assimilation terms. In this introduction, I provide information on dissociation, DID, and the assimilation model. I describe the case study methodology employed here. After introducing Kristen and her more active alters, I close with a discussion as to why I chose to examine her story. Dissociation The word dissociation represents a separation from something or someone. It is either the severance of an association with, or a lack of connection between things usually associated with each other. Dissociative symptoms may be experienced as ways of psychologically separating one’s self from uncomfortable, recurring, traumatic, emotionally intense, or boring situations (Ray, 1996). Clinical dissociation is described as alterations in consciousness that include various memory processes with three common aspects: amnesia, absorption, and depersonalization (Kihlstrom, Glisky, & Anguilo, 1994, Ray, 1996). These alterations occur in the usually integrated functions of a) consciousness b) memory c) identity, or d) perception. There are five dissociative disorders described in the American Psychological Association’s

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV- TR, 2000). They are Dissociative Amnesia, Dissociative Fugue, Depersonalization Disorder, Dissociative Identity Disorder, and Dissociative Disorder Not Otherwise Specified. As a response to trauma. Dissociative responses are often linked to trauma, violence, abuse, childhood sexual abuse (Bentovim, 2002, Herman, 1992). Dissociative disorders have been described as defenses originating from traumatic situations and have been described as a chronic form of post-traumatic stress disorder (Zulueta, 2002). As early as the 1880’s, Janet and Freud identified dissociation as a frequent response to traumatic experiences (Herman, 1992). Avoidance is thought to be one of the primary responses to trauma or abuse (Bentovim, 2002). When humans are faced with trauma or intense feelings, they may be able to physically avoid them. For example, when I drive by a bloody car accident being attended to by emergency personnel, I can choose to look away. I can choose not to watch violent television shows or attend scary movies. In these ways, I can refuse to allow the painful images to enter into my psyche. However, physical avoidance is not always an option, especially in cases where an adult or child is helpless to turn away from traumatic experiences or images. Dissociation and attachment style. Specific types of attachment patterns during early childhood are seen as contributing to a child’s vulnerability to dissociation when faced with trauma (Barach, 1991, Putnam, 1993). The disorganized /disoriented attachment pattern in infancy has specifically been linked to an increased degree of dissociation in later life (Barach, 1991, Liotti, 1992, Main & Solomon, 1990). Children in the Ainsworth Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978) that were identified as having a disorganized attachment pattern ( Main & Solomon, 1990) displayed a number of contradictory responses, including a freezing or stilling of the body, when reunited with a parent. In many cases, the contradictory responses occurred when the child viewed the parent as either frightening or frightened. A child that is raised with such an attachment, where the comforting caregiver also is the source of fear or abuse, may find it difficult to make sense of such inconsistency. As the child struggles to understand a discordant experience, one possible and creative defense may be to develop multiple, dissonant, and segregated internal models of attachment (Blizard, 2003, Liotti, 1999). This attachment model involves a dissociated self in which each personality develops a separate and unique attachment with the caregiver.

Dissociative Identity Disorder Formerly known as multiple personality disorder, DID is described in the DSM-IV TR (2000) as one of the dissociative disorders. Diagnosis includes meeting the following four criteria: A) Two or more separate and distinct personalities or ways of being (referred to as alters). Each alter personality must have a consistent pattern of thinking about and relating to the environment and to the self. B) More than one of these personalities takes turns inhabiting the body and controlling the behavior. C) Memory loss beyond normal experiences of forgetting. D) Symptoms not due to substance abuse or other medical conditions. In children, the symptoms must not be related to developmentally appropriate imaginary friends or fantasy play. The presence of alters are considered a distinguishing feature of DID. In addition to consistent ways of being in the world, they each maintain a significant life history. Alters also display a range of functions and emotional responses (Kluft, 1984a). Frank Putnam (1989) described alters as “highly discrete states of consciousness organized around a prevailing affect, sense of self (including body image) with a limited repertoire of behaviors and a set of state dependent memories” (p. 103). Individual alters demonstrate differences in affect, self-concepts, roles, conversation styles, behaviors, personality types, and body images. Many clinicians and researchers who work regularly with clients diagnosed with DID assert that there are common categories of alter personalities. Commonly found alters include hosts, persecutors, children, suicidal, protectors, helpers, administrators, cross-gendered, promiscuous, substance abusers, demons, imposters or substitutes, experts, and reporters (Putnam, 1989). Fragments of alters are also evident in DID. They present as much less developed than alters and are limited in their roles, feelings, and responses (Kluft, 1984 b). However, both alters and fragments serve important roles in the personality system (Putnam, 1989, Watkins & Watkins, 1988). Even angry or dangerous alters have necessary functions in the system such as keeping secrets of abuse, isolating an overwhelming emotion, or sequestering off traumatic memories (Putnam, 1989). Brand (2001) asserts that ignoring or “doing away with” an alter or fragment that is perceived as evil, bad, or unnecessary in therapy “will jeopardize the entire treatment” (p.141). The primary behavioral phenomenon of DID is the switch in executive control from one identity or alter to another who then engages with the world and its events. These switches can be particularly problematic as alters are separated in varying degrees by amnesic barriers created to isolate experiences or feelings. Barriers halt or distort the interchange of experience,

communication, or memory between alters. Once dissociation is found to be an effective method of protecting one’s self during a traumatic or distressful experience, it becomes a viable option for future protection. Over time, amnesic barriers become increasingly reinforced or strengthened. Dissociating may become an automatic defense mechanism, default position, or habit. Repeated episodes of this defense mechanism and the creation of alters, albeit creative, may solidify the amnesic barriers and the further development of alters behind the barriers. As the alters spend more time in the body engaging in new experiences, they become larger. Despite the sense of relief initially provided by the process of dissociating, at some point, the defense mechanism may no longer be necessary if the threat ends. Rather than being experienced as a creative adaptation, the symptoms of dissociation or DID may instead be experienced as increasingly intrusive or chaotic. Without considerable change in the system (perhaps through therapy), amnesic barriers guarantee significant gaps in experience and memory. Most clients with DID present in therapy with a characteristic set of shifting somatic complaints and psychological symptoms (Steinberg, 1993, Lowenstein, 1991). They describe some cluster of memory loss, time lapses, intense headaches, abdominal pain, finding items in their possession that don’t belong to them, being called names that they don’t recognize, and meeting new people who insist that they have met previously. Often, they report an extensive history of childhood abuse or trauma (Lowenstein & Putnam, 1990, Putnam, 1989). However, in many cases, clients (and therapists) initially focus only on symptoms of other disorders such as depression, obsessive compulsive disorder and eating disorders. Clients often arrive at therapy unaware, unable, or unwilling to share their uniquely multiple experiences of self and the world. In these cases, diagnosis is particularly difficult. The lack of continuity in experiences, understandings, insights, articulations and memories presents significant challenges for those who struggle with fragmentation, as well as for their therapists. Solidified systems generally resist change, and the duration of therapy is often lengthy (3-5 years post diagnosis but frequently beyond 5 years) and time consuming (often 2-3 outpatient sessions per week) with reports of occasional inpatient placements for many clients (International Society for the Study of Dissociation, 2005). Therapeutic change for clients diagnosed with DID has often been explained as some type of integration, fusion or movement towards a unitary sense of self (Kluft, 1986, Ross, 1989). However, some theoretical perspectives have suggested that therapeutic change may

instead be viewed as an increased collaboration between a client’s alters (International Society for the Study of Dissociation, 2005). Some of these approaches have turned from reducing the number of alters and, instead, focus on increasing the internal dialogue between the various alters (Anthony-Black, 1999). Shemen, (1993), suggested that integration into a unitary self forces dissenting alters into a position of retreat. Instead, she advocated for an internal community approach and hopes for “the possibility of respectful conversation among them” (p. 103). The Assimilation Model The assimilation model (Stiles, 2002; Stiles, Elliott, Llewelyn, Firth-Cozens, Margison, Shapiro, & Hardy, 1990) is an evolving description of the process of change for individuals in relation to problematic experiences. It was primarily derived from and empirically supported by analyzing therapy case studies. Such case studies tracked problematic experiences across sessions over the course of completed psychotherapies of different theoretical orientations (e.g., client centered, cognitive, experiential, and psychodynamic). The ways in which unique problematic experiences (e.g., criticism, anxiety, depression, abuse, a specific trauma or event) were assimilated over the course of therapy served to support, amend and enhance the assimilation model. With each case study, new information permeated the assimilation model, resulting in the continual building of theory (see Stiles, 2009). Cases of those who experience DID have the potential to be particularly relevant for the assimilation model. Like DID, the assimilation model views the self as multiple and is described using the metaphor of voice (Honos-Webb & Stiles, 1998; Stiles, 1997, 1999a, 1999b, 1999c). The model assumes that all experiences leave traces. These traces can be reactivated at a later date, often in response to similar events causing the voice of the experience to emerge. Voices, in this sense, describe a similar range of phenomenon that others have called I- positions, imaginal others, and multiple selves (Cooper, 2003, Rowan, 1990, Schwartz, 1999). For example, voices in assimilation terms represent a part of the self that can speak and act somewhat autonomously. They are agentic and seek expression when they are addressed. That is, they respond when they are triggered by circumstances they encounter. They most often emerge during encounters with situations that are somehow similar to the experiences they originally were created around. For example, after a child experiences the death of a loved one and genuinely mourns the loss, future losses may trigger a voice that prompts a similar type of mourning. As the child matures and faces additional losses, new experiences of loss become linked and emerge subsequently.

Internal voices are linked together through shared (or joint) understandings of signs, words, and communications called meaning bridges. The construction of a meaning bridge suggests that there is increased access to the other voice (Brinegar, Salvi, Stiles, & Greenberg, 2006). Although different voices reflect unique experiences, they can become linked, or assimilated, to form a community. Voices with similar themes may link together to build a community of voices (Honos-Webb, Surko, Stiles, & Greenberg, 1999; Honos-Webb & Stiles, 1998). For example, a multitude of losses, through death, relocation, and rejection may link together to form a larger constellation of voices that represents losing loved ones. A well- functioning community is then comprised of interlinked voices that can effectively negotiate conflicts through communication with one another. If the voices work together well then the person's action in the world successfully represents and expresses the person's broader experience. In the case of loss, an individual begins to have a certain perspective on loss and (based on that perspective), predicts how future losses may be experienced. When faced with yet another loss, the community’s voices serve as resources in making sense of and getting through future losses. However, problematic experiences may engender problematic voices that don’t easily communicate or fit with the larger group. A voice is considered problematic when it is discrepant from the community, represents a conflicting position of the center of experience, or is a trace of a traumatic experience. For example, if the death of an abusive partner triggers some feelings of relief, that voice may not easily mesh with a community geared to mourn loss. The new loss may be experienced quite differently than predicted. Encounters between these problematic voices and the larger community are typically painful and generate negative affect (e.g. anger, anxiety, shame, crying, and fear; Stiles et. al., 2004). They are often unable to be assimilated into the community without extensive negotiation, a process that is often painful and takes time. This often involuntary denial of discordant voices may act out or produce overwhelming negative emotions (e.g., nervous breakdown, repetitive hand washing, addiction, or depression). In the case of loss, as the discrepant voice is hidden or suppressed, it may gain power, eventually causing problems for the larger community that has only previously experienced regret and sadness. In order for this unique voice of loss to be assimilated into the large community of voices, it must enter into dialogue and negotiation with it. At some point, for the community to make sense of discordant feelings and experiences, the problematic experience of relief in

reaction to a death must be faced and explored. If the discrepant voice can be heard and understood by the larger community, then some negotiation may be worked out. Perhaps, the mourning community might broaden its conceptualization of loss and allow for such unique experiences. In response, the relieved voice may feel understood and accepted. Theoretically, the voice of relief would then feel less need to act out (or scream out) producing psychological symptoms. Links with the larger community allow it to moderate its volume and behavior. The old community (in negotiation with the voice of relief) forms a changed community of the loss experience. The assimilation model suggests that all individuals contain internal multiplicity, are multi-voiced, and regularly assimilate discrepant voices. However, as the process of negotiation among conflicting voices (and dissociated voices) may be difficult and cause psychological distress, dialogue often is avoided. Difficult though it may be, the assimilation model suggests that therapeutic change occurs through dialogue between the client’s internal voices (Honos- Webb et. al 1999) as well as between the therapist and the client. Zone of Proximal Development (ZPD). Though originally used to describe a child’s cognitive development and a style of learning by Vygotsky (1978), recent authors (Leiman & Stiles, 2001; Osatuke, Glick, et al., 2005, Brinegar, et al., 2006) have suggested that assimilation can be aided by therapeutic ZPD work. Vygotsky described the ZPD as the “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers” (p.86). In contrast to learning in isolation, one might be guided to work at a slightly more advanced level by engaging in shared skills with a more advanced other. Shared skills, resources, or knowledge are then internalized. Therapeutic ZPD suggests that as clients work with therapists, they are often guided, encouraged, or nudged to work slightly beyond where they are at. This work can then facilitate assimilation Assimilation and DID In assimilation terms, dissociation is described by Stiles, Osatuke, Glick and Mackay (2004, p. 95) as “an intensity of affect so great that one of the voices is automatically suppressed before it is recognized by the other. Voices do not remain in contact and do not become linked.” The authors suggest that because these voices are not linked, their resources remain inaccessible. The intense feelings that would normally be associated with a traumatic encounter, for example,

are then avoided, resulting instead in a display of minimal affect. In cases of DID, the process of assimilation seemed certain to be complex. In the assimilation model, we use the term subcommunities to refer to the multiple selves, self-states, and alters experienced in dissociative disorders (Humphreys et al., 2005, Osatuke & Stiles, 2006). However, the term is not meant to be synonymous with the word alter. Instead, a subcommunity is a word that describes a smaller part of the larger community. In the case of DID, the smaller portion (subcommunity) is the alter and the larger community is the whole person. Whereas, alters will always be a subcommunity of a larger community, subcommunities are not always alters. Subcommunities may initially be kept hidden from each other as a self-protective stance. Later, the amnesic barriers may grow stronger between the subcommunities and, the subcommunities may grow larger behind these barriers. This type of walled off fortress makes it difficult for subcommunities to be assimilated, insofar as each is unknown to the other (due to amnesic barriers). Creating a dialogue between subcommunities--alters--facilitates assimilation. Each subcommunity is comprised of its unique set of traces of experiences (voices), some of which may be discrepant voices that struggle to be assimilated. For example, the helping parts of an angry alter may need to be heard, assimilated and viewed as resources within that alter, rather than silenced. As a result of the assimilation process, the helper parts may become more active (speak out) and the angry parts may moderate its expression (i.e., may allow space for the helper parts) (Humphreys, et. al. 2005). Together, a new way of being can be negotiated within each individual alter. For clients diagnosed with DID, it is necessary to build meaning bridges both between subcommunities and within the discrepant parts of each subcommunity. Assimilation of Problematic Experiences Sequence One product of previous research on the therapeutic change that occurs through internal dialogue is the assimilation of problematic experiences sequence (APES; Stiles, Morrison, et al., 1991, Stiles, 2002). Analogous to Piaget’s or Erickson’s stages of development in which universal challenges or stages are assumed as a human ages, the assimilation model suggests that similar patterns or stages of change occur for most individuals as they engage in psychological change. The APES (see Table 1) tracks an identified, discrepant experience as it moves toward assimilation into a larger community of experiences. APES stages ranges from being warded off, avoided, or unaware of a problem to a level of mastery where the problem is worked through and

incorporated into daily life (Stiles, 2002). In this study, coinvestigators used the APES as a tool to assist in their conceptualizations of the assimilation process.

Table 1. Assimilation of problematic experiences sequence (APES) 0. Warded off. Client is unaware of the problem; the problematic voice is silent or dissociated. Affect may be minimal, reflecting successful avoidance. 1. Unwanted thoughts/active avoidance. Client prefers not to think about the experience. Problematic voices emerge in response to therapist interventions or external circumstances and are suppressed or avoided. Affect is intensely negative but episodic and unfocused; the connection with the content may be unclear. 2. Vague awareness/emergence. Client is aware of a problematic experience but cannot formulate the problem clearly. Problematic voice emerges into sustained awareness. Affect includes acute psychological pain or panic associated with the problematic material. 3. Problem statement/clarification. Content includes a clear statement of a problem--something that can be worked on. Opposing voices are differentiated and can talk about each other. Affect is negative but manageable, not panicky. 4. Understanding/insight. The problematic experience is formulated and understood in some way. Voices reach an understanding with each other (a meaning bridge). Affect may be mixed, with some unpleasant recognition but also some pleasant surprise. 5. Application/working through. The understanding is used to work on a problem. Voices work together to address problems of living. Affective tone is positive, optimistic. 6. Resourcefulness/problem solution. The formerly problematic experience has become a resource, used for solving problems. Voices can be used flexibly. Affect is positive, satisfied. 7. Integration/mastery. Client automatically generalizes solutions; voices are fully integrated, serving as resources in new situations. Affect is positive or neutral (i.e., this is no longer something to get excited about).

Case Study Methodology A therapy case study can provide extensive and detailed data around one client’s experience of the change process. It is the depth of one individual’s distinctive experience in therapy that is explored rather than comparisons of particular categories of experiences across a population. Case study research is different from statistical hypothesis-testing research, yet Stiles (2005, 2009) argues, it is an equally valuable method of psychotherapy research. Analysis of a single case may include comparing numerous observations on different aspects of a case to many tenets of a theory (points of contact, see Appendix B, Stiles, 2009). In this way, there are a

multitude of theoretical issues that can be observed and compared. Campbell (1979) suggested that the observations and comparison of multiple aspects of a single case with clinical theory is equivalent to the degrees of freedom in a hypothesis-testing study. The new information that is learned from observing a clinical case may then permeate the theory. If the theory does not already account for the observed experiences or ideas, then the observations may lead the investigator to elaborate, alter, extend or reject the theory. In this way, scientific theories may be fine-tuned to more accurately represent researchers’ observations. This process provides a flexible view of theory, one that remains permeable to changes in environment, culture, biology, politics, values and world events, (Stiles, 2009, Stiles, et. al., 2006). Case studies are central to this kind of theory-building and have driven assimilation research thus far (Glick, 2002, Honos-Webb, Surko, Stiles, & Greenberg, 1999, Osatuke, Stiles, Shapiro, & Barkham, 2000, Salvi, Glick, Gray, & Stiles, 2006, Stiles, Meshot, Anderson, & Sloan, 1992, Varvin & Stiles, 1999). We believe that new information that arises from Kristen’s story has the potential to permeate and enhance the assimilation model as well as the study of dissociative experiences. A similar analysis of case study research has been offered by the president of the International Society for the Study of Dissociation (ISSTD). Somer (2006) asserted that “the DSM and ICD reductionistic diagnostic systems are incapable of satisfactorily articulating the complex phenomenology and dynamics experienced and manifested by individuals with DID” (p. 2) and that “most evidence of successful Dissociative Disorder (DD) psychotherapy comes from single-case studies (SCS) and series of clinical trials…” “The most fitting methodology for DD psychotherapy research is the SCS design.” He proposed that “we should strive for better understanding of the nature and mode of particular DD psychotherapy aspects that actually result in therapeutic change.”(p. 3). As both areas of research value case study methodology, an assimilation analysis of a client diagnosed with DID is appropriate. However, in addition to its potential for scientific contribution, there are several other reasons why I chose to use qualitative research and a case study. On a personal note, my commitment to talk therapy, my BA degree in English Literature, as well as my interest in biographies naturally drew me to narrative and qualitative research long before I met Kristen. My interest and biases valued the telling of stories rather than quantitative analyses. Furthermore, after deciding to focus on Kristen’s change process, I believed an

intensive qualitative analysis would allow her to have a voice in the final product as well. As her former therapist, I felt it was essential that we minimize or negate any objectification that could potentially occur during research. I wanted to present Kristen’s struggles in a respectful way, one that did not glamorize the pathology of her fragmentation, but, rather, focused on her determination and courage in therapy. A qualitative study, though at times painfully prolonged, appeared to be the best way to present Kristen’s story of change. Throughout our therapy, Kristen frequently encouraged me to share her story with my colleagues at academic conferences and in journal articles. Once she started to experience some relief, Kristen became determined to help others and felt her story had the potential to do so. She insisted that she wanted others to know the pain that she went through and how much she believed therapy had helped her. As one way to tell her story, at termination Kristen presented me with a beautiful, handmade scrapbook from the alters as a way for them all to have a voice. This scrapbook was used as the final data packet we considered in this study. Throughout this document, I have frequently quoted Kristen, presented transcripts from her therapy sessions, and shared her drawings and notes so that she could have a voice in this story of change. The Client Kristen, at age 16, was brought to the Miami University clinic by her mother after she had disclosed for the first time to her school counselors that she had maintained, since age 8, an internal world filled with various characters, all with names and unique personalities, who engaged in sex, drugs and violent acts. She described them as rock stars, family members, probation officers and fans who led exciting imaginary lives. In addition to her chaotic internal imaginal world, Kristen reported a loss of memory and time. She also described difficulties in making and sustaining relationships. An only child, she had poor social skills and no friends. She linked her distrust of others to having been repeatedly bullied by her peers throughout her childhood. Kristen struggled with her school work and was enrolled in special education classes in high school. She could not remember lessons from day to day. She suffered from severe allergy attacks, asthma, and frequent headaches which caused her to miss an inordinate amount of school. At the beginning of our therapy, Kristen and her alters spent hours alone in her basement or bedroom acting in what she first called her “imaginary world.” At school and with her family, Kristen rarely remained present and frequently dissociated. When she dissociated, it always

surprised her. She felt like she had “no control over what was happening.” Often, an alter’s sudden appearance seemed to be triggered by interpersonal interactions that she experienced as overwhelming. She retained no memory of what occurred during these episodes and lost days at a time. Her fear escalated as she knew she was “not normal” but couldn’t articulate or make meaning of her internal chaos. With her parents’ consent, she committed to engaging in therapy. Over the next four years, Kristen actively engaged in extensive internal reflection and a deep commitment to a healing therapeutic relationship. She attended weekly, sometimes twice weekly, sessions with the intent of making positive change. Over time, Kristen initiated and sustained a number of friendships and engaged in a year long romantic relationship. She was able to face her fears about visiting her elementary school where she had experienced bulling. During the school visit, Kristen spoke with the teachers who had not protected her, reminded them of her struggles, and thanked those who helped her. She did not dissociate while on the visit and remained present as Kristen. At termination of therapy, Kristen’s headaches and asthma attacks rarely occurred. She was a valued employee at a job that she had held for over two years without incident. She graduated high school, applied to college and was accepted as a freshman. She had no suicide attempts, inpatient hospitalizations, or psychotropic medication. As therapy with DID clients often continues for years, and as I was a graduate student attempting to make timely progress through a PhD program, I was unable to continue therapy with Kristen beyond the four year mark. Kristen was then transferred to another therapist who had experience and training in working with clients diagnosed with DID. In anticipation of termination, Kristen created a scrapbook as a parting gift. She said, “You already told your story [in two academic articles], it’s my turn to tell my story.” In the scrapbook, she integrated drawings, letters, and thanks from herself and the other alters. She included sections from the previous journal articles I had written about our work together. Kristen’s story appeared genuine, logical and reflective of the work she had done during therapy. She successfully articulated her change process. At the time of the transfer, Kristen continued to experience a multiple sense of self as well as occasional episodes of unwanted dissociation. However, for the most part, she remained present as Kristen. She both asserted and demonstrated that she needed her alters to take control of her body much less frequently. Her ability to articulate her felt sense of multiplicity to her new

therapist upon meeting her was significant. During a joint session with both therapists, she sat comfortably on the floor, remained present as Kristen, discussed her experience of dissociation, described in detail her alters, and shared her drawings and map of her alters. Kristen’s Worlds and the Alters The two worlds. Throughout four years of therapy, Kristen consistently described her alternative experiences as occurring in two “worlds”. She referred to her interactions with her parents, school, and home as occurring in her “real world.” Kristen initially described her second world as the “imaginary world.” However, she reported that this name had long troubled her. She repeatedly asserted how real the imaginary world and its occupants were. They were not figments of her imagination. In the second year of therapy, Kristen expressed a desire to rename the world. She was interested in giving it a special name, perhaps as a way to reflect its substance or importance to her. Together, we agreed to call her alternative world the imaginal world. Whereas, all of the alters, except for Kristen, had access to the imaginal world, only some of the alters (Zac, Madonna, Ike, Tay) were consistently able to take over Kristen’s body and access the real world. Most of the others (Hanson, Taylor, Zachary, Jessie, Max, Megan, Ive) rarely, if ever, stepped in for Kristen in the real world. Prior to our course of therapy, these imaginal world alters lacked voice and action in the real world. The degrees of access are demonstrated in Zac’s drawings of the alters (see Appendices F-O) where the alters with power or access to both worlds are drawn with bi-colored hair. In these same pictures, the alters with significant power in their worlds are drawn with pentagrams. Though early on in our therapy sessions, Kristen appeared to have extensive knowledge of her imaginal world, I was later informed that it had been an alter, Zac, providing most of the information. Instead, I learned that Kristen had limited knowledge of the imaginal world. When Kristen (as Kristen) presented information about the imaginal world, it reflected the missing bricks (as she described it) in her various amnesic barriers. Zac described the imaginal world as an exciting and busy world running parallel to Kristen’s rather lonely real world. She said that things were “always happening” in both worlds and likened them to two movies playing simultaneously next to each other twenty-four hours a day. It seemed these two very different worlds were playing non-stop in Kristen’s head.

Kristen. Clients diagnosed with DID generally have at least one alter personality who makes room for the others. Kristen’s presentation in therapy matches the following description of host alters by Putnam (1989): The typical host personality is depressed, anxious, anhedonic, rigid, frigid, compulsively good, conscience-stricken, and masochistic, and suffers from a variety of somatic symptoms, particularly headaches (Kluft, 1984c). Host personalities are often overwhelmed by their life circumstances and present themselves as powerless and at the mercy of forces beyond their control or comprehension (p.107). Kristen, the host alter, (see Appendix F) was an only child who was overly involved in the success or failure of her parents’ marriage. She identified herself as heterosexual but, prior to therapy, never had a boyfriend. She presented as shy, depressed, passive, and insecure. She reported a significant number of somatic symptoms and suffered from chronic allergies and headaches. Kristen demonstrated poor social skills, described her self as “not normal” and sustained few friendships. Her style of dress was feminine and subdued. Her vocal tone was nasal and difficult to understand. Kristen generally presented in therapy with a flat affect. Zac. A famous rock musician, Zac (see Appendix G) was the primary alter and a socially sophisticated, reporter personality. She initially presented in therapy pretending to be Kristen. Months later, after identifying herself, she presented as angry and assertive. She reported that she had direct access to Hanson (the angriest alter). However, as our work progressed, Zac more frequently presented as helpful, friendly and caring. She maintained a good sense of humor, laughed often, and readily recognized the irony in life. A lesbian, Zac reported participating in a very active sex life in the imaginal world. Her vocal tone was clear and assertive. Her body movements were broader than Kristen’s. Zac dressed in masculine clothes and favored a flashier pop culture style of dress. She generally presented as energetic in therapy. Madonna. A nurturing female, Madonna (see Appendix H) was similar in some ways to the famous pop vocalist of the same name. Kristen’s Madonna was described as blonde and beautiful with significant dancing and singing skills. She, too, was a popular singer with activities and touring schedules that frequently mirrored the actual star’s schedule. Despite her busy schedule, Madonna occasionally arrived at therapy sessions to report on Zac or Kristen. Often during moments of internal chaos, Madonna acted as the voice of reason or peace maker. Her vocal tone was clear and, her physical presentation was calm, mature and feminine.

Hanson. A 130 year old feminine soul, Hanson (see Appendix I) was described by Zac as "the most evil of all, almost like a demon." Hanson said she had a horrible childhood, one in which she lacked adult nurturance or protection. She disclosed that she was originally a witch during the Salem witch trials and was persecuted unmercifully. As a baby, people attempted to kill her by hanging her repeatedly. When Zac was born, Hanson’s spirit entered Zac’s body and remained. Hanson described herself as the part of Kristen that was suicidal. Ike. A second sister of Zac, Ike (see Appendix J) was a sexually active heterosexual 18 year old. She reported numerous sexual liaisons in the imaginal world. In the real world, she occasionally stepped in to assist Kristen. Ike shared that she “won’t jump in as quickly as Zac will.” Rather, she preferred to “let Kristen try to help herself.” Ike and Tay often acted as bodyguards for Zac. Tay. Zac’s sister, Tay (see Appendix K), was a hypersexual, 20 year-old lesbian. She reported that her role was primarily sexual. When Zac was otherwise occupied, Tay stepped in for Kristen. Easily stressed, she appeared much less capable than Zac. Deemed the good driver, she often replaced Kristen in the car. Her presentation in therapy was less active or aggressive than Zac, but more energetic than Kristen. She managed her role well for short periods with some significant struggles over situations where she was forced to act beyond her limitations. Zachary, Isaac, and Taylor. These were three replacement brothers of Zac, Ike, and Tay. They seemed to be secondary characters in Kristen’s system and rarely entered the conversation or therapy room. Two of the brothers caused Zac a great deal of problems. Zac called Taylor and Isaac “Dumb Asses,” whereas Zachary was referred to as nice. Jessie. Zac’s 12 year-old sister, Jessie (see Appendix L), overlapped with Hanson and was said to have direct access to her. Zac’s drawing of her included numerous bruises on her body due to the abuse she endured daily. In the imaginal world, Jessie’s mother beat her if she spoke with Zac, came to Kristen's therapy sessions, or came out to others. Jessie liked secretarial duties and replaced Kristen when she was temporarily employed as a secretary. Zac referred to Jessie as “just a memory bank.” At termination, Jessie promised to keep the memories of therapy. Megan. One of Zac’s many girlfriends in the imaginal world, Megan (see Appendix M) was described as kind, open-minded, strong, and accepting of others. She was modeled after an idealized acquaintance of Kristen’s in the real world.

Max. Zac’s brother. Max (see Appendix N), was socially and intellectually mature for a five year old. Max reported that his primary role was to have sex in the imaginal world. Ive. Ive (see Appendix O) was a young girl with no voice. Her hands were cut off by her imaginal parents in the imaginal world when Kristen was in the fourth grade. Ive arrived after Kristen wrote a threatening letter to a class mate at school and was punished for it. Why I Chose This Case The story of Kristen’s internal multiplicity is a fascinating story, but more importantly, it is a theoretically interesting clinical case. The changes that occurred as Kristen’s alters worked together in therapy seemed particularly relevant for assimilation analysis. I believe her various accomplishments, improved social skills, self-report, parent report, observer reports, scrapbook story, and increased ability to articulate her experience of multiplicity was representative of movement through some of the APES stages. Whereas Kristen began therapy fragmented, she appeared to end therapy with improved negotiation and communication between her various alters. In addition, this progression of change in therapy is well documented through audio tapes, progress notes, transcriptions and client produced artifacts. Though Kristen continued to struggle with dissociation at the time of transfer, she seemed much improved. My interest in Kristen’s improvement led me to extensively investigate her course of therapy. I wished to know how she changed. In earlier papers and presentations I wrote about and presented Kristen’s change process. Though much was learned during these studies, with specific regard to the assimilation of anger in two alters in Humphreys et. al., (2005) and in conceptualizing her process through an EPCP lens in Humphreys & Leitner (2007), it remained unclear how Kristen and all her alters moved from fragmentation to increased negotiation. Design Building on previous work, the task in this study was to further understand and describe this process of change using the assimilation model. It was also meant to build theory as it permeated the assimilation model. I began this study by choosing data from four years of therapy notes, transcripts, and reports as well as client produced letters, emails, and drawings. I constructed 21 packets of chronological data representing Kristen’s course of therapy which I presented to six coinvestigators. They independently and then collectively analyzed each packet looking for places where the theory and their observations seemed to overlap or failed to

connect. These overlaps (labeled as points of contact) served as the basis for the account of Kristen's progress in therapy reported in this document. Method Participants Client. This single case study focuses on Kristen’s experience of DID. Previously diagnosed with intellectual functioning in the borderline range with a significant indication of socio-emotional difficulties, she had received a combination of school-based and counseling between the ages of ten through fourteen. At age sixteen, Kristen re-entered therapy at the same university-based clinic (a departmental training clinic) where she had previously received services. At age eighteen, she was diagnosed with DID after years of experiencing symptoms consistent with DSM criteria. At age twenty, Kristen was transferred to a community-based therapist who had training and experience working with DID. This paper focuses on Kristen and the four years of therapy (2001-2005) she received during her teen and young adult years at a university-based psychology department training clinic. Both Kristen and her parents signed multiple releases (see Appendix A) allowing this research to be conducted, recorded, and presented. No financial compensation was offered or provided for this participation. Kristen and her parents paid for the therapy at the clinic’s normal (very low) rate. Identifying information has been changed. Therapist and lead investigator. The lead investigator (and author) of this study is Carol Humphreys (me), a White, doctoral student in clinical psychology at Miami University. I was Kristen’s therapist for this four-year period of time. At the time of Kristen’s therapy intake, I was a 42-year old single mother of two young adults, returning to school for a PhD in Clinical Psychology. I had previously worked as a master’s level teacher, social worker, and child therapist. In addition to my professional experience working with children and adolescents, I had volunteered for over 18 years in multiple scouting groups, youth sports, community organizations, and parent/teacher organizations. While in graduate school at Miami University, I had seven years of experience as a therapist at various placement sites and as an employee in the surrounding community. In September of 2008 (three years after my work with Kristen ended), I completed a year long APA approved internship at Napa State Hospital in Napa, California. While there, I provided individual and group therapy for mentally ill clients who had committed a crime (often violent)

and been found Not Guilty by Reason of Insanity or Incompetent to Stand Trial. Theoretical influences. I view myself as a humanist and identify my theoretical orientations as a blend of Experiential Personal Construct Psychotherapy (EPCP) and Archetypal Psychology. The following paragraphs summarize these influences as I worked with Kristen: EPCP focuses on the early relational wounds (Kelly, 1955) that may limit the development of deeply intimate human relationships. These ROLE relationships (Leitner, 1988. 2000) are viewed as having the potential to both affirm and disconfirm our core constructs. Those with histories of relational injuries are often seen as retreating from intimacy. Indeed, all of us have relational patterns that include both moving towards and pulling away from intimate connections with others. Psychological symptoms can be viewed as signs that we have retreated excessively from ROLE relationships. In some cases, symptoms may also serve as a way to retreat from the terror of ROLE relationships (Leitner, 1985). For example, dissociating might be considered to be a retreat from being intimately known or knowing others (Humphreys & Leitner, 2007). EPCP privileges ROLE relationships as the therapist 1) focuses on coming to know the client’s process of construing self in relationship and, 2) creatively works with the client as together they develop a ROLE relationship. Archetypal psychology (Hillman, 1975) regards image and the processes of imagination as foundational to its theory. It rejects the idea of the unity sense of self as seen in a monotheistic or hierarchical view of psychology. Instead, an archetypal approach identifies with a polytheistic view of psychology and suggests that living with the many is a better account of actual lived experience. The many include Gods, goddesses, characters, egos, identities, archetypes, images, dreams, animals, intuitions, ... Pathology is viewed as occurring when the others are not properly attended to. Attending to the others in therapy and in life involves remaining open to multiplicity, engaging with the ongoing life of imagination, recognizing the inherent archetypes of a culture, valuing dream work, and reestablishing the connections between soul and human activity. Archetypal theorists value the conception of imagination that focuses on an imaginal world, where Gods, the psyche or soul, dreams, shadow, evil, archetypal figures, and symbols all are valued separate from the subjective experience. One example of this archetypal influence worth noting regards the naming of the imaginal world. Although Kristen initially entered therapy calling her internal system an imaginary world, we later agreed to call it the imaginal world. Though I don’t recall the specific

details of the final decision, it is probable that Kristen may have picked the word up from me, although I did not intentionally impose it upon her. The word, imaginal, has long been used in archetypal psychology (Hillman, 1975) and, I was in an archetypal practicum and reading Hillman’s works at the start of therapy. Supervisors. Over the course of Kristen’s therapy, two licensed psychologists served as clinical supervisors. The primary, enduring supervisor (Dr. Julie Rubin) was a White female and a former special educator who specialized in psychological assessment and the development of special educational programs for children. Dr. Rubin had over 20 years experience as a psychologist and clinical supervisor. The second supervisor (Dr. Roger Knudson), a White male, specialized in archetypal therapy and had over 25 years experience as a psychotherapist and clinical supervisor. He was the supervisor for this case during the first three months of therapy. Dr. Knudson later served as a consulting supervisor. As a researcher, I had several years of experience studying the process of change in psychotherapy and, more specifically, the assimilation model. During this research, Bill Stiles, PhD served as my chief consultant and academic advisor. Dr. Stiles, a White man in his early 60’s, is one of the originators of the assimilation model and has published and overseen numerous qualitative research projects using assimilation analyses. Coinvestigators. Six graduate students (two females and four males, all White) enrolled in the PhD program in clinical psychology at Miami University served as the coinvestigators for this study. They were Julie Swanson, Kathy Conaway, Hugo Schielke, Brendon Smith, Jonathan Fishman, and Chris Reiger. At the beginning of the project, they were in their third year of graduate school or beyond and ranged in age from 25-40 years. Their life experiences were diverse (e.g., single, divorced, single parent, and partnered). Two of the students had entered the PhD program with Master’s degrees, three had previously worked in the mental health field, two had worked in education, and two had entered Miami directly after receiving their undergraduate degrees. One of the coinvestigators was from a rural Appalachian background, two were from large east coast cities, and two completed their undergraduate degrees in the south. They maintained divergent areas of clinical interest (child, adult, couples, and family therapy in addition to interest in school-based preventative work with adolescents) and, they differed in theoretical orientations (humanistic, CBT, experiential personal construct, interpersonal, family systems, client-centered). At least half of these investigators were familiar with the assimilation

model prior to their recruitment for this study. Two had participated in Miami University’s Assimilation Research Group (ARG). ARG was a voluntary research group that meets weekly during the academic semester to discuss assimilation research projects. The ARG members had extensive exposure to the literature involving assimilation model. Some of the coinvestigators had been present for earlier presentations on Kristen’s case during clinical case conferences or had read one of the articles describing other aspects of Kristen’s experience in therapy (Humphreys et al., 2005, Humphreys & Leitner, 2007). Measures 1) The APES (Stiles et al., 1992, see Table 1) was used as a tool by the coinvestigators to generate conceptualizations of Kristen’s experience of change. As described earlier, the APES is a theoretical, developmental sequence describing changes in the relationship between a client's internal voices as manifested in her external dialogue in therapy. 2) Points of Contact (POC) form (see Appendix B) was used as an organizing form to record observations. As the coinvestigators considered the assimilation theory (Voices, APES, internal dialogue, problematic experiences, community of voices, meaning bridges, etc…), they recorded points of contact or the lack of contact between their observations and the theory. The question was “What (in an observation) does or does not contact what (in the theory)?” Procedure Assimilation analysis. This study used an adaptation of the assimilation analysis (Stiles et al., 1992; Stiles & Angus, 2001). Assimilation analysis consists of four steps: 1) Cataloguing involves investigators immersing themselves in data from a single case of therapy. 2) Identification is when investigators identify and label major themes, voices and meaning bridges that are present in the therapy sessions. 3) Grounding involves raters selecting passages from the therapy record—the actual words spoken by clients—to support the conclusions that they have identified. 4) APES ratings are assigned to the identified passages. This understanding of the APES is used to make inferences concerning the degree to which a client’s internal voices have begun to assimilate with one another. Recognizing that a client’s spoken or written words, the dialogue between client and therapist, or the client’s drawings or artifacts are representative of a specific sequence of change as described by the assimilation model provides increased understanding of a client’s therapeutic change process (Stiles, 2005).

Ward method. An adaptation of the Ward method (1987), a process of arriving at consensus, was used as part of the analysis of this case study. Initially used during group design of architectural projects, this method has been used for a number of assimilation studies (Osatuke et al, 2005, Schielke, Fishman, Osatuke, & Stiles, 2009,). After independent work by the coinvestigators, they share their understandings of the data with the team. They then list the strengths of the other’s version and ignore perceived weaknesses. Coinvestigators are given permission to adopt and borrow from other’s work as they amend their original ideas, improving them by virtue of the added strengths they have newly incorporated. Through this process, group members’ versions tend to converge. Weak or confusing points or ideas are naturally left off the amended products. Construction of data packets. As Kristen’s former therapist, I had intimate knowledge of the data that was collected during her four years of therapy. The policy of the university clinic (where this therapy occurred) required that I audiotape our sessions. Policy also dictated that I erase tapes as a way to recycle them after writing up the progress notes. Prior to my decision to research the case, I erased many audio and video tapes of sessions. Nonetheless, I accumulated over 300 audio-tapes, 5 video tapes, 18 partial transcripts of sessions, progress notes for every session, 12 semester therapy summaries, and various psychological assessments and reports. In addition, there were hundreds of client-produced emails, notes, essays, and artwork. I arranged and maintained these pieces of data chronologically in locked files at the university clinic. Over a period of months, I reacquainted myself with this extensive amount of data. In consultation with my dissertation committee, I chose pieces of data that 1) were from moments across the course of therapy meant to represent her change process over time, and 2) addressed or reflected on Kristen’s observable changes (e.g., improved social skills, interpersonal relationships, academic progress, holding down a job etc…) as well as her and the alters’ psychological changes (e.g., dissociative experiences, confusion, suicidal thoughts, emotional responses etc…). I felt it was important to include a significant amount of client-produced data so as to honor Kristen’s voice. With consultation, I eventually consolidated over 200 pieces of data into 21 data packets. Training of coinvestigators. The six coinvestigators were assigned fundamental readings and provided instruction in both DID and the assimilation model (see Appendix D). They attended two, 2 ½ hour training workshops on 1) the assimilation model and 2) DID. These workshops were presented by the lead investigator before beginning analyses (See Appendix E

for syllabi). During training, the coinvestigators were provided some background knowledge of the client’s case. Each of the coinvestigators received an independent tutorial on research procedures. During this individual meeting with the lead investigator, coinvestigators were able to ask additional questions and practiced analysis with a sample piece of data. Coinvestigators' analysis. The coinvestigators’ task was to critically examine Kristen’s experience in therapy while searching for links to the assimilation theory. If aspects of the case did not seem to fit with the theory, the coinvestigators were instructed to suggest ways that the theory might need to change in order to account for their observations of Kristen’s experience in therapy. Thus, the coinvestigators both applied the assimilation theory to their observations and applied their observations to the theory. In doing so, they identified and interpreted voices, meaning bridges, subcommunities, internal dialogue and APES. Due to the large amount of data generated by four years of therapy, the data packets were separated into two sets that were considered in separate rounds of analyses. The Rounds of Analyses Round one. The lead investigator provided access to a locked file cabinet where the first nine data packets were stored. They independently immersed themselves in the data. During the cataloguing stage of analysis, they read over the pieces of data, familiarizing themselves with the case. They then used the POC form to record their observations during the identification stage. For an example of a completed POC from this study see Appendix C. During the final two stages of the assimilation analysis, they compared their observations of the data to the assimilation theory and compared the assimilation model to their observations. They identified and discussed any patterns of change that occurred over a number of data pieces. The coinvestigators were asked to include observations that they thought the theory should explain but did not. It was both expected and valued that as individuals they brought their life experiences (including clinical knowledge) to their conceptualizations. The coinvestigators then emailed their POC to the lead investigator who collected them into one document, dispersing them to the other investigators who then read each other’s POC, looking for particularly salient comments and ideas. They were asked to adopt, modify, or elaborate on other’s points as their own if they improved the story of change or advanced the general idea as to how the theory fit their observations. If they disagreed with another’s point, they were to leave the suggested POC off their list. Coinvestigators highlighted any of their

observations that were not accounted for by the assimilation model. They were then asked to offer suggestions as to how the theory could be expanded to account for their observations. After the coinvestigators compiled a revised list of POC, they emailed it to the lead investigator. The revised POC pages were merged once again and returned to the coinvestigators. The process of analysis was repeated until the list retained only the POC deemed strengths by the coinvestigators. With each iteration, the intent was not to debate with the other coinvestigators but to address future audiences. As each individual created the best possible product in their own view, it was expected that the lists of points would grow more and more similar, but it was not required. Any convergence was a byproduct of team members coming to similar judgments about what was best. The team strove for quality, not necessarily agreement. Throughout the process, the coinvestigators were encouraged to remain open and permeable to others’ opinions as they collectively constructed a theoretical account of change (grounded in data). A face-to-face meeting of the coinvestigators was then held with the following foci: The meeting should be 1) less about conveying content (that should be in the points of contact pages) and more about discussing problems they might have had in following the protocol; 2) a way for coinvestigators to feel connected to the larger project as well as their fellow investigators; 3) an opportunity to learn more about the perceived strengths of their peers’ POC. The resulting product was an agreed upon list of POC representing the first nine data packets. Round two. The lead investigator provided the remaining twelve data packets to the now five coinvestigators (one female had to leave the study). The new data packets spanned the second half of treatment chronologically. The coinvestigators once again performed the previously described assimilation analysis and Ward method. However, during round two, there was not a face-to-face meeting as the coinvestigators were, at that time, separated by geography. After two iterations, the resulting product was an agreed upon combined POC representing the final 11 data packets from Kristen’s course of therapy. Synthesis by lead investigator. As the lead investigator, I read over the combined POCs (representing 9 data packets from round one and 12 data packets from round two). The coinvestigators’ analysis resulted in over 250 POC and 64 pages of comments. I then narrowed down similar or repeated points into specific themes found in each packet. Due to time and space constraints, I chose to include in the following results the themes that appeared most frequently in the coinvestigators’ comments.

Results As in previously studied cases of therapy clients diagnosed with depression, anxiety, and borderline personality, we found that change in a client diagnosed with DID could be tracked and understood using the assimilation model. Coinvestigators identified evidence of internal multiplicity and voices. They found examples of voices responding to triggers and appearing to want to be heard and, they found meaning bridges that facilitated dialogue and negotiation between disparate voices. The coinvestigators confirmed that assimilation in a case of internal multiplicity permits smoother access to once-hidden or dissociated resources, even when those resources involve accessing another alter’s internal voices. These observations seemed consistent with the assimilation model’s theoretical tenets. We also elaborated several newer or added concepts that seemed particularly important in the case of Kristen. These concepts expanded aspects of the assimilation model that may have only been touched on lightly in previous research. They are briefly introduced below so as to foreshadow some of the more salient results presented in detail in the following 21 data packets. Elaborated Concepts Alters as subcommunities. As previously discussed, alters are not simple voices. Rather, they appear to be complex subcommunities comprised of both dominant voices and discrepant, internal, non-dominant voices. To make therapeutic progress in DID, it is necessary to build meaning bridges both within and between subcommunities. Experiences as resources. Kristen’s experiences had been parceled out amongst the alters for years due to her frequent dissociative episodes. She had little access to experiences of working through interpersonal problems, developing and sustaining friendships, standing up for herself, and interacting with boys. Instead, Zac and the other alters experienced those events and, therefore, had exclusive access to those memories. Through a process of assimilation in therapy, Kristen gained access to the alters and, therefore, their experiential resources. In the assimilation theory, experiences and all that is learned from them are considered resources. What happens to the alters during assimilation? Theoretically, then, assimilation is not a process of “killing off” (Zac’s term) alters (this metaphor suggests suppressing their experiences), but rather communicating smoothly with them, making use of their talents, and what they learned from previous experiences. Ideally, all voices (including those originally assimilated to dissociated subcommunities) should be able to speak when they are addressed by

life's challenges and opportunities. They should emerge smoothly through dialogue and negotiation among the voices. As the alters in DID are primarily constructed to have experiences that Kristen was unable to have, no matter how much access or negotiation occurred between her subcommunities, a residue of experience that only Zac or the others had remained inaccessible to Kristen. However, as the alters build meaning bridges between them, their access to each other’s associated resources simultaneously improves. Asymmetric Access in DID. Discrete subcommunities and one-way understandings contained by amnesic barriers typically characterize DID. These one-way understandings generally allow some alters to have more access to resources than others. In Kristen’s case, most of the alters had more access to her than she had to them. As Kristen engaged in therapy, the amnesic barriers were reduced and she gained access to the previously sequestered alters. Assimilating different alters at different rates. Subcommunities may assimilate at different times and rates. Whereas one subcommunity may agree to engage in the change process without much resistance (e.g., Zac), an older, and more entrenched subcommunity (e.g., Hanson) may take longer to enter into the assimilation process. Relationship. Assimilation suggests that an empathic, genuine therapeutic relationship involves the readiness and ability to form meaning bridges with multiple parts of people. Recent research on the assimilation theory has addressed this interpersonal aspect of assimilation (Brinegar et al., 2006, Goldsmith, Mosher, Stiles, & Greenberg, 2008; see also Stiles et al, 1995). Aspects of my training and personality and the theoretical approaches I was using that facilitated this sort of relationship with Kristen emerged as salient in our analysis. Zone of Proximal Development (ZPD). Therapeutic ZPD work can be considered a process of change that occurs within the therapy relationship. It is loosely described as meeting a client where she is at, working slightly ahead of her, and guiding her to work beyond her previous level of psychological experiencing. Throughout these results, we found numerous examples of therapeutic ZPD. Organization of Results The results are presented chronologically tracking Kristen’s shifting experience in therapy. Under each data packet heading, the contents are listed and followed by the reasons why I chose each packet. A brief summary of what we learned during analysis follows. I next divided

the identified points of contact and our comments into two broad categories, clinical observations and assimilation constructs. The clinical observations are organized by constructs under the following subheadings: Context, relationships, symptoms, academic, life skills, and therapy and assessment. Assimilation constructs are addressed under the following subheadings: Observations bearing on internal multiplicity, observations bearing on voices, observations bearing on therapy and the therapeutic relationship, observations bearing on APES progression, observations bearing on different APES, and emergent issues. If the coinvestigators didn’t comment on any of these constructs, I didn’t include the category in the results. Throughout, transcripts, quotes, and client-produced artifacts are presented to both honor and learn from Kristen’s and the alters’ process of assimilation. Data Packet # 1: Historical Documents a) A psychological evaluation of Kristen at age six. b) A large drawing completed during play therapy by Kristen at age eight. It is a two story house with ghost-like figures in each of the rooms. c) A number of therapy progress notes written by previous student therapists. d) A therapy summary when Kristen was 10-years-old. e) A psychological evaluation of Kristen at age 11-years, 10-months. f) Letters written by Kristen to her student therapists. Why I Chose This Data Packet. This data packet chronicled Kristen’s significant family history of depression, anxiety, schizophrenia, alcoholism, drug abuse, and suicide on both her maternal and paternal side. It also documented her journey through years of therapy and assessment. With the permission of Kristen and her parents, we were allowed access to these historical documents for this study. I felt it was important that the coinvestigators examine these documents in order to gain insight into her life-long psychological struggles. Other than during training, this packet included the first items that the coinvestigators analyzed. Perhaps because the coinvestigators were new to the task or very interested in Kristen’s childhood experiences, they identified over 60 places where the data seemed to contact, support, or challenge the assimilation theory. In the final round of analyses, they arrived at consensus on 31 contact points which are discussed below.

What We Learned In these historical records, the coinvestigators and I found significant evidence of internal multiplicity and psychological distress dating back to Kristen’s early childhood. These psychological assessments, diagnoses, and therapy notes clearly documented the magnitude and chronicity of Kristen’s own life-long struggle with her mental health. In reviewing this packet, we first noted the extent to which the therapeutic relationship and the therapist’s theoretical orientation influenced Kristen’s change process or assimilation of problematic experiences. In previous therapies, many of Kristen’s symptoms apparently had not been explored (e.g., seeing “infisible (sic) people” hearing voices, memory loss). Instead, according to therapy notes, Kristen’s reports of hearing, thinking, or drawing about negative activities often appeared to be ignored, discounted, and rationalized away in sessions. Clinical Observations Context. Even for an only child, Kristen appeared to be unusually sensitive to the state of her parents’ marriage. Notes indicate that she often was fraught with anxiety over their frequent mentions of divorce amidst chronic marital problems. According to documentation in this data packet, Kristen’s parents’ volatile relationship was interspersed with short periods of intense closeness and physical affection. Though they remained together, Kristen never appeared to feel a part of a stable family. Years later, Kristen’s parents confirmed that their marriage had survived a number of fights and temporary separations during Kristen’s early childhood. Relationships. All reports indicated that Kristen experienced a strained and disconnected relationship with her mother beginning in infancy. Though specific examples of their early struggles were unavailable, her mother acknowledged their difficult relationship years later after an intense family therapy session. She questioned whether their current relational struggles might be due to the undiagnosed post-partum depression she experienced immediately after Kristen was born. Though Kristen’s parents had desperately tried for years to conceive, Kristen’s mother remembered feeling overwhelmed and depressed once her baby finally arrived. According to Kristen’s father, his wife rarely held or spent time with Kristen during her first six months. Instead, her father reported that he was the primary caregiver. In therapy, Kristen shared that she had always felt “closer” to her dad and “not good enough” for her mom. Throughout Kristen’s childhood, both of her parents worked and, as a result, Kristen regularly attended daycare. At night, Kristen was frequently babysat by her aunts or teen cousins.

In addition, Kristen was often present at numerous adult social events and family vacations that included alcohol consumption. At age 14, Kristen’s parents reported that their daughter had never had a best friend or a stable group of friends. Instead, she often experienced bullying from her peers at school. She did have a close, sometimes volatile, relationship with a much younger female cousin. However, Kristen consistently had difficulty making and sustaining friends. Kristen did seem to feel connected to her early therapists. Many of her notes to them were affectionate and signed “Love, Kristen.” When she switched therapists, she often reacted with deep sadness, even writing to a previous therapist for years post-termination. Her three psychological assessments confirmed (based on school and home observations, teacher and parent interviews) that Kristen demonstrated significant difficulties in understanding social contexts and problem-solving social situations. Symptoms. Kristen’s records indicate that, as early as age four, she began suffering from a number of significant symptoms. They included: severe headaches, asthma, sinus infections, vomiting, chronic colds, neck pain, and constant skin-picking. Kristen struggled with confusion, anxiety, daydreaming, numerous fears, a short attention span, and extensive memory loss. Physically, she was described as a pretty but an extremely pale and tense child. Her parents reported that a neurologist diagnosed her with Attention-Deficit Hyperactivity Disorder (ADHD), Tourette syndrome (TS), and tremors. She was placed on Ritalin and Inderol but reacted negatively to the medication. By age six, Kristen had received a variety of diagnoses and was treated for Anxiety and Depression. Conflicting opinions regarding her diagnoses and treatment were reported. Reports indicate that she was overmedicated and, medication was halted. It’s unclear as to whether Kristen ever received an alternative prescription. Of note, however, is one report that mentions an incident where Kristen was accidentally dropped on her head as an infant. Though her parents reported that she was taken to the hospital where an MRI was completed, there were no medical records to elaborate on her accident or treatment. During a discussion years later, Kristen’s mother relayed her memory that the doctors reported a separation in her brain as a result. The family provided few other details but believed that the trauma caused a pinched nerve. The pinched nerve was identified at age seven by a chiropractor. Kristen then received treatment from him which was reported to have lessened some of her physical symptoms (vomiting and neck pain).

Academic. Kristen struggled academically in her elementary and middle schools. Beginning in first grade, Kristen received individual or small group tutoring in all of her academic subjects. She was placed on an Individualized Education Plan (IEP) and classroom accommodations were made. A speech problem was identified and she received special services for a number of years. Despite these accommodations, Kristen was transferred to a new school in order for her to repeat the first grade. In the second grade, Kristen’s teacher reported that she had difficulties with “completing tasks on time, reading, writing, spelling, public speaking, and math.” Throughout her school years, reports consistently indicated that Kristen worked below her grade level in all subjects, felt bullied by her peers, and had a high degree of absenteeism. Life skills. At age 11, Kristen was described as immature, often behaving like a much younger child. Despite being in the fourth grade, she continued to require help getting ready for school in the morning and cried when she did not get her way. Her parent’s greatest concern was Kristen’s absolute trust in strangers. Kristen did not understand that it was unsafe to accept rides, food, or money from strangers. She had difficulty remembering to look both ways before crossing a street, and had trouble obeying and understanding traffic signs. Kristen was often unable to state the day of the week or repeat what she had just said when asked. According to her parents, throughout elementary school, Kristen cried daily and displayed low self-esteem. Therapy and assessment. Kristen first received a psychological assessment at six years and 10 months. Her parents reported that she experienced a number of unexplained physical and psychological symptoms as well as significant academic and social struggles. She was referred by her school after an incident with a female classmate where a knife was drawn (either at her or by her). The evaluating psychologist wrote the following: Test and interview results reveal a mix of problems that do not yield a simple diagnosis…Kristen often talked in a sing-song fashion, her voice modulation was poor, and she spoke often like a younger child. Her tempo varied considerably- at times she responded very slowly, at other times at more ordinary speeds…Her experience of affect tends to be diffused and anger and fear may be fused at times. Wishes to be cared for and nurtured are evident along with some feeling of not being given enough and not being adequately cared for…The total picture is a mixed one that may include developmental as well as emotional elements.

Intelligence testing further indicated that Kristen functioned at the low average level. Her results suggested that she had deficiencies in general functioning, cognitive functioning, general immaturity, and affect modulation. An educational evaluation and neurological reevaluation were recommended. Continued psychotherapy was also suggested. Between ages eight and 14, Kristen was enrolled in at least four courses of therapy at her school and at the university training clinic. At age 11, Kristen received a second psychological evaluation. Her therapists and assessor were graduate students enrolled in a clinical psychology program and received supervision by licensed clinical psychologists. Kristen’s intellectual functioning was determined to be in the Borderline range between mild mental retardation and low average. Her general adaptive functioning was classified as low (.2%). In Kristen’s file, there were letters that she had written to her early therapists where she talked about having imaginary friends, being scared, feeling sad, and wanting “to die.” One note quoted Kristen at age 11 as saying, “I believe in ghosts, infisible (sic) friends, I hear voices.” Kristen decorated many of her letters with drawings of pentagrams and small child-like, violent creatures. Above the creatures were dialogue bubbles that read “I am evil” and “I am going to kill.” In the body of the letter, she wrote, “Here are some examplels (sic) of what I draw. I don’t know why I draw them. I just do.” This data packet also included a number of therapy progress notes. One of the notes referred to Kristen’s comments that she saw “animals, people and things that others don’t see.” Her therapist ruled out delusions and hallucinations. Instead, she suggested that Kristen’s invisible friends were a way for her to fantasize about being with famous people. The therapist noted that Kristen admitted that she drew to express her anger towards people that were mean to her but never drew these figures at school. When Kristen asserted that she often did not have control over what she drew, the therapist “talked with her about thinking before she acted.” Assimilation Constructs Observations bearing on internal multiplicity. Kristen’s complexity of internal experience appears to have been first identified when she was six years old by a psychologist who was unable to provide a “simple diagnosis.” The coinvestigators believed that Kristen’s vacillating psychological symptoms suggested alternative presentations of self and, perhaps, early experiences of internal multiplicity.

During a subtest of her first psychological evaluation, Kristen’s last line of an assigned letter was, “If you can not do it, then I will sue you.” She immediately concluded with the salutation, “Love, Kristen.” This sudden shift from a threatening statement to a loving line was seen repeatedly in many of Kristen’s early handwritten notes. Coinvestigators viewed these shifts as repeated expressions of emotional incongruence and conflicting internal perspectives. It was noted that Kristen’s age equivalents for the Wechsler Individual Achievement Test (WIAT) hovered around the age that her imaginal world came into being or became more complex. It was hypothesized that the limited sharing of information across self-states without meaning bridges led to additional confusion, as there were few consistencies between the two worlds. Or perhaps, with disconnection and various alters being present, it was impossible for Kristen to have access to much information in a coherent manner. She, therefore, began to lag behind similar aged peers. By age 14, there were copious examples of therapist notes, parent reports, and handwritten notes and drawings by Kristen that documented her experience of seeing people or things that others did not see. During eight years of various therapies, there were nine documents where Kristen wrote or was quoted as saying that she saw “Infisible (sic) friends, guns, people…” Records indicate that her various therapists ruled out her unusual experiences as delusions or visual hallucinations. However, these experiences were not understood as reflecting problematic multiplicity, so they were not systematically addressed or accounted for. Similarly, Kristen was equally consistent over the years in her recurring sketches of various characters engaged in violent or sexual activities. These images often were accompanied with evil symbols and conversation bubbles where threats or angry comments were written. Kristen’s inability to explain and, at times, even remember her drawings suggest that her artwork may have been one avenue for her alternate parts of the self to communicate their existence. The coinvestigators identified these conflicting internal and visual experiences as potential evidence for intrusive or unwanted thoughts and internal multiplicity. Observations bearing on voices. The coinvestigators suggested the following hypotheses regarding Kristen’s experiences of voices as a young child. Kristen’s psychological evaluation at age six stated that “She often talked in a sing-song fashion, her voice modulation was poor, and she spoke often like a younger child. Her tempo varied considerably-at times she responded very slowly, at other times at more ordinary speeds.” The psychologist’s remarks concerning

Kristen’s fluctuating vocal qualities were viewed as consistent with the Osatuke et. al. (2004) paper which described one woman’s internal voice as sounding noticeably different from a second internal voice. Coinvestigators felt that Kristen’s different vocal tempos may have reflected different voices or characters speaking. Kristen was diagnosed with TS, a diagnosis that was reported to be controversial amongst Kristen’s family, physicians, and teachers. She was subsequently treated with medication for a short time before the diagnosis was discarded. Lacking the original psychiatric report where TS was diagnosed, it was unclear which of Kristen’s symptoms were considered to have met criteria for the diagnosis. In later years and evaluations, TS was never considered as an appropriate diagnosis. The coinvestigators, therefore, suggested that if Kristen displayed any spontaneous vocal eruptions, socially inappropriate words or phrases, verbal tics or vocalizations such as shouting, grunting, throat clearing, or barking, they may have instead reflected alternate voices. These symptoms may have been misunderstood and misdiagnosed by the psychiatrist who, according to her mother, saw Kristen one time for twenty minutes. Observations bearing on therapy and the therapeutic relationship. The previous progress notes suggested Kristen’s lack of positive relationships as well as her frightening or angry relationships with her parents and peers appeared to trigger her suicidal feelings. In one incident, she reported thinking of strangling herself after her parent’s yelled at her. However, she said that she fought off the suicidal feeling by thinking of her beloved grandma and remembering her contract commitment with her therapist. This was viewed by the coinvestigators as evidence that safe or non-threatening relationships appeared to ground Kristen. We hypothesized that these early therapeutic relationships and her commitments to them seemed to have helped her to battle suicidal feelings and reframe from hurting herself on numerous occasions. However, within these therapeutic relationships, the coinvestigators collectively agreed that early therapy seemed to be helping Kristen to avoid rather than approach (or listen to) her voices and unusual visual experiences. A thorough examination of Kristen’s previous therapy records revealed that her sessions were primarily focused on helping her understand social situations as well as her own and other’s perceptions and feelings. They were described as being focused on learning to problem-solve social dilemmas, make friends, talk with her family, increase her self-esteem, and behave in a socially and developmentally appropriate manner. The previous therapists suggested that these interventions were helpful (i.e., “following school rules,”

“trying to make friends,” “no further incidents”). However, none of the notes mentioned sessions that invited a deeper exploration of Kristen’s internal experiences of invisible friends and voices or, her drawings of violent characters and pentagrams. Observations bearing on APES progression. Kristen’s chronic somatic complaints were well documented in the historical data. Her vacillating experiences of severe headaches, asthma, vomiting, chronic colds, neck pain, sinus infections, and skin-picking were viewed by the coinvestigators as consistent with suppressed problematic experiences (APES 0) See Table 1). Kristen experienced a number of voices that were angry and wanted to kill. She drew pictures of them without being able to reflect on them. They seemed to present as intrusive states of mind, ones that possessed Kristen when she engaged in drawing. In addition, Kristen repeatedly denied knowing why she drew such violent and evil characters. Coinvestigators found her denials as reflective of low assimilation (APES 0 or APES1). One therapy note documented Kristen’s response at age 10 after a peer threatened to physically harm her. This experience was reported as particularly traumatic for her. The coinvestigators hypothesized that Kristen may not have anticipated receiving such a threat because another alter may have escalated the situation without Kristen’s knowledge. That alter may then have pulled out leaving Kristen to experience the threat of violence with no forewarning. Though, keeping the interaction with her angry schoolmate warded off (APES 0) would have been adaptive in the moment, the resulting threat clearly disturbed Kristen. The coinvestigators considered Kristen’s experiences of seeing people and things as further evidence of low assimilation. They suggested that the people and things she saw may have been intrusions of unwanted thoughts or suppressed problematic experiences speaking out. They felt that her acknowledgement of these experiences seemed to suggest a vague awareness of problematic voices (APES 1). Observations bearing on different APES ratings. During analysis, the coinvestigators identified discrepancies in this data packet. Whereas some of Kristen’s handwritten notes discussed her imaginal world, others written around the same time denied its existence. Furthermore, though a few of the therapist’s notes reported on a Kristen who displayed some organized knowledge regarding her fragmented experience, other notes reflected a very confused and oblivious child. The investigators agreed that the APES levels fluctuated throughout the data and, perhaps, reflected very different presentations of self. They felt that some parts of Kristen

appeared to consistently know and understand more about her complex internal world than the others. From ages six to 14, the other alters appeared to be more assimilated (as represented by their ability to coherently narrate her internal experience of multiplicity) and, therefore, further along on the APES continuum (APES 3) for at least one of Kristen’s alters. Emergent Issues in data packet #1. Coinvestigators had been informed that I was in an Archetypal psychology practicum when I first met Kristen. They recognized its influence on my therapy. They imagined that the theory’s openness to the imaginal world and internal multiplicity may have encouraged or allowed Kristen’s alters to feel safe and, ultimately, speak out for the first time. They suggested that, as records indicated that Kristen’s voices were never seriously considered or engaged in therapy, the therapists’ theoretical orientations may not have acknowledged or valued internal multiplicity. In reaction to theories or therapists that were not open to internal multiplicity, the voices may have remained suppressed. Coinvestigators suggested that a therapist guided by a theory which was unwilling to hear or engage internal multiplicity might affect the client’s assimilation progress. In other words, the assimilation process might be hastened if a therapist was open and willing to listen to a client’s alternative self-parts, no matter how disturbing or dark these self-parts were. This influence could also be felt in a negative manner if the therapist’s theory privileged the suppression of alternative voices attempting to speak. The coinvestigators suggested that the assimilation theory might need to address this in relation to the therapist’s role in the assimilation process. Coinvestigators were curious as to whether interactions (with parents, therapist, etc.) would hinder or help the assimilation progress. They wondered what sort of interactions may have originally given rise to Kristen’s problematic voices and subcommunities in the first place. As coinvestigators were aware that dissociation has been linked to attachment theory, they suggested that relational influences may need to be further accounted for in assimilation theory. Coinvestigators noticed that Kristen’s psychological assessments repeatedly stated that she had difficultly concentrating. They wondered whether this difficulty was consistent with feeling overwhelmed by problematic voices. Coinvestigators suggested that this symptom appears consistent with early stages of assimilation and could be incorporated into APES 0 or 1. I realized that the coinvestigators were addressing a psychologist’s comments written approximately 18 years prior to our analysis. This time lapse caused problems for us as the report was unclear as to what Kristen’s experience of a lack of concentration specifically looked like.

We recognized that inattention or difficulty in concentration occurs for various reasons. Though I agreed that Kristen had struggled with inattention in our work in therapy, there were qualitative differences between her inability to concentrate due to illness, hunger, or excitement and her concentration difficulties related to her dissociative process. We did consider that, perhaps, the psychologist was suggesting that Kristen’s thoughts were being interrupted. If so, we hypothesized that it might have been due to an intrusion by warded off voices related to the internal multiplicity and lack of integration that we suggest she experienced as a child. The coinvestigators’ observations were, therefore, noteworthy. They rightfully suggested that having difficulty concentrating may be representative of early APES stages. However, due to the numerous reasons that inattention occurs, an inability to concentrate may also serve as evidence for other APES stages as well. Data Packet # 2: Beginning Therapy Sessions a) Intake summary (09/27/01) b) Progress notes 1st session (10/02/01) c) Audio tape of 1st session (10/02/01) d) Progress note 2nd session (10/09/01) e) A partial transcription of 2nd session (10/09/01) f) A pencil drawing by Kristen of some of her imaginary, non-famous characters Why I Chose This Data Packet These early sessions were chosen as the second data packet so that the coinvestigators could view Kristen at the beginning of therapy. I felt her confusion, suicidal ideation, and distress represented a good place to begin analyzing POC prior to the therapeutic change process. What We Learned It was in reviewing this packet that the coinvestigators first suggested that the subcommunities (alters), which were increasingly speaking out in therapy, were responding to Kristen’s and my developing relationship, my theoretical orientation, and my willingness to listen. Coinvestigators viewed this as different to her earlier therapies where any hint of negative thoughts or internal multiplicity appeared to be negated, concealed, or pathologized. They considered Kristen’s relationship with or assimilation of her alters to be generally at stage 1 of APES. However, there were various inconsistencies. At times, as suggested in the previous data packet, Kristen seemed to have some limited access to her internal multiplicity (suggesting

higher levels of assimilation). At other times, she appeared genuinely oblivious to her alters’ presence. These inconsistencies proved to be rating dilemmas for the coinvestigators. They saw them as possibly representative of vacillating levels of assimilation and, therefore, APES ratings out of linear order. They began to question whether the APES needed to account for this vacillation or seemingly backward movement in Kristen’s change process. Clinical Observations Context. At the age of 16, Kristen was brought in crisis to the university clinic by her mother. She had disclosed (for the first time) to a trusted school counselor that she maintained an internal, imaginal world with characters who engaged in a variety of drug activity, sexual acts, torture machines, and killings. The school counselor was concerned and immediately reported the situation to the Department of Children and Family Services (DCFS). An investigation soon followed. After being interviewed by a DCFS social worker, Kristen was petrified that they would place her in foster care. She experienced significant stress and suicidal ideation. Kristen’s mother then sought assistance from the university clinic as Kristen had previously received child therapy at the clinic. Her mother said that she didn’t “know where else to go for help.” Relationships. Kristen disclosed that she spent most of her time alone while at school and after school. When home alone she often remained in her bedroom or in the basement. Otherwise, she was with her parents, a few extended family members or a much younger cousin. Kristen used email to correspond regularly with a favorite grandmother who lived in another state. Kristen and her parents reported that she did not have friends or an independent social life. Instead, she often accompanied her parents to their adult parties and activities or remained home alone. Kristen’s parents reported that, perhaps because of the significant amount of time she spent with them, Kristen had witnessed problems in their marriage that included fights and a few physical separations. Kristen had experienced years of perceived bullying from her peers and, as a result, was reluctant to initiate friendships at school. Most of the time, Kristen ate alone in the cafeteria or spent her lunch period in the counseling office. She did occasionally speak with one female classmate. Most of Kristen’s teachers reported that she was very shy and rarely spoke in class. She was not attending church nor was she involved in any after school activities. For the most part, Kristen appeared to lead a solitary life. Symptoms. When this course of therapy began, Kristen no longer complained of excessive vomiting, tremors or tics. However, she did suffer from asthma attacks, allergies,

headaches, stomach aches, frequent colds and neck pains. Her parents reported that she often slept over 12 hours a night but was chronically tired. She sporadically received treatment from a chiropractor with little relief. Kristen continued to experience confusion, anxiety, daydreaming, numerous fears, a short attention span, and extensive memory loss. In addition to these symptoms, her most troubling symptom (as identified by her parents and school counselor) was her experience of a chaotic internal world filled with drugs, sex, torture, and killings. At intake, Kristen sat close to her mother and cried. Her speech pattern was slow and it was difficult to understand her due to noticeable nasal congestion, a symptom that plagued her in the years to come. Academic. Kristen was in high school at grade level receiving special education services. She attended some classes specifically for IEP students (e.g., math) and was mainstreamed into regular classes for courses in which she did not require individualized plans, like health and physical education. She was placed in a remedial English class and was removed from the room for short, one-to-one tutorials. Her teachers and parents reported that she fluctuated dramatically between engaged, interested behavior and disengaged “out of it” responses. Whereas one day, she might seem to master a math concept, the next day she was often unable to retrieve any memory of the teacher’s previous instruction. Her father reported that he witnessed similar shifts in memory or comprehension, often within one sitting, while helping her with her homework. Life skills. At intake, Kristen seemed much younger than an average 16 year old. Not only was she inordinately distressed at the slight possibility that she could be removed from her home by DCFS, she also appeared highly dependent on her parents in general. For example, although Kristen was old enough to drive, she was frightened of taking the test and failing. Kristen insisted she was not ready to drive independently. She was equally afraid of riding the bus to school and regularly asked her parents to take her to school. Kristen was terrified at the idea of interviewing for a job and refused to apply for part-time work despite her parents’ expectation that she find employment. Furthermore, although Kristen dressed herself for school, her mother regularly nixed her clothing decisions based on style, appropriateness, and coordination of colors. Kristen relied on her mother to purchase most of her clothes. She hated staying home alone and rarely agreed to do so. Therapy and assessment. Kristen arrived at intake expressing suicidal ideation but reported no means or plans to harm herself. She admitted that she was confused and

overwhelmed by her chaotic imaginal world and all that was occurring within it. In addition, she was highly agitated at the suggestion that she might be removed from her home. After meeting individually with her mother and then with Kristen, I recommended weekly therapy sessions to help her through her current period of crisis. The early sessions were focused on crisis intervention, building a therapeutic relationship, the process and results of the DCFS investigation, and Kristen’s interpersonal relationships. It seemed important to provide a safe place for Kristen to share and explore her long-held, secret imaginal world. By Kristen’s report, she had actively maintained this world since age seven, though parts of it were present even earlier. Whereas, it was initially a comforting world that she was able to retreat into when distressed, the world had increasingly grown to be a scary place filled with violent and sexual images and acts. The events that occurred in the imaginal world had intensified over time and were currently “out of control.” Kristen said that, in the imaginal world, she was able to do “things that I would never do in the real world.” As Kristen had never discussed her imaginal world in any detail with anyone, the pressure of it appeared to have become unbearable. In therapy, reports of the various characters and their illicit activities seemed to pour out of Kristen. However, her stories were confusing and seemingly illogical. Told in third person, the stories were disjointed with obvious overlaps of distinct topics or storylines, random and unrelated information, awkward starts and stops, and the appearance of internal interruptions. There was some structure or system that bound the characters together but the story remained convoluted. In therapy, we talked about how the two worlds (Imaginal and real) were quite different yet related in some ways. Kristen said that she felt like she had a great deal of power in her imaginal world and “NO power” in the real world. We explored both the similarities and differences of the two worlds. At our second therapy session, Kristen arrived with a picture she had drawn at home of a few of the characters in her imaginal world. She immediately asked to tell me about them. In reading the following excerpt from this session, it is helpful to know that, at the time, I believed it was Kristen speaking. I was naïve to the presentation of any alter personalities. In fact, I did not know there was a Zac character in Kristen’s world. Later, Kristen and Zac disclosed that it was primarily Zac that had attended all the early sessions in therapy. Kristen admitted she was “scared to meet a new person (therapist).” Looking back at this transcript, after meeting the various parts and coming to know their distinct personality styles, I am confident that it was Zac

reporting on the imaginal world. Later, when Kristen reported that she had been present during a session, she genuinely seemed to have access to only limited information about the imaginal world. Whereas, Zac seemed to tell a more organized story of events, Kristen often appeared quite confused. Furthermore, Kristen, who was often described as shy in person, was much less cavalier than Zac and rarely laughed at her own comments. Instead, she spoke slowly and tentatively. Later in our work, I realized it was only Zac who referred to herself as a “Psycho.” Until the last year of therapy, Kristen’s presentation lacked any display of anger. However, Zac was able to express a great deal of anger as demonstrated in this extended excerpt: C: Before we talk about your picture, do you want to tell me about how it went last week (meeting with the DCFS)? I know you were so nervous. K: It went pretty good, they are thinking about closing the case. C: Good, they came to your house? K: Yeah, they came to the house, looked in the fridge, and came up to my room. If they take me away from my home, my parents are gonna go ballistic. They asked me if I was going to see the counselor today. I’m like, “Yeah, she is very nice, I like her better than the school counselor.” I don’t know why they have to see my room. I wasn’t very comfortable. I was like lying down. They were like knocking on the door and I had to hurry up and situ up. I took the bad stuff down and hid the bad CDs. They know the lyrics are bad. She (Kristen’s mom) told me that I was starting to get real snappy and sarcastic to her and she said because we are moving, cause my cousin moved in right behind me. And, I’m like, that would be kind of like an odd reason that I would start being that way. Maybe, I’ve started to be more realistic to you, telling you “Hey, I ain’t really all that dumb just because I am in classes that I have help in…” C: There is a little tension between the two of you, isn’t there? K: Yeah. C: It’s good that you are talking about it. Don’t you think? K: Yeah. I told her that the little circle with the star in it meant evil. She didn’t believe me. So, she thought I was talking about the whole entire show (mother was watching television). I’m like, “I just said the circle with the star in it.” She goes all ballistic and she doesn’t talk to me. She didn’t talk to me the rest of the day today because I made fun of her show. She got pretty mad.

C: When the social workers came out to your house, did they talk to mom and dad alone or did they talk to you alone? K: They talked to them and to me. They looked around my room and asked me how you were. And my parents told them I was scared and they explained the custody thing. And I’m like, I had a problem with the school counselor asking you guys to take me home. C: I’m glad they came and listened to your parents. K: They said that the school counselor made it a bigger thing than what it was. Most likely, it is going to be closed. Thank God it is going to be closed because I really feel like suing that counselor or going and yelling at her. But, if I yell at her, I am going to get suspended. C: It sounds like she was doing what she thought was right but it doesn’t sound like she was really listening to you. Is that it? K: Yeah, I think she tries to get negative things out of people and eventually, it works until you get tired of her asking. C: Well, it is almost over. K: Something I forgot to tell you last time was that when I came here to see ya, the people were in the room. C: What people? K: From the imaginary world. And like, when she turned, I said something to them, and when she turns back and I am here. C: Did you say it out loud, or did you say it in your head? K: Uh huh. C: Are they in the room right now? K: No. C: Will you tell me if they come to visit us? K: Yeah. C: Okay, why don’t we look at the pictures you brought since we’ve got to that (drawings by the client of some of the people in her imaginal world). K: Okay. C: Is this the non-famous people? K: Yeah, the famous people look like they do no. Brittany Spears, Madonna…

C: (Reading aloud) “This is the guy who gets the drugs and drink, age 21. He never changes. He has always been 21.” K: Yeah, he is really messed up. C: He looks like it, doesn’t he? What’s that hole right there in his neck? K: That is when people can’t breathe through their mouth, sometimes, they get surgery and they have to breathe through their neck. C: (Still reading aloud) “Little sisters look alike?” K: Yeah, they had three more sisters, all three of them. They’re like twins and they all look alike. C: And these two are joined by their hair? K: Yeah, um…. That’s kind of weird because you can’t cut that hair. You have to go through a certain surgery. Its pretty messed up. C: I don’t think it is messed up. I think it sounds kind of clever. So, they are always together? They’re never alone? K: Yeah, they are never alone, always together. So, they can’t cut their hair off. They have to go to surgery like if somebody is connected at the hips. They’re going to have to go through that kind of process. C: Yeah. Now, this is your dad now, or a different dad? Is this the one that you live with? K: No, the imaginary world. C: And you are showing me the evil signs? K: Yeah, that’s his eyes. C: So, is this dad kind? K: Not really… C: How so? K: He actually told her to abuse me and stuff. But, he figured out that I found out and he is trying to get rid of me so I don’t tell Tay or Ike about it. Tay already knows, and Ike, I am trying to teach her to know. But see, I can’t say that. I can’t say anything. I have to give clues without being so obvious. C: Why? K: Because, he came through the house one night, and if I say his name, he will automatically be there. And he tries to talk to me, but he won’t get nothing out of me! I

just like ignore him, walk away, talk to other people. He is very strict on what I do. Now, why I was the person they abuse, I have no clue. But, Ike was born mentally retarded, Tay was normal. And I became a psycho. C: And who is this? K: That’s the mom, the first mom. C: And she had you, this is you right here? And this is a little sister? K: Yeah, um… After Ike was born, he went back to her, got her, and then it went all over again. So, basically Hanson has six sisters but only three brothers. C: And Ike is a boy? K: A girl. All three… Well, the normal group is all boys (Reference to the musical group Hanson) but I remade it so we are all girls. C: And this is mom’s fist? K: Yeah, that means she abused me, since I put that there to resemble that he was evil, I put that there to look like a fist because she is the one that abused me. C: And how did that mom abuse you? K: She would, like, get whips, hit me, or like throw me into a wall. It’s like when I didn’t have powers to go through things. And, see, I, like, still have the bruises on from when I was little and she abused me. But, I like gum in this acid. Its like the weirdest stuff helps me, like, acid helps cover it up. And then steaming hot water, like normal people will burn… C: But, not you? K: Exactly! It just covers up the bruises and stuff and one time, it kind of wore off. And, one of them asked, “What is that bruise?” I’m like, “I ran into the doorknob of the door.” (Laughs) C: It seems like, in your world, if something bad happens, you have a ways to change it or to, for example, you didn’t want the bruises. K: Yep. C: So, you solved that problem. K: Yep. Now they’re trying to ask for my forgiveness. That ain’t gonna happen! C: You’re not going to forgive them. Why?

K: Because, first of all, they really shouldn’t have chosen to abuse me just because I was first out and I was born a psycho. There is not sense to that. C: No. K: You should try to make it better. And I am really upset with the dad because he is screwing with every woman on the earth so I am like having sisters here and there but Tay and Ike are really close. C: Your closest ones. The ones you know the best? K: Yeah, we filled in the mothers with famous people, so we all have three fathers and three mothers. Brittany is mine. Tay’s mother is Jessica Simpson. Ike’s mother really doesn’t spend much time with us. Ike is going and screwing every guy in the world. Ike is the oldest of all of us but she was born last. (Laughs) C: So, (looking at the picture) what do you think? What does this mean for you? (pause) What is this all about? K: It means it’s a pretty screwed up world. C: This is? But, you’re smiling when you’re telling me that. It entertains you somehow. K: It’s just that I have been in it so long, like it’s like another part of my world. It’s like my second half. C: But, you recognize that there are some bad things in it? K: Yeah. C: It seems there are some good things too. You’re not alone in this world? Right? K: Yeah. C: And right now, you are an only child, right? K: Yeah. C: And, in this world, you are not an only child. K: Yeah. C: And, who is always there with you all the time, Tay? K: Yeah. C: Tay is always with you trying to help you. And, who is with you in the real world? K: My parents and my family and you. C: Yeah, I wonder if you will have a counselor come into this world.

K: I don’t know, pretty much when people try to help me because I like to do things on my own. So, like, one of the guys says, “Here let me lift that for you,” I like drop it. And, I’m like, I’m a girl. I don’t need a guy or anyone to do it for me. Assimilation Constructs Observations bearing on internal multiplicity. I first believed Kristen’s drawings of her imaginal world were simply representations of her imagination. In retrospect, it became clear to me that she presented the drawings as evidence of her experience of internal multiplicity. After analysis, the coinvestigators and I agreed that the picture was provided by some part(s) of Kristen as a way to communicate the organization of the imaginal world as well as introduce many of the alters. During the early sessions, Kristen (later reported to have been Zac) appeared to have extensive knowledge of the others. She reported in detail their roles and activities in the imaginal world. These discussions of Kristen’s imaginal world were identified by the coinvestigators as the first evidence of the presence of subcommunities. After reading this data packet, the coinvestigators wondered whether dissociating was some type of resource or adaptation for Kristen. They noticed that what they believed to be the unassimilated subcommunities (of Zac, Tay, Ike etc…) seemed to offer more resources than the assimilated voice (Kristen). Whereas Zac could solve problems (such as lifting heavy objects on her own rather than allowing boys to help), Kristen felt frightened by her male peers and was unable to even discuss their offers of help. We believed that the voices regularly stepped in to keep Kristen safe or from feeling uncomfortable. Observations bearing on voices. By the third session, the coinvestigators agreed that Kristen’s rather boring real world of social isolation and perfect, good-girl behavior remained in stark contrast to her imaginal world where numerous exciting voices engaged in illicit and illegal activities. Whereas one world was too light, the other world was too dark. Both worlds seemed obviously out of balance. Instead, they anchored opposite ends of a lifestyle continuum with few, if any, meaning bridges linking them together. Kristen’s repeated suicidal ideation was viewed as a response to her experience of internal chaos. It was clear that so much was going on inside of Kristen as she alternated or cycled between these two vastly different worlds and various self-states, subcommunities, and voices. The sudden shifts were difficult for Kristen to understand and caused her distress. For

example, when Zac had managed events for a few hours and, Kristen suddenly reemerged, Kristen knew little of what had occurred in her absence. Kristen once said that she was “always confused” after Zac or the others left. If a sudden transition happened during a conversation with her parents or peers, Kristen frantically scrambled to ascertain the context. In the meantime, she remained silent, nervously laughed, or offered noncommittal responses until she made sense of her surroundings and the current relational dynamics. Kristen said that, in those instances, her peers often made fun of her because she seemed “out of it” and her parents yelled at her for getting distracted or ignoring them. Kristen reported that many others called her “slow” or “not normal.” By the time I met her, Kristen’s response to episodes of automatic switching included wanting to die. This position seemed to reflect a lack of meaning bridges between the non- problematic voices and the Kristen subcommunity. Observations bearing on therapy and therapeutic relationship. Kristen’s disclosure to her school counselor that she had a violent imaginal world resulted in her mother once again seeking therapy for her daughter. Kristen’s confession was, by her account, the first time she had told anyone the full extent of her long held secret. During her intake and subsequent sessions, Kristen continued to elaborate on her imaginal world. However, over a year later, Zac reported that she had discussed the imaginal world in all of the early therapy sessions. The coinvestigators suggested that Kristen’s alters (Zac in this case) were unable, after years of secrecy, to be silent any longer. Instead, they were desperate to speak and, thus, leaked out information to the first interested party. They suggested that, perhaps, they were responding to having a non-judgmental therapist who empathically listened. The coinvestigators felt it was possible that the continued dialogue seemed dependent on my (as her therapist) openness to alternate ways of being, tolerance for Kristen’s dark side, and willingness to listen. As a result, Kristen was communicating more fully what she experienced. She articulated that which she hadn't put into words before, even though she may have previously used the same words (i.e., “I have infisible (sic) friends.”) The co-investigator’s hypothesized that my response was different than in her earlier therapies where her internal multiplicity appeared to have been squelched rather than explored. In other words, there were no meaning bridges for conveying her internal multiplicity between the earlier therapists and Kristen.

Observations bearing on APES progression. Kristen’s chronic, yet vacillating, somatic complaints continued to be viewed by the coinvestigators as evidence of the suppression of problematic voices and consistent with stage 1 of APES. Observations bearing on different APES ratings. The coinvestigators noticed a “jumping around” of APES stages regarding the experience of internal fragmentation. They wondered why, at times, Kristen demonstrated a great deal of knowledge about the imaginal world when, at other times, she seemed genuinely oblivious. They wondered whether Kristen was demonstrating assimilation that moved out of the traditional APES order. However, they also suggested that these discrepancies may have reflected her alternate voices or subcommunities (with different levels of assimilation) speaking. I confirmed their second hypothesis as during the third year of therapy, Kristen disclosed that Zac attended most of our early sessions so as to accurately report on her very confusing imaginal world. Zac knew much more about Kristen’s experience of internal multiplicity. The coinvestigators consistently assigned higher APES ratings when they analyzed Zac’s words or drawings. Data Packet #3: Early Sand Tray Work a) Photographs of sand trays depicting the real world and imaginal world b) Video tape of Kristen creating a sand tray. c) Audiotape of 11/28/01 session during second month of therapy d) Progress note of 11/28/01 session during second month of therapy Why I Chose This Data Packet It was in this data packet that the coinvestigators were introduced to the two sand trays (see Appendices P & R) that portrayed Kristen’s discrepant worlds. These sand trays were provided as visual depictions of Kristen’s internal system. I felt it was important for the coinvestigators to consider POC in more than the verbal transcripts as theory should contact experiential therapeutic work as well. As previously mentioned, it was later disclosed that Zac attended these early therapy sessions to report on Kristen’s internal multiplicity. In hindsight, it is apparent that Zac, for at least some part, constructed these two worlds in sand. Kristen (as Kristen) completed a second set of sand trays (see Appendices Q & S) three and a half years later. Those trays were chosen as a data packet for comparison purposes and are presented later in the results.

What We Learned These three-dimensional representations were further evidence of Kristen’s split self as well as the lack of meaning bridges between her two vastly different worlds. We agreed that the sand trays were the first example of therapeutic ZPD (Vygotsky, 1978, Leiman & Stiles, 2001) work. For example, I met Kristen where she was at regarding her imaginal world. Through reflections, gentle questions and encouragement, I led her to look deeper than she had previously. My questions about the two trays encouraged her to think and speak about the representations she chose. This guided elaborative process allowed her to more clearly articulate her feelings. The coinvestigators felt that this use of creativity (sand trays) and ZPD work in the therapy session allowed Kristen to express her internal experience despite her inability to initially wrap words around it. Clinical Observations Context. Kristen’s immediate crisis was resolved by month two of therapy. With no evidence of abuse, DCFS had closed the case and was no longer threatening to remove her from her home. However, Kristen and her mother agreed that the chronic stress and confusion she experienced in her daily life were larger problems and warranted continued therapy. Relationships. Socially, Kristen either isolated herself or became involved with seemingly uncaring peers. After the DCFS incident, Kristen, without hesitation, told her school acquaintances what had happened. She seemed to seek (and enjoy) attention by sharing her experience with random classmates. As a result, hurtful rumors about Kristen were circulated throughout her school. Kristen was often too trusting and demonstrated minimal personal boundaries in these and other interpersonal encounters. Symptoms. Kristen continued to complain of a variety of physical complaints such as headaches, stomach aches, and sinus problems which fueled her chronic absenteeism at school. Academic. Kristen remained enrolled in special education classes where her learning abilities continued to dramatically fluctuate. Once again, her teachers and parents reported that whereas one day she might demonstrate understanding for a concept, a day later she retained no memory of the lesson. In a similar manner, depending on the day, Kristen either appeared highly engaged in her education or completely disengaged. Though she was not a behavior problem, her parents and teachers often found her frustrating to work with due to her extreme fluctuations in memory and presentation of self.

Life skills. Kristen had yet to acquire any new, observable life skills. She continued to behave in ways appropriate for a much younger child. Therapy and assessment. Much of Kristen’s therapy during the second month focused on her anger towards her two friends. Between sessions, she wrote a number of letters to me about her interpersonal struggles. She also drew pictures of pentacles (“my evil sign”), torture machines, guns and knives. We talked about each letter, drawing, and interpersonal interaction. We discussed how she was expressing her feelings in a limited or superficial way with her words and a more aggressive way with her pictures. Kristen asserted that one of her therapy goals was to “get better at telling people how I really feel.” During this time, we discussed Kristen’s two worlds. I asked if she noticed that when her real world was filled with unresolved conflict or sexual tension, she seemed to explore her feelings in the imaginal world later when she was alone. She agreed and said that “a lot happens in the imaginary world when I am angry and filled with hate or love.” Kristen said that she could not tell others how mad she was because it might hurt their feelings. Instead, Kristen said that she would “role play” an interaction in her head rather than confront others in the real world. I recognized by our second session that Kristen seemed to respond positively to first drawing something that was troubling her and, later, talking about it. It appeared that most of Kristen’s drawings represented her internal experience. Upon entering the therapy session with pictures in hand, she generally had little explanation for them and often remarked, “I don’t know why I drew this, I just did.” However, with some exploration, she was often able to wrap words around the felt (and drawn) experience. Asking Kristen to concretize what she had long experienced internally was part of a creative process of change that I began to employ early on. Creativity has been described as an initial loosening of constructs followed by a tightening of meanings by George Kelly (1955/1991). Kelly suggested it was a cycle of initially experiencing the world vaguely, so that new meanings (or constructs) could then emerge. These meanings then become more precise or tight as they are tried on and adjusted accordingly. This process creates new ways of viewing the world (Leitner et al., 2000; Ravenette, 1993). At the onset of therapy, Kristen’s experience of internal multiplicity was originally loose, even chaotic. Ravenette, in a personal consultation (July, 2003), suggested that Kristen’s loose construct system could not be tightened with words until it had first been expressed. He suggested using drawings as a “child’s drawings will point to aspects of knowing which exist at

lower levels of awareness than that of verbal articulation” (Ravenette, 1980, p. 285). This consult influenced my decision to use open ended questions when asking Kristen about her drawings. For further discussion of this process and how Kristen’s drawings were used in therapy, see Humphreys and Leitner (2007). During the second month of therapy, I decided to use sand trays as an additional medium to help Kristen externalize and concretize her internal experience. I began the work by asking her to show me her imaginal world in one of the sand trays. Kristen (later identified as Zac) used a variety of toys to construct a rather complex and chaotic world. She placed a scepter representing power in the middle of the box, saying “the imaginary world has all the power.” She carefully placed a figurine representing herself in the tray and said, “She is the most wise and powerful person in the world.” Kristen placed a variety of toys in the tray that represented the “evil people, killing machines, and torture chambers” in her imaginary world. After setting up her sand tray, she talked about the colorful world that lay before her. Kristen described in great detail “killing off” or sexually torturing those who angered her. She spoke of performing at concerts, getting in physical fights, being kicked out of England for crude behavior, and injecting people with drugs. Later, I asked her to show me her real world in the second sand tray. In sharp contrast to her first depiction, Kristen (again as Zac) constructed a stark world where few people or relationships existed. Besides the small female figurine that was meant to be her, Kristen placed items representing her father (a truck), mother (a large, cloth doll), and therapist (a wizard). Her decision to include me in the sand tray seemed somewhat unusual as we were really just getting to know each other. There were no other representations of family members or friends. Instead, she continued to choose somewhat random items such as a blue cartoon character, adding, “I like Smurfs” and a horse, saying” I guess I like horses.” She chose a large plastic fly, saying, “I hate bugs.” Despite her very abstract imaginal world representation, Kristen chose only concrete examples for her real world tray. When I asked how she felt in the real world, she described herself as a combination of a “grumpy/crazy person” who has little to “no control.” While we discussed the two worlds, I placed the powerful Kristen character from the imaginal world into the real world and asked her how that felt. She paused and said, “It just doesn’t seem right.” We then discussed more of her feelings of helplessness in the real world. Having power in the real world seemed impossible to Kristen. Later, I placed the real world therapist (wizard) in the imaginal world and asked her how that felt. She said, “Kristen does not

need Carol in the imaginary world.” She said that she had tried having Carol in the imaginal world and the bad dad tried to control her so Kristen had to kill her off quickly to get her out of the world. She said that “Killing someone is the only way to get them out of the world.” Kristen said it was important for her to have the imaginal world. It felt “safe” and “helps me to face the real world.” She said that she was not ready to give it up but felt, at some point; she might have to move on as “it freaks other people out.” We discussed living with the imaginal world versus living without it. Assimilation Constructs Observations bearing on internal multiplicity. In reviewing this data packet, coinvestigators noted that, similar to Kristen’s drawings and verbal descriptions of her two worlds, there were distinct differences between her two sand trays. In comparison, the real world sand tray contained fewer toys than the imaginal world sand tray. In the real world sand tray, there were only two toys that were chosen to symbolize family members, one to represent her new therapist, and none to represent other relationships. In sharp contrast, the imaginal world sand tray was filled with toys representing numerous others (Zac, Madonna, Tay, Ike, dad, mom, etc…) There were various toys described as machines that were used for activities such as torture, drugs, sex, and killing. There was no overlap between the two worlds. These vastly different sand trays were again viewed as representative of the lack of meaning bridges between Kristen’s two worlds. However, as Zac presented the two worlds, her knowledge of them suggested she had some understanding of the two worlds. Kristen’s and my discussion after she completed the trays suggested that, although the imaginal world originally felt safe to Kristen (as Zac), it seemed to be a dangerous place for others (e.g., Carol was killed off). The coinvestigators thought that having power in contrast to feeling powerless was a determining factor in whether Kristen felt “safe.” They hypothesized that the imaginal world may have been created to provide Kristen with a safe place where she felt empowered and controlled the events. Reminiscent of Mair’s (1977a) suggestion that we often construct an internal sense of self that protects us from a threatening world, Kristen’s imaginal world initially allowed her to retreat from the relational threats she experienced in the real world. As she aged, her shifts into the various subcommunities and numerous voices increased in frequency.

Observations bearing on voices. Listening to the audio tape of the sand tray session, the coinvestigators reported hearing two distinct voices from the client at different times. Whereas one sounded bold and flirtatious, a second voice sounded meek and frightened. They hypothesized that these two different voices were representative of an internal conflict between opposing positions of the self. Observations bearing on therapy and the therapeutic relationship. The coinvestigators viewed the sand tray work as an important therapeutic intervention and evidence of therapeutic ZPD. In the sand tray work, I met Kristen at her level as she constructed a three-dimensional experience of her vastly different worlds. With hundreds of small toys to choose from, Kristen methodically picked out specific figurines to “show me” her worlds. After her trays were completed, we explored together why she chose each piece and what it meant in its tray. An essential component of this work included a discussion of the similarities and differences between the two worlds. Comparing the worlds back and forth, even temporarily moving a few of the figurines between the two worlds, helped her to articulate what one world was like and what it was not like. She had not previously thought about these differences and similarities, and in doing so, she appeared to move to a slightly higher level of assimilation. Kristen was asked to describe how the representations (drawings, sand trays) of her world and the alters in it were similar to or different from each other. Ravenette (1977, 1980, 1993) suggested that the essence of a construct (or belief) is its bipolarity and is best understood in the context of its opposite. This idea informed my decision to respectfully stretch Kristen’s constructs. With her permission, I placed the “strong Kristen” in the “real world” sand tray and asked what it felt like. We explored the use of the imaginal character of “strong Kristen.” She was able to explain that being strong or confident in the real world wasn’t an option. We discussed the various reasons why it didn’t feel right and, Kristen said that she had no control or power in the real world. After next placing the figurine representing Carol in the imaginal world, Kristen admitted that it didn’t feel right either. Though Kristen liked representing Carol, having her in the wrong world (imaginal) forced her to “kill” Carol. At times Kristen struggled to find the right words to describe her experience. By specifying or wrapping words around her choices and what they represented, she was, in many cases, articulating, for the first time, her internal experiences.

However, it was difficult for Kristen to tolerate much outside her original and disparate conceptualizations of the two worlds. Articulating the rigidity of each world was the first step in initiating a dialogue between two opposing experiences. As her understanding increased and the dialogue progressed in therapy, meaning bridges were built between the opposite experiences. The coinvestigators felt that the sand tray work introduced the idea of building meaning bridges between the two worlds by engaging them in dialogue. Observations bearing on APES progression. Coinvestigators noted that during the sand tray session when the two conflicting voices spoke, there was evidence of negative affect. They observed that the negative affect and confusion arose when the problematic interaction of the two voices was forced. This was considered consistent with APES Stage 1 where affect is negative but unfocused. Emergent issues in data packet # 3. The coinvestigators wondered whether a meaning bridge -- suggesting increased knowledge of the imaginal world -- was already present while Kristen’s increased awareness represented her growing trust in the therapist. They questioned whether researchers can ever know if observable evidence of assimilation (as tracked in therapy sessions and interviews) is due to actual assimilation or increased trust in the therapist. They considered that, perhaps, in this case, Kristen chose to share something that may have been assimilated long before. When we only track assimilation within therapy or interview transcripts, are we instead seeing the natural progression of increased trust between a therapist and a client? Data Packet #4: Home Visit a) Audio tape of 09/02 two-hour home visit b) Progress note of home visit Why I Chose This Data Packet This home visit was a key moment in therapy as identified by both Kristen and myself. While touring her home (in particular, the basement), Kristen detailed the imaginal world that she had developed and acted out for years. I felt this audio-tape and the progress note would provide the coinvestigators with a window into the complex structure of her internal system. What We Learned Like the sand trays, the home visit was split into two separate tours of Kristen’s discrepant worlds, both real and imagined. Coinvestigators felt that the two tours reflected Kristen’s internal split and the amnesic barriers inherent to DID. We thought that this home visit

signaled the beginning stages of breaking down those same amnesic walls. Prior to the home visit, the imaginal world was kept separate and hidden from Kristen and her parents. However, the home tour disclosed the extent of Kristen’s fragmented experience to her parents. As we walked through the house, her mother and father were alerted to (and disturbed by) Kristen’s unusual and comments about imagined others. These disclosures increase both Kristen’s parents and my knowledge of the separate worlds. At the same time, speaking out loud about each world made them and their occupants more real for the other alters. As we talked, Kristen was faced with aspects of Zac’s world and visa versa. These verbal descriptions of the worlds represented early stages of joint understandings, shared signs, or meaning bridges between the two discrepant and previously dissociated worlds. However, we considered, for the first time, the extent to which Kristen’s experience of separate worlds may have reflected her developmental stage as a teenager. We acknowledged that teens often dabble in multiplicity as they try on different identity roles. We agreed to remain sensitive to this issue throughout our research. In this data packet, we again found evidence that ZPD work and the therapist’s theoretical orientation had an important influence on assimilation. We agreed that the assimilation theory could further benefit by an increased focus on the relational components of assimilating problematic experiences within therapeutic dyads, families and friendships. Clinical Observations Context. Kristen weathered a number of personal dilemmas during her first year in therapy, including a two-month break from therapy over the summer. Despite an intense fear of her parents’ splitting, Kristen survived their chronic relational struggles and a one-month separation. Though she reported some suicidal ideation during these taxing situations, she repeatedly denied having had a plan or means to hurt herself. Relationships. By this time, Kristen reported that she had two female friends. One friend she rarely saw outside of school. Her second friend, although they had known each other since first grade, only called her when she wanted something. Kristen often gave gifts of money or clothes items to these girls which were rarely reciprocated. As a result, Kristen reported feeling used. Despite repeated wounds, Kristen was unable to defend herself or terminate the unhealthy relationships. She continued to call these two peers her friends.

Kristen required significant support to get through two, very difficult incidents. The first incident involved the sudden death of a beloved, former babysitter. Kristen reacted dramatically and grieved for weeks after his death, although she had not seen him for years. She appeared quite depressed, felt it was her fault, and became obsessed with his death and funeral. At around the same time, Kristen became intensely involved with a small Pentecostal church after being invited to attend by a new acquaintance. She attended regularly for three months as a way to make new friends. After Kristen shared her experience of her imaginal world with the pastor, the church soon became intent on exorcising her “evil demons.” They regularly brought her up in front of the congregation, surrounded her, and spoke in tongues. Kristen became quite confused and frightened. She repeatedly said she did not want to speak in tongues and wanted to stop attending. However, she felt unable to say “no” to her new friend. After I met with Kristen’s parents and suggested they investigate, they eventually ended her involvement. Despite quickly losing her new friend, Kristen, she expressed relief over their decision. However, Kristen’s interpersonal struggles continued to fluctuate over the year. After transferring to a new school part-time, Kristen was suddenly surrounded by a group of new peers and teachers. With varying results, she attempted to develop new friendships. Kristen also had a few dates that included some kissing and touching. These interactions were especially confusing. Symptoms. Kristen’s symptoms continued to fluctuate. At times, she struggled with extreme nasal congestion, asthma attacks, allergies, head-aches, and neck aches. On a few occasions, she went to the chiropractor with some relief. Oftentimes, she arrived at therapy appearing physically ill and later, left suddenly improved. The opposite also occurred. Academic. Kristen attended her IEP meetings with her parents and, for the first time, asked questions of the school staff. After a lengthy amount of discussion and negotiation, she transferred to a new high school part-time. In the morning Kristen attended her old high school where she engaged in core academics. After lunch, she was bused to an alternative program off- site where she participated in vocational training. For the most part, Kristen handled this switch quite well. However, on at least a few occasions, she missed the bus reportedly due to memory loss and confusion. Life skills. During this time period, Kristen started babysitting for her toddler-age cousins. She appeared to mostly enjoy the experience. However, the responsibility became overwhelming on more than a few occasions and she had to call her parents for assistance. Prior

to her school transfer, she began working a few hours a week at her old high school’s bookstore. In addition, Kristen’s father hired her for office work as a way for her to earn spending money. Kristen also applied for a learner’s permit and began driving with her parents in the car. Therapy and assessment. Kristen and I developed a strong therapeutic alliance during the first year of therapy, and she appeared to benefit from our sessions. She consistently attended weekly therapy, requested additional sessions if necessary, and called the clinic on at least eight occasions when under extreme duress. Therapy included talk, play, art, music, sand trays, role- playing, two chair work, and empty chair work. Our work focused on Kristen’s identity, role, and relationships. She was an active agent of change in her therapy as she often requested homework, always completed it, shared items of significance, responded well to most interventions, thought about therapy outside the therapy room, and enthusiastically looked forward to our sessions. At the request of her and her parents, I participated in two Individualized Education Plan (IEP) meetings with her school teachers and treatment team. Nonetheless, Kristen struggled throughout the year in many ways. She had, on several occasions, expressed suicidal ideation (with no means or plans). These feelings often arose during times of escalated stress at school or at home. In each incident, Kristen eventually was able to ask for help and work through her feelings in therapy. Despite the episodes of wanting to die, Kristen never had any suicide attempts, hospitalizations or psychotropic drug treatment. Crises were worked through but her general confusion, loss of time, poor memory, and daily interpersonal struggles remained. For example, Kristen remained extremely confused about her own power, the extent of it or lack of it in the real world. When her babysitter died, she said, “It’s my fault. I masturbated the last few nights and God doesn’t like that.” As she was aware that she (as Zac) was able to kill off people in the imaginal world on a whim, Kristen believed that her behavior was somehow responsible for killing her babysitter. Kristen felt the same way when her parents separated. At one point, she also imagined that if she were dead, “world peace could happen.” We explored these struggles over power, control, and blame in therapy. At around the six-month mark of therapy, Kristen began to shift in her presentation of the imaginal world. Whereas, she had previously referred to it in the third person, she was now telling stories of what was happening in the imaginal world in the first person. This first person

presentation escalated during her church-going experience. At the same time, the violence and sexual activity in the world intensified. In addition, the characters (Zac, Tay, Wes, & Madonna) began spontaneously introducing themselves to me in therapy. In almost every session, for some part of the fifty minutes, one of the characters, other than Kristen, identified her or himself as being present. When this occurred, Kristen’s physical and vocal presentation would change. She would suddenly slouch or pull herself up in the chair. Her hands might abruptly become animated or she would swing her legs repetitively in contrast to her normally inanimate (almost stiff) demeanor. Her voice fluctuated between sounding louder and stronger or weaker and more nasal. Sometimes she spoke clearly and was easily understood. Other moments, she muttered and I often asked her to repeat herself. Zac came to session resistant to any perceived efforts attempting “to change Kristen” and called me (Carol) a “Bitch!” Zac insisted that Kristen didn’t need me and my attempts to “get rid of the world.” Zac and Kristen said they were afraid for Kristen to live without the imaginal world, that “she needs it.” We spent time discussing my belief that Zac was created to help Kristen and it would not help Kristen to suddenly kill Zac off. Both Zac and Kristen seemed relieved. In some sessions, they tried to catch me up on the history of the imaginal world. They often regaled me with stories of how they had originated. I was told that Zac came out when Kristen was in kindergarten and her peers were making fun of her shoes. I heard from Zac that Hanson was “hundreds of years old” and “was born under a tree.” Another alter, Ive, came into existence without hands only after Kristen was punished for writing a threatening note to one her bullies. During these sessions, Kristen often reported headaches and retained no memory of what was said in her perceived absence. Kristen repeatedly asked me to visit her home so that I would understand her world better. She had long talked about the dances, concerts, games, rituals and violent activities that her imaginal characters only participated in at her home and particularly in her basement. As a former social worker who visited client’s homes, I felt comfortable with the idea. I also thought it might provide a healing experience for Kristen to share more of her secret world with someone who felt safe. After the summer break, my supervisor and I agreed that I would make a home visit. I audio-taped the session as Kristen took me on a tour of her home and basement. Kristen’s home appeared new and was immaculate both inside and out. The family greeted me at the door. After her parents led the way into the kitchen, Kristen identified herself

as Zac and reported that she would be giving most of the tour. Kristen would be available for some portion of the tour when the parents were around. I nodded and, after chatting briefly with the parents, all of us were escorted through the rooms. While in Kristen’s room, Kristen, with encouragement from her parents, showed me her neatly organized videos, tapes, and picture albums. Many of them were of Madonna’s music and concerts. She showed me where she does homework and where her dog slept. A bit later, we were in Kristen’s parents’ bedroom and I asked her where was the picture she had told me about (the one in which Mama Jean is confined). Suddenly, there was a shift in presentation (from somewhat shy to assertive) and Zac pointed to a blank wall and said “Right there.” Kristen’s dad then said “Kristen, there is no picture up there.” There was an awkward moment as Zac ignored him, pushed right past him, and continued the tour. As we walked through the house, she pointed out areas where the characters danced, held concerts, killed people, had sex and did drugs. After we had waked through most of the house, Zac told Kristen’s parents that the rest of the tour was “My tour!” They proceeded to the kitchen to wait. I was then led back into Kristen’s parents’ room and Zac told me about what happened in that room. Zac pointed to empty chairs or walls where she saw her “drug dealer guy” and Mama Jean, “the one who seemed to know most everything.” Zac said that Mama Jean was very busy and she (Zac) would sense her when she (Mama Jean) wanted to come out. At one point, Zac climbed on the bed and turned the wood spindle on the headboard to try to get Mama Jean’s attention. Zac continued to talk about the people in her world including one that I was accidentally leaning on. I asked her if all of these parts of her were also at her old house (as Kristen’s family had only lived in the home two years.) She said, “Yes, but it was kind of hard.” Zac reported that they did not previously have a basement and everything that happened could be seen by others. But, with the basement at the new house, there is “private time.” Mama Jean suddenly identified herself as being present (in Kristen’s body) and explained what led to her living in the picture on the wall. She commented on how hard the move to this new house was for Kristen. She mentioned that Kristen had been approached by a few guys, one of whom she may have had some interest in. Mama Jean appeared to have maternal concern for Kristen. She reported on the others as well. When asked how the world began, she likened it to a child’s imaginary friends. She repeated that, as Kristen’s peers were very cruel to her, she needed a world where she felt included. Mama Jean believed that Kristen currently needed to get it out

in therapy to lessen her depression. When asked if she were comfortable with me being there, she said, “I knew you were coming, but I didn’t have time to prepare.” She thanked me for coming. Mama Jean said I needed to know everything in order to help Kristen. She brought up the movie Sybil and she said that she had not seen it but Kristen had, and that she related to it. I mentioned that Sybil had gone through such horrible abuse in her childhood apparently unlike Kristen. Mama Jean said that Kristen’s abuse had been emotional. She did not think that Kristen could continue to live with the imaginal world forever and that it had to eventually end. Mama Jean talked about the suicidal feelings Kristen has had in past. She said, “Zac is there to help her when she gets those ideas in her head.” I said that I would want someone to help her. She agreed. We ended our meeting and Mama Jean stayed in the bedroom. As we left the room, Zac remarked, “She is a very busy person.” We proceeded down the stairs to a large and similarly immaculate basement with few items in it. There was a couch, coffee table, an entertainment center, chairs, a fold up table, and a few storage boxes. Zac again insisted on taking me through two different tours. The first one consisted of walking to the right of the basement staircase and talking about each of the things we saw. Her explanations were literal and relatively benign. For example, she said, “This is a table where Kristen sits” or “This is a box with board games in it.” I followed Zac back to the staircase as she made an almost robotic turn to the left of the stairs in the opposite direction of our first basement tour. All the furniture and items were then identified as more violent components of the imaginal world. They were described as torture or sex machines where people engaged in sex with multiple partners or were killed. Zac provided details of the specific rituals and activities that occurred throughout the basement. After her descriptions, Zac performed a dance from her concert tour. Though she described herself as a talented musician and dancer, her steps were somewhat off-beat and awkward. There was a significant discrepancy between my experience of her dancing and her perception of her performance. After dancing, Zac mentioned that a cousin in the real world had been on drugs and killed himself in another home prior to Kristen’s birth. She said that Kristen had repeatedly heard the story growing up and felt it was somehow her (Kristen’s) fault. I asked Zac how it felt to have me there as a witness to her world. She said that it felt weird but she had been pretty excited all day and had even practiced her dance earlier. Zac said “I’m totally lost in this world as much as everybody else is. It doesn’t make any sense and I’m in

the process of trying to figure it all out.” At the end of our talk, I asked if she felt like she had accomplished what she wanted from my home visit. She said, “Yes” and that somehow she felt it would help me help Kristen. Zac agreed with Mama Jean, stating that, “Kristen is depressed.” We concluded by “undoing our steps” or walking back exactly the way we came as we left the basement and went upstairs. During this time, my supervisors and I continued to wait for a consultation as we actively researched and considered the possibility of a DID diagnosis. Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators noted that Kristen and Zac provided two separate tours of the house and basement. During the first tour, the parents accompanied us. Kristen’s description of the house focused on the real world activities that occurred in each room with only a few comments about imaginal others. Later, when Zac and I walked through the house alone, she shared copious detailed descriptions of where imaginal world activities occurred. During the second tour, Mama Jean disclosed a great deal of information in order to facilitate me in helping Kristen. Like the drawings, verbal descriptions, and sand trays, this segregation of the two worlds (and two tours) was viewed as evidence of at least two, separate and distinct experiences of her self. Coinvestigators saw this as evidence of internal multiplicity and the communities of self. However, it is possible that the separate tours reflected the kind of multiplicity that we all have across different roles or relationships. Perhaps, Kristen was reacting similarly to other teenagers by trying to keep secrets from her parents (a relatively common form of multiplicity among adolescents). Though that may be one piece of Kristen’s identity puzzle, I concurred with the coinvestigators that the segregated tours had more to do with presenting her segregated bodily experience. There was clearly some overlap or rapid switching between the two (Zac and Kristen) early in the tour. Whereas, Kristen was present for some portions of the tour (in her bedroom, the office and kitchen), by the second tour, it was primarily Zac with a short visit from Mama Jean. I believe both Kristen and Zac wanted me to experience in person their multiplicity. Observations bearing on voices. While listening to the audio tape of the home visit, the coinvestigators noted that Kristen and Zac switched from 1st to 3rd person and back again several times. Before the tape concluded, Zac said, “When I talk about Kristen, sometimes I go into the “I.” The coinvestigators hypothesized that this struggle to maintain a single perspective was

evidence of the experience of internal multiplicity. They thought this back and forth articulation of self might be evidence of switches from one self-part to another. The audio tape alerted the coinvestigators to changes in Kristen’s voice. For example, Kristen’s meek voice transformed into a forceful sounding Zac when describing the imaginal world. The shift from a quiet or shy voice to the louder, more aggressive sounding voice appeared obvious to the coinvestigators. Interestingly, other voice changes were noted when Zac was confused by questions I asked. The coinvestigators suggested that these shifts in vocal quality were perhaps evidence of internal contradictions within Zac. Whereas, feeling frightened or angry appeared to be triggers for Kristen to flee, allowing Zac or the others to speak in her place, feeling confused seemed to trigger alternative voices within Zac to speak out. Observations bearing on therapy and the therapeutic relationship. Throughout the tour, the client allowed her imaginal world to become real for me. The coinvestigators felt that this was about Kristen’s willingness (based on the strengthening therapeutic dyad) to share how the imaginal world was lived as real. It seemed that Kristen and Zac wanted me to understand their lived, bodily experiences. For example, Zac presented a mini-concert as an example of her musical career and Kristen showed me where her Madonna videos were obsessively organized. Sharing their physically experienced worlds seemed vitally important. In later sessions, both Zac and Kristen began to assert that they felt heard, understood, and appreciated. They increasingly asserted that my knowing more about each of their worlds would help me to help them, and, in particular, it would help Kristen. Coinvestigators thought that this home visit continued to represent the breaking down of walls that had been built between the two lived worlds. Whereas prior to the sand tray work and home visit, the worlds had been experienced as separate, and the imaginal world had been mostly hidden from Kristen and her parents, they were now being presented as parallel to each other. A joint understanding about the worlds was explored. The coinvestigators thought this visit was an experiential exercise that helped the alters to continue building meaning bridges between the two worlds. Kristen and her parents shared signs during the tours as well. My willingness to speak with Zac (and the alters) during therapy and at the home visit was deemed noteworthy by the coinvestigators. Though I first spoke with Zac out of ignorance (with no knowledge of shifting), my theoretical orientations (Humanistic, EPCP, Archetypal) allowed me to honor what I first considered as the imaginal others while accepting Kristen’s

experience as her truth. Once I realized the extent of Kristen’s internal multiplicity, I decided to continue speaking with the alters. If Zac showed up for therapy, then I spoke to Zac. I met and worked with whoever came to therapy on their presenting problems regarding the imaginal or the real world. Coinvestigators felt that I served as a conduit between them, increasing their knowledge of each other. The coinvestigators saw this as representative of ZPD and suggested I worked a little ahead of the alters pulling them up, just a bit, with each relational encounter. Observations bearing on the APES progression. On the audio tape, the coinvestigators noted that several times while touring the basement, Zac said, “It’s confusing” and “It doesn’t make any sense.” This appeared to be a problematic voice within the subcommunity of Zac representing a conflicting position of the self. As much as Zac needed an imaginal world to live in, parts of her were confused by the world. Not understanding or knowing everything about a world that she was meant to be in control of appeared to trigger this vocal change. This internal contradiction was considered consistent with APES vague awareness~ emergence. Or, once again, they wondered whether this could this be other alters popping in and out. The coinvestigators identified a meaning bridge between Kristen and Zac when Zac commented on occasionally slipping into the “I” when talking about Kristen. They suggested that the recognition of the shared self was consistent with Problem statement/clarification of the APES. Additional meaning bridges between many of the alters were identified when Zac reported that they had agreed to try and get Kristen to talk in therapy. Observations bearing on different APES rating. The coinvestigators again asked about whether or not we were seeing something they labeled one way meaning bridges. They repeatedly noted that Zac seemed to understand Kristen but Kristen did not know Zac. They suggested that this might be labeled a one way meaning bridge, as there seemed to be a meaning bridge from Zac to the client but NOT visa versa. My understanding of this non-reciprocal knowing was different than the coinvestigators. I initially saw it as similar to some real world relationships. It is not uncommon in many relationships for one person to understand another’s experience and yet not be (or feel) understood in return. We see this experience in friendships, romantic relationships, family dynamics, and in therapy. The parent frequently understands the child but not visa versa. Or, a perceptive person often understands why her best friend acts a certain way although the friend

understands little about the other. Certainly, in therapy, a therapist often has insight into her client whereas the client knows little about the therapist. I viewed this non-reciprocal knowing of the other as evidence of the dissociation that occurs in DID. For example, in DID, it is often common for at least one of the alters to know much more about the host than the others. Often known as a reporter alter, he or she is able to report on multiple events crossing at least some of the amnesic barriers. Emergent issues in data packet # 4. The coinvestigators noted that Kristen’s parents seemed confused and upset about her imaginal world (e.g., Dad vigorously told her there was nothing on the wall). Perhaps Kristen’s imaginal experiences could not be assimilated to her real life community because her parent’s invalidated her experience. Coinvestigators felt that this relational component may have something to do with the lack of assimilation in dissociation or DID. Many of our comments and discussions focused on why assimilation occurs or doesn’t occur and what kind of relationships impede or encourage the process. We considered that every relationship has its own set of inherent barriers. Theoretically, the barriers are affective: encountering the other is painful or somehow dysphoric, and this stops or distorts the communication. This phenomenon happens both between people and within people. However, the coinvestigators suggested that as the assimilation model increasingly accounts for relational aspects of the process within the therapeutic dyad, it might focus on how the family of origin has accommodated or stifled assimilation as well. We also felt that, based on the discrepancies between Zac’s and Kristen’s assimilation process, the model needed to account for subcommunities assimilating at different rates. Data Packet #5: Client Notes to Therapist and Self a) A story, “The Unknown Girl” b) Letter to Carol, 10/04/01 c) Letter to Carol, 12/30/01 d) Various other letters from first year (Zac & Kristen) e) Letter from Zac, 01/03 f) Letters from Kristen,03/07/03 and 03/08/03 g) Letter from both Zac & Kristen, 07/14/03 h) Two letters from Zac, 07/17/03 i) A story, “Once Upon a Time,” 09/03/03 school journal

Why I Chose This Data Packet These letters and stories were written by Kristen in-between her sessions over the first two years of therapy. They reflect the struggles that Kristen encountered in her daily life. They also reflect the fragmented sense of self that Kristen increasingly felt comfortable sharing in therapy. I felt that by searching for points of contact (or no contact) between the theory and Kristen’s written expression could provide additional insight into her assimilation process. What We Learned It was in this data packet that the coinvestigators first saw evidence of co-consciousness in the letters that were signed by more than one alter. Their simultaneous presence appeared to reflect growing team work or dialogue between the subcommunities. During analysis, we recognized that most of the alters still were not directly talking to each other and, instead, were using the therapist to share information with the others. We explored this idea of therapist as conduit for early communications between the alters. We wondered if this dynamic typically occurs before the alters were able to talk directly to one another. Perhaps, this dynamic reflected an early developmental stage of building meaning bridges in cases of DID. We considered whether the construction of meaning bridges between the alters and the therapist was a necessary stage prior to the creation of those meaning bridges that were capable of crossing subcommunities and amnesic barriers. The coinvestigators again reported evidence of vacillating APES stages which they suggested might reflect Kristen taking steps backward in the change process. However, we agreed that any case of DID is complex and multi-layered. In these early data packets, as well as in Kristen’s early therapy, it was often unclear when alter switches occurred. Understandably, the coinvestigators had some difficulty knowing which alter they were rating. On numerous occasions, they believed Zac was Kristen and rated accordingly. In hindsight, these steps backward appeared to reflect the raters’ confusion over who was communicating. Similarly, the coinvestigators were confused by what they labeled one-way meaning bridges. They felt these reflected where, for example, Zac knew more about Kristen than Kristen knew about Zac. And though the coinvestigators wisely pointed to these as examples worthy of rating, they used language that did not accurately reflect what was identified. A meaning bridge in assimilation simply means a shared understanding of signs and, therefore, can not be one way.

In addition, the coinvestigators were still learning about dissociative experiences and lacked an understanding of the inherent structure of DID where some subcommunities are created to know more than others. Amnesic barriers are created to contain the flow of information between the alters and the host personality. Not surprisingly then, some subcommunities appeared to be further on the APES than others. With these issues, I considered the coinvestigators observations as valid but suggested these examples said less about Kristen’s change process and more about the amnesic barriers that are at the core of DID. Clinical Observations Context. Since beginning therapy, Kristen demonstrated a genuine commitment to getting better. She attended sessions regularly and telephoned during moments of extreme duress. She was open to new ways of looking at events and worked both in and out of our sessions. During the same period, I discussed Kristen’s chronic symptoms with my supervisors at length and sought out consultation. I read about and researched symptoms that seemed similar to Kristen’s. I explored with Kristen and her parents her life-long experiences of memory loss, identity confusion, depersonalization, and feeling “split inside.” We agreed that the DID diagnosis best described her fragmented internal experience and her distressful real world experiences. Soon thereafter, I enrolled in a nine month course focused on dissociative experiences in order to further my understanding of Kristen’s experience. Relationships. After her school transfer, Kristen made a few new friends. She was finally able to sit with a group in the cafeteria rather than eat alone as she had done for years. She dated occasionally, attended three school dances, and spoke up for herself more often. However, Kristen was easily confused and distressed by seemingly simple interpersonal interactions. In response, she frequently dissociated. For example, although she went to the homecoming dance, she retained little memory of the event. Instead, she later reported that Madonna went to the dance. On another occasion, when a boy approached her at school, she reported that Zac stepped in to handle the interaction. Kristen was only able to say that she “freaked out” as the boy walked up and touched her arm. Kristen couldn’t remember anything that Zac said. Symptoms. Most of Kristen’s symptoms remained. Her physical symptoms (i.e., asthma, congestion, headaches) persisted with only short periods of relief. Kristen continued to have episodes of feeling out of control in her imaginal world. She occasionally experienced suicidal ideation though she never had a plan or means. As previously mentioned, Kristen was

increasingly opening up in therapy about her fragmented sense of self. Perhaps not surprisingly, Kristen’s symptoms often escalated during or after a difficult therapy session. Academic. Kristen worked appropriately with her IEP teams at both her vocational and home high schools. She maintained decent grades with the assistance of numerous special education accommodations. Kristen often used her school counselors as resources when she was stressed. She frequently visited them for grounding, support, and advice. Life skills. Kristen enrolled in driver’s education classes and continued to drive with her parents as passengers. However, she reported that it was Tay or Zac that was doing most of the driving as she was “afraid to drive and that’s what they’re good at.” On her own volition, Kristen quit her job at the bookstore and applied for a number of other jobs. She successfully interviewed for a restaurant job and was hired. Therapy and assessment. In therapy, Kristen and I explored her identity, role and relationships in both her real world and imaginal world through the use of talk, art, and some play. We also engaged in psycho-education with assigned homework focusing on topics such as peer relations, family dynamics, and normal social development. I encouraged Kristen to find ways in-between therapy sessions to feel grounded, self- soothed, or calmed. One activity that provided some comfort included writing me letters which she would then bring to therapy to share. Her alters soon began to write letters as well. They often described their own activities (such as performing a concert in Britain or getting married to each other) but also regularly reported on Kristen’s experiences. They expressed their concern for her and provided helpful information and tips for me to consider in my work with Kristen. The first fifteen minutes of our sessions often included me reading these letters out loud. I did this in order to refrain from developing special alliances with any of the alters. I felt this was important as Kristen regularly discounted her own voice, felt less than the other more exciting parts, and deferred to them. I wanted to send the message to Kristen that, although I honored the various alters, I first honored her, and therefore, my alliance was with her. I reiterated this primary relationship with Kristen during her 49th session when she said she didn’t want to know what Zac wrote in one of her notes. I explained that the work we do in therapy included me not hiding anything from her. I said that, “I can’t have a relationship with Zac unless you know about it…Kristen is the client and I will work with whoever else she brings to session but only if it is okay with her. Ultimately, Kristen is my client.” When she looked

confused, I said, “I am putting you in charge of your imaginal world.” She said, “That’s complicated.” I then said, “When Zac tells me something, I can’t keep it hidden from Kristen.” She said “Why?” I explained that I believed my job included helping all the different voices to communicate instead of splitting off from each other. As an aside, I expressed this same theory to the alters when they appeared in therapy as well. Throughout these discussions, Kristen seemed surprised that I valued her voice. The therapeutic goal was to help her feel empowered and reframe from colluding with an alter (or system) that maintained secrets. When I first began reading the letters signed by Zac or the others, Kristen demonstrated little or no memory of having written them. As time progressed in therapy, she displayed some memory of the letters being written as well as their content, but her memory remained limited. At school and during this same time period, Kristen wrote a number of short stories for her English classes that seemed to narrate her experience. In sharing these with me, she often said, “I want you to know me so you can help me.” The alters often made similar comments such as, “We want you to read these so you can help Kristen.” These notes and stories appeared to be important to her life narrative. They were aspects of Kristen’s story that she and her alters wanted me to know. Assimilation Constructs Observations bearing on internal multiplicity. Many of Kristen’s letters were signed by multiple subcommunities (e.g., Love, Madonna, Zac, Kristen.) These co-signatures suggested that they were simultaneously present (co-consciousness) and attempting to emerge at the same point in time. The coinvestigators suggested that it represented some type of team work or dialogue between the subcommunities. Observations bearing on therapy and the therapeutic relationship. Coinvestigators noted that Zac, in a few of the letters she signed, asked me to help Kristen. This request seemed to reflect the strengthening therapeutic relationship between Zac and me as well as between Kristen and me. The therapeutic relationships crossed amnesic barriers. The coinvestigators noticed that not only did I refuse to align myself with any of the alters by keeping secrets from the others, the alters, of their own accord, used the therapist to talk to one another. Zac purposefully disclosed information knowing it would be shared with Kristen. This supports a previously noted view of me (as therapist) serving as a conduit for early communications between the two alters. Coinvestigators wondered if this dynamic must occur

before the alters can talk to one another without a therapist. This dynamic could be an early developmental stage of building meaning bridges. It was suggested that the meaning bridge may have been between Carol and Zac. This bridge allowed Zac to feel able to talk to Carol, to express her concern for the client, and to offer herself up for help. Observations bearing on APES progression. Opposing statements in Kristen’s early letters seem to represent conflicting positions and a lack of communication between voices and subcommunities. These conflicts were considered consistent with Vague Awareness/Emergence (APES 2). However, Zac often wrote of her desire to avoid dialogue between her internal voices and the alters consistent with Unwanted Thoughts/Active Avoidance (APES 1). Later, Zac wrote, “Sunday I saw MADONNA. I asked her what I should do.” This suggested an early stage of negotiation between alters while working together on a problem. Working together reflects increasing dialogue between the voices or subcommunities which is consistent with Application/Working Through (APES 5). At midpoint in the letter writing, there seemed to be a lack of communication between the alters. Coinvestigators suggested a regression in assimilation had occurred consistent with APES 0 or 1. They further noted that this non-linear movement between APES stages could be accounted for by the client moving backwards to a safer stage after having shown insight. It was hypothesized that she may have experienced anxiety over the thought of changing. In the final letters, Kristen and Zac both stated that Kristen should be present more often and working on sustaining her presence. This reflection was found to be consistent with Understanding/Insight (APES 4) or Application/Working Through (APES 5). Observations bearing on different APES. The coinvestigators again suggested that it may be possible for two subcommunities within one body to be at different levels of assimilation around the same issue. Levels of assimilation regarding the experience of internal fragmentation appeared to differ for Zac and Kristen. During the first year of therapy, Zac was trying to find a way of helping Kristen (e.g., leaving notes about the system for Kristen to see, reporting information to the therapist early in therapy, and later using the therapist as conduit) because she was unable to communicate directly with her. Zac demonstrated knowledge of the fragmented self and sought help. She was at a higher level of assimilation than Kristen whereas; Kristen seemed to be at the early APES levels.

The coinvestigators again suggested that what they labeled a one way meaning bridge was occurring between Zac and Kristen. They pointed to a letter that was written in the first year of therapy indicating that Zac was aware of the thoughts and feelings of Kristen, yet Kristen was unaware of Zac’s experience. A meaning bridge reflects a shared understanding of a sign, therefore, we now understand that using a term such as one way meaning bridge is not precise in assimilation terms. I viewed these examples as evidence of the amnesic barriers that are at the core experience of DID. Emergent issues in data packet # 5. The coinvestigators suggested that using the therapist as a conduit in order to build early meaning bridges between internal voices could be accounted for in one of the APES stages. Data Packet #6: Semester Summary and Emails a) Kristen’s emails to me (06/19/02- 08/03) b) Summary of 28 sessions (05/08/02-12/17/02) Why I Chose This Data Packet Similar to the letters and stories previously analyzed, these emails were written by the client. Signed by Kristen, Zac, Madonna, Tay, Jessie and others, they illustrate Kristen’s sense of internal dialogue, fragmentation, amnesic barriers, and conflicts. Whereas the emails are in the client’s words, the summary of 28 therapy sessions is written in the therapist’s voice. It describes my understanding of the process and progress of Kristen’s first two years in therapy. These two pieces of data read together provide a rich picture of Kristen’s complex internal experience from both perspectives. I felt the alters’ and my chronological accounts of change might provide numerous opportunities for APES ratings and POC. What We Learned Similar to the client-produced letters in the previous data packet, these emails and therapy summaries track Kristen and her alters’ change process over time. Though the emails were originally signed by separate alters, before long, they were signed by some combination of the alters. Messages were suddenly being sent by two or three alters who appeared to agree on the various topics. We viewed this phenomenon as reflective of the change process that was occurring as the alters began to first experience assimilation within them and later, between them. For example, as Zac’s disparate internal voices (e.g., angry and helper voices) began to

build meaning bridges and work together; Zac was increasingly able to build meaning bridges between her and Kristen, allowing them to collaborate or co-exist. Clinical Observations Context. When therapy was temporarily placed on hold in June of 2002 due to our summer schedules, Kristen and her parents were provided with emergency contact information. In addition to providing emergency access, it seemed important to allow Kristen a continued sense of connection after she spent nine months building a relationship. As so many of Kristen’s struggles appeared to be a result of feeling abandoned, we did not think she was internally strong enough to weather the perceived loss of her therapist. My supervisor and I decided that in order for Kristen to feel connected (and not abandoned,) she could email me occasionally. I explained to Kristen that email couldn’t replace therapy and was only meant to allow her to maintain a connection. I asserted that I would only answer her emails once a week and, she agreed. Relationships. During this period of time, Kristen worked to communicate in a healthier way with her parents. Whereas in the past, she had been enmeshed in the ups and downs of her parent’s volatile relationship, she began to realize that their adult problems were not her business. This was a difficult paradigm shift as Kristen, who was often privy to her parents’ arguments, felt responsible for the status of their relationship. In therapy, she recognized and articulated that if her parents split, it wouldn’t be her fault. Outside of therapy, Kristen’s social life grew simultaneously as she demonstrated less interest in her parents’ relational struggles. Symptoms. Kristen experienced little observable relief from any of her previously reported physical symptoms. She also suffered from low self-esteem, relatively poor peer relations, chronic family problems, and difficulty understanding her imaginal world. She continued to dissociate when stressed. Academic. Kristen maintained decent grades in her special education classes at school. She began to excel at her vocational school and reported enjoying the hands-on instruction. She continued to use her school counselor for crisis intervention. On at least six occasions, Kristen called the clinic from her school counselor’s office in tears. Life skills. Kristen began to demonstrate developmentally appropriate life skills. She worked part-time at a restaurant, negotiated a higher salary with a male boss, rejected the advances of a boy who treated her poorly, attempted new friendships, and went on a few group

dates to amusement parks, movies, concerts, and sporting events. Furthermore, Kristen was suddenly spending time on the phone with her peers, something she had never done before. Therapy and assessment. In many ways, Kristen was demonstrating positive, observable changes in her real world. However, she spontaneously brought more and more of the dark parts of her imaginal world into therapy or in her emails. She often talked about episodes of feeling lost, evil, confused, disconnected, lonely, depressed, and frightened. The complexity of her imaginal world was overwhelming to her and, often, confusing to me as well. With consultation, supervision, and continued education in the area of dissociation, I had come to believe that the only way for Kristen to get better was to allow the voices to feel heard, to honor them as resources that had helped her survive her difficult childhood. I believed that the years of therapy where she squelched and hid her internal world in an effort to look “normal” and act more appropriately had only further solidified her secret internal world. In one session, Kristen said that she was always scared what people would think about her if she told them what was truly going on in her internal world. In talking about the pros and cons of having such a world, Kristen said, “In a way, its cool cause you can talk to yourself. But, in a way, it’s kind of scary because you can totally flake out and not know what’s going on.” She discussed her previous therapy at the clinic: how she first played games and drew pictures, later she played and talked, and now, it was mostly all talk. She remembered her work with one previous therapist as follows: It was really weird because when I was with her, I was drawing this stuff, and like all these people were in the room and its like, at that age, somebody shouldn’t have that, like, because, I mean the room was like filled, I wasn’t there by myself. But, I was little and I didn’t know how to talk to a therapist like I do right now, so, its just like I kept it in and kept it in. It was just like normal to me… I suggested that, perhaps, as Kristen grew and changed in therapy, she would no longer need all the others in the same ways that she needed them when she was young. In June of 2002, the emails began. The first ones appeared to be written tentatively and were signed by Kristen. Soon, however, they were signed by others in her imaginal world. As I quote these emails throughout this paper, I use her punctuation and spelling. In July, an otherwise benign email that was unsigned read, “Zac said the next time she sees you she would kill you.” The next email read, “There is something wrong about me (I want to tell you now so I don’t forget) EVIL things keep my mind occupied. I have no clue why, but it

does. I scared my grandma, because I wanted to buy a book with EVIL things in it.” It was signed “everyone.” This email (signed by “truly forgive”) was sent in August and prior to my home visit: Zac has a question for you. Could I or Madonna, but I most likely know it better than she would, give you the tour of the basement? Because, I can show some thing that I would like to show that they don’t know about. Only you and your supervisor are aloud to take a tour. I know how impotent it is for Kristen to show it. As long as I am with you Tay and Ike won’t mess up. If you want Kristen to show I don’t care, but if something happens to you. I can’t help. I can only help if I am there. I hope you understand what I am saying. I am truly sorry by threatening you (in the earlier email). I was drunk and on drugs that day. It was nice talking to you. And I hope you forgive me. I messed my life up petty bad. I wish I could start over but I can’t. I hope to see you soon. If you can help Kristen, maybe you can help me. Just don’t let other people know. Because a lot of people look up to me. If I change real quick they will know and get made at me. I need to go now. I hope you will talk to me again after what I did. Two weeks later, Zac emailed the following: Sorry I felt strange about asking you stuff. Because you are Kristen’s helper person. I am giving you the tour!!! I hope that is ok. Anyway, I want to perform a song for you… I am mad at Kristen. She wanted to cry with you in that room (in therapy). She didn’t because I was there. I am only going to say this once and once only. She can’t tell herself apart any more. Please don’t tell her that but it’s true. Why do you think she always talks about me all the time? Most of the time it’s me. Madonna told me to tell you she is going to be there Monday, and she might bring Tay. Do you want to know why Kristen was smiling yesterday; it was me, she would not let me talk to you. Kristen is just there, it is really me. She needs the help, because I am her. She made me and now is me. I am there to help her. But, she wants me to be her instead of being herself. I can KILL her for it, but I can’t, it would be just like getting a pet and KILLING it. Love, Zac After our first summer break, I continued to allow Kristen email access as it seemed to provide the various parts of Kristen a forum for speaking out. In session, I made a point to go over the emails that had been sent to me, even reading them verbatim out loud. I felt it was important to refrain from developing any special alliances that excluded Kristen. I believed that

additional secrets could potentially harm her. After much discussion, Kristen and the various alters agreed to this arrangement in order to maintain the desired email access. The alters did not always attend or speak in our therapy sessions. Oftentimes, we focused entirely on Kristen’s real world struggles. When this occurred, they seemed to use the email as a way to alert me to important events or the need for my assistance in both the real and imaginal worlds. In early December, 2002, this unsigned email was sent after a therapy session: Hi, I hate to admit it but I kinda need your help. I am sorry that I was mean and did not want to talk much to you the last time. But, Zac is having a big meltdown. She found the two people that can KILL Zac. It started when Madonna came in and saw Zac in bed with Wes. When Zac saw Madonna, Zac told Madonna to get in bed so that Wes can sleep with his girlfriend Cindy. ZAC DID NOT HAVE SEX WITH WES. But Madonna does not know what to think besides she is losing Zac because of Madonna’s mother. Zac knows all of this because Madonna asked if it was okay if Madonna could talk to Carol about it. So, now here is the problem. Zac wants one of the guys to KILL Zac. But, if that happens, we all die and Kristen could be in a big mess. I still feel needs more time and help before Kristen goes by herself. Kristen could KILL herself right after Zac dies. I know I been a pain in the ass, if you want to help me fine, if not fine. I just thought I should say something, because Carol is to help Kristen with Kristen’s problems. Kristen does not know this is going on. I understand if you don’t want to help me, because of my actions toward you. My job is to get Zac out of this feeling…Love Three weeks later, a disturbing email was sent and signed by Kristen. Though it appeared almost suicidal in nature (and appropriate follow-up in session was required), it was more about the sacrifice of a weak sense of self to a stronger alter personality. Why the hell do I go to you? No offence to you, you are a nice preson. You try to help me and I fail. Why should I waist my time. I can not make one dision with out aks you about it first. So it is use less. I need help I just can’t find it. Look at me, I am going down. I am going so far in the dark, I can’t even see the little light that I was going to. I am stuck. There is no hope for me. I should have ended it a long time ago. I wish you could help me. But I am just like the others. So, Zac is coming to see you now. I hope this does not scare you because this is the truth. You have been talking to Zac all this time. But there was a few times I have talked to you. See, I can’t even talk to you. I go threw

Zac. But, Zac forced me to go those times. So this is going to be the last time I talk to you hope fully. I am sorry for the Shit I put you threw. Sorry. Bye. Kristen A few weeks later, Zac wrote in an email, “Ok, we have a problem. Kristen left like two nights ago. I am looking for her and hopefully, I will have her by Tuesday.” Two days later, Zac sent this update: Carol, Kristen is still lost. I am trying my hardest to find her. She runs every time she has a chance now, I have no clue now…I wish I could find her so bad. She needs to talk more. I was trying to go on our honeymoon (Zac married Madonna) then she left. I was thinking of leaving her (Kristen) by her self for a week but now I am stuck until she comes back. I really hate when she does this to me. I hurt myself trying to find Kristen. I think that is a good thing, because I think that shows how much I care… Love, Zac Soon thereafter, Kristen returned and we were able to explore these emails in session. We also explored her desire to dissociate and let Zac take over her body. In March of 2003, Kristen sent the following email: I feel like duck (sic) taping my mouth, locking myself with a knife in the darkest room. I would slit my wrists and slit my neck and tummy. Finally, I will bleed to death. Have a GOOD day. Bye, Love Kristen. This was the most distressful email I had received from Kristen. It was the only one that included such an explicitly detailed plan for hurting herself. Therefore, I contacted Kristen and my supervisor immediately. Kristen reported that part of her wrote the email “just to let the pressure off” and part of her wrote it “Cause I was really feeling that way.” She did say that she “would not have actually done it.” At the end of the phone conversation, she promised that she would not hurt herself. We made an appointment for a session the following day. Kristen then asked me to speak with her parents. I informed her parents of the email and my concerns. They agreed to closely supervise her. The next day in therapy, Kristen and I talked about how such an email really gets everyone’s attention. However, she said that if she holds it in, “It will get bottled up and then we’ll have a huge explosion again (like when she first came to therapy).” Kristen expressed relief at having the email outlet for her to express herself. I reiterated that I won’t always be available via email and that it can not be considered therapy. She said, “I know. That is always why I wait for a response back before I do anything to see what you have to say and stuff…” In exploring

the email further, it seemed to have been triggered by some confusing interactions with her mother and the absence of Zac in the imaginal world (Zac was away at a concert). Ten days later, Zac emailed the following: She left again. Two days now I guess, I can’t leave her alone any more. Cuz she gets too depressed. I will stop everything I am doing to help her. I can’t handle a week, if she leaves me for a week I don’t know what to do. Three months later, in June of 2003, Zac sent another email: We have a lot to talk about. A lot WE need help, but most important Kristen needs it. She came back and left after she knew what the day at work was going to be like. I am trying to get her, but for some reason it is shuting me off, the first time I been shut off if I carrie on her life a lot of people would not be here. At this point I am scared because if I have to be her for the rest of my life I would be in jail. I think that Kristen dose not want to say any thing more than what she has said. I think me and her can read each other minds. I am not sure, but I think so. I will explan it this way. One meeting you guys had, she told you that I had to talk to her. Now how can she tell you that if me and Kristen can’t talk to each other? Then another meeting she told you that I had to tell you about a picture. Then I told you that Kristen needed to talk to you. How can we tell you that, but we don’t talk to each other? If you list(en) to your tape I think you will understand what I just explaned. Please let me know soon. I just need to know if I am losing my mind. I have to go spend the rest of the day with her dad. Love, Zac In June I received an extended email from both Zac and Hanson. In the subject line, it read, “CAROL HELP ME PLAESE.” Zac identified herself at the beginning of the email but, at some point, Hanson took over. The shift seemed to have occurred about half way through the email. I placed *** where I believe Hanson stepped in as the writer. The email reads as follows: When Kristen comes back you need to have a talk with her about leaving and totally shutting me off like this is KILLING me. Normally, she dose not shut completely out mostly but not completely. Friday, you better hope to God or who ever the HELL is in charge of this world that I can get a hold of Kristen. I can not take to worlds on me hands. I have a huge problem in my world and now I just FUCKING save myself just because I was thinking about Kristen’s life. I think her mom and dad will appreciate what I did for her, that is right, they don’t know me, I am just a face that might go out and KILL people,

for all they know. I will talk to you first be for I come to a final choice on this. But you should know I am pretty PISSSED right now. I need to go, I can’t type any more stuff, because you help real people. *** Just copy this FUCKING letter and show it to her FUCKING face maybes she actually find out that this is so very FUCKING hard on me. What happens to her is way too much on me. She gets abused mentally, I get abused physically. Do you see it CAROL? The fate? The scared little girl crying because she has no clue on what to do? She locks herself in a room in the dark crying for you to come and hep her. Do you see it CAROL? Come on don’t be afraid it is only me the one you won’t to know so badly. Come play with me CAROL, come you will have fun. The little girl wants you but can’t get you. Too bad her fault. Oh well I guess now we see eye to eye on things. Come on CAROL we I will be nice to you. I hope. We can have so much fun and reach that girl together. I am the one that can get you here. I would love to see you and so dose the little girl. Have a nice day CAROL. Love ya. Hanson In August of 2003, I suddenly received a series of eight emails from Hanson written over a few days. These emails demanded that I play a game with her. In her first email, she wrote: DO YOU WANT TO PLAY THE GAME OR NOT, I AM WAITING FOR YOU GOD DAMNIT. NOW COME AND PLAY THE FUCKING GAME WITH US… In her second email, she continued with the following: NO RULES. JUST IF YOU WIN, YOU SAFE, YOU LOSE, SHE DIES…WHY DO YOU NEED TO HELP KRISTEN? I AM TAKING GOOD CARE OF HER, BUT YOU HAVE TO GO INTO OTHER PEOPLE BIZNES DON’T YOU? After I invited her to talk with me in a therapy session, Hanson replied: WHY DO YOU WANT TO MEET ME??? IT WOULD BE BAD FOR ME AND YOU. DON’T YOU GET IT? I AM HERE TO DISTROY THINGS. NO ONE HELPED ME IN THE PAST SO NO ONE IS GOING TO TRY NOW… After a second invitation to speak with me in therapy, she responded: “BULLSHIT NO ONE CAN HELP ME IT IS TO LATE.” I replied in an email, “You are very angry, indeed! I guess I would be too. I can understand you may not want help but do you understand that Kristen wants help?” Hanson then agreed to attend session and speak with me rather than play a game over the email. Her last email to me was as follows:

WHEN DO YOU WANT ME TO COME AGAIN? YOU ARE NOT GOING TO HAVE FUN WHILE I AM TALKING TO YOU. AND JUST TO BE SAFE YOU MIGHT WANT TO TIE ME UP. I received the following email from Zac in August of 2003: I am willing to help, don’t get me wrong. I will do every thing in my power to help her. But, I can’t be there 24-7. I don’t want to be mean but I really don’t feel like talking to you. I am trying my hardest to help. But every one has a free will. I can’t always be there for her. I know Jessie has been telling you some stuff and that is the mean reason I don’t want to come. You might have cops there, boot camp general, and my family and then it will be hell for me no matter what. You are already pissed at me. I am sorry but I did not plan for me to do these things. I know I make bad judgments but that is who I am. I can’t change. Someone has made me the way that I am and until she changes her mind I will change. I am sorry for every wrong thing I have done. I can’t handle myself. I am the main person in this world but I can not compete with Hanson, she may be a part of me but she is more in Kristen. Think about it. Hanson is there to kill. Kristen came to you, because she was going to kill her self, right? Hanson has been with her longer than any of us. I wish I could stop her, but the only one that can is you. Hanson is doing all of this just to get back at you for making her come and see you. She did not kill you but she is making plans to kill some one you are working with…We need as much help as we can…Please help. I don’t care if I am gone just as long as Kristen is still here. Please help get this away. Please. Love, Zac Kristen sent other emails over the year, of course. Some were as practical as simply arranging a time for our next session. But these emails were of particular interest. Not only did they serve as a forum for the alter’s voices, they helped me to understand Kristen’s experience of her imaginal world in-between sessions. During Kristen’s 60th therapy session, Kristen shared that she didn’t have much hope that she would be able to understand her life on her own. She said that when something upsetting happens, it’s like “I just get hit with something and I just think about it for the longest time and I try to figure it out. It’s kind of like a dream…That is pretty much how I think of my life as just like a set of dreams… My whole life is a dream because none of my self is real, basically…”

In the therapy summary, I suggested that Kristen still appeared unable to self-soothe when emotionally overwhelmed. I reported that she continued to dissociate and/or reach out to a safe person for grounding when under duress. As her therapist, I was often the person that Kristen increasingly opened up to about the complex and fragmented self that she had developed for years and long held secret. The therapy summary included recommendations for Kristen to continue weekly or (occasionally) bi-weekly therapy with email and phone contact as needed. It was recognized that occasional phone or email contact, though not therapy, could feel therapeutic to Kristen if faced with an emergency. It was suggested that additional testing including the MMPI-A, Rorschach, House Tree Person (HTP), and the Roberts Apperception test be given. As Kristen was still a minor, additional parent/therapist meetings were recommended. Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators noted that, early on in the emails, there appeared to be distinct differences between who was speaking and who was not. When the various alters spoke about Kristen’s real life or imaginal life, a rigid, either/or perspective was evident. For example, either it was Zac (who presented as angry or aggressive) or it was Kristen (who was child-like and insecure) who presented contradictory perspectives in their emails. However, in other emails (mostly later ones), the voices seemed to be working together which suggests an increase in the dialogue between the divergent voices. Similar to their analysis of the handwritten letters from the clients, the coinvestigators suggested that the emails provided powerful illustrations of Kristen’s experience of internal multiplicity. Not only did the context of the emails support multiplicity, the multiple signatures also did so. For example, whereas some emails were signed by Kristen, Zac, Madonna, Hanson, other emails were signed by a combination of alters, such as Zac and Madonna. In still other emails, there were numerous signatures and references to “We.” Observations bearing on therapy and the therapeutic relationship. The coinvestigators viewed Kristen’s and Zac’s written requests for therapist self-disclosure as evidence of a growing desire and tolerance for relational intimacy. They viewed this as a sign of positive growth within the therapeutic dyad. Observations bearing on APES progression. By chronologically tracking and analyzing both the content of the emails as well as the assortment of signatures in the emails, it was determined that Kristen’s and the alters’ early practice of sending separate and distinct emails

gravitated over time to a more collaborative written expression. Coinvestigators noted that the emails reflected various APES ratings dependent on who was writing the email and when it was written. They identified an obvious progression through a number of the APES stages, most noticeably for Zac and Kristen. All of the early emails, regardless of the signature attached to them, reflect some chaos and confusion around the experience of fragmentation. Kristen’s emails originally expressed ignorance as to what was happening to her. Later, she admitted that “not being around (present) much is a problem” (APES 0-3). In contrast, the emails signed by Zac demonstrated some understanding of Kristen’s experience. Yet, Zac believed the only solution was for her to step in and take over during moments of distress. In her emails, Zac began to ask me to help Kristen and herself. Zac later emailed her realization that Kristen needed to stay present more often so that she could grow from the experience (APES 2-5). She stated, “I can’t always be there for her.” Unfortunately, Hanson’s emails only appeared later in our therapy. They stopped soon after I spoke with Kristen about terminating our work together. The emails were angry and threatening. Though Hanson made some progression in therapy, her emails were not necessarily found to reflect change as measured on the APES. The emails served as evidence of increased dialogue between the subcommunities or alters, their internal voices, and any new voices emerging. The coinvestigators identified an increase in perspective-taking (increasing inclusion of other voices’ and subcommunities’ perspectives). They acknowledged that differentiation between the various subcommunities’ continued as well as increasing problem statement formation. They found evidence of beginning meaning bridge building (see 06/15/03). They felt the subcommunities were increasingly serving as resources to one another and, in particular, to Kristen. Observations bearing on different APES ratings. The emails reflected many of the alters’ discrepant opinions regarding assimilation. For example, Zac fluctuated between killing off others in the imaginal world and helping organize the alters to work together to help Kristen. The emails served as evidence that the alters began therapy at different stages of assimilation. Whereas the host alter appeared oblivious to the others early on in therapy, Zac quickly often wrote about many of the others. Even Hanson, who few others had access to, knew about some of the alters and their activities. Within each subcommunity, the initially disparate voices began

to communicate and negotiate with each other. As their assimilation occurred, the subcommunities later reported and demonstrated an increase in their communication with the other alters. These communications allowed for increased understanding of the other (empathy) and led to increased assimilation. Emergent issues in data packet #6. The coinvestigators were concerned about the sense of loss that the alters may have felt when faced with the idea of integration or assimilation. A number of the alters repeatedly asserted that they did not want to be pushed out of the system. If helping Kristen meant assimilation would occur, they feared being “killed off” in the process. Coinvestigators asked if the theory addressed such a loss. They wondered whether the autonomy of independent voices was jeopardized when dialogue and bridge building began. However, assimilation theory suggests that the autonomy of voices is not jeopardized during the process. When assimilation occurs, all parts remain available to the others as resources. Rather than lose their individuality, they work together for a greater cause. There is smooth access between the voices as they imperceptibly negotiate shared responses. They don’t have to become one; rather, their dialogue is so smooth that transitions are barely noticeable. Instead, I believe that this perceived sense of loss by the alters was due to a weaker or less effective meaning bridge between Kristen and the other alters. If she knew more of their feelings (had more awareness of them, more empathy for the others’ positions) and shared more signs with them, she might understand this process better and not perceive it as a potential loss. When there is a lack of shared signs or joint understandings, meaning bridges are non-existent or relatively weak. When the voices don’t feel heard, then there is a battle for power. Where empathic negotiation occurs, there is room for a pluralistic model. Data Packet #7: Therapy Summary, MMPI-A Reports a) Summary of 74 sessions, 04/15/03 b) Zac’s MMPI-A c) Kristen’s MMPI-A d) Extended reports on MMPI-As Why I Chose This Data Packet This therapy summary chronicled Kristen’s progress in therapy from my perspective. The results on two Minnesota Multiphasic Personality Inventories- Adolescent (MMPI-A; Butcher et. al., 1992), one by Kristen and one by Zac, reflected their divergent personalities. The extended

reports on their independent results further articulated their significant differences. I felt these results were compelling and worthy of further examination. What We Learned These two very different but valid MMPI profiles (see Appendices T & U) confirmed much of what we had already considered regarding Kristen and her primary alter’s internal experiences and external presentations. We agreed that they reflected two disparate subcommunities, each with internally conflicted voices. As the coinvestigators acknowledged the presence of the subcommunities’ internal voices, they more fully understood the complexity of assimilation occurring in cases of DID. They agreed that, in this case, assimilation seemed to occur within subcommunities prior to assimilation occurring between subcommunities. Clinical Observations Context. In many ways, Kristen seemed to improve in her real world during this time period. She experienced successes at school, home, and work. She increasingly opened up about her imaginal world and the alters spoke for themselves in session at least a third of the time. . Relationships. Kristen admitted that she had an imaginal world to her parents and friends for the first time. This process of disclosure often backfired, causing her pain as others explicitly discounted or made fun of her frightening or illogical stories. However, even when others meant no harm, Kristen appeared hyper-sensitive to their facial expressions and words. She often misread and misunderstood their responses. As Kristen grew bolder in her decision to be more honest about what she was actually experiencing inside, she felt hurt when someone questioned the validity of her story. We regularly worked on Kristen’s boundaries around recognizing who was safe to share her fragmented self with. Symptoms. Kristen continued to struggle with a variety of physical symptoms. Her nasal congestion fluctuated within each session. For example, at the beginning of some sessions, I might not be able to understand her due to a congested tone and her frequent nose blows. Later, in the same session, her congestion would suddenly improve, she would not use the provided tissues, and her words were easily understood. Kristen demonstrated short losses of time and memory both outside of therapy and during therapy sessions. For example, on one occasion, she had no recollection of using a tissue when I later asked her to throw it away. At times, I would often mention something we had discussed previously and she appeared confused as if she had never heard the content of our discussion before.

Academic. Kristen continued to experience success at school with the help of a committed IEP team and numerous accommodations. She began to believe that she would graduate. As a result, Kristen’s self-esteem and confidence seemed to be slowly improving. Life skills. Kristen demonstrated increased independence by studying for her driving test, paying her bills regularly, breaking up with one boyfriend, dating a new boyfriend, babysitting for her relatives, and staying home alone when her parents were away. Therapy and assessment. As therapy continued, my supervisor and I felt that additional testing might benefit both our and Kristen’s understanding of her internal experience. I asked Kristen whether she would be interested in completing the MMPI-A. After I explained what the test would be like, that there were no wrong answers, and that it would simply tell a story about her experiences, Kristen agreed and appeared excited. I was concerned if Kristen would remain present or if Zac and the others might intervene. I spoke with her about the importance of the test reflecting only her experience and she agreed. The week before she was scheduled to complete the MMPI-A, Kristen and I discussed whether or not she had power over when Zac steps in for her. At first, she stated, “I have no power.” She then said, “Sometimes I can, sometimes I can’t.” When asked when she can, Kristen said, “Sometimes when she (Zac) talks to my parents about serious things, I am kinda like there, listening.” I wondered out loud as to whether there was some type of power or choice on her part in standing by and listening on specific occasions. She agreed. However, after thinking it over for a bit, she said, “It doesn’t seem like I have any power.” Suddenly, Zac said, “Kristen left by the way.” I asked, “She doesn’t like this serious conversation, does she?” Zac said, “She doesn’t like it at all!” I suggested that Kristen may not want to imagine that she has some internal power or choice over whether or not she dissociates when things become difficult. Zac said, “Right, she’s scared to change because she is thinking about everybody else. She never thinks about herself and when she does, she gets too depressed and then she starts to cry.” When I mentioned that Kristen believes that Zac has all the power, Zac said, “No…It’s like half and half.” After discussing the division of internal power with Zac, we discussed Kristen’s upcoming test at length. Zac promised to stay away during Kristen’s testing period and. suggested that, since they shared the power, she (Zac) should also take the test. At the next session, Kristen completed the MMPI-A in three hours. My supervisor and I decided that I would administer the test orally as Kristen had historically demonstrated poor

reading skills and a high level of test anxiety. We were concerned that it was good ethical practice to oversee any struggles that Kristen might experience with her decision to maintain one stable sense of self throughout each three hour test. Therefore, it was determined that having Kristen take the MMPI-A with her therapist present on both occasions might best facilitate the therapeutic work. I asked each question aloud and, after her response, I filled in the bubble representing her answer. Throughout the test, Kristen was responsive and did not appear anxious. On a few occasions, she asked if she could respond with a “maybe” answer rather than a true or false response. In those cases, I reread the question and she talked through her reasoning to arrive at a true or false response. During the test, Kristen asked me to define several words. She requested a few examples of a word in a sentence. At the end of every fifty questions or so, I asked Kristen if she were comfortable and who was taking the test. Throughout the test, she responded that it was indeed Kristen answering the questions. Her responses seemed to be consistent with the content and personality style that Kristen had previously presented in therapy. At the next session, Zac reported that she had “observed the testing for a while but then I left the room so Kristen could take the test.” A month later, Zac completed the MMPI-A. When asked if she was ready to begin, she said, “Let’s do it!” I again administered the test orally and checked in throughout to make certain that Zac was present and answering the questions. Her responses appeared consistent with the content and personality style that Zac had previously presented in therapy. The following two MMPI-A results reflected the contrasts between Kristen and Zac: Kristen’s MMPI-A results. Kristen’s low scores on the L and K scales indicate her willingness to describe her problems. Her elevated score on the F scale suggests a high degree of candid reporting. Though her profile can suggest some “faking bad,” it is representative of those adolescents who suffer from significant general maladjustment and symptoms of severe psychopathology. The lower score on the TRIN scale indicates consistency in her responses. Kristen’s scores were clinically elevated on 8 out of 10 scales. Her results suggested numerous somatic complaints, inhibitions of aggression, and a need for affection. Her responses were consistent with adolescents who are in trouble, unhappy, dissatisfied, and unsure of themselves. Kristen often described herself in therapy as depressed, insecure, and help-seeking. Her results also demonstrated an elevation on the Hysteria scale reflecting her reaction to stress, which includes developing physical problems and somatic complaints. Her results on the

Psychopathic Deviate scale reflect her experiences of family problems and poor school adjustment. Anxiety, disagreements with parents, persecutory ideas, interpersonal sensitivity, and naïve, uncontrollable thoughts are seen in her elevations on scales 6 (Paranoia) and 7 (Psychoasthenia). Her elevated scores on the Schizophrenia scale suggested she experienced suicidal feelings, not fitting in, school problems, and the possibility of sexual or physical abuse. Kristen’s thoughts of self-harm had been well documented in therapy. However, dating back to the Miami’s clinic’s first interaction with Kristen at age 10, she had never reported any experience of sexual or physical abuse. However, Kristen did report that her imaginal world was filled with torture, rape, and sexual activity. Kristen’s elevated score on the Social Introversion scale appears to be consistent with her experience of having few friends throughout her life. Zac’s MMPI-A results. The validity scores appear to be similar to those in the first profile. However, Zac’s scores are only elevated on five of the ten scales. Her highest elevation is on Scale 4 (Psychopathic Deviate) which is consistent with adolescents who experience family discord, problems with authority, aggression, involvements with drug and alcohol, and poor school adjustment. Zac had readily admitted in therapy to all of these behaviors. Her elevated scores on scales 4 and 6 (Paranoia) are consistent with adolescents who can be described as paranoid, argumentative, hostile, destructive, or acting out. They often engage in externalizing behavior and may be representative of a physically abused or sexually active teen. Zac is a female, although she acts and dresses in a typically macho way. She identifies herself as a lesbian. The elevation of her Scale 5 (Masculinity/Femininity) on this profile is consistent with the client’s presentation as it describes a female who identifies with typically masculine qualities. This profile displays much less depression, physical complaints, unusual experiences, and social introversion than the first profile. These two profiles reflect previously observed differences. For example, whereas Zac acted out when upset by killing others in the imaginal world, Kristen held things in and became depressed. Her feelings were rarely articulated and, instead, were demonstrated through somatic complaints. Whereas Kristen presented as more feminine, Zac presented as more masculine. The MMPI contains a number of validity checks. These two profiles appeared to be valid and reflective of severe pathology. It is very unlikely that someone of Kristen's low level of sophistication with psychological tests could have faked such different and valid profiles.

Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators unanimously agreed that these two, very different set of MMPI results support Kristen’s maintaining at least two very distinct personality types and, therefore, confirm internal multiplicity. The different profiles appeared consistent with the presentations of Kristen and Zac during therapy sessions. Kristen’s scores were elevated on eight clinical scales. Zac’s scores were elevated on three clinical scales. Coinvestigators felt the results suggest that the non-assimilated experiences (Zac) are more resourceful in daily living than the assimilated community (Kristen). They drew this conclusion from Zac’s generally lower scores which suggested she was in less psychological distress. The summary of therapy sessions identified several alters’ primary concern, that of an exaggerated sense of power or the opposite, a lack of power. Coinvestigators viewed this as evidence of a problematic voice and representing a conflicted position of the self. Observations bearing on therapy and the therapeutic relationship. When therapy began, Zac resisted, hid her presence, and actively asserted that “I don’t need therapy, Kristen does.” Coinvestigators later noted that, despite her initial resistance, Zac eventually decided to work with me instead of against me. Zac said that she made this commitment specifically as a way to help Kristen. In retrospect, her commitment to the therapeutic relationship was an essential piece of the change process. As she worked with me, Kristen changed. However, Zac seemed to make positive changes, becoming much less angry and violent. Observations on APES progression. Kristen reported in session that she was increasingly able to make some particular choices about when one of the alters took over or stepped in. This awareness of the others and, her subsequent decision to deny the others unbridled access felt like new behavior and suggested empowerment on Kristen’s part. The coinvestigators viewed this as representing Resourcefulness/problem solution (APES 6). They felt that the formerly problematic experience had become a resource and was being used for solving problems. At this stage, voices are used flexibly and the affect is positive and satisfied. However, I disagreed with their rating of this phenomenon. Though, I did indeed believe Kristen’s early choices were evidence of increased individuation, therapeutic progress, and of meaning bridges under construction, I viewed them more as tentative movements towards further assimilation. As a therapist, Kristen’s movement away from Zac reminded me (metaphorically) of the developmental stages in a small child’s life. For example, when a toddler steps away from

a safe caregiver, there is often a shared dialogue between the two about the movement. However, on many occasions, the child moves away without asking and, suddenly, looks back to make sure the caregiver is still present and within reach. In some cases, the child runs back at the earliest sign of discomfort. At other times, the caregiver tells the child “No” and the child proceeds despite the admonishment. In other words, there is not always an agreed upon discussion of this movement away from the other and, more often than not, there is a sudden return to the safe caregiver. Though this stage is a necessary step of development, it is not equivalent to APES stage 6 where the voices are used flexibly and the problem is being solved. Though Kristen did make some choices, she continued to find herself suddenly taken over by Zac or the other alters when under duress. She and Zac were not discussing who would remain present and who would leave. Kristen’s limited access to Zac did not reflect smooth access to all of Zac's experiences and resources as suggested with APES 6. Observations based on different APES ratings. Although Zac arrived at therapy comfortable with her expression of anger in both worlds (APES 5–6), her anger changed (moderated) during treatment. This shift in Zac seemed to occur through dialogue between her discrepant, internal voices. These voices appeared to engage in internal negotiation. For example, Zac, a powerful, angry self-state presented as a caring, self-sacrificing protector of Kristen. At various times, she stepped in to aggressively halt abuse or to protect Kristen from feeling pain. Part of her lamented taking control so much of the time as she preferred partying in the imaginal world. Yet, a separate part of her felt compelled to ‘‘keep it together’’ in order to assist Kristen. Her almost paternal pride in Kristen’s increased ability to stand up for herself was quite unlike the part of her that thought nothing of torturing someone in the imaginal basement. When she attended the parent meeting and served as a teacher, the part of her that was a self-centered rock star seemed quite distinct. Zac often reported feeling torn between the disparate parts of her self. In therapy, she allowed these conflicting voices to speak out and negotiate with each other. Though anger for Zac was never a problem, as her internal parts (e.g., Killer, protector, partier, self-centered celebrity and teacher) engaged in more fluent negotiation her expression of anger moderated in both worlds. These two levels of assimilation as experienced by Kristen and Zac suggest that assimilation, for those who experience dissociation and have more than one community of self, may look quite different than for those who maintain a single community of self. Assimilation

for those with multiple self-states (subcommunities or alters) may initially occur by building meaning bridges between the various subcommunities (e.g., Zac and Kristen). In addition, assimilation may occur within individual subcommunities through dialogue between internal voices (e.g., killer & teacher). The assimilation model for a client diagnosed with DID does not suggest the loss or suppression of any part of the self; rather it describes a process of change in which problematic voices are identified and heard. Negotiation follows and the disparate voices learn to collaborate with each other. Assimilation did not result in a killing off of Zac as she had initially feared. Instead, as Zac’s internal voices increasingly dialogued, she became accessible to Kristen as a resource rather than a problem. This sort of moderation of extremes is characteristic of problems getting assimilated. What often begins as an intense and disparate problem, generally softens as it is integrates into a larger understanding and experience of the problem. This therapy summary quoted a number of sessions where Zac asked me for help with Kristen (and herself) or offered to help Kristen. This illustrates the curious one-way understanding that seems to characterize DID (e.g., the alters know much more about the host's experience than vice-versa) due to amnesic barriers. Emergent issues in data packet # 7. During this time period, it became clear that Kristen was developing a new sense of personal agency. The changes appeared to reflect a combination of natural (biological, psychological and social) development associated with the teen years, a strong therapeutic relationship and the assimilation of the alters. However, coinvestigators also suggested that Kristen may have developed a completely unknown, previously nonexistent agentic voice able to counteract her earlier sense of powerlessness. They suggested this voice may have been created as she explored her imaginal world in therapy. As the coinvestigators analyzed Kristen’s change, they questioned if the assimilation model accounted for the development of agency in the APES. The assimilation model proposes that new experiences always create new voices--or add to old ones. If the experiences involve active agency, then the voices are likely to be active and agentic. As Kristen was encouraged and intrinsically rewarded for her agentic work in therapy, she was increasingly able to generalize that voice to other settings (e.g., with her parents, friends, or in school). Lots of people talk about constructing an observer position out of the experiences of therapy. The specific quality of what is constructed depends on the content of the experience, of course. As Kristen and I worked to increase her agency, an agentic voice naturally emerged.

The coinvestigators again pointed to potential one-way meaning bridges. They suggested that Kristen’s knowledge of some of her alters’ existence reflected some meaning bridges. However, as there was no direct evidence of dialogue between her and the alters, they wondered if this reflected one-way meaning bridges. However, gaining access to others always implies the presence of meaning bridges. Kristen’s increasing knowledge of the other alters suggests meaning bridges were present. Access without identifiable dialogue could instead mean smoother access. It is also possible that dialogue between alters was occurring between sessions and was not evident in therapy or in the data. Data Packet #8: The Alters Speak a) Progress note, 08/15/03 (Discussing therapy, Zac and Hanson #111) b) Progress note, 08/13/03 (Hanson & Jessie visit #112) Why I Chose This Data Set I chose these two sessions because Kristen’s articulation of her experiences of the imaginal world in session #111 was the most logical and comprehensible description thus far. I also felt that Zac and Hanson clearly described their perceived roles in Kristen’s life. What We Learned In this data packet, the alters presented simultaneously shared experiences, engaged in dialogue with one another, created more meaning bridges, increased their inclusion of other voices’ perspectives and broadened an over-arching sense of self within and between voices. In addition to containing further evidence of internal multiplicity, this data packet seemed to highlight the importance of the therapeutic relationship and interventions in therapy. We felt that my willingness to hear the alters speak (such as Hanson) made it less frightening for Kristen to share the darkest parts of herself and allowed for the creation of meaning bridges. We also conceptualized my work with Hanson and Zac to think in new ways about their roles in Kristen’s self-system as further evidence of ZPD work. Clinical Observations Context. By this time, my supervisor and I had met with Kristen and her parents about her diagnosis. During a two hour meeting, I explained that Kristen met the criteria for the diagnosis of DID. During our meeting, I provided numerous examples of Kristen’s symptoms, imaginal world and life-long struggles. We discussed what it meant to dissociate and to have DID. Kristen said she was not surprised by the diagnosis. Though her parents had asked if she had multiple

personalities a few times during the course of therapy, they were understandably confused and asked a number of questions. I recommended two books about DID for them to read. Relationships. Kristen spontaneously tracked down an old acquaintance (a former classmate who had bullied her). She initiated a get-together. The two began to spend time together, occasionally sleeping over at each other’s houses. Kristen was particularly intrigued by her friend’s openly bi-sexual status. Her interest may have fueled the developing relationship. Though the friendship didn’t last long, it allowed Kristen closure with a former enemy. Symptoms. Kristen’s physical symptoms continued to fluctuate. As before, she continued to dissociate when stressed, particularly when faced with interpersonal dilemmas. Academic. At the time of these two sessions, Kristen was on summer break and recently returned from a family vacation. Prior to her trip, Kristen attended two Junior/Senior high school proms, one with a boy at her own school and one with a girl at a friend’s school. Life skills. Kristen was still a valued employee at the restaurant but was planning to find a new job. For the first time, Kristen joined an after school activities group (Gay Straight Alliance). Despite her parents’ attempts to dissuade her from joining GSA, they were, at first, tolerant of her membership. However, they soon made it difficult for her to attend meetings. Kristen expressed her anger at her parents over their control of her life. Eventually, Kristen’s interest in the group waned as she was unable to sustain a relationship with any of the members. Therapy and assessment. Kristen and I continued to meet in therapy once a week, though, we occasionally we added a second session if Kristen and I felt it was necessary. Second sessions occurred if Kristen reasonably requested it, felt overwhelmed, or admitted suicidal ideation. Her alters often shared time in therapy, updating me on events in the imaginal world, sharing the history of the system, providing insight into Kristen’s experience, and looking for help with their own difficulties. In the early months of therapy, I rarely knew who would arrive at the therapy sessions or who was talking. I eventually made an agreement with Kristen and Zac that whoever came to session needed to introduce him or herself. This occurred most of the time. Occasionally they forgot or I recognized a shift prior to an official introduction. At the 111th session, Kristen explained why she came to therapy. She reported that she wanted to “have a better life, good relationships, and stronger social skills.” She said she wanted “to be happy.” Kristen identified the aspects of friendship that she considered positive:

“communication, trust, working together, friendly interactions, no fighting, and helping each other in hard times.” Kristen said that she hoped therapy would help her achieve these things. I asked her how therapy could help her with the imaginal world. She said she wasn’t sure. She said, “For some reason, I want it (the imaginal world) to be gone because I don’t know how I can get married someday and deal with that too. It mostly happens… the imaginal world like comes out in evening time and carries out into the next day, so its like if I get married, I don’t know how I am going to deal with it…you get married and here you got to pay attention to the kids and him, and then here you are wandering, talking to air, he’s going to know what’s the heck going on….but I can’t see myself getting rid of it, it would be too hard.” When I asked why, she responded, “First, you can’t kill off Zac, which is the main source, cause I made all the people with the highest power can’t be killed. Also, I can’t just see myself stopping cause I’ve done it so long, its like a routine.” I asked her if there was something she felt was helpful to her about maintaining the world. Kristen said, “I get a break…I just like leave and let somebody else take over…Sometimes, when I get upset, the thing is I feel like a bunch of pressure, like pushing me down. It really doesn’t make sense but I know when it is getting ready to change, like in here I’m just talking and I just feel this really heavy pressure like somebody is going to come in.” We discussed that sometimes she seemed to have some control to make a change and, at other times, she didn’t. We talked about how having her world was both a positive and a negative experience for her. Part of her wanted to get rid of it but most of her did not want to be without the imaginal world. She admitted that she wanted the help when times were tough. Kristen said that without it, she might have wanted to kill herself. We talked about how an adult should have stopped the bad things (the bullying) that happened to her when she was just a little girl. Since they didn’t, Kristen found a creative way to help herself. We talked about the level of creativity she accessed in building such a complex world. I suggested that there were a few choices she could now make about her world. One possibility might be that she could cut it off, deny it or destroy it. Another possibility might be to let it control her. Still another possibility might be to get the voices to work with her and each other in a more harmonious manner. Kristen believed that it would be difficult to get the world that was originally created as an evil entity to work together nicely. I suggested that her disbelief might be because she had not experienced all the parts of the world working together and she agreed. I asked her if she knew all the parts of the world and she replied, “No.” We discussed how the world had changed over time. Originally, the world was

created to help her when she needed help but as she seemed to need it less and less, it was not working as well for her, at least the way it was originally created. She wanted to have it around but not need it as much. We talked about how this would be another one of our goals for therapy. Kristen then shared that she believed Hanson was trying to take over Zac in the imaginal world. She believed that if that happened Hanson would kill her, although she didn’t know how. I suggested that often those that act out have been wounded. I suggested that perhaps, Hanson had a horrible experience when Kristen was a child. Kristen said, She did…I don’t know what happened…but that’s part of her history… She had very, very bad things happen to her all the way up until she was 30 and nobody helped her out so when she died of old age, her spirit came back to life and got into Zac when Zac was born and then Zac had her like all in her life and then sometimes, Jessie gets it…only a little bit of it in Jessie only because Jessie is young and she can’t handle too much of it only because Jessie doesn’t know that she is a person with split personalities yet…Hanson is 130… We spoke of how angry Zac and Hanson must be because of the horrible things that happened to them when they were little, yet we both commented on how Kristen didn’t ever get angry. She said, “When I get mad, I cry…When I get mad, I can’t express it…” We talked again about how the voices were originally created to help her but they soon became busy with their own activities. Kristen said the following: They can talk to each other…Hanson is really like the killing side of Zac, so that’s why Zac hurts people, its because Hanson comes out. Its like Hanson is always in her head, no matter what, its not like how I can leave and Zac comes in, its like Zac is there, Hanson is there but Hanson doesn’t really come out because she would have to literally tie her down in case if she gets upset. They kind of work together because they like understand each other and where clear view is coming from because you get somebody who keeps annoying you for everyday for two days, you’re about to kill them so you just go ahead and take care of it. A week later, Zac identified herself at the beginning of the 112th therapy session. Zac said, “I don’t care if she (Hanson) comes out to you but you need to make sure that you know that she is secure or that you are half way across the room…Something can set her off, stupid things, like if the light is on, she’ll get like pissed at you, so Yeah…its like some simple thing

she gets really pissed. Then some things she, I don’t know, she just has her own mind and its like, no matter what, she gets pissed, someone dies…” When I asked who would die, Zac responded, “Well, the part that she doesn’t know, you could be a possibility or Megan or Madonna, my three brothers, Jessie…” I asked Zac if it looked like a safe place for Hanson to come out and she said, “I think it is a safe place, besides you are in the room…ehhhh…but you might come out with a bruise or something…” I repeated to Zac that I was not afraid. I told her that I had worked with violent people before. I reminded her that I could not do therapy over email. I reminded her that one of Kristen’s goals in therapy, getting the voices to work with her, entailed us getting to the bottom of her voices. Therefore, it was best to talk with her in person, if Hanson wanted to say something. Though hesitant, she said, “It’s up to you.” Hanson then arrived at session. When I asked if she had wanted to talk to me for a while, she responded, “No, not really…cause you’re stuck in the middle…cause you’re helping Kristen…” I asked, “Is that good or bad? Are some parts good and some parts bad?” She said, “Yeah, for the most part, well, I think the easy answer is to just kill her off, by bits and pieces, and then she can like die slowly but you’re like, talking and I don’t know, because she is so depressed and she doesn’t know where she is…in her life.” I shared that my plan was to help Kristen because she came and asked me for help. Hanson responded, “Yeah, but see how I do it is I start from her past and work up.” Hanson then told me a bit about her story and confirmed that she was 130 years old. She said that she has been around since Kristen was born, not for any specific reason but because Hanson was simply there. C: How long has Kristen known about you? H: I think she has known me all my life because I have been scaring her a lot. I am basically her suicide part of her, Yeah…Umm.. I don’t know how to work with upset and sadness and crap. I am, like, go lie down in the middle of the road, and let a car run over you (laughs). C: If Kristen is hit by a car, you and the others would be dead as well. In killing off Kristen, you are killing off yourself. H: But see, that’s the better part…because once I am gone, I can go to a different person. C: But, it is causing Kristen a lot of pain for you to kill her off.

H: I think it is easier for me to kill off her past though, then to start her on her life that is right now and then start working backwards because then she’ll keep bringing up her old school and everything like that. So, I am killing off the past and like, its like, piece by piece…the thing is, in the real world, she really won’t die… C: It’s just her memories of the past that you are killing off then? H: Yeah…” I then asked about the possibility of the memories simply resurfacing when Kristen is 30 or 40 if all Hanson does is deny them or kill them. H: They can, there can be a brain where you store it all. But once you actually kill the thought off, it doesn’t come back. I asked how she felt about being in the room with me. H: Weird, first of all the room is white. It’s just weird to actually be out here. C: But you’ve known about me for a long time…and those emails, we went back and forth and you were really pissed in that one you said “BULLSHIT, it’s too late to help me”. H: Yeah, nobody can help me. I don’t think anyone could ever have helped me. I asked if it would help to hear Kristen’s and my goals for therapy and she said, “That’s fine.” C: Kristen wants to be happier; she does not want to die off. She wants to be happier... H: It would be easier to kill off the memories and like, try to start her off in a new, happy life and I guess that’s what you are trying to do. C: Yeah, but I’m not trying to kill off the memories, I’d rather she bring the memories here and we talk about them and try and understand that it wasn’t Kristen’s fault. H: I know but its kind of, like, too late to try and change it… Oh people, can change, its just that it would be easier to change the past…either you kill it off or you try and change it to make it a happy past. C: Or, can you change the way you look at the bad things that happen to you? That’s what I think…I think that if I talk with Kristen and we look back at the bad things that happened in her past, then we can gain some understanding, now that she is an adult. H: I don’t think it will go far. Because seeing Kristen getting upset for something you said and then she has Zac come in for her. I really don’t think she can do it.

C: I think she can. I think that she has tried really hard the last few years to face some of her problems. I think she is working hard in therapy and she wants to have a happier life. H: It could be. C: I could be right or you could be right. My job is to help Kristen because she came to me for help. H: Oh C: And your job is to? H: To kill off her bad memories. C: And what do you think if Kristen and I keep working on this? What is going to happen to you? H: Nothing. I’ll be there until the day she dies, whenever that is. C: What would happen if she came to you and asked you to work with her more? To not kill off the parts of her that you think are bad? H: I don’t really listen to people. They tell me to do something, I won’t do it and plus, I don’t even talk to Kristen because if I ever got a hold of Kristen’s brain, then she would be in serious trouble. C: I think that Kristen and I have decided that we think everybody can work together as a team. H: They can until a certain point. They get to a certain point where they can work with a team. This world ain’t meant to work as a team. I mean everybody’s got their different things and since everybody is different, they get annoyed real easy. I’m not saying that it can’t happen but it can only go four people to a group and they got to have the same personality, kind of like. Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators felt this data packet was rich in reflecting internal multiplicity. They pointed to when I asked Zac if Jessie had talked with Kristen about Hanson visiting as an example. When Zac responded, she said, “No, actually Jessie kind of overheard your conversation, and she told me that you desperately needed my help.” This example supports a community of self, dialogue between Kristen’s internal voices, meaning bridges, and a joint understanding between Kristen, Zac, and Jessie. The voices were not consistently working together, but they worked to help each other (APES 3).

The coinvestigators were very interested in the appearance of Hanson. When Hanson reported that her job is to “kill off her bad memories,” they suggested that Hanson was an agent of the active avoidance of problematic experiences. Somehow, Hanson served to keep negative or frightening things away. The researchers agreed that the appearance of Hanson in a therapy session served as evidence for internal multiplicity. Observations on therapy and the therapeutic relationship. The coinvestigators took particular note of Kristen’s assertion that if she had been with a therapist who hadn’t talked about her imaginal world, she would have killed herself. They felt this example served as additional support for a theoretical model that emphasizes the expansion of dialogue and relationships between the voices in therapy. They felt our work did not, as previous therapies had, suppress the dark (or imaginal) side of Kristen. Instead, my theoretical model (influenced by Archetypal and Experiential Personal Construct Psychotherapy) allowed the voices to feel heard by a therapist, enter into dialogue with the other alters, increase their understanding of each other, and, eventually, to serve as resources for each other. They felt I facilitated the process of building meaning bridges between the various alters. The coinvestigators believed that by speaking with Hanson in therapy, I demonstrated that it was possible for a conversation to happen between us without Hanson killing me (Both Kristen’s and Zac’s fear). They believed this may have made it easier for Kristen to bring Hanson, an extremely important (and scary) alter, back and work with me as opposed to being afraid of Hanson and keeping her suppressed. While Hanson and I disagreed about many things, a meaning bridge was initiated between us as we coexisted in the same room. The coinvestigators noted additional evidence of ZPD work in these two sessions, As Kristen and I spoke, I suggested other possibilities for the alters, including the idea that voices might be able to find new ways to work together “in a more harmonious manner.” Providing her with potentially new conceptions of how to work with internal multiplicity allowed her to stretch her thinking in new ways. The coinvestigators felt that my one-to-one work with Hanson also facilitated the building of meaning bridges between Hanson and the other alters. As I challenged Hanson’s old way of thinking while still honoring her belief system, her rigidity relaxed a bit. At one point, Hanson said “Nobody can help me…I don’t think anyone could ever have helped me…They couldn’t have touched me, cause I was the bad baby nobody, I mean, they had to put gloves on, just to hang me so…” Carol: “Do you think Kristen felt like that when she was little,

that she was the bad kid?” Hanson: “Yeah.” This was viewed as representative of increased empathy on Hanson’s part for Kristen. The coinvestigators also felt it was consistent with increased understanding and insight (APES 5) between Kristen and Zac. They suggested that the problem was formulated and understood in some way between the voices and, that they had reached an understanding with each other (a meaning bridge). Observations bearing on APES progression. However, the coinvestigators’ comments were conflicting and, I partially disagreed with them. From my perspective, there was the beginning of meaning bridges but not a firm understanding between Kristen and Hanson. I believed this because in the same data packet, despite their comments above, the coinvestigators also noted that Kristen had seemed threatened or frightened by Hanson, so much so that she did not want to see Hanson’s emails. They felt these interactions (or the avoidance of them) were reflected in an APES Stage 2 or 3. They wrote that Kristen appeared to be resisting reciprocal dialogue with Hanson, which seemed to indicate some continued avoidance of this part of her self, perhaps because she did not want to face the pain that Hanson held. The coinvestigators recognized that Zac knew more of Hanson but remained wary of her as well. As for Hanson, she certainly knew about Kristen and the alters (from her perspective). However, articulating that she and Kristen may have felt the same as babies was the first sign of empathy that Hanson demonstrated towards her. For the most part, Hanson served as an authoritarian voice with a controlling, abusive attitude. Though they all spoke of each other, there was little room for dialogue or negotiation. As Hanson and I continued to work together, meaning bridges between Kristen and Hanson were beginning to be built. Assimilation was occurring through the work in therapy but was not yet at APES 5. Prior to this data packet, Hanson had long been an unwanted thought which Kristen actively avoided (APES 1). Even in this first session, Kristen preferred not to think about the experience or see Hanson’s emails. Hanson (as a problematic voice or subcommunity) emerged in response to therapist interventions or external circumstances and were initially suppressed or avoided. As we worked, Kristen soon became aware of Hanson’s presence and role as she emerged into her sustained awareness (APES 2). However, Kristen could not formulate the problem clearly. Her affect during the times when she felt threatened by Hanson often included

acute psychological pain or panic. She knew Hanson was a problem but could not clearly articulate why or what to do. In this data packet, Kristen appeared to demonstrate APES 3 (in relation to feeling internally fragmented) as she explained the relationships between the others, saying “They can talk to each other…Hanson is really like the killing side of Zac, so that’s why Zac hurts people, it’s because Hanson comes out…They kind of work together because they understand each other.” These comments suggest an increased understanding of the alters and their roles. Kristin was aware of the communication path that was necessary to get hold of Hanson (through Zac). Opposing voices were differentiated and could talk about each other. Affect was negative but manageable, not panicky. Kristen demonstrated a more complex understanding of the relationships between the alters and their relationships to one another during this data packet. Kristen’s ability to tolerate these visits by Hanson suggests the development of meaning bridges, an understanding of self across multiple contexts, and an increased metacognition. Emergent issues in data packet # 8. Kristen discussed her ambivalence about keeping the imaginal world. She stated that she would like to have the imaginal world around but to not need it as much. She spoke of her worries as to how it might interfere in the future in her anticipated roles as wife and mother. She spoke of her need for the alters as well. This tolerance for ambiguity around changing the imaginal world was evidence of growth. The coinvestigators felt this represented a problem statement and a meaning bridge formation. Data packet #9: Identity Confusion a) Progress Note, 10/29/03 b) Letter from Kristen to therapist regarding her sexuality Why I Chose This Data Packet I chose this session and the accompanying letter from Kristen to demonstrate an additional aspect of the struggle that she experienced with regard to her identity. As she entered her teenage years, Kristen found herself attracted to both females and males at different times. The attraction to both sexes had previously occurred only in the various alters in the imaginal world. However, as Kristen began to rely less on the alters, she found herself having feelings for both sexes. She discussed her confusion in therapy. Kristen said that she knew her alters were male, female, heterosexual, and homosexual. She was confused as to how to make sense of who and what she was. This knowledge complicated her experience of dating, sexuality, and identity.

What We Learned In this data packet, we witnessed Kristen as she increasingly demonstrated a desire to build an intimate therapeutic relationship despite the potential threat of rejection. We understood her desire and ability to discuss the therapy relationship as both evidence of positive change as well as a vehicle for further change. We saw her struggle with her sexual identity as she learned about and managed her male and female as well as gay and straight alters. Kristen’s growing ability to integrate some of her alters’ perspectives as she honestly disclosed to her parents her conflicted sexual feelings was viewed as further evidence of assimilation. Clinical Observations Context. For the first time since we began therapy, Kristen inflicted a superficial wound on her arm with the scissors. She immediately showed her parents the wound. They called the clinic and reported the incident. I spoke with Kristen on the phone and we scheduled an appointment. As Kristen was afraid to be alone after the cutting incident, Kristen’s parents drove her to our session. Kristen and I discussed the incident in therapy. She once again admitted feeling suicidal (without a plan or means) due to a number of events that had occurred at school and home. She admitted that during the act of cutting herself, she felt frightened and stopped immediately. Kristen promised that she would not act out again without first asking for help. Relationships. In September of 2003, Kristen began to feel more comfortable about expressing anger at her peers and parents. She didn’t seem to need Zac to step in to handle these interactions as much as she used to. This behavior was new and suggested change. However, in October, Kristen had a very difficult time at her school and with her peers. She had been questioning her sexuality and attending the GSA group at school for a few months. She had also spent time with two peers who identified themselves as lesbians. Kristen heard that rumors were suddenly being spread at school that she was gay. Though she began to question her own sexuality, she was intensely disturbed by these rumors. Throughout this period, Kristen’s parents were convinced that she was being influenced by the GSA members. They were firmly against her “being gay” and they applied pressure on her to stop associating with her gay friends and activities. Symptoms. As the rumors at school persisted, Kristen reported an increase in her physical symptoms. She complained of headaches, sinus infections, stomach aches, and feeling dizzy. These symptoms were painful enough to cause her to miss school and work.

Soon after our emergency session, Kristen appeared to be doing better. She was able to talk about cutting herself and how it understandably resulted in the loss of her parent’s trust. Academic. Kristen was now attending her vocational school full-time. She initially seemed to manage the transition well. However, during this period of sexual confusion, she began to struggle with completing her homework. Her school attendance suddenly plummeted. Life skills. In contrast, Kristen began a new after school job with increasing responsibility. She transitioned into her new position with little effort. Kristen successfully passed her driver’s test (on her third attempt with Zac helping her) and consistently drove herself to work and therapy. However, when she missed a few days of work, she was quite anxious about possibly being fired. Kristen had her father call to report her absence rather than speak with her new boss. Therapy and assessment. Kristen arrived at this therapy session with a two page letter that she asked me to read out loud. In it, she asserted a growing recognition that she feels more comfortable sexually with girls rather than boys. The idea of being with a girl feels much “safer” to her than being with a guy. She was confused as to why she perceives girls as safer since she has “not been sexually abused by a guy.” She reported that when she goes to bed at night with a girl’s name on her mind, she is able to sleep without her stuffed animals. Kristen admitted that girls can be as horrible as guys. In fact, she acknowledged that it was a girl who had started the horrible rumors. We continued to discuss the letter and she said, “I think I have made up my mind that I am a lesbian.” Kristen would like to write a letter to her parents and present it to them in a therapy session. She would like to tell them that she has long felt attracted to females. Despite her previous comments to her parents about wanting to marry and have children, the thought of having sex with a guy made her sick. “It’s like, they got to know the truth and, it’s like really hard because they think like as soon as I went to Gay Straight Alliance, I started thinking about that. So, its like, no, it’s been around since sixth grade but you really haven’t known it.” We talked about why it felt important for Kristen to have her parents know the truth. She wanted them to know who she really was. I asked her if this was the only way she wanted her parents to know the real her. She said, “No, but I think it is a good start… They need to know and they need to get the fact that they need to start treating me like an adult. ” I remarked on what a big step this was for her. She said, “It is a really huge step and it is scary and I really want to hold back but I think it is important to get it out.” I asked if that was all Kristen or was it Zac

influencing her as well. Kristen believed that it was all her wanting to share her true self but also recognized that she is taking on more of Zac’s traits. Kristen said she was scared that “Zac will disappear and that would not be good, if I become too much like Zac…I feel like I am changing and staying the same at the same time…” Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators felt there was significant evidence of voices and the assimilation theory in this data packet. They took particular note of a few transcribed portions of therapy. When asked why a certain decision was made, Kristen replied, “Actually it wasn’t my choice to make…pretty much Zac’s choice…you can feel when all of them is in there and you can tell when it is going to happen again…” Though in many ways, Kristen’s voice still seemed to be silenced by Zac’s voice on occasions, she demonstrated some awareness and understanding of when an alter is about to take control and who makes the decisions when that occurs. Coinvestigators suggested this reflected more of the assimilation issue at the level of understanding and insight (APES 4). Kristen provided the following example of an event at school where she felt almost forced by one of the alters to ask a question. She said, “Somebody was striving me to ask that question, somebody around me, somebody kept punching me or stabbing me until I got it out…I got a really sharp pain in my stomach, the pain was so bad…” Coinvestigators suggest that this comment reflected a conflicting position of the self that was determined to speak. The subcommunity appeared unable to step in for Kristen and use her body to speak. Instead, the other alter asserted itself physically until Kristen felt compelled to speak. Observations bearing on therapy and the therapeutic relationship. The coinvestigators noted that Kristen and I spoke openly during this session about our relationship and its progress. Kristen articulated that she now felt more comfortable talking with me than she had a year prior. However, she acknowledged that, at times, working with me still felt threatening in some ways. This process discussion demonstrated that Kristen was increasingly able to talk about both her growth and her limits within our relationship. While relating with me was still experienced as potentially dangerous, Kristen had experienced that it is possible to connect without the catastrophic results that she had previously predicted. This growing desire to engage with me in an intimate therapeutic relationship, despite the potential threat of a relational wound, both reflected and facilitated Kristen’s change process in therapy.

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Observations bearing on APES progression. In this data packet, the coinvestigators identified several examples of the inclusion of the alters’ perspectives representing conflicting positions of the self. They identified numerous episodes of dialogue between client’s internal voices (e.g., around the sexuality issue). For example, Kristen’s subsequent decision to share her choice of sexual orientation with her parents was viewed as a level of assimilation not present before (APES 4). Kristen said that the statement about being a lesbian was all her but she recognized that she was taking on more of Zac’s traits. She remained scared that that “Zac will disappear and that would not be good, if I become too much like Zac…I feel like I am changing and staying the same at the same time…” This was viewed as a strong example of continued assimilation. It was also noted to be Kristen experimenting with integrating the two oft-times conflicting alters. Coinvestigators felt there remained a fear that during assimilation (or integration), something might be lost. Kristen wondered that if she took on another’s traits, it might cause that alter to disappear. In assimilation terms, these examples were considered consistent with Understanding /Insight (APES 4). Coinvestigators felt it suggested increased collaboration or negotiation between voices as they increasingly served as resources to one another in general and to Kristen in particular. For example, when Kristen was asked if it would be difficult to disclose her sexuality to her parents, she said, “Zac will be there, just in case, I get too emotional.” In discussing her desire to be honest with her parents, Kristen said, “They need to know, and they need to get the fact that they need to treat me more like an adult.” This comment by Kristen was viewed by the coinvestigators as evidence of substantial progress. They believed she was increasingly able to listen to and act on her voice of wanting to be heard and known by her parents. In this instance, Kristen did not become so frightened that her only option was to dissociate. Perhaps, the alter that became activated whenever her parents or others were mad at her was no longer as threatening because it did not stop her from being honest with her parents about her sexuality (APES 4 or 5). Data Packet # 10: Tay Visits Therapy a) Progress note, 02/11/04 b) Zac’s Letter to Kristen’s Dad

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Why I Chose This Data Packet This data packet again focused on Kristen’s identity confusion and her confusion over dissociating. When Kristen (as Kristen) suddenly began to engage in behavior that was not normally Kristen-like behavior, she was perplexed. She could not determine whether or not she was switching to an established alter, creating a new alter, changing in therapy, or simply maturing. Tay’s visit to therapy added a new perspective to both Zac’s and Kristen’s experiences. I felt that the coinvestigators would find evidence of POC in these struggles. What We Learned We identified evidence of internal multiplicity and APES progression in this data packet. We examined Kristen’s confusion over her new, un-Kristen-like behavior and determined that she was beginning to gain access to the other subcommunities. We noted a number of situations where Kristen seemed to choose to dissociate and allow other alters control over the body. Clinical Observations Context. Prior to this February session, Kristen’s father called to tell me that Kristen had lied to her parents and snuck out with the car at night to go visit a boy. He was concerned that their punishment for her might be upsetting. Her father reported that Kristen had written a letter to them explaining the event. In the letter, he recognized that Zac had switched in half way and spoke about Kristen in the third person. He said that it was the first time that they had actually seen evidence of an obvious switch in self-states. Relationships. Shortly after our October, 2003 session, Kristen told her parents that she believed she was a lesbian. They were extremely resistant to the idea. Her father described Kristen and her mother’s relationship, already problematic, as particularly affected by this news. A month later, Kristen suddenly became serious about dating a young man. It is unclear whether her decision to date a male was related to her internal identity confusion and/or the pressure from her peers and parents. Within two months and after some pressure to engage in sex, Kristen ended the relationship. Kristen admitted that it was the pressure for sex after the first month that gave her the courage to break up. She stated that, in the future, she would be “turned off by someone who talks about sex too much” or stares at her breasts instead of her face. This experience suggested that Kristen appeared to be growing in her ability to express her feelings and assert her boundaries without Zac stepping in to handle the interaction. Indeed, on a number of other occasions, Kristen demonstrated her anger towards her boyfriend and parents

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independent of Zac. She said, “I just want people to like me. I don’t want to hurt people like I have been hurt but I am getting a bit of a temper with people.” Symptoms. Despite this positive progress, Kristen continued to have episodes of automatically dissociating during times of significant stress. For example, Kristen, while driving, was almost involved in two car accidents. In each case, Kristen was initially navigating, made a mistake, and became terrified by the near miss. Zac immediately stepped in to take over the wheel. Kristen also had stressful moments where she chose to bring in one of the alters because she “couldn’t take it.” In addition, she had a few additional episodes of feeling suicidal (without plans or means). In addition to her continued commitment to therapy, she made a number of phone calls to the clinic during times of stress. Academic. Kristen was once again doing well at school and working towards graduation. Life skills. By the beginning of the New Year, Kristen was excelling at work, dating another young man, attending a number of social activities, and hosting her first party since early childhood. Kristen’s decision to throw a party at her home and invite a number of her friends and casual acquaintances was of social significance. Therapy and assessment. At a December, 2003 session, Tay presented at therapy and had much to report. While doing so, she agreed that her role included protecting Kristen: C: I got your email. T: Ok, that’s good. C: Yeah, so what, um, what made you write that email? T: Because Zac went into the basement, and one of the guys that can kill her went down after her and, um, she, like, I don’t know, she was going to sacrifice him, but then she’s like wait a minute and I guess, like, she had, like, a run-through of what happened in a couple of days, and then she, like, gives him the knife and says, “Come on, throw it at me.” And he got all confused and he’s like wait a minute, isn’t it supposed to be the other way around, and she just kept insisting and then when she turns his back, he threw it, she caught it, she throws it back at him. And she’s like “If you’re going to kill me, you’ve got to do it the right way. It’s like Okkk. C: That worried you. T: Yeah because normally she doesn’t threaten herself, and like she hasn’t done that since like, like, fifteen years ago, so it’s kind of weird and like the…what’s really strange

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is, Hanson came the night before and, um, he accidentally stabbed Ike in the head, and Madonna got called off to work, and then Madonna comes because Hanson’s in the car on the way back, and, like, Madonna kind of like stopped Hanson, like, she’s the only one that can stop Hanson from hurting anybody. Why I don’t know, but that’s what happens. And like she like stopped it after it like went through Ike’s head. And then Zac came back, saw what Hanson did, and she felt really guilty for doing that so she just went out of it. C: So why does all this concern you? I mean, why is it bothering you? T: Because I, it really doesn’t concern me, but I thought you should know because it could hurt Kristen if Zac kills herself off. C: How’s Zac feeling now? Should I talk to Zac about that? T: Zac is like happy, um, me and Ike are trying to keep her out of the basement right now, because she gets in my circle, and then somebody in her circle, like, the person that could kill her is in her circle, but she has to be in my circle and actually die in that circle, so she doesn’t know why we’re keeping her out of the basement; she has no clue what’s going on, and she, she, just doesn’t know why we’re acting… C: So you’re not keeping Kristen out, you’re keeping, you’re keeping…Zac out. T: Yeah because yeah, Kristen can go down there, it won’t hurt her, but if Zac goes down there, you know, it would probably end so really…but see if Kristen goes down there, it’s automatically Zac, so basically we’re keeping everybody out (laughs). C: Yeah, I see, yeah…so you’re kind of protecting Kristen in a way. T: Pretty much, I guess. C: Who do you think I should talk to about this? T: I don’t know, whoever you want to. C: Do you think it should be Kristen or Zac? T: I don’t know, Zac would probably deny it, like, we brought it up and she’s like I ain’t trying to do that, so…you want to talk to about it. C: Well, and what will happen, if, if Zac dies off, what will happen to you? T: Probably go with her. C: So it really could hurt everybody?

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T: Well, I don’t care about myself, I mean, it’s just that if Zac goes bye-bye, Kristen could too… C: How could that happen? T: Because Zac is such a big part of her. So, I don’t feel that Kristen is exactly ready to be by herself yet. C: Yeah, I don’t think Kristen thinks she is either. And I don’t think she is either, I would agree. She needs all of you. T: Well, basically, she just needs Zac, but then Zac got lonely, so we came, so…it really doesn’t matter to the world, it just matters for Zac to be there. C: Yeah, I see, I see….well…and I asked Kristen what’s happening in the imaginal world, and she doesn’t know… T: She doesn’t know. All she knows is Zac is upset, Madonna went away, and that’s about it…so… C: And Madonna is off; she called off her concert or something? T: Yeah, because her manager is being a butt. C: It seems this thing between Madonna and Zac is affecting a lot of people. T: Yeah, um…the thing is that, um, we can’t tell Aunt Jackie that Zac…since Zac is so immune to drugs now. It’s kind of like medication for her to control her personalities that she has, so, um, Madonna, when she came into the car that night, she, um, told her mom right there that Zac has to get back on drugs, or you’re going to have a whole bunch of people doing whatever. So Zac took heroin that night, so thank God for that, because hopefully the kids won’t come back for awhile, so… C: So how can we get Zac to not want to hurt herself? T: Pretty much that’s a good question, because basically we haven’t dealt with this for a long time, so we really don’t know how to handle it (laughs). C: Yeah, well I think it’s important that I talk to Zac…today my friend Meredith is going to draw some pictures with Kristen, and Kristen had asked if Zac could draw as well…do you know if there are any problems about that happening? T: No, Zac’s really excited…um C: Who should go first, do you think?

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T: I think Kristen should be there the whole time seriously, but she keeps putting a little pressure on Zac to draw because Zac has been drawing for awhile, but see if Zac draws there’s going to be blood in the picture, and that wouldn’t go too well I don’t think…so… C: That would be ok. Whatever Zac draws would be fine. So maybe if I have Kristen there at first, and then we take Kristen out for a break, and then we ask Zac to come… T: That’ll work. C: Alright, well, Tay, I appreciated your email; I thought that took a lot of trust to email me. I mean, that must have been scary. T: It kind of…I don’t know…it’s just like I had to tell somebody. Ike already knows, and you can’t tell other people because then you would have like all these police like surrounding Zac and then showing them that something’s up, and then Hanson would come and then we would probably not have a house, so, it’s very hard because Zac doesn’t like to hurt girls, like, she’ll talk rude with them, but she won’t like physically hurt them in any way, and just knowing that she stabbed Ike in the head is going… C: I thought Ike stabbed her in the head…I got confused. T: No Zac… C: Zac stabbed Ike in the head. T: Yeah. C: And Zac cares about Ike, so that’s odd. T: Yeah. C: Was it an accident? T: Yeah, because Hanson was there. C: Why is Hanson back? T: Because, like, when Zac is off drugs for like two weeks, any personality could come, and Hanson is a personality. C: Um hm…and why was…Zac was off drugs because of Madonna’s mom being in town. T: Exactly C: Was it also because Kristen went to California? T: I really don’t think so because Zac did it last year. C: She went to California fine last year?

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T: Yeah, so… C: Did Zac go to see the aunt as well? T: Yeah, that was chaos because aunt didn’t know that she was a lesbian, so we had to tell her, so therefore, Zac had to sleep with the guy instead of a girl, but she doesn’t like the girl so it wouldn’t matter, but grandma thought it would be safer for her to sleep with the guy. And Zac put a little pillow to divide them. C: Who was the guy? T: Wes. Then Madonna walks in and that’s when it all started. C: So it did start in California? T: Yeah, pretty much. C: Hard to leave the house, isn’t it? T: Kind of. I really don’t like leaving it because it’s like, kind of like, I don’t know what movie it is, but you’ve got this mountain with a huge crystal in it that sends out radio waves, that’s kind of like how the house feels to me. C: That’s where the main…the heart of it… T: Yeah. C: And the farther you go away, the weaker the radio waves are… T: Yeah. C: California is pretty far. T: Yeah, but she can survive a pretty far distance, but just like I guess all this frustration, because she is scared what Madonna’s thinking, and here you got Madonna confused because she has no clue what aunt is thinking. C: Why can’t we get Madonna and Zac to talk about what they’re thinking? T: They, they, tell what they’re going to talk about to somebody else, but they don’t actually work out their problems. C: Yeah I think we need to do that huh.… it’s kind of like couple’s counseling…I’m the therapist for the couple. T: Kind of… C: Ok, well I totally appreciate you coming and talking…is there anything else that you want to tell me? T: That’s pretty much it.

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C: And how’s it going to be for you after you leave? Where are you going to go? T: Uh…probably to a bar (laughs). C: So after you leave how will it be for me talking to you, I mean, what will you think about, will you think Oh I talked to Carol or…? T: Umm…I’m kind of just surprised that you wanted to talk to me (laughs). C: Why? T: Cause of the way that I was when I first came… C: Because you weren’t as talkative the first time? T: Yeah and kinda rude so… I apologize for that. C: I appreciate your apology. T: I just…I don’t know…it kind of felt weird writing to you to because normally I don’t go to people for help, but I kind of thought it was a serious matter. C: Yeah it sounds like it…I think it’s hard to ask other people for help, especially when you barely know me. T: Yeah. C: But it seems like I’m getting to know a lot of different people; there’s probably more that I’ll meet… T: Pretty much. C: I just wonder why this Hanson popped up…because of this drug thing? T: It is fairly complicated because Hanson basically tries to overrule Zac so you’ve got…it’s kind of like, have you seen Me, Myself, and Irene? It’s where Jim Carrey plays this cop, everybody picks on him, he gets this other personality that hits the people, that made fun of them, like, they, this guy played cards, the nice cop tells them to move it, it’s still there, and then it comes in to where he drives the car into the wall, so it’s kind of like that. C: Who has that movie? Do your parents have it? T: I don’t know, my aunt does. C: How many times have you seen it? T: Probably about three, four. C: Why so many times?

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T: It’s funny, because some of the parts are funny. I mean, one part he unfolds a newspaper, and, and, this is the mean personality, and squats down in these people’ front yard because their dog always goes to the restroom in his yard, and then his wife always takes the paper and sits on the toilet. So he walks in, gets the paper, unfolds it, and starts to go in their yard. And then here you see like brown stuff going down, and it’s like, oh my gosh, and then it’s his sons having ice cream… C: Oh my goodness…so when you watch that movie, do you relate to some of it because of the personality thing? T: Um…not really just basically how like Hanson is trying to overrule Zac… C: Did it give any ideas to Kristen after she saw that movie? T: Uhhhhhh…I don’t think so… C: Yeah, well, okay…thank you. T: Nice talking to you C: I’ll see you again I hope. T: Who do you want to talk to? C: Who’s there? Sounds like we’re going to have to talk to Zac, but is Zac around? T: Yeah, you wanna talk to her? C: Um huh, yes. T: Okay Less than two months later, at the February, 2004 session, Kristen and I discussed her struggle to be honest with her parents regarding taking the car without their permission. She insisted that it other alters took the car, even though she was partially present. Therefore, she felt she shouldn’t be blamed. Kristen was confused as to how culpable she was in a situation where she dissociated and the alters acted inappropriately. C: It’s a big thing to write a letter and let Zac come through to them. It’s a big thing for your parents to see more of you, to understand you better. K: Yeah, and I think the main reason Zac came in is to give a little introductions to what is going to happen (at a family session). C: Really opening up about yourself to your parents. K: Yep, they gotta know. C: Yeah, they gotta know and they want to know, I think. Right?

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K: Yeah, but they do want to make the problem worse. They always make the problems worse. When they were yelling and screaming at me about taking the car, it was hard because I didn’t do that. It’s hard to explain to them because I don’t want to tell them about the split personality. Its like, you know what, if I knew what I did, I would tell you. Because half of the crap you guys yell at me for, I don’t even know that I did. I would like to know beforehand what I did so that I know what I am getting yelled at for. C: What could the parents do? K: It’s fine for me getting the consequences, its just that half of the time; I don’t know what I did. I am tired of getting blamed for something I did not do. It’s like, yeah, I was there, but I wasn’t. C: Who should be blamed? K: I don’t know who actually it is but is somewhere between ten people. Later, we discussed her experience of switching (one alter taking over control of the body from another alter) and her changing sense of self. K: I usually follow rules but its hard cause lately, I want to talk to my boyfriend. C: It’s hard because you are pulled and is that somebody else or is it that you are changing who you are? Do you think you will always be the one who will follow the rules? K: No, but see, I don’t know because I have had them (the alters) so many times, I don’t know. It’s kind of weird to say that I am changing because, it doesn’t feel like it. It feels like a new part is being made into me. C: Because in the past, you have stayed the same but somebody came to do the bad things or show the anger. So, now that you are doing bad things, you are thinking that maybe, it is someone new? K: Right. It could be that I am changing but see, I don’t know because the experience feels almost like switching. C: Because it is so different to imagine that you could be different so when you are different, it automatically feels like switching? K: I don’t know. It’s kind of weird because I am kind of used to everything being in a set place so it’s like it feels so weird because I can feel a switch in my body and I am okay. C: So, it could be a switch?

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K: But see, we don’t know that and there is like no way to test if that is really happening. C: No, we don’t know. We just know that it feels like a switch and, yet, there is something different about it. It may be just a normal part of growing up and having your own opinions that are different than mom and dad’s opinions. K: Yeah C: It seems like there is this part of you that we don’t know if it is you changing and growing or if it is another personality, there is this part of you that wants to break the rules. K: Yeah, is there like a test? Cause it is highly driving me nuts. Is there a test to find out what it is? Because it is driving me nuts because it feels so much like I am switching into a different person. But yet, I am like there and it is highly confusing and I need to know. C: So, when you switch to Zac, you know it is different. So, then you know it so it feels okay? You are used to it? But, this new one feels different? K: Yeah, It’s like it’s not me. I understand what you are saying about the change but the way it feels like inside, its like I switched into someone totally different. Assimilation Constructs Observations on internal multiplicity. The coinvestigators suggested that this data packet continued to provide evidence of multiple selves, internal dialogue, voices as traces of experience, and voices as center of experience. Kristen’s comments about feeling like she switched into “someone totally different” reflected her experience of internal multiplicity. Tay’s arrival and comments about Zac’s problems in the imaginal world also reflected multiplicity. Observations bearing on APES progression. In this data packet, the alters were talking about each other, suggesting APES stage 3 (Exploring/tentatively recognized). Kristen was viewed as including more of the positions of other voices in her overall presentation of self. She seemed to be allowing other voices more influence in her meaning and decision-making. The discussion about Kristen expressed that she was not quite sure how to make sense of it all suggesting she remained somewhat confused. Emergent issues in data packet # 10. It was again suggested that Kristen used Zac as a perceived resource to actively avoid facing intense emotions. For example, when Kristen allowed Zac to step in during the parent meeting, she was relieved of experiencing what she perceived as a potentially hostile interaction. The coinvestigators suggested that this was evidence that the

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amnesic barriers were, in essence, a welcome protection or resource for Kristen. Coinvestigators wondered how the theory would conceptualize this action as it could be viewed simultaneously as active avoidance (APES 1) and using other voices as a resource (APES 6). Data Packet #11: Zac’s Perspective a) Therapy session, 02/18/04, mostly transcribed Why I Chose This Data Packet This data packet contained Zac’s and my discussion of hers and Kristen’s processes of change in therapy. Zac explained that as Kristen found relational comfort with her new boyfriend, she used the alters (and therapy) much less. Zac acknowledged that Kristen was speaking up for herself and remaining present more often. She admitted that she had also changed and was less apt to kill in the imaginal world. I felt this session was a typical example of Zac’s and my working relationship. I believed that the therapist and alter relationship was a great place to search for potential POC between theory and clinical practice. What We Learned Coinvestigators identified further evidence of Kristen’s and Zac’s assimilation process and therapeutic ZPD work. We learned more about Kristen’s increased access to the alters and, simultaneously decreased need to use them. We heard of Zac’s desire to take over the body less often. We agreed that my willingness to hear the alters in therapy helped them to lessen their need (desire) to take over Kristen’s body as frequently. In earlier therapies, the alters’ voices appear to have been ignored. The coinvestigators suggested that engaging in dialogue with the alters allowed them to speak, feel heard, negotiate, and collaborate. Clinical Observations Context. Kristen (19 years) accepted her parent’s punishment for driving the car without their permission. She completed their restriction and chores despite believing that ten others were present in the car and should share the blame. Relationships. Kristen’s relationship with her new boyfriend intensified as she spent more time with him on the phone and at school. Simultaneously, her emails and phone calls to the clinic in-between therapy sessions declined. She also spoke less with her new girlfriends and family members. Despite their growing intimacy, Kristen chose not to disclose her diagnosis to her boyfriend. Of note, both she and Zac informed me that it was always Kristen that spent time with her boyfriend. Other than at bedtime, Kristen was dissociating far less.

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Symptoms. Kristen was feeling well and had few complaints about her health during this early dating period with her new boyfriend. Academic. Kristen continued to plan for high school graduation and a party at her house. Life Skills. By this time, Kristen had become a trusted employee at her job. So much so, that she was able to influence her manager to hire her new boyfriend as a fellow employee. Therapy and assessment. Zac explained many of Kristen’s relational struggles and dissociative experiences. She discussed how she had changed during Kristen’s therapy. C: So, here Kristen is with a great boyfriend, a peer, someone who is so kind to her, and it’s so hard for her to believe that anyone could be so kind to her. It feels so good, it almost hurts that it feels so good? And that hurt, she just has to get it out somehow… Z: Yeah, now that is starting to make sense. C: So, the question is what made it so hard for Kristen to believe that someone could be so nice to her and that it hurts when someone is so nice to her? Z: Because she has been hurt so many times through the years, it is ridiculous…I mean first through eighth grade, all she did was get picked on and she hasn’t done anything to those kids and parents yelling and screaming and she hears all that. I want to say that she was, like, so emotionally abused. So, when something happens to the emotions, like somebody is so kind to her, its like wait a minute, you can’t do this to her, you can’t… After talking about Kristen’s new ability to remain present when she was with her boyfriend, Zac talked about how it felt to spend less time stepping in for Kristen. C: I remember again when you first starting to come to therapy and you didn’t want to come so much at first. And you were angry and I think there was a fear that I was trying to cut you out of the picture. Z: Yeah C: And now, I hear you saying that you want to pull out of the picture, and that you no longer need to be around. Z: Well no, I feel like I need to be there but not, to like, cut me out. I just mean mainly because its like I got other stuff to do and I can’t always be there. It’s like she needs to try it more on her own. C: It sounds like she is.

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Z: She is and that is why I like it so much because now I have my own time. She is still afraid to go to sleep though. C: She is scared to fall asleep. When happens when she is asleep as Kristen? Z: It never happens. C: What happened when she was little and she fell asleep as Kristen? Z: I don’t know. C: Do you think it’s possible that something happened to Kristen when she was little? Z: The more I think about it, I think something did happen. Because, now, I am mainly coming out when it is dark outside and a few times during the day. But, it’s like she sleeps so scared. It’s like at nighttime she doesn’t feel safe being in her own body. But, I don’t think her parents molested her or anything. I don’t think her parents are that horrible to her. C: What about anyone else? Z: Could have been but I have no knowledge of it. C: Yes, you also have no knowledge of this part of her today that drove in the middle of the road. She is so angry. It seems there is something bubbling up that none of us knows about. Z: Yeah, it gets me to think more about what happened to her in her childhood. It is kind of like putting a puzzle together and now this is the final last few pieces. It’s like everything is coming together at once. C: And, it is scary. It’s scary that she could be so happy and it hurts. Why would it be so scary if you felt happy? And why is it so scary at night? Z: I don’t know. C: I think it is interesting that more and more you are saying that you want her to step in and take charge of things. Z: I know it because it can’t be me all the time. I mean, my name ain’t Kristen. It’s like “Get out of there.” C: What will it be like if Kristen is staying Kristen most of the time? And you only come in, say an hour a day? Would that be enough time for you?

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Z: Seriously, I still do carry on everything. It won’t shut me off. I am like, “Oh yay, I get an hour, oh yay, I get ten hours, like being out in the real world, I’m about to just like throw a huge bomb on it. It’s so messed up. C: And you have your own rich world, your own life going on? Z: Yeah, it’s like two separate lives in the same body all the time. C: And happening at the same time? Z: Yeah, like when, actually, I fall asleep. So, her body is asleep and then I go party. Okay, her body is still in there and she is still breathing and it is still her. She has dreams and she remembers the dreams. It’s kind of like putting the little baby down for bed basically. C: Do you think the fact that Kristen has asked you to come out and speak to her parents this Friday has something to do with all of this coming to a head? K: Yeah, I think she really wants her parents to understand how important it is to get everything out and mainly, she just wants it all to come together and she is starting to get scared because sometimes she sees something that she normally does not do. She sees that she does it and she gets all freaked out about it. C: Like taking off in the car at nighttime, breaking a rule? Z: Yeah, it’s not like her. C: It’s not like the old her. Z: Yeah, it’s like she is starting to like become, like emotionally mature, basically. C: Things are changing for Kristen and for you. There seems to be a big shift. Z: Yeah, yeah, I ain’t killed anybody for a while so… C: I know that. I know that. Z: It’s kind of weird but, you know, when I get highly upset, you know, I’ll slash somebody’s throat and they won’t die. I mean they’ll just bleed. C: So, you’re changing as well? Z: Yeah, but, you know, its life, everything changes, so… C: Yeah and is change always easy? Z: No, and I could care less what happens if I live or don’t. I mean, it’s like, she needs it, and she needs a time out basically.

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C: And change is not going to be easy for Kristen. It hasn’t been easy. So, how does Kristen keep herself safe in the midst of all this? I think of a volcano, and there is all this gold at the bottom and you want to get the gold out, but there is a lot of rumbling and lava…How do we help her take care of the gold? It has to happen it seems like. Z: Yeah, just keep coming to therapy. C: Yes, but it reminds me of the process she is having with you. She needs you less and she needs me less as well, too (Z: Yeah). She still needs you and she still needs me but with less intensity. She is not as dependent on us as much (Z: Yeah). She asks for us to come to see me or she asks you in (Z: Yeah)…It reminds me of two years ago, when I said, you and I were going to have to do this together. That I wasn’t going to take your place, that you wanted to help her and I wanted to help too and eventually, she wouldn’t need us, which is our hope. Eventually she won’t need us (Z: Yeah). What a wonderful life for Kristen if she doesn’t have to be calling her therapist every couple of days (Z: Yeah). But for now, I want her to know that now its kind of the in-between time. She is not quite there yet. So, if she needs to call, she should. Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators further noted that Kristen’s understanding as to why she had created different selves (e.g., to help her cope with things that were overwhelming) seemed to be helping her to recognize her state-shifts more (“it’s like switching.”). They viewed her improved ability to describe her internal multiplicity as evidence of the disintegrating amnesic barriers, increased access to the alters, and assimilation. Observations bearing on therapy and the therapy relationship. The coinvestigators noted that when Zac and I discussed Kristen’s fragmented experience, Zac appeared to move to a higher level of assimilation. They suggested that, as my understanding was seemingly more comprehensive, Zac was gently pulled towards a deeper understanding of Kristen’s experience. When Zac said, “Yeah, now that is starting to make sense,” she demonstrated such movement. Coinvestigators identified this dialogical process as ZPD work which repeatedly appeared successful in helping Kristen (and Zac) make change and achieve APES progress in therapy. Observations bearing on APES progression. The coinvestigators pointed out that, in this session, Zac displayed curiosity about Kristen’s internal experience, suggesting movement

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towards increased empathy for the other. They identified this as again consistent with APES 3.9 with Zac as the voice of focus. The coinvestigators also found evidence of APES 4 (Understanding) with a meaning bridge built between Zac and Kristen as to each other’s experiences and roles. Zac described the shift in her role; Kristen needed her less and Zac was okay with that. Empathy and understanding increased as their awareness of each other’s positions grew. Observations bearing on different APES. The coinvestigators felt that, throughout this session, Zac demonstrated a sufficient understanding of Kristen’s dynamics and problems consistent with APES later stage 3, early stage 4, whereas, Kristen remained at a lower stage. Data Packet #12: Zac Meets the Parents a) Family meeting, 07/07/04, mostly transcribed b) Kristen’s drawings, a) map of her internal system, b) picture depicting conflict over her boyfriend coming into the imaginal world. Why I Chose This Data Packet This session (and the sessions that led up to it) seemed to primarily focus on a few issues. One issue centered on Kristen’s automatic compulsion to dissociate when under duress. A second issue was her internal struggle over where true intimacy belonged in her life. Whereas, in the past, intimacy (and sexuality) only occurred in the imaginal world, having a boyfriend had caused her to desire increased physical and emotional intimacy in the real world. I felt that this shift was worthy of analysis. I also felt it would be helpful for the research team to examine the family meeting and Kristen’s decision to work through some of her suicidal feelings. What We Learned We learned more about Kristen’s internal multiplicity, relational struggles, and her dissociative processes as described to her parents. We also learned that, though Kristen had increased knowledge of the alters (increased access to them), she used (needed) them less frequently as she engaged in more intimate relationships in the real world. The coinvestigators noted that the violence decreased in the imaginal world as Zac engaged in therapy. This change suggested that extreme alters may moderate with assimilation. Kristen’s decision to work through some of her suicidal feelings on her own appeared to demonstrate that she had accumulated new resources.

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Clinical Observations Context. At Kristen’s request, another family session was held at the end of February. Kristen’s parents were officially introduced to Zac for the first time. Though it was awkward, Kristen, Zac, and her parents reported being pleased with the outcome. Her parents gained some understanding of Kristen’s experience. They requested additional materials to read about DID. Relationships. Despite their increased understanding of Kristen’s diagnosis, her parents found it difficult to change their entrenched parenting styles. In particular, they continued to maintain high expectations for her in most areas of her life. Both of her parents pushed her to work full-time. Though Kristen was 19 years-old, her mother still critiqued and attempted to control her hair and clothing choices. Kristen responded with a new behavior by repeatedly defending her decisions to her mother. She insisted that “I can’t dress for other people.” Kristen spent much of her free time with her boyfriend. They attended the senior prom together. However, she found the escalating intimacy between the two of them somewhat frightening. She vacillated between desiring a physical connection with him and being repelled by their increasing sexual activity. Similar to many young women her age, Kristen considered her boyfriend her highest priority and, as a result, distanced herself from many of her friends. Symptoms. Kristen repeatedly discussed her inability to disclose to her boyfriend her imaginal world or DID diagnosis. Nonetheless, it was quite difficult for her to keep that part of her life separate from him. Before long, Kristen began to speak of a character in the imaginal world with his name. This placement of him in her internal world created a tremendous amount of internal conflict. As a result, it seemed that the imaginal world became overly active at nighttime. At the same time, Kristen complained of intense headaches after experiencing any physical intimacy with her boyfriend. Academic. By July of 2004, Kristen had graduated from both her vocational program and her high school. Kristen toured the local community college and met with the special education offices. She decided to apply and, to her disbelief, was accepted. Life skills. Kristen’s graduation party was well attended and deemed a success. Kristen remained present, demonstrated new social skills, and appropriately hosted the party. She continued to excel at her job, working almost 40 hours per week. Kristen attended church regularly with her boyfriend and his family.

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Therapy and assessment. At this family meeting, Zac officially introduced herself to Kristen’s parents for the first time. During our sessions leading up to the meeting, we had explored why Kristen wanted Zac to come out to her parents and how she would go about it. At one point, Kristen had remarked that her primary reason was, “so that they can see my anger.” In the following excerpt, Z=Zac, C=Carol, P= Parents, S=Supervisors. C: I feel that I should let you take the lead. Z: How do you want me to take the lead? C: Its up to you, you said that you wanted to introduce yourself. Z: I’m Zac, basically the aggressive part, angry part of Kristen, like when she was at school and she couldn’t handle it and I came in and took care of it for her. That’s pretty much it, not unless if you guys got more questions… P: Why are you angry? Z: She made me that way P: Who is she? And why did she make you that way? Z: Kristen… To handle her anger problems better. P: That what I am trying to say. What are the anger problems? What are the reasons? Z: Because of all the kids, like emotionally abusing her and it got her like upset, like she’s not worth anything so she made up an imaginal place to interact with people and stuff like that. It is like when she was younger, and she was upstairs, and you’d ask what she was doing and she was playing. No, she was in the imaginal world and like, talking to us basically. So, she wasn’t really playing, it was more of my world with her in it… C: And you were saying to me, that you have talked to mom and dad many times, that they have interacted with you? Z: Yeah, like mainly when she gets highly upset and she doesn’t know why she is upset for, so, I usually come in and try to help her. I’m not coming in as much because she needs to handle more problems on her own. You can’t always substitute a life but, yeah. Did I answer that pretty well? C: Are you feeling comfortable? Then you are doing a good job. S: I thought it was extraordinary. Kristen really felt picked on (Z: Yeah) and really did not have (inaudible…)

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Z: No, it really hurt her because its like, she didn’t do anything to the kids and all of a sudden, she is getting picked on, and called names and she didn’t know why. P: She may never know the answer. I mean kids can be mean at times, very mean. So, there may never be an answer to that. Z: I’m not looking for an answer; I am trying to help her. P: Okay C: And that has been your job is to help Kristen, and when Kristen first started coming to therapy, were you stepping in a lot during that time? Z: Mainly, but when she came in here, I would have like walked because I don’t want to come to therapy. I don’t need it. C: I think the first couple of times we met, you were pretty angry, and thought that I might be trying to kill you off. Z: Yeah, But, I already explained that (laughs). P: So, you don’t think that anymore? Z: No, we try to help Kristen as much as we can. I am with Kristen like 24 hours, 24/7, whatever you call it, and she only sees Carol like once a week or maybe two times a week. So, it’s kind of like helping her. When she gets really upset and suicidal, I will try to come in to let her calm down, since she is like upset and angry and in that killing mode, I get really rude. So, yeah. C: So, sometimes, actually when maybe the parents have thought that Kristen was being rude to them, it might have been you. Z: Yeah, it could have been me, not her because she doesn’t want to be rude to people because they could hurt her emotionally again. So, its like she trying to work with it a little bit more than she used to, but mainly, like the past few years, if she got angry at you guys, it was me coming out towards you but being Kristen. S: Zac, do you remember when you first realized how much you needed to protect Kristen? You do an incredible job. (Z: I try) And it has worked well. Do you remember when it began? Z: Roughly around third grade, when she started to actually talk to us. We were there through first and second but the main thing that set it off was third grade. S: What was different about third grade?

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Z: This girl, a little preppy, slut, whore, whatever you want to call her. She was friends with Kristen and, they went to the park together. Kristen was like, “Oh Yeah, I like you.” Then they spent some time together, and then she spread some bad rumors about Kristen. It’s like, she had friends up until she (the other girl) came in. I think that if she didn’t come in, everything would be a whole lot better. I really think that she’s the cause of everything, but that’s my opinion. P: You’re saying that she took all Kristen’s friends away and started the rumors? Z: Yeah, pretty much, Yeah, and because like first grade and second grade, she played with that kid, Sara. She was friends with that girl Sherry but once third grade hit, they were getting further away from Kristen, so…It’s hard to be that little and wondering why kids won’t play with you and she doesn’t have the courage to ask, so it kind of gets a little upsetting and aggressive. P: Did you ever ask why? Z: No, because I wanted her to try and do it before I come in and do it. The reason I didn’t come out as much at school is because I could have killed a few people. I did not like them. I don’t want Kristen to get in trouble and, as aggressive as I am, something bad could have set off and she could be in jail for the rest of her life. The main part I think I did was when I went to the principal office one day and I think that’s about it. C: So Kristen’s way of handling all that hurt and that pain was to pull back, and you stepped in, because you could take it, because you were stronger, somehow? Z: Yeah. S: It’s scary being that angry? Z: I’m used to it. I mean it’s not a big deal to me. S: It sounds like you handled it well. You were able to keep it under control. That’s amazing. Z: Yeah, I keep things under control because you got to think that if I do this action what’s gonna happen to the person [Kristen] and they probably won’t know why what happened. So, it’s better to control most of the aggressive stuff. C: Because, if you acted out, then it might get Kristen in trouble and Kristen would have to take the responsibility.

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Z: Yeah, and then you try to explain to the court, “Well, it was a different part of me” and they’re like, Yeah, that’s a lie. So, it’s like, “oh Yeah, you’re just making it up.” S: I think its pretty impressive. I wasn’t that mature in your grade. Z: What happened is, when we were born, we were born at a certain age. S: Yes, I’ve heard that on tape. It’s interesting to hear it from you. Z: So, its like when our parents had us in the imaginal world or whatever you call it, I was born at age 18 with all the knowledge and stuff of an 18 year old person so it doesn’t make any sense, but that’s like how Kristen created it and how Kristen wanted it. S: And, it’s working. Z: Yeah, so as long as it works, I’m okay with it. C: Yes. I think that is the thing, when Kristen was very young, it helped her a lot and all the different parts of Kristen came together and really helped her. Then as she grew older and older, it wasn’t quite as successful sometimes, and she couldn’t hold it all contained. I think, is this right? (Z: Yeah) then it came to a head and when she first came back to therapy, I think two years ago, it had kind of come to a head and was no longer working as well (S: Yeah). So, now we are trying to find ways to keep those parts of herself, for Zac to still be around, but Kristen to be able to handle things a bit more on her own and not be so reliant on all of you. (Z: Yeah) So, that’s kind of been our work in therapy and what we’ll still be working on. S: You okay with that? Z: That’s cool. It works. C: Is it working? (Z: Yeah) Have there been changes since you first came out to therapy? (Z: Yeah). We were talking Wednesday about some of those changes for you. Would it be helpful to share those with them? Z: How I have changed? Um… There’s less killing and shit that has been going on. It just turned down the highly violent stuff. It’s not as violent as it was. It like slipped down. P: Does it still happen as often as it did? Z: Me, killing people? Uh Yeah, I mean it’s not like I kill somebody everyday just when they highly piss me off or something like that. And, I get irritated. Of course, I ask them to talk first but if they keep nagging and nagging, it’s like, JUST GO AWAY! C: At this point, I wanted to check in with all of you and see how you’re doing.

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P: I am fine. I am just listening right now. Z: You don’t like the killing part? I can tell. P: I think it is extreme. I think there are other ways to deal with it other than killing. It might be more me not understanding what you mean. Z: Pretty much, it’s like I don’t really control if I kill somebody. It just really depends on how upset Kristen gets or something. It has a relationship of how upset she gets and like, at that person, she’ll create that person into our world and then it, kind of like, kills them off. And, then she won’t worry about that person anymore. It’s not really like I am just meaning to kill everybody who annoys me. It’s just it kind of helps her (Kristen) because then it is not sitting at the back of her mind, basically. C: Can I use that example of the time that Kristen got mad at her dad during the day? Z: Um… I remember that a little bit. Go ahead. P: You mean you killed me? C: No, wait a minute. Let me explain. What happened one time in therapy was Kristen was very angry at you in the real world, maybe you wouldn’t let her go somewhere or do something, I can’t remember. It was about a year and a half ago. Kristen didn’t know how to handle that anger at the dad that she loves so much, she couldn’t integrate being angry at loving father. So, instead that night, Zac, in the imaginal world, killed an imaginary dad. He didn’t look like you but was an imaginary dad character in the imaginal world. So, I think that is the best example of Kristen feeling the anger, not knowing how to handle it, and then Zac taking care of it in the way that Zac knows how to take care of it which is just to kill them off. It is important to note that in the imaginal world, often times, there are killings and then the person comes back later. Z: Yeah, Yeah, not everybody actually dies. If I kill them, at some point in time, they will come back into the world and like, be living and stuff, so its not actually a killing, “oh, you’re dead, bye. See you in the graveyard.” It is basically killing off the memory, basically. P: Or killing off an emotion and not an actual person? Z: Right, but in our world it is people, all the feelings toward somebody or something. It is a feeling. But I say that I kill people because I see them as people. You guys can’t.

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After additional discussion, the session concluded. The parents left the room and Kristen arrived to drive home with them. She recalled little of the meeting. Regular weekly therapy sessions continued throughout the first half of 2004. However, as Kristen became more involved with her boyfriend and his family, she rarely asked for an additional session or called with an emergency request. After a period of relatively few phone calls and emails, in April of 2004, Kristen left me the following phone message: Hey Carol, this is Kristen. I know it is three o’clock in the morning, but I just wanted you to know that I had a suicidal thought and it was very, very tempting. But, I worked it out and I talked it through with the person that I had a problem with. I guess we will talk about it on Wednesday not unless it is really serious and you need to talk with me tomorrow. I am going to church and I will be out after 12:30 tomorrow. My promise to you was that if I got a suicidal thought, I would call you, so I called you. I worked it out. It was kind-of hard. The thought is still in my head but not as strong as it was. So, if you want, you can call me. When we discussed this incident, Kristen reported that the conversation with her friend was very difficult, and her head had hurt throughout their talk. However, she remained present as Kristen and “stuck through the pain.” When I asked why she chose not to call in Zac to handle the problem, she said “I mean, she will be cussing out the ying-yang and I really didn’t want her (Zac) to go off. I needed to handle it myself.” Kristen admitted that she didn’t like the confrontation, that “It was so hard.” Her explanation of what led up to her feeling suicidal and the subsequent self-soothing was as follows: K: What it feels like is, if I am hurting other people, and then they get mad at me. Then they hurt me back. It is kind of like a hurt battle type thingy. I don’t know… C: So, you got your feelings hurt and you immediately felt suicidal. K: I got hurt because I made her mad and I don’t know why. I was starting to get frustrated with myself because I don’t understand why I think she is mad at me. C: Did the suicidal thoughts come in when you started getting frustrated? K: Yeah C: And, you were kind of angry but not really angry but kind of angry? K: Yeah

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C: So, you feel very frustrated and a little bit of anger and then you start to feel like “I’d rather just be dead then deal with this?” K: Oh yeah. C: So, in the past when you got that point, you would either call me right away… K: Yeah C: Or Zac would come in right away… K: Yeah C: But this time you felt that and, instead, you stuck in and had a conversation with the person. K: Yeah, which was very hard. C: At the end of the conversation, did you feel suicidal? K: Uhhh… A little bit but not as strong as it was when the conversation started. C: So, you found a way that, as hard as it was, you got from feeling really suicidal to just a little bit suicidal? K: Yeah C: So, you were able to calm yourself down? K: Yeah, and that is why, I couldn’t because I couldn’t call you while I was in the middle of the conversation with her, and it was like, maybe if I try and talk to her a little bit, it will calm down. We talked about how she had never worked through this level of an interpersonal problem before. This problem-solving experience felt significant to her. By the end of our therapy session, Kristen reported that she was no longer distressed or suicidal. As the year continued, Kristen began to ask additional questions about the DID diagnosis and describe her experience of “needing them (the alters) less.” In May, she said: I guess we are combining or whatever. Cause, it feels like a switch but its like, it’s kind of weird because it kind of feels like you are dead at that time and then you switch back to life. It is really confusing. I don’t know how to explain it…Why does it feel like I am still switching and stuff? It is like I am on the verge of coming into one person…It’s really confusing…I know that Zac is still there but I don’t really go for her or call her out. At the 07/07/04 session, Zac identified herself at the beginning of the therapy and immediately asked for a piece of paper as she wanted to draw something. She seemed very tired and her

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speech was quite slow. When I queried her about her health, Zac said, “That is because I got infected with sperm and I am really high and drunk at this point.” Zac then proceeded to draw. One was a picture of her boyfriend and the ways in which he is now becoming a character in the imaginal world. There is a conflict because Kristen wants him in her imaginal world and Zac disagrees because “it is going to be a great big problem.” The second picture was a map of her internal system. When I asked her why it might be a problem, she responded as follows: Z: Because it’s going to affect everything! Even though people in the world can get into it, he cannot get into it. And here Kristen, when she hears him in the real world, she tries to rearrange it and bring him back up here. But, see, that is the other problem. Every time we try to name somebody this, it goes back out and that can’t happen unless we slit his throat. The reason I am getting irritated is because the person that he is (the boyfriend), he is coming in and I don’t know how and he is coming in like it is normal, like this is a normal function, which doesn’t make any sense, but it is the same exact person that is out there that is coming in, that ain’t good. Normally, when a person out there comes in, it changes the real person…It changes their whole different point of view and this person here, this boyfriend (in the imaginal world named after Kristen’s real boyfriend) is trying to have sex with me since I’m in high school and drink. And, he knows that I’m a lesbian and I don’t like it. There is only one problem because it is the exact same person. C: Is the real boyfriend trying to have sex with Kristen? Z: That I don’t have a clue because it is not his body, it is his mind. Which is driving me insane because I don’t know what is going on and it doesn’t make one bit of sense… The only thing that changed with him is that he has a scar right here…I mean she can handle it out here (the real world), but once he gets in here, and it keeps going back and forth and back and forth and back and forth, Kristen can handle this more than in here, but she wants the name in here but once she gets it is here, she can’t handle it. C: I remember when I was in the imaginal world for a while, I was killed off. Z: Yeah, this is kind of more difficult. Cause, it’s in Kristen’s head and everything is going through it and she thinks if she kills him off in here (imaginal world), she’ll actually kill him off out here (real world). C: Is Kristen losing touch with reality and the imaginal world? Is she getting the two confused when it comes to this new boyfriend?

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Z: I think, I am not really sure. C: And, that didn’t happen before they started having sex? Z: No. I think it is like emotional shock waves bouncing off each other but I really don’t know because I have never seen this happen like this before…I know what’s going on but as much as to why he keeps coming in and going on…It is so complex right now. Now, we have this guy really without a name right now. Because, we can’t give him this name. Cause, if we give him this name, it could affect him. C: Because what happens in the imaginal world affects what happens in the real world? Z: No, not really, because I am so confused right now, going in and out and in and out. It’s so complex, I don’t know if it will affect it or not because right now he’s in here, and he knows what is going on… Assimilation Constructs Observations bearing on internal multiplicity. Zac’s comments to the parents that therapy “just turned down the highly violent stuff” suggested that she, too, was changing. Similar to the findings by Humphreys et.al., (2005), these passages suggest that extreme unassimilated voices (e.g., intense anger) or subcommunities (e.g. Zac) may become increasingly moderated as access is gained to the other subcommunities and their resources. Zac and Kristen’s conflict over whether her real-world boyfriend should enter the imaginal world interested the coinvestigators. They recognized that Zac was exhausted by the battle and felt it reflected a lack of a meaning bridge around the boyfriend. However, they recognized it could be representative of a growing assertiveness on Kristen’s part. Her ability to stand up for what she wanted, despite Zac’s misgivings, was new and required a stronger sense of self. They believed this struggle was representative of internal multiplicity in dialogue. Coinvestigators also noted that Kristen was confused by her boyfriend’s move to a new place and his sudden use of alcohol and drugs. This type of behavior by an intimate other was foreign to Kristen outside of the imaginal world. We found this consistent with the assimilation model and its assertion that when unassimilated experiences are evoked, they lead to confusion. The coinvestigators also viewed Zac and Kristen’s disagreement as evidence of a problematic voice representing a conflicting position of the self. They felt that amnesic barriers were disintegrating as each felt safe enough to battle through differing opinions.

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Kristen’s decision to work through her suicidal feelings and only contact her therapist because she promised to, suggests additional assimilation and the acquisition of new resources. Emergent issues in data packet # 12. Kristen’s insight into why she chose to remain present and work through a problem rather than call Zac in to handle it suggests an increased level of awareness and a decision not to dissociate. Kristen’s comment that “I know that Zac is still there but I don’t really go for her or call her out” suggests that as she gained access to the alters and learned more about them, she chose to use them less. Data Packet #13: A Second Parent Meeting a) Audio-tape of family session on 08/11/04, Zac speaks to Kristen’s parents. Why I Chose This Data Packet In this session, Zac clearly articulated how the imaginal world was created. She explained the complexity of the world and Kristen’s daily experience of it. Zac elaborated on the alters’ wish to work together and the obstacles that prevented it. Zac described the process of the “bricks” coming out of the amnesic barriers that isolated the fragmented parts. These insights from an alter’s perspective seemed to be valuable information for the coinvestigators to explore while searching for POC between theory and experience. What We Learned In this data packet, we learned more about Kristen’s change process from the alters’ perspectives. This was, perhaps, the first time that the coinvestigators collectively acknowledged that the subcommunities experienced internal voices. They began to see the complexity of the assimilation that must occur in a case of DID. For example, not only did Zac assimilate with the other alters, her internal voices were also in the process of assimilation. We further witnessed the alters increased collaboration (due to increased access to each other) on a specific goal (helping Kristen) as both accelerating the assimilation process and representing increased assimilation. Clinical Observations Context. Kristen requested a second family session with her parents. As much as she wanted the meeting to occur, she again chose to have Zac speak. Kristen admitted that she was afraid to talk about the imaginal world with her parents. She felt that Zac still knew more about the world than she did so it would be better for Zac to speak. Relationships. Kristen’s romantic relationship continued to intensify with her boyfriend. He gave her a promise ring which she was terrified of losing. Though she hated leaving her

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boyfriend behind, Kristen traveled with her mother to a neighboring state to attend a Madonna concert. This mother/daughter trip was an important bonding experience for them. Symptoms. Kristen continued to dissociate but, more often, seemed to be consciously making a decision to do so. Her experiences of automatically dissociating occurred less frequently. However, while on the mother/daughter trip, Kristen became quite ill with bronchitis- like symptoms. Despite feeling sick, she insisted on attending the concert nonetheless. Both Kristen and her mother confirmed that, during the performance, all of her symptoms (coughing, sneezing, elevated temperature, headache, difficulty breathing) suddenly disappeared. After the concert, they immediately returned. Academic. Kristen struggled to make a decision regarding attending college. She was thrilled (and proud) to be accepted and, consequently, felt obligated to attend. However, Kristen also felt overwhelmed by the demands of her parents, boyfriend, work, and therapy. She finally disclosed that a big part of her wanted to “take a year off.” Life skills. During this period, Kristen demonstrated interest in obtaining her file from DCFS regarding their investigation of her at age 16 (see initiation of therapy). She made a few phone calls, expressed her anger at the department for the way they handled the situation, and began the process of obtaining a copy. Therapy and assessment. In preparation for the second parents’ meeting, we spent time discussing what Kristen wanted from the session. Zac attended a session and, as seen in the following words, reported that Kristen wanted them to: Understand what is going through Kristen’s head. They think that it is more concentrated on everyday life but here she has a whole other world in her head. So, she is concentrating on both all the time. That’s pretty much it. And, how confusing it is for one world that she totally made up and nobody really understands any of it. Sometimes she gets confused between the two. At this same time, there was an increase in the appearance of the other alters in session. A number of them arrived at these sessions, intent on providing me with history or information about Kristen and her imaginal world. Zachary came to therapy for the first time, saying, “I think it (therapy) is good. I think that it helps Zac even though that she doesn’t think that she needs it and she really, I don’t know, but it did help her out.” Jessie arrived as well and reported on Kristen’s early childhood:

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I think she (Kristen) had a good childhood up until her uncle dies and then it really went downhill. After her uncle died, she lay in the street and waited for a car to run her over. And then she started seeing invisible people which I don’t know if it was us that she saw or if it was dead people. Ever since then she can see people walking around and stuff, that aren’t really there. So, like, she scared herself to death because she thought her house was haunted which it could have been and she did all those magical things like those séances and candles…I think they (her parents) did a pretty good job but I think her mom was a little like, I think her mom has a bad rampage thing…I was around absorbing the information but I really didn’t come out until the middle of third grade or beginning of fourth. That’s because I am guessing she just had all those thoughts in her head and she really couldn’t speak them out to the people so I guess that what she was doing was controlling it but right around there, she could actually put names to it. Notice that most of the imaginal world is famous people. She’s never gonna be Madonna and she met Hanson for the first time in her life. But, you know that is rare that you would get to do that. So, she put famous people’s names because she thought that they would be nicer than the people at her school. It was like we were there but we weren’t really made until around third or fourth grade. In this August meeting, Zac spoke for the first half of the two-hour session at Kristen’s request. Kristen asked for this meeting because she wanted her parents to better understand the confusion she experienced daily. During the meeting, Zac spoke with Kristen’s parents about Kristen’s internal struggles and her progress in therapy thus far. She discussed the origin, development, and current status of the imaginal world. Zac shared the pictures of the alters that she had drawn over a period of three weeks of the various alters, describing each one. She answered a number of the parent’s questions. In describing how the imaginal world originated, Zac continued: People that she [Kristen] was obsessed about [e.g., Madonna, Hanson, Zac, Tay etc…], she made as her friends, on a whole different level… Pretty much, everybody gets abused…How it is related to the imaginal world is my biological parents [Zac’s parents in the imaginal world] abused me. It has nothing to do with you guys abusing Kristen…I think she felt when she [Kristen] got hurt so bad emotionally, it is abuse. I think it comes down to when she [Kristen] gets emotionally abused in the real world then somebody

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gets physically abused in the emotional world, the imaginal world.” She continued, saying, “It’s kind of like an imaginary friend. But Kristen figured that the friend would get lonely, so she made another friend and another… Now, there are over a hundred. It’s like she made a whole entire family…Even when Kristen is here and talking to you, I am still doing a concert or giving an interview. The imaginal world keeps going on in her head. She has all that in her head. It’s like half of her brain is the imaginal world and the other half is the real world. Later in the session, Zac said that she was “starting to back off so that Kristen can learn to take care of things.” She added, “If she gets highly upset, I’ll step in. I won’t leave her all alone but she has got to take over some of this stuff.” She pointed out that whereas Kristen used to automatically shift to an alter when stressed, more and more, “It is in control.” She guessed that it was about two-thirds of the time that Kristen was able to make the decision to either remain present or dissociate. Zac said that there was not a lot of sharing of information (from one alter to that other) at that point. But, she said, That’s something we are trying to work on right now…She (Kristen) doesn’t feel normal. She has other problems. She is trying to come out of that. But, it is hard. That’s what we are trying to do, work together. But, I can’t. There is a wall between them. As she (Kristen) gets better, a brick comes out of the wall. When I asked Zac if she knew how much Kristen was aware of the things that Zac was sharing in the meeting, she replied, “Very little. That wall is still there.” Assimilation Constructs Observations bearing on internal multiplicity. Coinvestigators pointed to Zac’s comments, “We’re trying to work on getting everybody to know everything. That’s what I’m trying to work on, us to try and relate and work together.” They suggested that this was evidence of the internal voices and their commitment and effort to dialogue. It demonstrated that the amnesic barriers between the alters were reducing. After reading the previous 13 data packets, the coinvestigators recognized that each alter represented a subcommunity. That is, each alter had different internal voices of his or her own. For example, Zac was a subcommunity in the sense that she had various internal voices that dialogued, worked, or negotiated with each other.

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Observations bearing on therapy and the therapeutic relationship. The alters agreed to support the family session in an effort to improve Kristen’s relationship with her parents. When Zac spoke to Kristen’s parents during the meeting, she presented information about the alters and the system’s dynamics. Coinvestigators saw the dialogues that occurred before and during this session as explicit examples of internal and external relational work facilitated by therapy. They felt that helping Kristen’s internal community collaborate on a shared goal increased assimilation. They suggested that educating Kristen’s external community and support system (her parents) as to about her internal dynamics indirectly facilitated her assimilation as well. Observations bearing on different APES ratings. In the parent meeting, Zac spoke about Kristen’s confusion, Kristen’s inability to discuss her experiences, and how she (Zac) wanted to help them to better understand their daughter. In this example, Kristen used Zac to communicate essential information to the parents. Kristen called upon Zac as a resource which suggests that there were meaning bridges built between them. However, Zac continued to show that she knew more about Kristen than Kristen knew about her. Whereas Kristen still fluctuated in her understanding as to how the two worlds were connected, Zac said, “It makes perfect sense when you put it together.” The coinvestigators felt that, in contrast to Kristen’s limited understanding of the fragmented system, Zac demonstrated APES Stage 4. They felt her knowledge reflected the construction of meaning bridges between the two worlds. Emergent issues in data packet # 13. Kristen’s and Zac’s asymmetric access as discussed above raises a theoretically interesting point. We wondered what APES levels of the host's experience looked like from the perspective of a subcommunity. By analogy, I might say I've understood (assimilated) a good deal about Kristen, but what has she assimilated about me? One way to address this issue might be to discuss it as the assimilation of particular experiences. We agreed that the idea of asymmetric access needs additional research and thought. Data Packet #14: School Visit a) Progress note, 1/26/05 b) Progress note, 02/02/05 Why I Chose This Data Packet When I asked Kristen what were important moments or events in her change process during our termination work, she named a few key therapy sessions such as the home visit,

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parents’ meetings, and school visit. Both Kristen and I agreed that this visit to the site at which she believed many of her problems originated turned out to be an important moment of change. In planning the school visit, I learned that Kristen had long wanted to face her childhood fears but was nervous about how she would react. I hoped that she would feel safe enough to give voice to her pain on site, and, that by giving voice to it, her burden would lighten. As it turned out, seeing the elementary school through adult eyes, talking about the incidents that occurred while she was a student there, and speaking up to her former teachers about their responses to bullying all helped Kristen face her fears. She realized that she was no longer defined or limited by the bullying incidents that occurred when she was a child. This experience helped her to re- story her life narrative. I believed the coinvestigators would benefit from analyzing an important moment of change in therapy as identified by both Kristen and I. What We Learned In this data packet, the coinvestigators witnessed Kristen’s growing ability to remain present while Zac or the other alters took primary control of the body. We viewed her developing co-consciousness as evidence of meaning bridges being built, disintegrating amnesic barriers, the dialogical process, ZPD work, and APES progression. Together, we agreed that visiting Kristen’s former school was a creative therapeutic intervention and a key moment in therapy. The coinvestigators felt such flexibility and creativity aided further assimilation as Kristen was able to face her significant fears and memories of the school within the safety of our therapeutic relationship. Clinical Observations Context. Kristen continued to demonstrate progress interpersonally and professionally. She remained committed to therapy and arranged her busy schedule around our sessions. Relationships. Kristen experienced another profound loss when her great-grandfather suddenly died. She reported that she was doing much better with his death than she had with previous losses. However, she was upset that her parents insisted that she go to work rather than stay home with the family while they planned the funeral. We discussed why she felt it was important to stay home. She said, “To feel safe… feel a part of my family…be around those who love me.” We discussed why her parents wanted her to go to work. She said they felt there was, “No need…they’ll handle things…they think I need the money to make my car payment.” I

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encouraged Kristen to communicate directly with her parents, and ask for her emotional needs to be met. Later, Kristen left the message that her parents allowed her to stay home. Symptoms. Kristen’s physical symptoms fluctuated depending on who was present when speaking. She was particularly congested prior to visiting her old school to face her fears. Academic. Kristen decided not to attend college and, instead, to work full-time. Despite the excitement of being accepted, she was able to admit that after years of special education, she was insecure about her ability to succeed in higher education. In addition, her decision was partially based on her desire to spend more time with her boyfriend as she continued to grow closer to him and his family. It was based on the fact that her parents wanted her to work full- time and she found full-time work very difficult. Adding college classes to her exhaustive job schedule, relational demands, and intensive therapy sessions seemed impossible. Life skills. Despite problems at her job, Kristen exercised age-appropriate decisions in addressing her concerns. For example, rather than complain about her boss’ poor communication skills, Kristen tried to speak with her about her confusion. After little changed, Kristen looked for a new job, filled out a number of applications, and interviewed with potential sites. During the holidays, Kristen experienced a great deal of stress around “finding the perfect gifts for everyone.” She continued to feel controlled by her mother who, she felt, expected perfection of her. Kristen shared her desire to move out of her home and live independently. However, she admitted she was frightened of living alone or away from her parents. Around this same time, Kristen experienced another near-accident while driving. She became unable to remain present as Kristen while driving in winter weather conditions. Out of fear, she often chose to have Zac or Tay take the wheel. Therapy and assessment. Kristen and I spent time during many of our sessions making sense of and working through the childhood wounds she was able to bring to therapy. For example, she always referred to her elementary school experience as traumatic because she had been bullied by her peers. Kristen felt isolated from the others due to her poor social skills and academic abilities. She remembered feeling “not normal.” In talking about her school experience, Kristen often remarked that she wished she could go back, face her memories, and talk to the teachers. Coincidentally, this became a possibility as I was hired to work part-time at the school. After much deliberation, we decided to hold a therapy session on-site at her former school. We then prepared for weeks for the visit by watching a few videos and reading some

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stories about bullying. Kristen and I explored her conflicted feelings about returning to her former school. She, as Kristen, was finally able to express a great deal of anger at the teachers and her parents for allowing the bullying to occur. I viewed her new-found ability to articulate her anger as a healthy step in her process of change. Together, we identified three goals for the school visit: 1) Face her fears 2) Recognize that the childhood bullying no longer held power over her 3) Empower her. As the work progressed, Kristen seemed to find it easier to express her emotions around her experience of childhood bullying. She realized that how she felt as a child when the bullying occurred was not the same as how she felt as an adult. She was able to recognize that her perspective had shifted. Kristen seemed no longer stuck in the emotions associated with her childhood experience. This was new. The week before the visit (01/26/05), Kristen urgently apologized for failing to return a bullying video that she had taken home to share with her parents. We talked about how it felt to forget the video. She said that she was afraid that I would be angry with her despite our years together and her experience of me. I shared with her how it felt for me to be lumped into the way others have treated her in the past. We discussed our relationship and the hope that she can generalize some of what she is experiencing with me to future relationships. Kristen then brought up her excitement and fears about visiting her old school. I suggested that we change our plans. However, she was adamant about returning to the school. She said she wanted to go and “face my fears.” Kristen was not sure exactly what she was worried about but suggested Zac explain. I agreed on the condition that she would attempt to stay partially present during my talk with Zac. I asked her to imagine herself hovering nearby, watching our interaction. Zac arrived and reported that Kristen was worried that she would be upset to see her former teachers as well as the places where she was bullied. Kristen was not certain how she would respond. It seemed that Kristen was worried that she might see another child being treated like she used to be treated (e.g., bullied). However, Zac felt Kristen could handle it. She promised to be available to help if Kristen needed her. Zac had no qualms about visiting the old school and thought it would be good for Kristen. Zac mentioned that it could be hard for Kristen to hover nearby during our session but agreed it might “be really good if she could.” Kristen returned reporting that the hovering experience was “Weird.” I asked, “Weird bad or weird odd?” She said, “Weird odd. It was just all blurry.” We discussed what it felt like to

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hear part of what Zac said in session. We talked about how I would ask her to remain present more often so that she can eventually know all the parts of herself. Kristen agreed to keep trying. On 02/02/05, Kristen and I continued to discuss the upcoming visit to her former school. Kristen had requested this step in her recovery and reported being both excited and frightened about the visit. In exploring her feelings, it was clear that my work at the school seemed to have first made Kristen mad as she felt betrayed. She then realized that it was a perfect opportunity to go back and visit, something she has long fantasized about. Kristen said that in order to progress to the next level of helping herself, “I have to go.” We again explored what she wanted and needed out of the visit. We talked about what she would specifically like to do while at the school. She had some ideas and said, “Tell you about what happened to me as we walk around the school. And, say hi to the teachers.” Throughout our conversation, Kristen appeared nervous so we discussed coping strategies to use if she began to feel distressed. We worked on a visualization technique so that she could self-soothe. Kristen reported that it calmed her immediately and she felt relaxed afterwards. But, she also said it felt “weird, a different weird.” Later in the session, I again asked to speak with Zac about visiting the school. I encouraged Kristen to remain partially present, hover near Zac, and stay in the background in order to listen to our conversation. She agreed to try. Zac then arrived, reiterating that she still felt fine about the visit but Kristen’s anxiety was escalating. Zac insisted that she would remain with Kristen while at the school. She would only come forward occasionally to report on how Kristen was feeling if Kristen was unable to tell me. Zac said she would signal to let me know if she became in control of Kristen. I then asked Zac about Kristen remaining present the previous week when Zac came forward. She reported that it was difficult for her and everything was blurry for Kristen. However, she said that she would like it to get easier so that Kristen could hear what Zac was saying. I asked Zac, “If you had one thing to tell Kristen, what would it be?” Her face turned red and she almost cried as she said, “You ask emotional questions, don’t you?” After an extended pause, she responded, “That I will always be there and that my biggest hope is that we can work together as a team.” This was the most emotion, other than anger, that I had seen Zac display. She seemed deeply touched that Kristen might be able to hear her hopes. A week later, Kristen and I met for an extended therapy session at the elementary school where she had once felt so wounded. Kristen and I began our session in my office. We talked

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about how different it felt to be there as an adult. She repeatedly said, “It seems much smaller.” I reminded her that she is an adult. She seemed quite taken with the idea that she was now seeing the school through adult eyes and it didn’t look nearly as frightening. We explored her concerns prior to going over to the classrooms and did a relaxation exercise so she might feel calm enough to move on. She responded well to the exercise and we continued on our tour. We walked around the school grounds while exploring her memories. Despite her fears, she was able to remain present as Kristen throughout the session. She spoke with her teachers and reminded them of the bullying she had experienced. She thanked one teacher for protecting her. She asked another why she did not step in and stop the bullying. Kristen consoled a fifth grade girl who had recently experienced bullying by her schoolmates. After it was over, Kristen was shocked at how “little everyone looked and how little the rooms looked.” Kristen was proud of herself for talking to the teachers, principal and student about bullying. Though Zac remained available to Kristen, she never took control and, Kristen never used her visualization technique during the school visit. Assimilation Constructs Observations bearing on therapy and the therapeutic relationship. The coinvestigators noticed a number of therapeutic interventions that they felt gently pushed Kristen towards change. They were particularly interested in the hovering technique that I asked her to use in our sessions. They noticed that Kristen’s awareness of the alters improved as she worked to remain present in some capacity when a switch occurred. By remaining partially present, Kristen was not able to run away entirely from stressful situations. Instead, she was encouraged to experience co-consciousness. As she repeatedly hovered nearby when Zac or the others arrived, her tolerance for stress increased over time. Kristen’s understanding of and empathy for the others increased as she retained some memories of each encounter. The coinvestigators suggested that change occurred while Kristen’s tolerance for remaining present grew. The coinvestigators suggested that my decision to work with Zac as a secondary means of helping Kristen remain present was significant therapeutic work. They felt this served as additional evidence that, in many cases, therapists may personify and speak directly to alters or other internal voices as ways to facilitate assimilation of the whole body. The hovering technique was viewed as ZPD work as Kristen had not previously remained present when a second alter stepped in. Encouraging her and her primary alter to attempt shared consciousness was working slightly ahead of their natural inclination. With my support, the coinvestigators felt that Kristen

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moved to a higher level of functioning resulting in an increased ability to tolerate both stress and co-consciousness. This movement indicated increased assimilation. The coinvestigators further noted that both Zac and Kristen worked in therapy to address their anxieties about returning to Kristen’s former school. During our discussions about the approaching visit to the school, they were able to share consciousness with each remaining present while the other spoke. This work seemed to reflect change. Observations bearing on APES progression. The research team pointed to Kristen’s interpersonal progress as evidence of further assimilation. They suggested that Kristen was using insights developed in therapy to help make progress in the real world. As many of the alters (including Kristen) were using their understanding of the system to work together to make positive change, we considered this consistent with APES 5 (Application/working through). Kristen’s and Zac’s co-consciousness was considered to reflect further assimilation. The coinvestigators noted that when the hovering technique was first used in session, Kristen reported that it felt “blurry and fuzzy.” They noted that even the experience of feeling blurry was significantly different than APES 0 which often involves a violent shifting between voices. With each attempt, when Kristen hovered over Zac, she experienced less blurriness. The coinvestigators suggested that the emotional proclamation by Zac, “I will always be there and my biggest hope is that we can work together as a team,” appeared consistent with APES 5. Emergent issues in data packet #14. The success of the hovering technique and increased co-consciousness appeared to represent new ideas as to what assimilation may look like in cases of DID. Further research on two alters smoothly accessing the same experience in real time could further inform the assimilation model. Data Packet #15: Facing Loss and the Group Meeting a) Progress note, 03/23/05 (Kristen talks about dissociation) b) Progress note, 04/14/05 (All alters sitting at table together) c) Picture 04/14/05 Why I Chose This Data Packet This data packet addressed Kristen’s reduced need for the alters and her fears over potentially losing them. It included evidence of increased communication and collaboration between the alters as they came together for a group meeting.

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Prior to the meeting between the alters, Kristen and I spoke of her decreased dissociation, fears of termination, and reduced need for the alters. Though she enjoyed working through her problems without her alters, Kristen worried about upsetting them because she was “taking up all their space.” She commented on her fear that the alters might “burst out” if not allowed sufficient time in the body. During the group meeting, at Kristen’s request, the alters each reported on how they felt about Kristen needing them less. Kristen later reported that this was another crucial moment in therapy. I felt the coinvestigators would learn more about Kristen’s dilemma (needing the alters less but not wanting to lose them) and the subcommunities’ dialogical process. What We Learned As Kristen engaged more actively in real world relationships, she gained resources in the real world and, thus, seemed to need her alters far less. Although she had increased access to her imaginal world (as her amnesic barriers disintegrated), she chose to access it less. Kristen’s growing ability to remain present and to choose to dissociate less appeared to represent significant changes in her internal system. We believed that her articulated insight into the pros, cons, and fears of needing the alters less reflected assimilation. At the same time, Zac’s demonstration of smoother access to the other alters suggested increased assimilation, dialogue, and negotiation between them. Clinical Observations Context. After the school visit, Kristen reported that she was “surprisingly fine.” Relationships. Kristen’s focus, however, was in another direction as she and her boyfriend were planning a vacation together with her family. As she had still not discussed her diagnosis with him, she was worried that she might dissociate during their first overnight trip together. However, she was determined to work through any problems if they occurred. Kristen independently listed a number of resources she could use to take care of herself while away including the following: listening to relaxation audio tapes, documenting her feelings in her notebook, speaking with family members, and calling her therapist, if necessary. Kristen noted, with a great deal of pride, that she had been successful at working through some interpersonal problems with her boyfriend’s mother and sister. Symptoms. Kristen disclosed that she was remaining present more often during stressful times. In therapy and in emails, she was able to genuinely reflect on why she was dissociating less as well as her fears about doing so.

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Life skills. Kristen reported that her work situation had improved. Her boss was now communicating more effectively. However, Kristen remained convinced that she should continue to search and apply for a new job. Therapy and assessment. Due to clinic policy, at the initiation of therapy, I had informed Kristen that therapy was time-limited. We had briefly discussed termination many times since that first meeting. However, ending our work was always viewed as somewhere in the distant future. I never imagined that I would be seeing Kristen for over four years as most clinic clients were seen for just one semester. I knew therapy was coming to an end as I progressed academically. In the spring of 2005, I first spoke more seriously of an eventual termination. Kristen immediately became agitated at the idea of ending therapy. We explored her fears around termination and having “to start over with someone new.” She shared that it would be “exhausting and impossible.” Kristen felt that if we ended our relationship, it meant that our work was “all a waste of time.” She felt it meant I had never really cared. After this discussion, Kristen arrived at the next session expressing concern for her boyfriend who had broken his arm the night before. She talked about going to the hospital to be with him, spending the night at his house, checking to see if he was breathing, and staying up all night worrying about him. Kristen discussed the fears she experienced immediately after hearing that he had hurt himself. Her primary fear was that he would die and she would lose him. After discussing this anticipated loss at length, I suggested that it sounded similar to her feelings about our relationship ending. She agreed and, we talked about her fears of losing those she loves. In the 03/25/05 therapy session, Kristen discussed her worries about what was happening with her alters. She worried that they had left or would leave her if she continued to do well. Kristen didn’t believe that she would be able to live without them and didn’t want to get rid of them. We talked about whether the alters had left or whether they were just communicating better or working together more efficiently. Kristen believed they were still present, just busy and not stepping in to help her all the time. She thought they were coming out at night in limited ways but not when she was with other people during the day. She recognized that she was trying to work through interpersonal struggles on her own more often and she was happy about that but remained cautious. Kristen was worried that if the alters were suppressed that they would then explode all of a sudden (as they did when she first came to therapy). We explored her fears and thoughts at length. We talked about how long it had taken her to learn a new way of being. She

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repeatedly mentioned that she had missed out on so much by dissociating all the time (although she was quick to add that she was glad she had the alters to help her). She wished she could change overnight but realized it took hard work and time. Kristen’s fear of abandonment seemed to be triggered in relation to her alters as they stepped in less and less to help her. Near the end of the session, Kristen suddenly said that Zac wanted to speak. Zac then came out and discussed a number of things that were occurring in the imaginal world. She talked about Kristen’s fear of the alters’ abandoning her. Zac said they were glad Kristen was handling things better alone. However, she recognized that Kristen was probably feeling deserted. I asked if there was a way Zac could reassure Kristen that the others were still available in some capacity. Zac said she would try. In the 04/14/05 session, Kristen disclosed that she enjoyed trying to work through her interpersonal struggles on her own without Zac or the others stepping in. However, she reported that she was worried that they wouldn’t like the fact that “I am taking up all their space.” In other words, that she is not allowing them time in the body. I asked if there was a way that we could find out how they felt and she said she didn’t know but Zac would know. We agreed that Zac could come out to tell us how the others were feeling about not being needed so much. Kristen then switched and Zac arrived. When I posed the question as to how she felt about not stepping in as much, Zac said she was happy to have the break because she was pretty busy in the imaginal world anyway. She did say that if Kristen really needed her, she would step in and help. I asked her how the others felt and she said she had no idea. I asked her if there was a way we could ask them all and she said that she wasn’t sure. I asked if there was a room in the house that all of them could gather in at one time for a meeting so we could take a poll. Zac said there was a big round table in the kitchen where everyone in the house who was available could meet. I asked her to pull them in for a big meeting in the kitchen. She took some time and seemed to call them all together. At one point, I asked if they were ready and she said,” wait a minute” as it was taking a few of them some time to get there. Once they were all seated, Zac drew a picture of who was at the table. She appropriately left spaces in her drawing where no one was sitting. Those seated were Zac in the middle of the table, Tay, Ike, Megan, Max, Madonna, Zachary, and Ivy around the table. Zac then offered three times to either translate what they said or allow them each to speak. Twice I said Zac could translate but she seemed to ignore my choice. Finally, after she repeated her request for the third

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time, I suggested it might be best to hear each of them respond to my questions and she readily agreed. One by one, we went around the circle and after the initial hellos, I asked two questions of each of the alters that were present. The first question was “How do you feel about Kristen needing you less and handling things on her own?” In each case, the alter responded that it was okay that they were stepping in for her less. Each had a different reason why it felt okay depending on his or her personality. For example, if they were busier in the imaginal world such as Tay and Megan were, the alter might say it freed him or her up to do her own stuff such as party or go to the hospital for treatment of bruises. Madonna, the caregiver, was able to see how wonderful it was that Kristen was growing in this area of her life and responded accordingly. The next question I asked was “Who keeps the secrets?” Each of the alters said that Zachary and Tay kept secrets when asked. In addition, Hanson knew the most from Kristen’s past and would never tell. I asked how they liked coming together at the meeting and they seemed fine with it, although it was the first time it had ever happened and felt “weird.” A few of them said it was their chance to get to know the others better. At the end of the meeting, Zac stepped back in and we talked about their comments. Zac shared how strange it felt to have the alters all together at one time. She then brought Kristen back to drive home and I summarized the others’ comments. Kristen said, “It feels much better knowing they aren’t mad at me (for not needing them as much).” Kristen was obviously nervous until the end of the session when she felt reassured that the alters were not angry at her. As Zac, she was slightly more animated and at ease. Each of the alters presented differently in voice tone and body language. Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators noted that Zac easily discussed in session how she felt about not being needed as much by Kristen. Zac seemed happy for the break, stating that she had “things to do in the imaginal world (concerts, trips, etc).” Though she said she was unable to speak for the others, she displayed smoother access to them by calling them into a group meeting for the first time. Once present at the table, there was communication between them suggesting increased access to each other. The alters agreed that they were fine with Kristen needing them less, although they disclosed divergent opinions as to why each one felt that way.

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Coinvestigators felt that Zac’s ability to call the group together demonstrated that she had also increased her access to the alters, suggesting increased dialogue between her and the other alters. However, they noted that Kristen remained unsure as to how Zac and the others felt and required some reassurance from Zac (internally) and me (externally) before her fears were alleviated. This group meeting, the divergent opinions among the alters, and the negotiation between them were seen as dramatic examples of Kristen’s internal multiplicity. Observations bearing on therapy and therapeutic relationship. The coinvestigators noted that I spoke with the various alters that presented themselves in therapy. During these appearances, they often shared their feelings about Kristen and her inability to handle stressful interpersonal events on her own. Kristen took an active part in calling all of the alters to a meeting with her therapist. She wanted to know how they felt about her moving forward without their continual presence. I specifically asked them to discuss their feelings about Kristen handling things on her own. Each alter responded that it was fine. The coinvestigators felt this therapeutic intervention was crucial at this juncture. Not only did it confirm that the alters were supportive of Kristen living a more independent life, it encouraged increased communication between the subcommunities. As the dialogue increased, the assimilated voices and subcommunities became more accessible (Kristen could call on them if she wanted), but they were needed far less. The coinvestigators felt that this increased communication between Kristen and I, Kristen and the alters, and between the various alters represented increased assimilation. Observations bearing on APES progression. Coinvestigators noted that Kristen’s statement, “It feels better knowing they [alters] aren’t mad at me” is consistent with a meaning bridge between the various alters and Kristen. They suggested that her understanding of most of the others (e.g., Madonna, Zac, Tay) and her experience of fragmentation seems to have grown consistent with APES 4 (Understanding /insight). There was still not sustained periods of direct access between Kristen and the alters but she was increasingly gaining access to them. Though the affect was mixed, there was unpleasant recognition but also some pleasant surprise. Observations bearing on different APES ratings. Around the same time, the coinvestigators found some of the alters’ experiences in relation to the other alters consistent with APES 5 (Application/ Working through) as the they were working together to address Kristen’s problems of living. Throughout the work, their affects were positive and they remained

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cooperative. However, Hanson (and, perhaps, unknown others) remained mostly resistant to change and unassimilated to the larger community of self. Emergent issues in data packet # 15. As Kristen assimilated more resources into her Kristen community, her imaginal community seemed to grow increasingly silent in the real world. As the alters become more accessible to Kristen, they were needed less. Data Packet #16: Hanson a) Progress note, 04/20/05 b) Progress note, 04/30/05 (Hanson, Zac, Kristen) Why I Chose this Data Packet Both these sessions seemed to be good examples of Kristen’s shifting relationship with her alters. In the first session, she reflected on her ability to need her alters less during times of stress. She provided an example where she chose not to dissociate and, instead, used a number of resources that helped her get through a difficult time. Kristen reluctantly acknowledged that she was changing in a positive way. Her hesitation seemed steeped in poor self-esteem. Ten days later, Hanson appeared for the second time in therapy. Her input concerning Kristen’s early childhood struggles was valuable as the others knew little as to the system’s origin. The discrepancy between her reasons as to why the system began and her timetable of its origination was interesting and worthy of examination by the coinvestigators. Of particular note was Hanson’s eventual admission that she was created to help Kristen. Thus far, all of the alters, (including Hanson) asserted that Hanson was Kristen’s enemy. Hanson had previously described herself as having no role in helping Kristen. Her revelation during therapy seemed to confirm that all parts had a role in the system and could potentially be resources. This was discussed in later sessions as Kristen worked to understand her internal multiplicity. After Kristen and Zac heard that Hanson admitted this role, they found her less frightening. I felt this shift represented significant assimilation. Kristen appeared strongly affected by the appearance of Hanson. She had a difficult time staying grounded as Kristen and desperately wanted to slip away. As she was struggling to stay present, she verbally processed fighting the dissociative pull. This improved ability to stay present and to reflect on the experience represented another key moment in therapy.

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What We Learned Hanson’s concession that she was initially created to “kill off the bad memories” proved to be significant for the rest of the alters. Their moderated opinions of her suggested the development of meaning bridges between them. The admission seems to have been something of a meaning bridge, in and of itself, as it was an explicit sign. However, Kristen remained incapable of co-consciousness with Hanson suggesting limited assimilation. We saw these examples as evidence of assimilation as increased access to the others. Clinical Observations Context. Kristen was growing in her ability to identify and name her feelings. She was learning how to cope with the intensity of them without dissociating. She was beginning to believe that she would keep growing if she kept working in therapy and between sessions. Relationships. As Kristen dissociated less frequently, she found herself facing a variety of interpersonal problems. Having a serious, long-term boyfriend was a new experience for her as was dealing with his large, very involved family. Though she enjoyed her boyfriend’s sisters and mother, she resented their over involvement in her romantic relationship. Relationship struggles were new to her and she often found the interpersonal demands that were being placed on her quite overwhelming. She felt her boyfriend and his family desperately wanted her attention. However, she perceived herself as entirely unable (and, at times, unwilling) to meet their needs. Whereas in the past, she had allowed Zac or Madonna to handle her various misunderstandings, confrontations, and negotiations, Kristen was now determined to gain her own set of interpersonal, problem-solving skills. Symptoms. There was fewer episodes of dissociation but the alters were adamant that we not forget them. They spoke out in therapy, reminding me of their roles in the system. Life skills. Kristen found her full-time work schedule to be exhausting. In addition, she continued to disagree with her supervisor on numerous issues. Therapy and assessment. At the 04/20/05 therapy session, Kristen and I discussed the ways she had handled her feelings during a recent confrontation in comparison to the ways she might have handled them a few years ago. Kristen said “Originally, I would have thrown myself in the river or lay in the road.” She said, “I would have left my body and let Zac step in and get me out of the road or river.” Kristen thought that after a few months of therapy, she may have called to talk with me right after a problem occurred. She acknowledged that during her recent

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conflict, she did not jump in the road or into the river. She did not dissociate. Instead, she remained present as Kristen and tried at least six techniques to soothe herself prior to calling me. She took the following steps: 1) She moved away from a chaotic party crowd, 2) She paced up and down the hill at the park, 3) She used positive self-talk, 4) She spoke with her parents about her feelings, 5) She called her older cousin and asked for help, and 6) She spoke with an aunt about her feelings. Only then did she call to talk with me. At no point did she pull for Zac to handle things. When I asked, “Why?” she said, “I thought it was good for me to try and handle it.” Kristen and I discussed the personal growth she demonstrated. Kristen agreed that she had made progress but couldn’t wait for the day when she didn’t “get so overwhelmed in the first place.” We looked at her trajectory of change and talked about the probability of future change. At the 04/30/05 session, Kristen initially spoke about her work and boyfriend. She then brought up a previous discussion we had about Hanson potentially coming to session. Kristen shared that she was worried Hanson would hurt me. Soon thereafter, Zac stepped in and encouraged me to be careful as Hanson was very angry. After I assured her that I could handle the interaction, Hanson suddenly stepped in. Throughout our conversation, Hanson appeared angry, insolent and surly. Her hair hung down in front of her left eye, her legs were spread wide apart, her toes were tapping constantly, her hands were clasped together, and her arms were crossed. She did not smile and, at times, almost appeared to snarl. For the first 15 minutes, she answered in mostly one-syllable responses. After numerous attempts on my part to engage her, she began to answer with complete sentences. It seemed she was intent on communicating that she was unhappy to be in session, felt it was a waste of time, hated Kristen, hated me, hated therapy, and did not want to help anyone. When I asked her what she might do if she really got mad at being in the session, she said that she “could break the glass or hurt me.” I told her that the rules included not hurting Kristen’s body or mine. She said, “I don’t care. I like to break rules.” I let her know that I appreciated her being in session and not hurting anyone. I did not want to get into a power play with Hanson so I reflected my respect. She appeared slightly responsive to my approach. After some additional introductory discussion, Hanson said, “I was created to be locked up in a padded call (due to her evil personality).” She repeatedly told me that she would “never change” and “was created to always be the same.” When asked about Kristen’s childhood, she reported a list of difficult experiences that began in first grade. When I asked why the system

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was created, she said, “because of the school stuff, the kids were always mean to her and because her parents worked all the time, so, loneliness.” Hanson said the world began at age five. When I said that I was confused, that I didn’t understand why Kristen needed all of them BEFORE she went to school if it was the school experiences that caused her stress, she took a while to answer. She finally said that it was originally like a group of imaginary friends that she used to play with when her parents were busy and after school started it became something different. Hanson smirked at me and then said, “I could be lying or I could be telling the truth.” We then spoke more about her role in Kristen’s system. After repeatedly denying that she cared for Kristen at all, at some point, she admitted that she did indeed help Kristen. I reflected her statements and asked, “So, you do serve some purpose in the system? So, you do help Kristen in some small way?” After a significant pause, Hanson finally responded, “Yes.” Zac later returned and I processed the experience with her. When I asked to speak with Kristen, she said it would be difficult. I asked to check in with her regardless. Kristen arrived and appeared exhausted. She rubbed her eyes, looked sleepy, and said she had a “huge headache.” I worked with her to center her body using some grounding exercises. She said, “It’s hard for me to stay here. I am trying but it is really hard.” After additional reflection on her inability to remain present, Zac suddenly returned. Assimilation Constructs Observations bearing on internal multiplicity. Kristen was unable to hover above while Hanson spoke and was unable to recall anything that occurred while she was present suggesting the presence of a strong amnesic barrier between them. Immediately upon Hanson’s departure, Kristen reported having a very difficult time staying grounded as herself and reported wanting to “slip away.” The coinvestigators viewed Hanson’s presence as filled with anger towards Kristen and the other alters. However, they felt that Zac had been able to protect Kristen from the rage of Hanson most of the time. This depth of intense emotion (so much so that Kristen needed protection from it) signaled a lack of assimilation. Coinvestigators felt this suggested that parts of Kristen’s experience (as represented by Hanson) had not yet been accessed or assimilated. Observations bearing on APES progression. Coinvestigators noticed that Kristen handled an interpersonal emergency on her own without calling for Zac’s help. Kristen described why she didn’t call Zac in, “I thought it was good for me to try and handle it.” Zac felt similarly, and so “chose not to step in so that Kristen could practice handling stress on her own.” This was

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viewed as a shared agreement that Zac was not needed. It seemed that Kristen was drawing from her Zac community less often because she had access to more resources when she faced difficulties. Kristen only called her therapist after handling the situation herself which was new behavior. This example of accessing the resources of the others in order to resolve her dilemma was viewed as consistent with APES 5. Kristen was actively working through her experience of internal fragmentation. She increasingly understood how to work with them and without them. Observations bearing on different APES ratings. In sharp contrast, Kristen’s assimilation of Hanson was viewed as remaining at a very low level of assimilation as witnessed by her inability to remain partially present. Hanson, on the other hand was finally able to admit that she was indeed created to protect Kristen which suggested some movement on APES. Emergent issues in data packet # 16. Whereas the increase in assimilation made sense in existing assimilation model theory, the notion of the changing location of Kristen’s voices was not accounted for. Kristen was not simply ‘assimilating’ Zac. Rather, she was adding some of Zac’s resources to her (Kristen) community so that Zac was needed far less. Many of her new skills were partially coming from Zac. Data Packet #17: Hanson and Pictures a) Progress notes: 08/05/05, 08/10/05, 08/13/05 b) Audio tape 08/13/05 (Hanson) c) Pictures of alters Why I Chose This Data Packet Kristen left therapy in a much improved state in comparison to when she arrived. I believed her work around termination issues accelerated her assimilation of alters and hoped the coinvestigators would find evidence of POC in the material. I further recognized that Hanson’s sudden retreat from therapy (after her previous engagement with therapy) was a defensive response to the impending termination and worthy of exploration. With regard to the drawings of the alters, I believed the visual representations could 1) serve as a window into what Kristen experienced but was unable to articulate and, 2) would balance out the types of data offered. What We Learned In these therapy notes, we continued to learn more about the role of Hanson in Kristen’s system. This knowledge confirmed our belief that, despite the four years of therapy, there remained a significant amnesic barrier built around this subcommunity.

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We also learned more Kristen’s termination work as she processed difficult emotions while remaining present (suggesting assimilation). We witnessed Zac’s ability to experience complex emotions rather than concrete anger as she lamented over the end of therapy, both for Kristen and, surprisingly, for herself. We felt this reflected her assimilation of the disparate parts of herself as well. The coinvestigators agreed that the drawings and the way we used them suggested meaning bridges, dialogue between the alters, and therapeutic ZPD work. Clinical Observations Context. In May of 2005, it was necessary to begin termination work. I first broached the subject with Zac and asked for her help with Kristen. I told her that I would be terminating therapy sooner than anticipated. I explained the logistics of my being a student, having to work under a supervisor’s license, and needing to finish the next step of my program in a timely fashion. I discussed the norms of the clinic protocol and suggested that we had been very lucky to work together for four years as most student therapists only work one or two semesters with their clients. I said that I would talk about a specific date with Kristen but it would probably be before Christmas. At first, Zac’s face turned red and she looked as if she would cry. I asked if she wanted to cry. She insisted that she was NOT going to cry but admitted she was sad and angry for Kristen. I asked how she thought Kristen would take the news. Zac replied, “She will probably just shut down or get suicidal. It’s too hard for her to start over.” I suggested that termination might be hard for Kristen if it were in six months or 2 ½ years. She agreed. We talked about why it would be so hard for Kristen. She kept saying the work needed to be finished and I reminded her that one is never finished and that therapy helps at various times with the process of making positive change in one’s life. I answered her questions as honestly as I could. Throughout the session, I reflected her anger and beliefs. I explained termination, ethics and legalities. She repeatedly pointed out how bad it would be for Kristen to finish early. Zac said she wasn’t mad at me, she said, “I am mad at the [university] system.” She continued to try and negotiate a continuation of our work together. Zac said that she wanted to write a letter or go talk to the people in charge. I suggested she do that in order to get her anger out in the real world rather than limit it to the imaginal world. Zac arrived at the next session with a seven page handwritten letter addressed to my supervisors requesting that I be allowed to continue therapy with Kristen. We discussed it at length and, by the end of the session, she seemed to unhappily accept the situation. We both

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agreed that termination would be difficult for Kristen. I asserted my hope that the work Kristen and I did around ending this relationship would be a healing experience for her and she would generalize it to other relationships. In the past, ending relationships had previously caused her psychological pain. Her response to loss regularly caused dissociation and often led to suicidal ideation and, occasionally, a suicidal gesture. At the next session, Kristen and I discussed terminating therapy in five months. Soon thereafter, Kristen cancelled a few sessions at the last moment. When in session, she displayed a sudden decrease in staying present and, an increase in the alters’ presence. However, before long, there was evidence that Kristen was choosing to remain present in session and, genuinely expressing her intense feelings around losing this relationship. She shared her feelings with her parents and they requested (and later attended) a meeting with me and my supervisors. During this meeting, Kristen (as Kristen) often led the discourse and asked appropriate questions. By August of our last year together, Kristen was able to honestly discuss our impending termination with marked sadness yet calmed herself prior to leaving a session. Interestingly, in one session, Zac remarked, “Kristen is handling it (saying goodbye) better than I ever did.” Relationships. At the same time, Kristen’s relationship with her boyfriend had continued to intensify. She explored her mixed feelings about him in therapy. It seemed that she no longer idealized him and was able to appropriately identify numerous reasons why she believed he might not be the right partner for her. She said, “I don’t think we have a healthy relationship.” Kristen initiated a break up with him although they eventually reconciled. Symptoms. Kristen agreed to sinus surgery, something she had previously refused due to an intense fear. She recognized that it might be frightening but she was determined to face it. Life skills. Kristen chose not to switch jobs. She suddenly initiated discussions about new activities such as dance, photography, and fitness. She participated in a friend’s wedding and traveled out of state (for the first time without her parents) to visit her grandparents. Later she took a second trip on an airplane alone to visit a friend. Therapy and assessment. At the 08/03/05 session, Kristen and I initially processed some of the relational struggles that she was experiencing. Zac then appeared and continued working on the “unfinished business” of drawing all the parts of the self (see Appendices F-O). As Zac drew each self-state, I asked how one was different from the others. This process of teasing apart

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the way that each was unique from the rest was a way of understanding her construct system. Whereas, one self-part may have been a caregiver, another was viewed as abusive. A week later, at the 08/10/05 session, Kristen spoke of the upcoming nasal surgery she would be having. She said she was “terrified to death” but “knows I have to have it.” We explored her fears and one of them was that she was afraid of the needles and of potential problems with the sinus surgery. We talked about her fear of death and discussed how different it was for her to be afraid of death when, just a few years ago, she reported wanting to die. We brainstormed some ways to deal with the anxiety while being given a shot. Kristen wanted her parents to be with her throughout the sinus surgery. I suggested she take the relaxation tape and listen to it if she felt anxious. I also suggested that she let the doctor know how afraid she was. She seemed resistant and we explored why telling a doctor her true feelings seemed so difficult. Kristen then talked about the interpersonal problems that she was working through with her boyfriend and her parents. We explored the choices she was making in how to handle each situation. For the most part, she was being effective at dealing with the others in her life. Kristen switched and Zac arrived. She immediately began drawing more of the others as this is a project that seems important to her. I asked “why?” She described the need to “get it all out” and said, “For a long time, Kristen carried all this in her head along with school and her family and the kids. I don’t know. Getting it all out seems important.” When I asked what might happen if she didn’t complete some of this unfinished business, she said, “She might get suicidal again.” As Zac drew each of the four pictures, I asked what made one different from the other. Whereas BIO MOM is a “Sex Beast,” Madonna is “really nice.” After completing the drawings, we talked more about why it feels like we have to compress three years of therapy into a few months. Zac reported that she would bring Hanson to the next session. As our 08/13/05 session began, Kristen talked about the upcoming sinus surgery. We explored her fears and the ways she hopes her parents will help her get through it (by taking her there, walking her in, taking care of her afterwards) Kristen and I discussed her previously identified responsibilities in therapy and how they were being condensed due to the time constraints. Kristen realized she needed to develop more of a support system prior to therapy ending but was having difficulty making the phone calls. We discussed the ways that Kristen had learned that she could still care for and be cared for by another even though the other was separate from her. We then linked this to our experience of

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the therapy relationship. She reminded me that, at first, she felt lost when I would leave and later, she felt that I still cared, that I was still out there, and that she could remain present despite the pain of missing me. She reported that she did not spontaneously dissociate due to my absence. Kristen was able to say that she knew I would always be with her and she would always be with me after our separation. “Its weird to end knowing somebody still cares.” Zac then arrived with an update as to how well Kristen was doing in the midst of ending therapy, a friend’s move, her sinus surgery, and her boyfriend issues. Zac reminded me that Hanson came to speak as well. Hanson arrived looking surly and acting resistant to meeting. However, she tersely answered my questions about her role (“A container for Kristen’s anger”), when she first arrived (“When Kristen was 1 year old”), and examples of events she contained (e.g., grandparent dropping Kristen as a baby, cousins rejecting her at age four, kids at school pulling each of her arms in a tug-of-war at age five, boy kicking her in school at age six, parents fighting…). She described her job as one in which she held “all Kristen’s anger so she doesn’t have to deal with it.” She said she was the grandmother of Zac, mother of Zac’s bio-father (the one who abuses). “I was the first.” She then split into the other parts, as Kristen grew older. Hanson said, “It’s kind of like a split person splitting into another multiple splits.” Hanson and I talked about therapy terminating. She said she could care less if therapy ends and sees her role as continuing. We finished our talk and Hanson appeared slightly moderated or less harsh. When I said, “Well, I may talk to you again before our last session,” she replied, “I hope so.” Zac returned and said “Well, I am glad to see there is no blood all over the walls.” We discussed Hanson’s comments, the upcoming sinus surgery, and Kristen’s weekend plans. Zac commented that Kristen was doing better with the upcoming termination than she had imagined. Assimilation Constructs Observations bearing on internal multiplicity. In speaking with Hanson about termination, I stated, “The hope is that you will come forward and help the system.” Despite Hanson’s earlier claim, Hanson replied, “It’s not my job to help.” The research team suggested that Hanson was evidence of a problematic voice discrepant from the community. The other alters appeared afraid of Hanson and did not communicate directly with her. There were thick amnesic barriers between the two as Kristen had been unable to know or remain simultaneously present with Hanson. There was a long history of Hanson’s failure to negotiate with the rest of

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the community. However, as seen in the last data packet, Hanson admitted that she was created to help Kristen which suggested the building of a meaning bridge. Her sudden retreat after hearing the therapy was about to end suggested a defensive response to the impending loss. Kristen’s old pattern of reacting to impending loss was to withdraw as well. Her determination to stay present throughout the termination work (and feel the pain) was a courageous stance and, in the coinvestigators opinion, a healing one. Observations bearing on APES progression. This data packet reflected Kristen’s decreased dissociation and suicidal ideation. Coinvestigators suggested her progress was evidence of APES Stage 5. They recognized that the alters were increasingly aware of each other and representative of APES stage 5 as well. They were all actively working through problems for the greater goal of helping Kristen. Emergent issues in data packet # 17. The coinvestigators continued to question whether the assimilation model can accurately account for the various ways that different voices or subcommunities handle the same emotion. For example, they noted that Hanson’s comments suggested that the two have disparate experiences of anger. They surmised that Kristen was unable to acknowledge her overwhelming anger as she feared it might lead her to violence. Instead, she actively suppressed her anger so that she did not act out. Data Packet #18: Termination, Co-consciousness, and Jessie a) Progress note, 08/20/05 b) Progress note, 09/03/05 Why I Chose This Data Packet During this period of time, Kristen’s feelings of loss, loneliness, and abandonment weighed heavily on her. Nonetheless, she was actively processing her feelings and remaining present for the therapy work. Kristen’s courageous decision to talk about the upcoming therapy termination helped her realize that some relationships naturally end despite the continuation of positive feelings. Kristen’s growing ability to co-consciousness seemed to represent increased access to the alters. As we neared termination, I thought it would be helpful for the coinvestigators to examine the ways in which Kristen and the alters were gaining access to each other and working through the impending loss of therapy.

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What We Learned In this termination work, we heard from another alter (Jessie) about her role in the system and learned more about the imaginal world from her perspective. We explored Kristen’s growing abilities to remain present when under duress and experience co-consciousness when her alters controlled her body. We saw her choose to remain present during sinus surgery with the intent of learning more about the experience in order to grow. We witnessed her facing the termination work as Kristen, responding proactively by writing a protest letter to the clinic, and meeting with my supervisors. These behaviors were viewed as additional evidence of her ability to access Zac’s assertiveness and confidence as resources. We felt she was experiencing increased access to the alters and their resources and demonstrating assimilation. We recognized that Kristen, in choosing to remain present more often, was accumulating new resources as Kristen as well. Clinical Observations Context. Despite disagreeing with the decision to end our therapy work, Kristen was committed to the termination work and attended session regularly. Relationships. Kristen continued to struggle with her problematic relationship with her boyfriend. She repeatedly spoke of breaking up with him for good, but couldn’t imagine herself alone or with another man. Kristen continued to battle with her parents who fluctuated, she believed, between treating her like a child and neglecting her. Symptoms. Kristen had outpatient sinus surgery during August. She called in crisis the night before. She reported that she was petrified and couldn’t sleep. Over the phone we explored her fears. Fully present despite the fear, Kristen told me that her primary fear was the needle entering her body. We talked about the relaxation techniques she had already attempted (warm shower, bubble bath, music, journaling, relaxation tape, talking about her fear, etc) I suggested a few others and she agreed to try them. When I asked why she wasn’t bringing in Zac to handle this as she would have in the past, Kristen said, “Because the reason this is hard for me now is because, in the past, Zac has come in for this. I didn’t learn how to get through it. I have to learn how or it won’t ever get better.” Kristen was, maybe for the first time, able to calm herself prior to a potentially traumatic event. The sinus surgery was successful, and Kristen seemed to experience a week of noticeable relief. However, her father soon called the clinic reporting that Kristen had suddenly reverted

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back to her nasal-sounding voice. Once again, this difficult-to-understand voice appeared sporadically in therapy as well. Life skills. By August, Kristen and her parents had written letters to the clinic requesting that therapy continue. They met in person with me and my supervisors. Kristen asked a number of questions at the meeting. She remained present as Kristen and appropriately expressed her anger about ending our work earlier than she expected. Therapy and assessment. Days later, at the beginning of our 08/20/05 therapy session, Kristen blurted, “I broke up with my boyfriend again!” We spent much of the session exploring her decision. Kristen said she told her mother “I can’t take this anymore. I am working so hard to get better and never have suicidal thoughts but when he yells at me, I get suicidal thoughts again. I don’t need this.” Kristen said that her decision had to do partially with “anger” and partially with “putting up boundaries.” Though she was willing to move on, her hopes were that “he will apologize, change his attitude and behavior, and we will end up together.” We made a list of the things that were important to her in any relationship. We then talked about ending our work and transferring to a new therapist. Though she cried, Kristen was able to talk realistically about the termination of our relationship. She was also able to successfully self-soothe by the end of therapy. At the 09/03/05 session, Kristen and I first discussed her relational struggles with her boyfriend and her parents. As part of her goal to learn more about her diagnosis, we watched parts of the ISSTD’s video “Understanding Dissociation.” I paused the video at various spots while we discussed what the professionals meant and whether or not what they were saying related to her. I regularly asked her if she felt comfortable and if she understood what they were saying. She repeatedly asserted that she was fine. I asked if Kristen would like me to check in with the others before the end of therapy and she agreed and said, “…It helps you but it helps me somehow, I’m not sure how but it does.” Zac arrived at session and proceeded to describe the others in the imaginal world: Jessie is just a memory bank. Ike and Tay are basically my powers but they are there helping out Kristen with different parts. Tay takes her alcoholic thoughts, wanting to drink, not wanting to drink. Ike is basically more the sexual parts of Kristen and I am just an idiot. I am the power source, more the reporter. I pretty much get everybody together. I am the anger, sex, drinking, drugs, and thinking. We take that in because Kristen

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doesn’t want to do those things. We just do it to help her because we don’t want her to be a drug addict or alcoholic. She doesn’t want to do all this break the law type crap. Jessie then spontaneously identified herself. She promised to keep all the memories of therapy. She would “try to remind her (Kristen) that she did get better, that she did accomplish new things.” However, Jessie believed Kristen will inevitably backslide after the end of therapy. She said, “I will try to help her to keep where she is now.” Jessie then shared that she first appeared at the end of third grade when a girl at Kristen’s school asked her to spend the night and her parents said “No.” The girls at school then began to harass her and Jessie arrived in response. I asked how her opinion as to how Kristen is different now compared to five years ago. Our discussion continued as follows: J: She is not a goody-good like she was. Like, she is starting to explore things. Because she thought that she would never have sex until she married and then she met her boyfriend. She is more of an actual person instead of trying to be somebody that she is not. Its like she tried to be like an angel type of person and then she is realizing that that can’t happen in the real world. C: That she is more complicated? That she can’t be goody-good? That she wants to have a richer life and experience some things, like maybe taste an alcoholic drink or have sex? Like not always be perfect? You’re saying she is growing? J: Exactly. It is really, really good to see her at the point that she is. It is difficult when you have stuff in her head and you have no clue about it. You store stuff in your head and then it breaks off into little branches kind of like little branches growing out of your head. It’s all contained in this one area and I guess that is where the headaches come in. Because, you got all this stuff and, you know, she is not saying it or expressing it as well. So, you know, now she is learning how to deal with it which is very, very good. And I can tell you it is going to be very, very difficult to get the early memories from Hanson. Because Hanson can lie to you, like I mean she could say that Kristen was sexually abused and then you are going to get worried and then try to figure that all out. Well, none of us have no intentions of that. As much as sex is in this world, I don’t think it happened. I think it was that her cousin got it and that is how it got into there. Hanson can lie to you about things. She can be honest but you won’t know that she will be honest and you can tape it and she is one person you will never be able to figure out.

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C: Hanson has the memories of her early childhood but she won’t tell the truth about them. To me, that sounds like she is trying to keep them secret. J: I don’t think it is a secret. Yeah but Hanson is a person that does not like anybody cause when Zac gets really pissed off at somebody to the extreme, Hanson comes in and kills off that person and Hanson never met them before. It is just somebody gets mad and she gets pissed off. I think Hanson got made up, I think Hanson was finally discovered when the movies came out and people with DID and the people are going to jail because their other personalities killed. I think that is what set Hanson off. And that is how Hanson got her so much anger. C: That’s a lot of anger for a little girl. (Yeah) Even before she went to school? (Yeah). That was even before the kids picked on her. What was so hard during those early years? J: I am guessing it was her parents’ fighting and also she was scared of the house that they were living in because the house they were living in, I know houses make noise but it sounds like there was an actual person walking in the attic. I mean it didn’t sound like little creeps, you can hear footsteps and her bunk bed shook and don’t know how it shook and the TV turned on, kind of like her house was haunted and she was scared and her parents were fighting a lot, especially her mom. Then they have a party, and you know when you are a little kid, you are kind of scared of the dark, so they had the hall light on and her aunt turned off the hall light and she was screaming and stuff and nobody came because the party is downstairs and they have very loud music, and nobody came and because she was scared of the dark, she was just sitting in the dark and nobody came. Jessie then talked about the scrapbook that Kristen is working on to tell “her story of therapy.” She said that each of the alters would be completing one page. Zac then returned to talk and we concluded with the following: C: So, I guess the group as a whole has worked together to not harm Kristen. Z: It is really hard to say. All of them have come in at different times but it has been there for a very long time. They have been there every since I have been there. It is very complicated. The way that I try to explain it is that, you know, I am the youngest but I was born first. It is to symbolize that everyone was made at different times. You know, my biological parents were made up after I was born.

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C: It is upside down? (Yeah) Well, it is important that everybody gets the message that therapy is coming to an end and I am hoping that anything they can do to help, they would do to help. (Yeah) That would be appreciated. As I concluded the session with Kristen, I asked her if she remembered who I spoke with during therapy. Kristen said she knew I talked to Jessie and, remembered a good portion of the conversation, but wasn’t sure who else arrived. I repeated that Kristen’s body or mind was able to remember Jessie’s comments. Clearly, Kristen had been successful in remaining co-present during some part of the session. I applauded her for remembering the middle portion of the session as that had previously been difficult. I said, “That is one way the communication will get better, is for you to try and remain present when the others speak.” Kristen agreed. Assimilation Constructs Observations bearing on internal multiplicity. In this data packet, Kristen was terrified to have outpatient surgery. As noted above, when asked why she wasn’t just letting Zac handle it, she replied, “Because the reason this is hard for me now is because Zac has come in for this in the past, and I didn’t learn how to get through it. I have to learn how or it won’t ever get better.” Kristen’s desire to get through her sinus surgery on her own, despite her intense fear, without calling in Zac was evidence of significant change. The coinvestigators suggested this represented APES Problem Statement/Clarification and APES Understanding Insight. Stage 5-6. Instead of immediately dissociating, Kristen appeared to be challenging her understanding of her use of the alters to face her real world difficulties. Assimilating resources to Kristen’s community seemed to make Zac unnecessary or undesirable as a resource. Jessie’s arrival and promise to keep the memories of therapy also suggested internal multiplicity. Her description of the world and its branches seems to describe Kristen’s community. In some ways, her description almost seems to reflect a deeper degree of understanding about the system than previously displayed. We wondered how much it reflected Kristen’s absorption of my case conceptualization. Indeed, skeptics might suggest that it is an example of parroting the therapist. However, we felt that Jessie’s role as the therapy memory bank may suggest that she is, to some degree, the internalized therapist voice. In other words, Jessie may be the voice of Carol in Kristen. Observations bearing on APES progression. The coinvestigators noted that Kristen remained present while Jessie spoke in the middle part of the session. This ability to remain

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present was viewed as APES 5 (Application/working through). They suggested that by remaining present, Kristen was attempting to build experiential meaning bridges with Jessie. However, I suggested that remaining present reflected a bridge had already been built. Kristen had access to Jessie during session. Co-consciousness occurs as amnesic barriers disintegrate which reflects internal dialogue in cases of internal multiplicity. Coinvestigators identified an important shift in the sessions considered in this data packet. Kristen listened to her own needs and drew personal boundaries when she (not Zac or another alter) broke up with her boyfriend. Kristen did so because the boyfriend failed to consider her needs and feelings. Increased boundaries were viewed as consistent with APES 5. The coinvestigators felt that the alters were becoming resources for Kristen to call upon when needed. These examples were considered consistent with Stage 6 (Resourcefulness). Data Packet #19: Similarities and Differences in Termination Work a) Progress note, 09/24/05 b) Drawing of Ive Why I Chose This Data Packet I believed that Kristen’s termination work, despite her fears, reflected significant change. In the past, Kristen’s experience of loss was primarily negative. All of her relationships had ended due to fights, bullying, illness, abuse, and death. After a loss, she often became emotionally paralyzed and resisted building new relationships with others. My hope was that our parting would demonstrate that endings can occur naturally (and not due to trauma) even when two people care about each other. Her willingness to articulate her pain as well as initiate a new therapeutic relationship was significant and, I felt, contained possible POC. What We Learned Kristen’s growing ability to remain present and retain memories when the alters appeared was viewed as increased assimilation and rated accordingly on the APES. We understood that as Kristen was able to remain coconscious for extended periods, she gained additional access to the alters. We also realized, conversely, that as she gained increased access to the others, she remained coconscious for extended periods. We also learned that Kristen’ struggles to make sense of how she was similar, yet different from others diagnosed with DID seemed to reflect her desire to further understand her experience, as Ravenette (1977, 1980, 1993) suggested, in relation to its opposite. Similarly,

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Kristen’s confusion over the similarities and differences in goodbyes suggested that she was attempting to understand how relationships (and their terminations) are different. Clinical Observations Context. As the end of therapy approached, Kristen continued to experience significant distress over the eventual loss of our relationship. She seemed to respond by deepening her commitment to therapy. This renewed commitment was evident as she arrived early to sessions, worked feverishly to fill in missing information on the various alters, processed her feelings of loss out loud in session, remained present as Kristen during emotional sessions, efficiently worked on therapy homework, and reported the sudden completion of numerous small tasks that had been previously discussed and long ignored. Kristen and I spent many of our sessions focused on the upcoming termination. As noted earlier, I had recommended that she continue therapy with a new therapist. At her request, I spent a few months working to find someone who was trained in work with people who have DID and potentially interested in working with Kristen. Through our mutual involvement with the ISSTD, I was able to find a local therapist who was interested and available. At the same time, Kristen reported difficulties working on the scrapbook that she was determined to make as a parting gift for me. Kristen said that she knew she was putting if off because it was “so hard emotionally.” It seemed that whenever she sat down to work on it, she would stare off or become distracted. At each meeting, we talked about her desire to continue therapy. Kristen admitted that postponing working on the scrapbook was her way of postponing or not facing the ending of our relationship. Relationships. Kristen remained separated from her boyfriend. Though she missed him, she recognized that they did not have a healthy relationship. She particularly missed his mother as they had become quite close. At the same time, Kristen was getting along better with her parents. The impending therapy termination appeared to unite them. They shared a common goal to keep me as Kristen’s therapist. Kristen appreciated her parents’ attempts to protect her from the pain of a significant loss. Symptoms. Kristen was still recovering from her outpatient sinus surgery. Her nasal congestion continued to fluctuate. She was not dissociating as frequently when stressed.

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Life skills. Although Kristen was a valued employee at her job, she had long been discontented with the type of work (grocery bagger) she was doing. Kristen began researching a new career in the secretarial or medical field. Therapy and assessment. Kristen began the 09/24/05 session by talking about a coworker who quit her job. She talked about how hard it was to say “goodbye” to someone she cared for. I asked her how this goodbye was similar to our goodbye. She said, “It is going to be very emotional…It is hard to compare.” We worked on Kristen’s understanding of some things being similar, yet different in the two goodbyes. She did not identify differences and, instead, said that that the similar part about the goodbyes was, “Just opening up to a person, which is very hard to do…And I always looked forward to seeing her.” I then asked her to compare the differences between her coworker’s goodbye and saying goodbye to her boyfriend. She said, “It was hard because she seemed like she really cared... She listened...She wasn’t trying to tune out...It wasn’t a one-sided conversation like with my boyfriend.” When I asked her for similarities, she said, “It is kind of hard to relate to that. Probably, I am going to miss his sense of humor...” We explored the differences and similarities between the losses. Kristen and I then continued to process our upcoming termination. She said, “I wish it did not have to happen but I know it does. It is coming way too soon.” We talked about our upcoming meeting with the potential new therapist. She expressed a significant amount of anxiety about meeting her. She said, I am like really excited but I am also down. I don’t want this relationship to end.” We talked about her wanting the new relationship to be a good one. Kristen and I discussed the self-help book on DID that she was reading. It was a book that was causing her some confusion. She asked numerous questions about the author’s use of terminology. She said, “I am still confused on host. I don’t know how they can just describe one as just one host because, like, Zac could be the one who is born and I could be a personality and I could be the one with a problem.” I suggested that only she can identify the host. She responded that “Me and Zac are basically the main hosts and seriously, now they are trying to say that there is one host. I just don’t get it.” We talked about how it is okay to disagree with the writers. Kristen also said she was confused by the section in the book on feeling numb. I reminded her of her stories of feeling numb as a child during bullying episodes as a way not to feel the pain. Kristen made numerous comments about the similarities and differences between the author’s experience and her experience. Kristen and I agreed that it seemed helpful for her to

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think about what is similar and what is different while reading another person’s experience. Kristen appeared confused by the author’s idea of an internal persecutor and, she asked a number of questions. We discussed it further but she continued to struggle with the idea. We then looked at a number of Kristen’s drawings. She wanted to make sure she had duplicates for the scrapbook she was making and for the new therapist. Kristen and I discussed the pictures of her old sand trays. Kristen said, “That would be cool if we could do them again and compare them.” I said we could try and do it next week and she agreed. We made a list of all the things we wanted for the meeting with the new therapist. Kristen talked about how hard it had been for her to call the dance studio as we had previously discussed. She compared her reluctance to call the dance studio to her willingness to call the new therapist. Whereas, she had quickly called the new therapist, she was reluctant to call the dance studio. Kristen articulated the depth of her resistance. She said, “It is the very last thing I want to do.” I explained that I had suggested it as it offered the possibility of a positive social situation and a brain and body connection. I gave the example of Kristen dissociating when she hurts so that her body did not have to feel the pain. Kristen said that she would like yoga or something else instead. So, I again encouraged her to find something else that appealed to her. I applauded her for realizing and speaking up about the fact that a part of her was unwilling to follow through with calling the dance studio. When talking about the upcoming interview session with the new therapist, Kristen said, “It is hard to open up to new people. Because it is more me and she could probably get the impression that I don’t want to work because I won’t say much.” I asked if that was something she could say out loud to her in our first meeting. We role-played the way she could open up about her fears. Kristen said that she hoped to get to know the new therapist the first time. She planned to bring her photo album with copies of the primary alters in case the new therapist wanted to see them. She asked me to bring a copy of my article and I agreed. Zac then arrived and we discussed the end of therapy. She talked about being willing to come out and help during the interview session with the new therapist if necessary. She reported that the therapist seemed “way too happy on the phone...almost preppy...” We talked about the ways people are different. Zac thought that she would be the one to talk about the DID stuff cause Kristen might be too scared. However, she thought she would be asking if the new therapist wanted to meet the others. She said, “I hate to play people like that but it would be

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better for Kristen to ask her the question.” I asked if she were doing it to protect Kristen and she said, “I seriously think she will never ask for it. So, pretty much.” Zac drew a picture of Ivy for the scrapbook and the new therapist. As she drew, Zac described Ivy as age seven with a purple head because of how much she was abused. Zac said Ivy had mixed emotions and that is why her mouth was curved up and down. She had no hands because the bio parents cut them off when Ivy told a secret. Zac said she was trying to get them back because Ivy loves to write. The session continued as follows: Z: Ivy is confused because she hasn’t been abused basically as much as I have. Actually, probably like maybe ten less. C: Why did the biological parents cut off her hands? Z: Because she likes to write a lot and they think that she would have wrote a letter to the police and get them in trouble. C: What would she have written about? Z: Just all the abuse that is going on and trying to stop it and, you know, she likes to write true stories and she doesn’t like to write that fakey stuff. She keeps a diary and actually they burnt her diary because it had the abuse messages on it. C: Who burnt the diary? Z: Taylor or Isaac because the biological parents try to make them do a lot. The hair was burned with the diary. I know that I am scaring you with all this abuse that is going on. C: I am not scared, I work hard to try and understand all of you... (She then drew Tay who is the guardian of Ivy.) Z: She is brown because she has been burned a lot. That was her abuse, she was burned a lot. Instead of having bruises all over, she has been burned. As you can tell she doesn’t like to wear a whole lot of clothes. C: How is Tay like you? Z: Power wise and she is not scared to speak up. She usually gives me everything that irritates her because she can’t deal with it. C: How is Tay different? Z: She is more sexually active and she hangs around guys all the time. C: How is she like Kristen?

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Z: Kind of like scared a bit. She really does tend to get scared. Like the guy will be abusing her and she gets scared. Even though she gets abused, she gets scared of the guy who is abusing her. I next handed Zac a piece of paper and asked her to place the others in proximity to each other depending on their relationships with each other. She agreed and drew a detailed map. While drawing, she talked about how close everybody was to each other. She drew Hanson as a dark line that crosses through a number of the others but seems to leave others completely alone. Zac suggested that she should bring the map to the session with the new therapist. After suddenly coughing, Kristen returned and reported that she remembered some of what had previously occurred. We proceeded to talk about what she remembered, the portraits, and the map. When we looked at the picture of Ivy, Kristen explained that it was Ivy who wrote the threatening note to the girl in elementary school. Her hands were cut off right after she was disciplined at school. This was the most that Kristen had remembered after Zac appeared. She said, “Somebody else is going to have to tell her (the new therapist) about it though.” We explored her fears again about meeting a new person. We created a list of questions that Kristen wanted to ask at the interview session on Monday. Assimilation Constructs Observations bearing on internal multiplicity. The coinvestigators noted Kristen’s increased ability to remain co-present with her alters and her improved memory during those episodes. They suggested that the more Kristen remained partially present during dissociative episodes (the more she had access to the alters), the more she remembered and understood what the alters said (reflecting increased assimilation). They suggested that Kristen appeared to have two separate centers (Kristen and Zac) rather than one. It was not clear if these two centers would ever be fully integrated, but Kristen was doing a better job of intentionally accessing Zac. The coinvestigators suggested that Kristen was better able to be assertive to get what she wanted (e.g., not signing up for dance classes as suggested). This was viewed as increased access to Zac’s resources, the accumulation of new resources, and evidence of change. Observations bearing on APES progression. Kristen’s assertion that Zac would have to be the one to tell the new therapist about her internal multiplicity because she was too afraid was seen as a choice. Kristen recognized her limitations which suggested some introspection. The coinvestigators viewed this as Kristen actively using Zac as a resource and found it consistent

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with APES Stages 5-6 (Application/working through and Resourcefulness/problem solution). They acknowledged the presence of a meaning bridge between Kristen and Zac regarding how they would negotiate meeting the new therapist. As it turned out, Kristen remained present for over half the time spent with the new therapist. Data Packet #20: Meeting the New Therapist and Wrapping Up a) Audio tape of 10/01/05 session b) Pictures of final imaginal and real world sand trays c) Session progress notes: 09/26/05, 09/28/05, 10/05/05 d) Large drawing of house with various floors for various alters Why I Chose This Data Packet It appeared that moving through the termination work had helped Kristen integrate and apply much of what we had been working on during therapy. Kristen began her relationship with her new therapist displaying an increased understanding of self and a variety of new social skills. Kristen’s presentation at termination was in sharp contrast to her initial presentation at the beginning of therapy and was worthy of examination by the coinvestigators. What We Learned In this data packet, we saw evidence of Kristen’s increased access to previously sequestered resources. We saw the experiential culmination of all that she had learned and assimilated during four years of therapy. We agreed that the lengthy termination work seemed to allow Kristen to have smooth access to her experiences surrounding the therapy transition. Clinical Observations Context. The new therapist suggested a few meetings where she and Kristen could meet to determine if it was the right therapy relationship for each of them. We agreed that a collaborative effort would allow for as positive of a transition as possible. When I asked Kristen what would help her the most, she shared her fear about meeting this therapist alone. As a result, Kristen, the new therapist and I agreed to overlap (with all three of us present) a few 90 minute sessions to help with this difficult change process. This unusual transition began with Kristen’s and her new therapist’s first meeting. It proceeded as follows: 1) I met Kristen in the parking lot of the new office. 2) We explored her immediate anxiety about meeting a new therapist. 3) Kristen checked in with the receptionist while I sat in the waiting room.

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4) We greeted the therapist together. 5) We walked up the stairs to the first meeting together. 6) I stayed with Kristen for the entire session. 7) Kristen asked a number of questions which we had previously discussed and, in some cases, role played. She also asked spontaneous questions. 8) At Kristen’s request, I brought copies of her drawings and pictures from her file. 9) Kristen explained the pictures and shared her story of the imaginal world. 10) We left the office together. 11) Kristen and I then had two individual sessions for her to process her feelings about the new therapist prior to their second session. At the second session, the following occurred: 1) Kristen arrived alone. 2) Kristen independently checked in with the receptionist. 3) Kristen and the new therapist walked up the stairs. 4) I arrived about 15 minutes later. 5) I stayed only 30 minutes leaving the session at the mid-point. 6) Kristen completed the meeting with the therapist alone. 7) Kristen walked down the stairs and left the building alone. 8) Kristen and I later met individually for our regular session. We processed her feelings about working with a new therapist. Kristen then met independently with the new therapist and they negotiated a working arrangement that would begin after our final session. Kristen and I spent another session addressing her feelings of fear, disloyalty, abandonment, anger, and hurt around making this transition to a new therapist. Relationships. Kristen’s parents were supportive of the new therapeutic relationship. However, they were worried about the fee which would be much more than the clinic charged despite an offered reduction. They were worried about the drive which required taking a freeway, something that Kristen had yet to experience as an independent driver. I believe they hoped that Kristen would no longer need therapy. Kristen discussed these issues with them, appropriately asserting her opinions. She repeatedly reminded them how important it was for her to find a good therapist. Her parents then offered to drive her until she was ready to drive alone.

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Kristen still struggled with her shifting feelings for her boyfriend. Though they were not back together, she had a difficult time imagining that she could live without him and remained hopeful that they would reunite. Kristen remarked on her own internal multiplicity saying that “part of me still loves him” but “part of me is feeling it is pretty much over.” Symptoms. Kristen was not displaying many physical symptoms. Her nasal congestion subsided. For the most part, Kristen dissociated less. Kristen no longer reported automatic, out- of-control episodes of dissociation; rather, dissociation appeared to be a choice. She was able to maintain some co-consciousness and often remembered what occurred during her absence. Life skills. Despite her rigorous, full-time work schedule, Kristen was doing well on the job. She successfully managed her health issues and low energy level by allowing herself sufficient relaxation time. She set personal boundaries around how many nights to go out and how late to take phone calls. Kristen appeared to be handling the loss of her boyfriend and the upcoming loss of her therapist with maturity. She was upset about both losses but seemed determined to work through her grief as best she could. Therapy and assessment. In September of 2005, Kristen and I met for the first time with the new therapist. At the 90 minute meeting, Kristen took the lead in interviewing the therapist and asked some important and necessary questions. She remained as Kristen for the first 45 minutes. Later, she switched to Zac and provided additional commentary and details on the system. Both Kristen and Zac appeared comfortable with the new therapist. I spoke minimally. After the session ended, Kristen and I stood outside for a few minutes and briefly processed the experience. Kristen said she felt good about asking the questions, and she liked the new therapist. However, she was worried that the therapist wouldn’t want to work with her. I suggested that I observed numerous verbal indicators that made it sound as though the therapist was interested in working with her. Kristen was unable to see any evidence of her interest. I suggested that she ask her in a direct question at their next meeting and she agreed. At our next session, we discussed the new therapist. Kristen said that her biggest fear was the possibility of rejection. We explored this fear and compared it to the actual events of the session. Kristen admitted that the therapist did indeed express some interest in working with her. We ended the session with a final list of the things that Kristen wanted to accomplish in our therapy prior to termination. They included completing two final sand trays, additional

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reading in her book about DID, drawing a big picture of her internal house, and looking over her file. We arranged our schedules to accommodate these tasks. The next time we met, Kristen completed two new sand trays. Unlike her initial real world sand tray which was filled with random items that were only minimally meaningful to her, Kristen chose fewer and more meaningful items for her real world sand tray. Each item she chose represented important relationships (including friends and family), feelings about her life, her job, her graduation and her work in therapy. It was a much less chaotic and more interpersonally connected representation of her life than her first real world sand tray reflected. Compared to the chaotic representation in her first imaginal world sand tray, the most obvious difference in her termination tray was its clear structure and organization. Kristen slowly worked as she carefully created an exact representation of her internal experience. Each toy or item represented one of the parts of her self that were previously unknown to her. Kristen described the circle round the alters as representing the brick walls (amnesic barriers) that separated some parts of herself from other parts of herself. The star drawn in the sand represented the power in the imaginary world. Later that week, Kristen said goodbye to the various secretaries and staff. She took pictures with her camera for herself and for the scrapbook she was creating. We had two more meetings planned with the new therapist and two more final therapy sessions. Assimilation Constructs Observations bearing on internal multiplicity. Kristen’s access to both worlds (internal multiplicity) and, her representation of them in sand trays (as opposed to letting Zac produce the trays) served as evidence of assimilation. Observations bearing on therapy and the therapeutic relationship. The decision for both Kristen and I to meet the new therapist together and engage in two overlapping sessions could be viewed as unorthodox or, perhaps, creative interventions. Regardless, both Kristen and the coinvestigators identified these shared sessions and the five months of termination work as important therapeutic moments. Not only were Kristen and her alters provided sufficient time to articulate and process the impending loss of one therapist and the beginning of a new therapeutic dyad, they were able (for the first time) to assimilate an experience of loss. The extended time and focus on the transition allowed Kristen to have smooth, mostly unproblematic access to her experiences surrounding the transition from one therapist to another. When we met the new

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therapist, Kristen spoke confidently with her about her diagnosis, asked preplanned questions, and showed her drawings of her alters. Observations bearing on APES progression. Coinvestigators suggested that Kristen’s ability to remain present through the first 45 minutes of the overlapping session with the new therapist was evidence of increased assimilation. In addition, coinvestigators noted that Kristen appeared to know her limitations for handling stress by asking Zac to step in during the latter part of the session with her new therapist. Kristen remaining present for much of what Zac then discussed and her return to say goodbye at the end of the session suggested significant change. These behaviors were viewed as consistent with APES 5 Working through. Emergent issues in data packet # 20. At this point, after having reviewed the complete set of data packets, the coinvestigators suggested that, because Zac had frequently stepped in for Kristen during her childhood, she had not assimilated many resources to her Kristen community. Kristen had not faced or worked through many of her fears. As a result, she had not learned the coping skills that would help her (as Kristen) deal with stress. Instead, Zac and the others became increasingly more competent at handling stressful situations. In addition, due to the amnesic barriers, her sequestered imaginal world (and the resources they had gained through engagement with the real world) was initially inaccessible to her. At the time Kristen entered therapy, she had few resources and her alters were automatically triggered to step in on an almost daily basis. Over the course of therapy, Kristen gradually assimilated voices making them more accessible. As assimilated voices are more accessible, Kristen grew in her ability to access the various parts (and their resources) helping her to become more successful at handling life’s problems. Data Packet #21: Kristen’s Farewell Scrapbook a) The scrapbook Why I Chose This Data Packet Kristen said, “It’s my story of therapy. You already got yours.” As this dissertation is meant to be a qualitative analysis of Kristen’s change process, I felt it was important for the coinvestigators to hear Kristen’s and her alters’ voice whenever possible and to see her at the final moment of therapy. What We Learned In this final data packet, we witnessed Kristen’s increased ability to remain present even during the termination of the therapy relationship. We read Zac’s confession that therapy, in

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addition to helping Kristen, had also calmed her. We felt this reflected assimilation within the disparate parts of Zac. The goodbye letters further confirmed that my willingness to engage the alters allowed them to feel heard, an apparently important part of the dialogical process. We observed that most of the alters collaborated (suggesting increased access to each other or assimilation between them) to create the scrapbook. In sharp contrast to the start of therapy, Kristen was able to understand, organize, and talk about her internal multiplicity. All of these behaviors suggest increased assimilation. Clinical Observations Context. Kristen wrote the following note regarding her process of change:

You know I am a lot busier now and I have noticed that I don't go into my world as much?? It has been with me a long time and it is kind of weird that it comes in so little now, but I guess that is what we are working on. I am fine with it, it is just that now it is like I am the only one, but I know they (the self parts) are still here but it is like it is me all the time. I have no clue if we are starting to work together or what. It is very confusing. I guess because I am not alone anymore????

Relationships. Kristen continued to struggle with ending our relationship. At the same time, she and her ex-boyfriend suddenly began seeing each other again. They were soon engaged. It appeared as if losing therapy, her therapist, and her boyfriend at the same time was too much for Kristen. Symptoms. Kristen’s symptoms remained the same. She dissociated less and demonstrated few physical symptoms. Rather than allowing Zac to handle the termination of our work, she remained present and felt the pain of letting go of someone she had grown to love. This was new behavior for her. At the same time, she allowed the alters to say goodbye Life skills. Though Kristen had consistently been driving herself to our therapy sessions via country roads, she was frightened to drive herself to the new therapist’s office. The new route included driving on the highway and she had yet to do that. Kristen asked her father to drive her to sessions and he agreed, though he insisted she allow him to teach her the route so she could transition to driving solo. Therapy and assessment. At our 10/08/05 session, Zac arrived at therapy with an important update on the increased activities in the imaginal world. There seemed to be a number of problems and Zac reported herself to be “more aggressive” as a response to the recent

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pressures. We talked about this being our second to last therapy session and she said, “What? Am I supposed to be sad?” In discussing whether or not she should be sad, she remarked, “Therapy has helped me be less violent but I am not sure why.” She repeatedly said that it didn’t matter that she was switching to a new therapist but said, “I will just have to watch her. I am not going to visit for a while. I will let the others talk but I will just watch. I have to watch to see if she will leave. It takes time to trust.” Zac suggested that her increased violence may be related to leaving me. She said, “Anger and sad are the same thing for me. If I am sad, it will look like anger.” Zac suggested that, perhaps, she is showing her sadness at ending therapy by being more aggressive in the imaginal world. Kristen later returned to the session and said “I just want to sit here and never let you go.” We talked about her feelings of loss. She then said, “I don’t want it to end, but I know it has to.” Kristen admitted that if we sat there forever, she would stop growing. Despite that knowledge, she continued to regret our termination. Kristen said that she believes she will see me again someday. I talked about the importance of imagining that this next session will be our last time together so that we can fully face, feel, and process the pain of ending a caring relationship. She agreed in principal but continued to imagine that we will see each other in the future. At our final session, Kristen arrived with her parting gift to me, a beautiful, hand-made scrapbook. She had worked on it since I first discussed termination with her. As she put it, “It’s my story of therapy. You already got yours [articles and dissertation].” In the scrapbook, there were numerous goodbye letters. One letter was from all of the alters, another from Kristen, and still others were from Zac, Madonna, Tay, Ike, Jessie, and Hanson. Next to each letter, Kristen pasted copies of the pictures she had drawn of each alter in therapy. There were photographs of Kristen and I that she had taken during our work together. Interestingly, Kristen had cut apart and pasted in the pages from the two articles that I had written and presented to her about our work together. The notes and letters from the scrapbook as written are as follows: From Kristen: You are wondering about if I have dreams, and what they are about. I have created an imaginal world that has been with me for my whole life. You always wanted to learn about it, and went out of your way to help me with it. Over the four years you have helped me grow in so many ways. Saying that, it really made me become the persons that I am today! Thank you so much for what you did.

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From Zac: Carol, it was nice to get to know you. I want to thank you for what you did for Kristen. She really needed to be heard. I think she is a better person then what she was four years ago. Also, you have calmed me down. I don’t know how but you did. I guess we needed to be heard too. I usually don’t be sencitive. I am going to miss working with you. It was fun and good for everyone. I wish it could continue, but I now it can’t. Even though I don’t like theripy, I am going to miss it. Also, I wanted to thank you for taking extra time to learn about DID and to learn about all of us. I know it was hard, because it is completely difarant than every think else. I guess you can say that I am upset, MAD, sad, and mainly pissed. You know I don’t usauly confse that I am sad, I really think this the only time that I have been sad. Any way I am going to miss you and talking to you. Four years is a long time to work with someone. You are going to be missed. Good luck on getting your PHD and what ever else you need for your line of work. I hope all gose well. GOOD LUCK!! AND HAVE SOME FUN!!! Love, Zac From Madonna: Thank you for all that you have done. You have done so much for Kristen and us, but mainly Kristen. You listen to her and us. That means a lot to all of us, well mainly us that are here to help. You have gone out of your way so you could help her. Zac and I respect you so much for all that you have done. You will be greatly missed. You are a very caring, nice, kind, and loving person. You are very, very good at what you do. I think you are the best and hope and pray that we can work with you again. Nobody is going to forget you. I want to say good luck on your PHD. Love, Madonn From Kristen: Carol, We have been together for four years and now it has to end. I don’t want it to. I am going to miss you so much. It is like I am losing part of myself. You have helped me so much. You let me face my fear of what happened in the past. You listened to me, what ever I had to say you listened. Four years go fast. It feels like we just started. You are the best and always will be. Whoever gets to work with you, I know will be a better person afterwards. Our work together is special. We learned about what was going on

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inside me, together. You have worked really, really hard with me. Even when you got confused, you stayed and worked through it. I hope you like this scrapbook. There was a lot of thought and work put into it. It is how our relationship was and what I learned about you in the last four years. We have learned about each other and gained each others trust. I hope we can work together again. Good luck with your PHD. I hope you have a lot of fun, and hope you can work with more people that have DID. You are going to be the best in whatever state you work in. I think we have some kind of friendship and relationship. Over the years I think we grew together. That is one of the reasons we worked well with each other. I am never going to forget you or the work we have done. Mainly, you are the one I’m going to miss. I want to thank you for working with me, and trying to understand me. I know it took a lot of work. Also you went out of your way to learn about DID so you could have helped me better. I appreciate every thing you have done for me. Good luck with your career and life. I am going to miss you a lot. I will never ever forget you. Love, Kristen. God Bless You!! From all of us: Carol, Thank you for trying to work with us to help Kristen. We can see a big change in her. You have helped a lot. We just wanted to say thank you, goodbye, and good luck. Good luck with what you are going to do and hope you have fun. Good bye. Assimilation Constructs Observations bearing on internal multiplicity. By the time therapy terminated, both Kristen and Zac were able to articulate more complex experiences than when they initially entered therapy. For example, Zac was able to acknowledge sadness (for the first time) in her letter. Similarly, Kristen was able to express her feelings about the loss of the therapy relationship without calling the alters in for help. Coinvestigators saw examples such as these as both subcommunities’ accumulating traces of experiences during therapy. Whereas, Zac appeared to have absorbed more of a capacity to be vulnerable, Kristen was better able to withstand difficult feelings in the context of her relationships. Zac and the other alters appeared to have assimilated experiences such as vulnerability that were previously exclusive to Kristen. Simultaneously, Kristen assimilated some aspects of the alters’ experiences (e.g., assertiveness,

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confidence, social skills). Increased access to each other’s experiences suggests increased internal dialogue. Observations bearing on therapy or the therapeutic relationship. The coinvestigators suggested that the collaboration (as evidenced in the scrapbook) between the separate alters and with me addressed why therapy helped Kristen. They suggested that when a person struggles with severe dissociation or fragmentation, progress in these very low levels of assimilation may require the therapist welcoming and engaging with the various voices or subcommunities. This was viewed as support for the idea that voices that are triggered want to be heard. The coinvestigators agreed with Kristen that my willingness to hear the fragmented parts and engage them in therapy assisted in her change process. The coinvestigators noted that Kristen spook in an autonomous voice in her goodbye letter. She utilized “I” throughout her page of the scrapbook and barely mentioned the alters, something that she had not often done in the past. Kristen was able to write of the intense emotional loss she was experiencing without calling in the alters to take over. Similar to our therapy sessions, the alters were given space in the scrapbook to write about their grief over the loss of the therapeutic relationship as well. Zac’s goodbye letter was viewed as evidence of her significant progress throughout therapy. Whereas, at the beginning of therapy, she primarily expressed anger and hostility, at termination, she was able to openly express a wider range of emotions including sadness, as she said, for the first time. Though early on, Zac insisted that only Kristen needed my help, Zac admitted in her letter that therapy helped her as well. Observations bearing on APES progression. The coinvestigators suggested that the scrapbook as created by the many alters working together reflected a meaning bridge as to what had occurred in therapy. They viewed this as at least Stage 5. They saw it as evidence of a well- functioning community of voices within the self. Kristen’s ability to write of the creation of the imaginal world in her scrapbook was viewed as consistent with APES level 5 or 6. Emergent Issues in Data Packet # 21. The coinvestigators suggested that both subcommunities (Kristen and Zac) remained present, but were changed in that they were able to assimilate aspects of experience that they were previously unable to assimilate. They viewed it not as though one subcommunity assimilated all of the others, rather that they shared consciousness and, therefore, each changed.

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The coinvestigators once again suggested that the assimilation theory needs to further address the impact that interpersonal relationships have on the process of assimilation. Discussion This analysis is the first time that the assimilation model has been applied in depth to a favorable therapy outcome of a client diagnosed with DID. Kristen’s case is particularly helpful to assimilation research because DID can be viewed as an extreme case of internal multiplicity where there are overt examples of voices and subcommunities. The case study strategy of theory building requires the accumulation of comparisons between many theoretically-based statements and a few detailed observations (Stiles, 2007). In this theory building case, coinvestigators found multiple points of contact (POC) between Kristen’s case and the theory allowing me to describe the case in assimilation terms. We first applied the theory to the case and arrived at our conceptualization of Kristen’s experience as described below. I present the coinvestigators’ speculations about the origins of Kristen’s fragmented sense of self. I follow with an assimilation overview of Kristen’s change sequence in therapy. The subcommunities’ change processes are then examined by contrasting two alters’ experiences. This case study allowed us to track the process of change as not the elimination of parts of the self (as some models suggest) but as the increased dialogue and negotiation between alters and subcommunities. By next applying the case to the theory, we found areas where we believed the theory would benefit from elaboration, refinement and modification. In a section on theoretical innovations and issues, I confirm our earlier assertions that alters are complex subcommunities (each with internal voices) of the whole self sequestered off by amnesic barriers. The process of building meaning bridges is then described as increased access to the other alters and is parallel to increased assimilation. The subcommunities’ asymmetric access as characterized by DID is explored. These one-way understandings generally allow some alters (or subcommunities) to have more access to resources than others. In Kristen’s case, the other alters had much more knowledge about Kristen than she had about them. I then present the coinvestigators’ assertions that therapeutic ZPD work may facilitate assimilation by guiding a client to work beyond her previous level of psychological experiencing. A section on process and the relationship addresses how Kristen’s voices and subcommunities responded to triggers and appeared to want to be heard in a therapeutic

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relationship. I suggest that, in assimilation theory, an empathic, genuine therapeutic relationship involves the readiness and ability to form meaning bridges with multiple parts of people. I continue to elaborate on our observations suggesting that theoretical orientation can facilitate or avoid assimilation of the alters. In Kristen’s case, a therapeutic approach that includes openness to internal multiplicity, the imaginal, and a willingness to develop relationships with all the parts of the self appeared to facilitate assimilation. I then highlight a few of the intervention strategies (email access, the group meeting, and co-consciousness) that seemed to be particularly successful in furthering Kristen's assimilation process. In a final section, I address limitations and methodological issues and some of the problems and suggestions for further research raised by this intensive case study. Our Conceptualization of Kristen’s Change Process Speculation about origins. Kristen’s parents reported that, after her birth, her mother was depressed and only minimally interacted with or held their infant daughter for at least six months. Years later, their mother-daughter relationship continued to be viewed as difficult by all three family members (see data packets #10 and #12). Evidence in the first few data packets suggested that Kristen may not have developed a secure attachment with her mother, father or extended family. There was significant evidence that Kristen grew up observing her parents’ volatile marriage filled with frequent fights, intense make-ups, and physical separations (data packets #1 and #2). Furthermore, although the details were unclear, Kristen’s parents disclosed that she was dropped by a family member as a toddler and sustained a brain injury. The coinvestigators hypothesized, based on the historical data in packet #1 and Kristen’s and her parents’ reports, that these experiences, along with many others, may have traumatized Kristen in various ways. We suggested that Kristen, as a very young child, may have dissociated or mentally removed herself from these events or interactions as a perceived way of coping with the chaos and trauma in her life. Two worlds. As a young child who thought in concrete terms and maintained little capacity for ambiguity, Kristen seemed to create (either subconsciously or unconsciously) the imaginal world as a way to avoid traumatic or troubling situations in, what she named, her “real world.” Zac and, later, Kristen reported that very early on (1st-3rd grade), Kristen began spending a significant amount of time throughout her day thinking about and imagining the characters and events in her imaginal world. It is unclear at what point in this process they began stepping in for

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her in the real world. Though some of the alters increasingly took control of her body as she aged, they all continued to simultaneously engage in activities in the imaginal world. Prior to therapy, not all of the alters had access to the real world. Although Kristen had some knowledge of the imaginal world, she was not fully aware of its details, structure, purpose, and power. Much of the early reporting in therapy regarding Kristen’s two worlds was offered by Zac or the others. This early coping via dissociation may have allowed Kristen to escape feeling intense emotion or difficult interpersonal interactions in the moment. Spending time in her imaginal world may also have provided Kristen with a rich reservoir of relationships and activities that she found lacking. As a result, however, she rarely faced or worked through her problematic thoughts and feelings in the real world. The more she engaged in this dissociative process (either volitionally or automatically), the less she experienced and learned in the real world. Repeated use of this mental process, whether conscious or subconscious, appeared to have made it more automatic that is, more easily triggered by similar events or feelings. Eventually, she routinely dissociated in response to relatively mild stressors such as her mother’s raised eyebrow, anticipation of an argument between her parents, or an approaching boy. As Kristen’s primary sense of self was increasingly absent in her real world, various subcommunities (alters) developed instead. These alters (contained subsystems of linked voices) were separated from the other alters by amnesic barriers. Amnesic barriers served to sequester the development of separate personalities, cognitive abilities, experiences, skills, and relationships. That is, experiences and skills (i.e., personal resources) were available to the alters but unavailable to the host personality. Over time and accumulated experiences, the alters grew larger on the other side of the barriers as they were repeatedly triggered. Whereas some of these alters’ amnesic barriers appeared solid from conception (e.g., Hanson), others grew stronger over time (e.g., Zac). This accumulation of skills occurred both during times of dissociation in the real world in which Zac or the others stepped in to replace Kristen and while the alters engaged in activities in the imaginal world. Growing demands. As Kristen aged, life became increasingly complex with more academic and family demands. She was required to tolerate ambiguity and abstract thoughts in and out of school. Her high school classes were challenging and she was expected to remember previous lessons. Kristen’s parents wanted her to find a job and “grow up.”

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The 16 year-old Kristen was further experiencing developmental changes similar to other teenagers (e.g., hormones, a quest for identity, and independence). She desired a romantic relationship but was confused by the many parts of her that were male and female, heterosexual and homosexual (see emails, descriptions of alters, and farewell scrapbook). She questioned her sexuality (data packet #9). Although she wanted to fit into a group, go on dates, and spend less time with her parents, she did not have the developmentally appropriate skills. Social interactions had always been particularly difficult for Kristen as she lacked relational skills, relational context, and a cohesive history due to her dissociative episodes (data packets #1 and #2). Yet, peer relationships seemed to increasingly demand a (more or less) coherent identity. Her peers were confused by her dramatically different presentations of self (e.g., painfully disconnected or wildly outgoing) and disparate clothing styles (e.g., modest or flashy). They grew frustrated at her erratic memory regarding events. Kristen’s teen world called for skills that she normally would have acquired through facing and resolving childhood dilemmas. However, rather than develop these skills in real time as Kristen, Zac or the others had stepped in and acquired fragments of more age-appropriate skills. Kristen was then able to acquire the learned skills only second hand by gaining access to the alters, which was an exhaustive learning process. In many ways, Kristen felt constrained by her antiquated system and desired “normal” development. The coinvestigators suggested that the demands of maturity began to overwhelm her carefully constructed, child-like system. Ineffective defense. Kristen’s immature compartmentalization of responses, thoughts, and feelings was no longer a successful defense for her. By the time she turned 16-years-old, she had few coping skills or resources and her alters were triggered to step in on an almost daily basis (data packet # 2). Her fragmented system was no longer efficiently helping Kristen. Instead, dissociating was causing her psychological pain (data packets # 2, #7, and # 13) and providing less sustained relief. Kristen entered therapy struggling to acknowledge, understand, and control the various alters and their behaviors. Assimilation: Overview of Kristen’s Change Sequence The coinvestigators concluded that Kristen and the other alters gained greater access to each other through internal (within and among alters) and external (with the therapist) dialogue. The coinvestigators arrived at the following description of Kristen’s assimilation of the alters.

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Despite her fear of intimate relationships, Kristen entered therapy hoping to trust her therapist (see data packet # 2). Simultaneously, most of the other alters also hoped the new therapist would help Kristen. In therapy, Kristen shared her pain and more clearly articulated her felt experience. The alters shared their individual stories while standing in for Kristen during various sessions (see data packets # 4, #5). When Kristen was present, she repeatedly acknowledged in her emails, notes, and therapy sessions that she felt heard and respected by the therapist. As a result, meaning bridges were built between Kristen and the therapist (see data packets #5 and #6). The other alters felt similarly heard and respected by the therapist (as reported in their parting letters see data packet #21), and meaning bridges were built between the other alters and the therapist (see data packets # 5, # 6). As time passed, the trust between Kristen and the therapist increased and between the others alters and the therapist. As the alters often were unable to speak directly with Kristen early in therapy, the alters used the therapist as a conduit to share information with her (see data packet # 6). As they were expressed, the meaning bridges with the therapist became available for communication among Kristen’s discrepant voices (see data packet #6). Meaning bridges were also built within each alter (see data packets # 5, #6, #21 and Humphreys, et. al., 2005) as the alters’ own internal, discrepant voices expressed themselves and felt heard in therapy. As these processes occurred, amnesic barriers (between alters) seemed to dissipate allowing the alters to communicate directly with each other (see data packets #13, #15). As communication between them increased, the alters prioritized needs, negotiated goals, and collaborated. Over time, the amnesic barriers dissipated (between Kristen and many alters). The alters later communicated directly with Kristen. At the same time, Zac made significant changes which led to a moderation of her angry voice. Assimilation characteristically leads to moderation of extreme emotion (Brinegar et al., 2006; Stiles, Leiman et al., 2006). As was discussed in a previous paper (Humphreys et al., 2005), Kristen moved from a denial of anger (APES 0–2), through acknowledging and expressing anger (APES 3-6), to using Zac’s expression of anger as a resource (APES 5-6) and, finally resulting in her effective resolution of her own anger during an argument (APES 6). Simultaneously, Zac moderated the violent anger she had exercised earlier in the imaginal world. Zac’s imaginary acts were less violent and she rarely tortured or killed impulsively. Kristen’s assimilation of her experience of anger progressed through numerous APES stages as she bridged the gap between two disparate parts of her self.

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Underlying this process, meaning bridges were built through increased communication and negotiation between the subcommunities of Kristen and Zac. Amnesic barriers slowly disintegrated and Kristen seemed more able to experience her anger. Kristen’s assimilation proceeded via negotiation between the two subcommunities. The greater accessibility of anger for Kristen reflected a greater mutual assimilation of Zac and Kristen into each other’s communities of voices. Both Zac and Kristen had to make accommodations to make this happen. Importantly, Kristen was not simply incorporating Zac or any of the others. The shared resources were mutually accessible. At termination, both Kristen and Zac had similar access to ongoing events in the real world. However, as a result of Kristen’s increased access to shared resources and her assimilation of new experiences to a common community, Zac and the other alters were less needed or desired (see data packet #12). This increased access reflected Kristen and the alters’ increased mutual assimilation. As markers of her improvement, Kristen decided to remain present rather than dissociate in the face of imminent sinus surgery (data packet # 18) and during the break-up with her boyfriend (data packet #20). When asked why she wasn’t just letting Zac handle the surgery, she replied, “Because the reason this is hard for me now is because Zac has come in for this in the past, and I didn’t learn how to get through it. I have to learn how, or it won’t ever get better.” As therapy progressed, Kristen’s understanding of why she had created different selves (e.g., to help her cope with overwhelming interpersonal interactions or intense emotions) grew. She seemed to recognize her state-shifts more often (“it’s like switching”). Kristen improved in her ability to describe her theory of fragmentation. As the amnesic barriers disintegrated, Kristen developed an increased understanding of the other subcommunities and their roles. Kristen began to stand up for herself and display more assertion. Kristen chose to present her experience of internal multiplicity in her final sand trays and scrapbook (data packets #20 and #21). Whereas, the scrapbook was completed by all the alters, the sand trays were Kristen’s work. Both artistic projects served as three-dimensional representations of her internal experience. They were equally recognized and valued by her alters, explicitly acknowledging mutual access. At the time of termination, Kristen and I participated in two sessions with her new therapist. She remained present through much of the session, opened up to her new therapist, asked preplanned questions, and shared her artwork (data packet #20). Kristen demonstrated

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numerous social skills such as assertion, confidence, and eye contact in the meetings. Her new behaviors, previously sequestered in Zac, were viewed as evidence of increased access to resources (e.g., experiences, skills, talents, learned behaviors etc…) and reflected assimilation. The Assimilation of Alters: Contrasting Zac and Hanson The alters’ change process appeared to begin, for most, as they shared some thoughts or advice in therapy or in a note or email as to what they believed would help Kristen. This occurred before they had direct contact with Kristen. Prior to assimilation, though some of the alters took over her body, direct communications from the alters to Kristen were experienced as physical symptoms (e.g., head or stomach aches), odd feelings, dreams, or in notes or drawings that were left behind. Most of the alters also lacked direct communication with each other and seemed to talk about each other rather than engage in dialogue. For example, Zac did not realize the substitute alters stepped in for her, Madonna did not speak with Mama Jean, and no one spoke to Hanson. Madonna and Zac were one early example of alters accessing each other (they married each other in the imaginal world) even though they experienced significant periods of non-communication. Over time, most of the alters’ access to each other grew as they eventually began speaking with each other (data packet #13 and #15). As termination neared, they seemed to have more access to Kristen. She had more access to them as well as she read their notes and hovered over them in therapy (data packet #16). Increased accessibility and increased assimilation occurred via meaning bridges (observable signs, words, or communication). The hallmark of the alters’ assimilation was their having access to each other. However, the alters were assimilated at different times and rates. The most obvious example of these differences can be seen by contrasting the following key moments of Kristen’s experiences of assimilating Zac and Hanson. Whereas Kristen’s assimilation of Zac occurred steadily throughout therapy, Hanson was warded off during most of the therapy. Her assimilation began only in the final year of therapy as she opened up about her role in the system (data packet # 17). However, as termination loomed, Hanson retreated, denied access to the alters; and her assimilation process was halted. The assimilation of Zac. Kristen entered therapy with some limited knowledge of Zac, although the extent of her knowledge is unclear. She seemed to recognize that Zac was somehow involved in her life though she was uncertain in what capacity. She did not fully realize that Zac was a part of her. Over time, she came to realize how frequently Zac stepped in for her during

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her childhood and early teen years. Kristen did not appear frightened by Zac’s anger, but she did display discomfort over her threatening or violent drawings and notes. For the most part, Kristen seemed to admire what she knew of Zac’s social sophistication and ability to stand up for herself when necessary. In our early work, there was no direct communication between them. Zac was, however, a very large part of Kristen’s life. So much so, that I, as the therapist, left many sessions wondering whether Zac or Kristen was the core personality. Though Kristen was the personality present at birth and carried the birth name, Zac was much more developed interpersonally. Kristen also wondered what constituted a host (as discussed in data packet #19). Earlier in therapy, she questioned whether she should die or give up, allowing Zac to remain as the “one in charge.” Kristen, Zac, and I eventually concluded that Kristen was the core personality for many reasons, not only because the arrival of Zac occurred at a later date. Nonetheless, Zac, as the reporter alter, did know a significant amount of information about Kristen. However, Zac originally had only limited access to Kristen’s thoughts, and Kristen had minimal, if any, access to Zac’s thoughts. Later, Zac began to question whether she and Kristen were suddenly reading each other’s minds as their access to each other grew. Zac also knew significant information about many of the others and their roles in the imaginal world. However, she was not originally speaking directly with all of them. She was closest to Madonna, and they engaged in dialogue (and a marital relationship) but she lacked direct access to many of the others. During the family meeting (see data packet #12), Zac reported that “We try to help Kristen as much as we can.” In data packet #13, Zac discussed the alters’ increased access to each other and her role in it. She said, “We’re trying to work on getting everybody to know everything. That’s what I’m trying to work on, us to try and relate and work together.” This was viewed as evidence of the amnesic barriers coming down between the alters as their dialogue (or access to each other) increased. Meaning bridges were being built- -though the access was not entirely smooth. Later, as discussed in data packet # 15, Zac called a group meeting. She sat at the center of the conference table and was able to directly address the other alters. Throughout the meeting, she reported on their availability and willingness to participate in the discussion. She asked each one to come forward and speak directly to the group (and to me). In addition, Zac reported on a number of side conversations that were occurring at the table. This meeting appeared to reflect the alters’ changing relationships suggesting improved access and assimilation between alters.

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In data packet # 16, shortly after this evidence of improved assimilation between alters, Kristen handled an interpersonal emergency on her own without calling for Zac’s help. She said, “I thought it was good for me to try and handle it.” Zac felt similarly, and so “chose not to step in so that Kristen could practice handling stress on her own.” This was viewed as a shared agreement or meaning bridge that Zac was not needed. This assimilation between the two may be related to the alters’ increased dialogue, access, and assimilation detailed in data packet #15. In the 18th data packet, Kristen chose not to have Zac step in during an outpatient surgery. Instead, she used a number of resources that helped her get through a frightening time. Kristen’s acknowledgement of this behavior as evidence of growth was significant. She recognized that she had smoother access to Zac (and her resources) but was choosing not to use her. Kristen could do that because she had also gained her own access to these resources. As termination approached, Zac acknowledged sadness (for the first time), and Kristen was able to articulate her feelings about the therapy relationship. Both subcommunities appeared to assimilate experiences of the therapy itself. Whereas Zac appeared to absorb a capacity to be more vulnerable, Kristen seemed more able to tolerate difficult feelings. The assimilation of Hanson. When Hanson was first discussed in therapy sessions, Zac described and drew her as a violent enemy of Kristen. She was an evil figure, “the suicidal part” of Kristen, and a serious threat to her well-being. Her emails in data packet #6 were particularly threatening. Initially, Kristen knew little of her existence. Zac reported early on that Hanson was resistant to both helping Kristen and therapy in general. The alters had long been frightened of Hanson. Prior to Hanson’s and my first meeting, Zac was extremely worried about my safety (see data packet #16). As Kristen gained access to the other alters and eventually grew aware of Hanson, she, too, was frightened by her. This fear seemed to have illustrated a warded off experience (in this case, the experience sequestered in alters) and was extreme and frightening. Despite being able to hover above some of the other alters (data packet #16), Kristen was unable to hover above Hanson. After attempting to do so, she couldn’t recall anything that occurred in her absence. Immediately upon Hanson’s departure, Kristen reported having a very difficult time staying grounded and reported wanting to “slip away.” At this point in therapy, the coinvestigators viewed Hanson as a warded off part- separated by an amnesic barrier. In an early visit to therapy, Hanson asserted that her job was to kill off Kristen’s past bad memories. She also discussed killing off Kristen and moving to another person’s body. However,

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in data packet # 17, she reframed her understanding of her role into one of protector. This reframe occurred in the therapy session and was perhaps influenced by the accumulated work in therapy. Nonetheless, Hanson conceded that, similar to the other alters, she had a role in protecting Kristen. Though her methods were unorthodox (scaring and threatening the others), she agreed that she was created to sequester the most painful parts of Kristen. Prior to this session, all of the alters, including Kristen, Zac, and Hanson asserted that Hanson was an enemy to the system. After Kristen and Zac heard of Hanson’s concession regarding her role in the system (protecting her from bad memories), they immediately found her much less frightening. This was an important moment in therapy. As the alters felt less fear, they seemed better able to gain empathy and understanding for Hanson. A meaning bridge was built over the shared role of protecting Kristen. As I encouraged Hanson to explore her role, the meaning bridge was seen as facilitated and articulated by the therapist (therapeutic ZPD work). Unfortunately, shortly after this break-through, we began the termination work which lasted almost five months. Almost immediately, Hanson withdrew from most of the therapy work and, unlike the others, did not participate in creating the farewell scrapbook. Zac reported that Hanson was, at first, angry with me for ending therapy, and, later, didn’t care. This suggested to me that there remained an unexpressed part of Kristen that was infuriated (or hurt) at being abandoned. In an attempt to engage her in the termination work, I did meet with Hanson a few times to discuss my leaving and to say goodbye. However, Hanson was relatively guarded at these meetings and, I was disheartened by the outcome. With supervision, I determined it was inappropriate for me to actively pursue working with her with termination looming over us. I hoped the next course of therapy would serve as a safe place for Hanson to continue the assimilation process. Assimilation for Hanson was, therefore, limited, although she did agree her job to “kill off bad memories” could be construed as helping or protecting Kristen. This reframe allowed Kristen and the other alters to gain some empathy for her and access to her. Hanson, in turn, also seemed as though she was beginning to moderate her anger towards Kristen and the alters. Not unlike Kristen’s assimilation of Zac, meaning bridges had indeed been built. However, in the case of Kristen and Hanson, the meaning bridges were slow to construct (almost three years into therapy) and quick to dismantle.

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Theoretical Innovations and Issues In many ways, this study confirmed the basic tenets of the assimilation model as well as the current conceptions of DID. Our findings raised a number of theoretical issues worthy of further investigation. Theoretical innovations and issues presented in this section include alters as subcommunities, increased access paralleling assimilation, asymmetric access, what happens to alters during assimilation, the assimilation of different alters at different rates, the influence of the therapist’s theoretical orientation, the therapeutic ZPD, and relational aspects of change. Alters as Subcommunities As discussed earlier, alters such as Kristen, Zac, Madonna, and Hanson can be considered subcommunities of the self, separated from each other to varying degrees by amnesic barriers. Though coinvestigators entered the study loosely referring to the alters as voices, they realized, after reading 13 data packets, that each alter included a considerable degree of the internal complexity. Each subcommunity encompassed numerous conflicting, internal voices. Zac was, for example, viewed as a subcommunity with disparate voices (e.g., angry and helpful) that dialogued and negotiated with each other (Humphreys, et. al., 2005) during the change process. As each of the subcommunities took control of Kristen’s body for some portion of time, each had had unique experiences in the real world (unbeknownst to the others). Each alter developed internal voices representing traces of these experiences. They gained skills and resources by learning from their experiences. However, when problematic experiences occurred, the alters also developed discrepant internal voices. The assimilation term subcommunity is not meant to be synonymous with the dissociative term alter. It is a descriptive term referring to the type of grouping. All alters are smaller parts (subcommunities) of the whole community but not all subcommunities are alters. Increased Access Reflects Increased Assimilation. Kristen and the other alters gradually assimilated their discrepant internal voices making them (and their acquired skills and resources) mutually accessible. Each subcommunity’s internal voices engaged in negotiation breaking down the amnesic barriers. The subcommunities gained more resources through this increased accessibility to each other suggesting further assimilation. As these assimilated voices or subcommunities were more accessible, Kristen, as the host, grew in her ability to access the subcommunities (and their resources) which helped her to become more successful at handling life’s problems. Simultaneously, by remaining present

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more often, Kristen was independently acquiring new resources as well. For example, she gained interpersonal skills (including a tolerance for difficult emotions) by frequently choosing to remain present while with her parents, friends, boyfriend, and therapist. Asymmetric Access between Host and Alters As DID is initially constructed as a way to keep the host separate from traumatic or distressful experiences, other alters contain most of the information and memories regarding certain problematic events or experiences. In Kristen’s case, until the final year of therapy after significant work had been done, the alters knew much more about the host's experience than vice-versa. For example, Ive knew about the threatening letter that Kristen wrote in elementary school, Zac knew about Kristen lying in the street after an uncle’s death, Tay knew when Kristen needed help driving the car, and Jessie was a “memory bank” for Kristen’s childhood. Kristen entered therapy with limited knowledge of these sequestered experiences. In assimilation language, the alters had more access to Kristen’s experiences and resources than Kristen had to the alters’ experience and resources. This can be referred to as asymmetric access. Our previous failure to understand or appreciate the theoretical meaning of this pattern led coinvestigators to frequently label asymmetric access one way meaning bridges. Throughout analysis, several examples were identified where one alter understood something in more depth than another. The coinvestigators were particularly concerned with the repeated examples of Zac understanding much more about Kristen’s experience than Kristen did. However, after consultation, it was my belief that these examples instead reflected the structure of the personality system where amnesic barriers are automatically created between alters. The idea of asymmetric access led us to think about perspective taking. Assimilation research has traditionally tracked the assimilation of problematic experiences into the dominant community through the eyes of the dominant community. The theory has suggested that the dominant community has the potential to know, or make meaning of the problematic experience only after positive change is made. However, this case study offered new perspectives. Kristen, as the host, can be considered the dominant subcommunity and the other alters as the non-dominant, problematic subcommunities. Thus, asymmetric access is a way of saying that Kristen had limited knowledge of her problems. Even in the previous work, the dominant community did not have access to or knowledge of the problems. The puzzling observation was then, that Zac and the other alters knew much more about Kristen than she knew about them.

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This asymmetric access in DID has been noted previously (Blizard, 2003, Humphreys et. al, 2005, Kluft, 1999). We wondered if it was possible that problematic voices knew or understood more about dominant voices and subcommunities. In earlier assimilation studies, the problems were much more delimited rather than organized subcommunities that took control of executive functioning. Researchers had little, if any, access to the perspective of the problematic voice. However, in this study, Zac (a non- dominant subcommunity), for example, spoke out a great deal in therapy. She discussed her knowledge of Kristen (the dominant subcommunity) and the other alters. This first hand access to Zac’s experience allows assimilation researchers to gain new theoretical insight regarding the process of change. We wondered, in hindsight, if we might have observed similar asymmetric access if we had been able to speak directly to problematic voices in previous studies. Could access be gained to these voices and experiences in the future? We agreed that access to non-dominant perspectives is available in therapies driven by theoretical orientations that attend to the multi-voiced self (as opposed to those that ascribe to a unitary self). They often engage in techniques such as the empty chair, personal position repertoire, or psychodrama to elicit discrepant voices. Art therapists might further suggest that artwork has the potential to provide access to suppressed or subconscious voices. Certainly, any type of therapy that allows for the alternative parts of a multi-voiced self to speak may provide access to the problematic or non-dominant voices. This idea would benefit from further research. Kristen assimilated different alters at different rates. The coinvestigators agreed that Kristen and the alters made positive APES movement around a number of problematic experiences. They pointed to evidence that Kristen, Zac, Tay, Jessie, Madonna, and even Hanson made some positive changes while in therapy, but at different rates. For example, whereas Zac and Madonna readily engaged in the change process, Hanson initially resisted assimilation. Hanson later made some minor steps toward assimilation by realizing and communicating that she shared a similar role with the others. However, once the termination of therapy was suggested, Hanson retreated from the process. Zone of Proximal Development. The research team viewed many of the therapeutic interactions and interventions as evidence of work in the therapeutic ZPD (Leiman & Stiles, 2001), that is, Kristen first attaining more advanced APES levels in her work with me and later reaching them without me. For

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example, in the early sand tray work, coinvestigators felt I introduced the idea of building meaning bridges between the two worlds by asking questions such as “What if we put Carol the therapist (from the real world tray) in the imaginal world sand tray?” I asked, “What if we put Kristen (from the real world tray) in the imaginal world tray?” Kristen and Zac were not yet able to think of such a cross-over at the time. In later therapy, I asked Kristen to verbally describe the ways Zac was alike or different from Kristen and Kristen was alike or different than Madonna while looking at the pictures that Zac had previously drawn of the alters. These questions were a step or level of understanding beyond what Kristen and her alters had previously considered. The therapeutic ZPD work included my role as a go-between or conduit for the alters in which I occasionally reported back to Kristen or the others something another alter said. By reporting on information that could not be tolerated in person, I worked slightly ahead of Zac, Kristen, and the others, pulling them up with each relational encounter. For example, when Zac and I discussed Kristen’s fragmented experience, both Zac (and Kristen) appeared to gain knowledge, insight, or empathy for Kristen, resulting in a slight move to a higher level of assimilation. One explanation for this phenomenon was that Kristen was listening and learning from Zac’s description of her experience. A second possibility is that as Zac articulated Kristen’s experience by wrapping words around it, Kristen also gained access to those words that allowed empathy to occur. As Zac shared words (signs) in order to assist me, perhaps, they inadvertently helped Kristen to find her position as well. I then responded by crafting words so to allow them to understand each other’s words. There are other possibilities as to why the meaning bridges were built during these ZPD moments. Nonetheless, dialoguing in therapy about problems often appeared to allow for the construction of a shared meaning bridge between the alters. An additional example of work in the therapeutic ZPD was my request for Kristen and the others to hover nearby in session while I spoke with an alter. Coinvestigators noticed that Kristen’s awareness of the alters improved as she worked to remain present in some capacity when a switch occurred. Though she had previously reported various episodes where she knew a limited portion of what had occurred with one of the alters, this was new for her to choose sustained co-consciousness. Essentially, I asked her to be mindful of something that was already occasionally happening. I asked her to be mindful of what she was doing and why she was doing it. When she first began using this approach, she was able to remember the first few words and

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the last few words of the verbal exchanges. As therapy continued, Kristen’s ability to remain present and her memory of what happened when she experienced co-consciousness improved. The Process and the Relationship Throughout the 21 data packets, the coinvestigators repeatedly questioned the voices’ and subcommunities’ motivation for speaking out during this course of therapy and not previously questioned. They agreed that at the start of therapy, Kristen’s alters (and their conflicting internal voices) appeared eager to engage in dialogue. Though I originally believed I was meeting with Kristen, she later confessed that various alters had stepped in to share information during early sessions. When I was finally aware of their presence, I was impressed by their determination to dialogue and their desire to feel heard. In many ways, the system presented with volcano-like features, already beginning to erupt at the time our therapy began. The research team wondered whether they had always been willing to speak and no-one listened or had something changed? The assimilation model suggests that a voice speaks when it is addressed. It is always in response to something. We wondered what had, more recently, addressed these voices and subcommunities. The coinvestigators suggested that it was primarily due to the therapist’s theoretical orientation which valued internal multiplicity and the dark side of human experience. They further believed that the type of relationship Kristen and I developed was essential to their speaking out. However, we also considered Kristen’s willingness to talk as evidence of the developmental changes that were naturally occurring in her life. The coinvestigators noted that, according to the extensive historical data, Kristen’s earlier therapies did not seem to invite a deeper exploration of her internal experiences of “infisible friends” and voices or, her drawings of violent characters, sexual acts, and pentagrams. Previous therapy notes appeared to repeatedly encourage appropriate social behaviors and discourage negative thoughts and feelings as well as any sense of internal multiplicity. For example, when Kristen drew pictures of violent characters, therapy notes suggested she was told not to do it at school and, instead, think positive thoughts. When Kristen wrote a threatening note to a peer and retained no memory of having done so, her therapist taught her social skills such as how to make friends. These experiences did not appear to be considered significant representations of Kristen’s internal experience by her former therapists. As a result, the coinvestigators collectively agreed that early therapy appeared to help Kristen avoid rather than approach or listen to her voices or fragmented sense of self.

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Coinvestigators suggested that my theoretical orientation (Experiential Personal Construct Psychotherapy and Archetypal psychology) supported my work to honor and understand Kristen's internal multiplicity. By simply listening and not reacting negatively to (or pathologizing) her initial stories of an imaginal world filled with numerous characters engaged in torture, drugs, death, and sex, Kristen and the alters eventually felt safe enough to speak, even if the content had previously frightened other adults (e.g., parents, other therapists, teachers, school counselor, and DCFS workers).This allowed the deepest (and, most overwhelmed) parts of Kristen to feel heard rather than ignored. I tentatively accepted Kristen’s and the alters’ sometimes seemingly bizarre, self-reports as their truths. Once they felt safe, they spoke more frequently, listened more attentively, and worked harder on breaking down amnesic barriers. After trusting that my therapeutic task was not to “kill” them off, the alters’ dialogue with me, each other, and Kristen improved. For the first time, Kristen and the alters were communicating more fully what she had long held secret. The theories that guided me allowed for the expansion of internal dialogue and relationships and may have assisted in building meaning bridges between the imaginal and real worlds, thus hastening the assimilation process. In assimilation language, an empathic, genuine therapeutic relationship involves the readiness and ability to form meaning bridges with multiple parts of people. Assimilation theory would also assert that this process is a necessary condition for assimilation to occur. Problematic experiences must be expressed or put into semiotic form so that others (including the therapist and other internal subcommunities) can understand it. These experiences are shared through signs (words and other meaningful actions, such as drawings or sand trays). Therefore, the process of allowing expression by the alters was a necessary step in building meaning bridges and hence facilitating Kristen’s assimilation process. In addition to the importance of a theoretical orientation open to alternate ways of being and a tolerance for the dark side, the coinvestigators felt that a therapist open to (and not afraid of) such internal discrepancy and abnormal experiences had the potential to facilitate the process of building meaning bridges in a case of DID. Remaining appropriately accessible (through emails, letters, and phone calls) to Kristen and her alters between sessions also allowed me a window into her experience of internal multiplicity. Not only was I able to work with whichever alter presented to therapy, I was given access to the alters that had been in control of her body during her regular week.

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The coinvestigators repeatedly suggested throughout the 21 data packets that the assimilation theory needed to more explicitly account for the effect of relationships on the change process. This study is meant to further elaborate the theory regarding this issue. Though the coinvestigators consistently identified Kristen’s and my relationship as a key to assimilation in the early therapy sessions, they viewed the final data packet as explicit evidence, from the client’s perspective, that change may not have occurred without our unique relationship. The first scrapbook letter that suggested this to them was as follows: Over the four years we have created a form of a friendship. It is not an actual friendship. You have helped me in so many ways like a friend would. Also, in so many ways, not like a friend. We have laughed a lot through the years. We shared a lot of feelings over the years. Mainly, I was the one sharing, but we both shared something. I shared my life and feelings. You have shared helpful advice for my life. Love is very strong and will stay strong. I fell like we created a loving kind of friendship, even though it is a different kind of friendship. But, it is still a friendship. They also pointed to the following comments in another of Kristen’s letters: You have helped me so much. You let me face my fear of what happened in the past. You listened to me, what ever I had to say you listened… Our work together is special. WE learned about what going on inside me together… You have worked really really hard with me. I think we grew together. That is one of the reasons we worked well with each other… Kristen and I frequently reflected on our evolving relationship. We discussed and I demonstrated, having flexible, yet, appropriate boundaries. These discussions modeled important relational skills that she was then able to generalize to other relationships. Coinvestigators suggested that my willingness to develop a relationship with the alters in therapy allowed the following things to occur: 1) As the alters finally felt heard within our relationships, they gained trust in me and the change process. With time, the alters became genuinely committed to therapy and were active participants. 2) As the alters’ sense of safety grew, they allowed for increased access to their resources. This provided me with a better understanding of Kristen’s system, thus facilitating my work as a therapist. 3) Originally, the alters were unable to tolerate direct communications with each other and learned more about the others through me. Early in their visits to therapy, I occasionally served as a conduit or go-

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between for the various alters. As I spoke of the alters’ visits, Kristen and the others gained some familiarity with their counterparts (albeit second hand). Their empathy for each other grew and the amnesic barriers slowly disintegrated. 4) Appropriate and respectful dialogical relationships were modeled for Kristen and her alters which they later generalized to both intrapersonal and interpersonal relationships. Successful Intervention Strategies The coinvestigators felt that one successful intervention strategy included my encouragement of Kristen’s internal community to collaborate on a shared goal (helping Kristen get better). This appeared to lead to increased assimilation as seen in the 13th data packet when various alters verbalized their commitment to helping Kristen spend more time in the real world . This collaborative effort was viewed as evidence of additional meaning bridges and the disintegration of amnesic barriers. The coinvestigators further identified the following techniques as successful intervention strategies and increased assimilation: Email. Allowing Kristen and the alters to have limited email access in-between sessions inadvertently served as a rich source of information for both the therapy and the research. As Kristen’s therapist, it allowed me a window into the world of the alters daily lives outside of therapy as they often spontaneously wrote emails when they were present (even though they may not have appeared in the therapy session). These emails served as verbatim material that assisted in the research as they detailed the alters shifting relationships with each other. Over time, Kristen’s early practice of sending separate and distinct emails changed to a more collaborative written expression. It became apparent that, as therapy progressed, there was increased negotiation and dialogue among the alters as demonstrated in later emails. Though the initial emails were originally signed by specific alters (e.g., Kristen, Zac, Madonna, Hanson etc…), the later emails were often signed by two or more alters suggesting they had co-written the email. The emails seemed to chronicle the decreasing divergence between subcommunities. Group meeting. One particularly successful intervention included calling together the alters for a group meeting as reported in data packet #15. Their ability to sit at a conference table together (with Zac leading the meeting) encouraged increased communication between them. Individually, and as a group, the alters confirmed their support for Kristen living a more independent life. This meeting modeled real time communication between the subcommunities.

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Hovering or co-consciousness. At around the third year of therapy, Kristen occasionally demonstrated a very limited ability to remain partially present when some of the alters stepped in and took control of the body. Asking Kristen to purposefully try to hover nearby when Zac or the other alters stepped in encouraged her to experience co-consciousness. With repeated practice, she increasingly grew in her ability to remain present. However, she was unable to achieve success with Hanson. When applied to the others, she found that the hovering technique allowed her to retain some memories of conversations and events. She was able to hear the alters speak, understand their perspectives, and gain empathy for them. This hovering technique appeared to lead to further disintegration of amnesic barriers and increased meaning bridges. Limitations and Methodological Issues A single case study can never yield decontextualized generalizations (i.e., isolated conclusions that we can make confidently). However, it can support a theory by making many points of contact between observations and the theory (Stiles, 2009). It is in some ways problematic that the therapist served a dual role as the lead researcher. As presented in the method section, I had numerous biases with regard to the work that I did as Kristen’s therapist. My affiliation lay first and foremost with her as a client rather than as a research object. Though this dual relationship has the disadvantages of bias, I believe it also has numerous advantages. As the therapist, I had extended access to and first hand knowledge of Kristen’s experience. The complexities of the case and the data packets required that the coinvestigators ask various questions regarding what was actually occurring in the therapy sessions. Having the original therapist available to respond assisted both their understanding and comfort level in dealing with transcripts involving a number of vacillating, chaotic self-states. Another problem was the coinvestigators’ unfamiliarity with the assimilation theory and DID. Despite two training sessions and additional readings, the topics were relatively new to most of the research team. As in the case of learning any new psychological theory, fully familiarizing one’s self with the assimilation theory and dissociative processes takes time. Coinvestigators agreed that the assimilation theory did not seem to sufficiently account for the influence of the relational world on the assimilation process. In part, their judgment reflected their unfamiliarity with the model and its research. More recent research on the assimilation theory has increasingly addressed the interpersonal aspect of assimilation (Brinegar et al., 2006, Goldsmith et al., 2008). However, their concerns proved to be a valuable stimulus

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that led the above discussion of how my relationship with Kristen affected the progress of therapy and of assimilation. Clearly, more theoretical and empirical work on the impact of relationships on assimilation is warranted. During the consensus process, some Groupthink (or agreement with others based on deferring to the majority) among coinvestigators may have occurred. This was evident in a few cases where the same section of a data packet was originally described in two discrepant ways, but, upon review, the entire team ended up agreeing with both, dissimilar descriptions. It is possible that there was some agreement based on confusion, lack of confidence, or the desire to avoid conflict within a friendly, respectful group. A general issue that was evident throughout the study was that coinvestigators’ use of the APES scale was not reliable. In some cases, where one coinvestigator suggested APES=3, another suggested APES=4. Despite their conflicting APES ratings, they often used similar words to describe the text. Though the APES may be a useful scale and the coinvestigators were quickly drawn to its application, perhaps the language associated with it has yet to develop to the point where people can use the language consistently. By using the APES ratings, the coinvestigators were clearly paying attention to something that occurred in the data packets that was important. Providing additional APES training for the coinvestigators may have alleviated some of the discrepancies in ratings, despite similar written descriptions of the POC . However, in the case of Kristen, where there was a multitude of voices and relationships, any researchers (and therapists) would struggle to keep it entirely straight. That is, perhaps assigning APES ratings for an individual who experiences DID is problematic simply due to the complex structure of the disorder. We further recognize that Kristen’s self-reports (occasionally what we based our APES ratings on) may not have always been reliable. The coinvestigators initially found it difficult to know exactly which alter they were rating on APES. Not only were the coinvestigators new to the task, their early POC responses were based on the data packets reflecting the first two years of therapy, well before I negotiated a rule requiring introductions after a switch. When therapy began, I believed I was meeting only with Kristen. The early transcripts and progress notes reflected this experience. Months later, after I understood more about Kristen’s internal multiplicity, I was informed that Zac had frequently attended early therapy sessions incognito.

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The coinvestigators described these discrepancies as fluctuating APES levels with examples of negative movement down the scale. On close consideration of the identified examples, I thought they, instead, involved different pairs of alters, such as different alters taking control of the body and demonstrating different levels of understanding (cf. Stiles, 2005). For example, it was clear that some parts of Kristen (primarily Zac) appeared to consistently know and understand more about her complex internal world than the others. The coinvestigators wondered if these examples reflected an area of the assimilation model that needed adjustment. Through repeat analysis and discussions (and as mentioned earlier), these examples of asymmetric access were instead viewed as reflecting the diagnosis of DID, a disorder where at least two distinct and separate identities recurrently take control of the body and are unable to recall extensive important information. Partly for these reasons, I have not attempted to formulate a consensual version of Kristen’s APES progress across the four years. These issues were not entirely unexpected as this was the first DID case that the assimilation theory (and this research team) had encountered. Not only are the amnesic barriers that occur in DID unique to the disorder, so too are the multiple levels of voices that occur due to the subcommunities’ elaborated personalities and abilities to take control of the body. Whether or not pathological fragmentation can be conceptualized and understood in ways similar to other cases of internal multiplicity is an area requiring additional research. Though the assimilation theory seems to apply to the change process that can occur in therapy for clients diagnosed with DID, our assumptions remain tentative. Finally, coinvestigators asked when one knows that perceived assimilation (as tracked in therapy sessions) instead reflects increased trust in the therapist. In other words, do utterances in therapy reflect assimilation that occurred much earlier because the client has finally grown in her willingness to share the experience with another? When we only track assimilation within therapy or interview transcripts, are we just seeing the natural progression of trust between a therapist and a client? How trustworthy are our observations? These issues are worthy of consideration in future assimilation analysis. And, Finally… The story of Kristen was and remains a rich source of clinical data. For over eight years, this work has taught and inspired me. It has also haunted, exhausted, and enlightened me. There is certainly a volume of both applied and theoretical puzzles raised by this material that I am

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tempted to address. However, in a thick and daunting scientific book that detailed every aspect of the lives of bees, I found some comfort in the words of Karl Von Frisch who wrote, “…with every insight, comes new questions. The end does not automatically present itself. Ultimately, we must choose to halt it.”

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Appendix A Releases

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Appendix B POC Form

Name______Team #______Date______

Briefly Describe Data set. Include any dates associated with data if possible:

Your Observations Contact or Lack of Contact with Theory Any Needed Elaborations of Examples? (Voices, problematic voices/experiences, meaning bridges, dialogue, theory? discrepant voices, community of self, APES etc…)

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Appendix C Example of a Completed POC Points of Contact Page: Folder 2

Name: Hugo Schielke Team #: 2

Briefly Describe Data set. Include any dates associated with data if possible:

Contact or Lack of Contact with Theory (Voices, problematic voices/experiences, Observations, Examples Any Needed Elaborations of theory? meaning bridges, dialogue, discrepant voices, community of self, APES etc…) Different relationships between different parts of client co-exist at the Intake summary (9/27/2001): Age 16 same time – while informally • Suicidal ideation recognized, this has not been • Somatic symptoms when talking about discussed enough in theoretical • Somatic concerns consistent w/ APES same and family interactions w/ parents language (though KO has begun at school. 0 (Warded off / disconnected) – something being warded off? talking about subcommunities esp. in • Elaborate imaginary world; many relation to borderline clients) • BUT K has connection to imaginary characters are famous performers world that is more in line with • Imaginary friends told her not to hurt In non-DID situations, I think of this awareness / emergence herself in terms of different relational roles or • Not quite at the point where there is a • Children’s services investigation has her partial-identities (a self-in-relation to clear problem statement very concerned specific other(s) or contexts), e.g. • No reason different relationships • Often holding back tears. friend, boyfriend, brother, son, between different parts of client cannot • ‘Parents used to fight a lot, but things are clinician, researcher, student, teacher, co-exist at the same time getting better”; etc. etc. • K has two friends (most ever had) • Would like to talk to someone. I see each of these role/partial identities as consisting of particular constellations / organizations of voices

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Appendix D Coinvestigators Instructions What is Carol actually asking me to do?

1) Use the assimilation model as a lens through which to view the case of Kristen. And use the case of Kristen as a lens through which to view the assimilation model.

2) Observe this case and its data carefully, always asking • “How does the assimilation theory fit your observations?” • That is always the question in research.

3) Read, sit with, listen and look at the data. Record your observations in your points of contact pages. Wearing your assimilation lens, record what jumps out at you. What seems related to this idea of the many parts of Kristen assimilating into the whole of Kristen?

4) Consider the assimilation theory (APES, voices, meaning bridges, etc…) and record points of contact or lack of contact between your observations and the theory. • Look for points of contact. You don't need to summarize what you think happened or to provide an overall retelling of the data.

• Instead, the question is “What contacts what?” You will list your observations of something from the data and something from the theory and an explanation of how they are related or not related.

• For example, are there voices in the data? Do they know of the other voices? Is there communication between voices? Do they understand any of the other voices? Do the voices appear to be in any of the APES stages? Are there any instances of one voice being completely disconnected from another voice or experience? (Warded off stage of the APES) Is a voice purposefully choosing not to face/address or look at another voice or experience? (Unwanted thoughts/active avoidance)? Is a voice aware that there is a problem but unable to formulate what it is? (vague awareness) Is there a clear statement of a problem/experience/voice identified that can be worked on? (problem statement clarification)? Is the experience or voice understood in some way/made sense of? (Understanding/insight) Are there any meaning bridges being built between the voices? Do two voices seem to be sharing information or in dialogue with each other? Are they coming to understand each other? Are they changing because of it?

• Point out places where the assimilation model needs to be elaborated so as to account for what you see.

• If you see a pattern over a number of passages then discuss the pattern. If you see pieces of data that link up or need linking to theory, say what the links are or where links are needed.

• Include observations that you think the theory should explain but doesn’t yet. Don’t worry about being the assimilation expert. Just write your thoughts down. (Maybe your point will help me elaborate the theory. If the theory already accounts for your point and

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you just aren’t aware of it yet, that is okay. We will catch it in the next round.) If you have a thought or feel something doesn’t make sense than there is a good chance someone else (perhaps someone in future audiences) will feel the same.

4) After completing the set, email your points of contact to me. I will then send them around as one packet and you will all receive them at the same time.

5) After receiving other people’s points of contacts via email. • Look for strengths and points of contact that make sense. • Adopt other’s points (cut and paste to your own list) if they improve the story of change or advance the general idea as to how this theory fits observations. • Modify or elaborate on others’ contact points if that will help. • If you don’t think it will help or if you disagree with another’s point, leave it off your list. • If you think another’s observation or example is a useful example of something other than what they wrote about, you may use the point of contact and write what you think about it. The general idea is to keep doing the task again, better each time. With each iteration, you will have more information to work with. Consider that you are always writing for an external audience. The goal is for each person to come up with the best possible story. You are entitled to take whatever you like and work on it or improve it. Elementary teachers beg, borrow and steal from other teachers for the greater good of the students. The goal is not to debate with other members of team but to address a future audience.

6) After compiling a revised list of points of contact, send it to me via email. Once again, I will send them all around at once as a packet.

7) Consider everyone else’s revised lists.

8) Repeat step # 5, always working towards articulating the best story of change possible.

9) Send to me once again.

10) Set up a meeting with the following goals: • Meeting is less about conveying content (that should be in your points of contact pages) but instead to convey process. • Connect with your team (community building) • Discuss the process, how you got where you are at. • What have you learned in this process? • Share strengths. Talk about what you really liked about what others wrote. • You may discuss particularly exciting points of contact but the goal is not to debate with other team members. It is a reflecting pool.

• If others share the content of what they have already written and it sounds like they didn’t encapsulate their points clearly, then coach/encourage them to write it down as they are discussing it.

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• If you are having trouble articulating exactly what you saw, then ask the team for help in providing reflections around what you are saying.

Each individual comes up with the best possible product in their own view. It is likely that the lists of points will grow more and more similar, but this is not required. Any convergence is a byproduct of team members coming to similar judgments about what is best. Each one does the best job they can. The goal is for others to help them do the best job they can. IF they converge, great, but that is not the primary goal. We are striving for quality, not agreement. You have free reign to use your clinical judgment as to whether or not observations are fitting or not fitting the theory. However, by providing all this early information, I am trying to make your judgment informed by an understanding of the theory, the background, the case, and the task.

Why am I asking you to compare your observations of the case to a specific theory of change? “Scientific research compares the theoretical descriptions with observations. If the experiences of the descriptions and the observations correspond, the theory is a good one… The job of researchers is to gather and describe appropriate observations, to see how well they match the theory. The job of theorists is to find the right words to describe what is seen.” Bill Stiles

Why do I believe it is so important for the assimilation model to account for this specific client’s change process in therapy? The short answer is that I would like to improve the assimilation model because theories can and should be important to real world practice. Accurately articulating what occurs during the therapeutic change process can make the theory better. The goal is a theory grounded in and reflective of real world examples. One of the long term products of this dissertation project is an improved theory.

Here is how Bill sees the connection between theory and practice: “Theories are important because they are the way scientific research affects practice. Psychotherapy theories (e.g., psychodynamic, person-centered, cognitive- behavioral) are rich and detailed conceptual tools that psychotherapists use to understand their clients and guide their interventions (Leiman & Stiles, 2002). Thus, the quality of the theories can powerfully affect the quality of the treatment clients receive. Inaccurate, confused, or internally contradictory theories can lead to inappropriate, inefficient, or damaging treatment… This is quality control on ideas through seeking experiential correspondence between theory and observation. It is never final, but it can always continue to improve.”

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Appendix E Syllabus Training Workshops for Coinvestigators Humphreys Dissertation Research

Purpose: To assure that all coinvestigators will have a basic understanding of the Assimilation model and DID prior to the analysis of case artifacts. Two sessions @ 2 ½ hours each

Training Session One 1. Pre-assigned Readings about DID: a. Kluft, R.P. (1999). “Current Issues in dissociative identity disorder.” Journal of Practical Psychiatric and Behavioral Health 5:3-19. b. Putnam, FW. (1989). The alter personalities. In FW Putnam. Multiple Personality Disorder. New York: Guilford,pp.103-130. 2. DID power point lecture 3. Outtakes and clips from the following: • Understanding Dissociation by the International Society for the Study of Dissociation (ISSD), 2002. • Multiple Personality: Reality and Illusion by Colin A. Ross, M.D., Produced for the Ross Institute by Manitou Communications & Hi- Comm Productions, 1998. • Treating Trauma Disorders Effectively by Colin A. Ross, M.D., Produced for The Ross Institute by Manitou Communications and Hi- Comm Productions, 1998. • A 60 Minutes story about Robert Oxnam and his experience of DID • Multiple Personality Puzzle • You’re Not as Crazy as You Feel: Inside the Inner World of Dissociative Identity Disorder, Produced by Wendy Lemke, MS., Licensed Psychologist through Quarterton Productions, 2005. • Sybil • The Three Faces of Eve

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Training Session Two 1. Pre-assigned readings about the Assimilation model: a. Honos-Webb, L & Stiles, W. B. (1998). Reformulation of assimilation analysis in terms of voices. Psychotherapy Research, 8, 264-286. b. Osatuke, K., Glick, M. J., Gray, M. A., Reynolds, D. J., Jr., Humphreys, C. L., Salvi, L. M., & Stiles, W. B. (2004). Assimilation and narrative: Stories as meaning bridges. In L. Angus & J. McLeod (Eds.), Handbook of narrative and psychotherapy: Practice, theory, and research (pp. 193- 210). Thousand Oaks, CA: Sage. c. Glick, M. J., Salvi, L M., Stiles, W.B., & Greenberg, L.S. (submitted). Building a meaning bridge: Therapeutic progress from problem formulation to understanding. Journal of Counseling Psychology. 2. Discussion of readings and questions about the experience of DID. 3. Powerpoint Lecture on the Assimilation model 4. Individual application of APES to a client’s experience of change described in a vignette 5. Discussion 6. Break up into groups with two new vignettes using APES to assign a rating of change to those described in the vignettes. 7. Discussion

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Appendix F Kristen as Drawn by Zac

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Appendix G Zac as Drawn by Zac

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Appendix H Madonna as Drawn by Zac

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Appendix I Hanson as Drawn by Zac

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Appendix J Ike as Drawn by Zac

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Appendix K Tay as Drawn by Zac

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Appendix L Jessie as Drawn by Jessie

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Appendix M Megan as Drawn by Zac

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Appendix N Max as Drawn by Zac

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Appendix O Ive by Zac

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Appendix P Real World Sand Tray at Start of Therapy

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Appendix Q Real World Sand Tray at Termination

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Appendix R Imaginal World Sand Tray at Start of Therapy

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Appendix S Imaginal World Sand Tray at Termination

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Appendix T Kristen’s MMPI-A

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Appendix U Zac’s MMPI-A

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