Among DID individuals, the sharing of conscious awareness between alters exists in varying degrees. I have seen cases where there has appeared to be no amnestic barriers between individual alters, where the host and alters appeared to be fully cognizant of each other. On the other hand, I have seen cases where the host was absolutely unaware of any alters despite clear evidence of their presence. In those cases, while the host was not aware of the alters, there were alters with an awareness of the host as well as having some limited awareness of at least a few other alters. So, according to my experience, there is a spectrum of shared consciousness in DID patients. From a therapeutic point of view, while treatment of patients without amnestic barriers differs in some ways from treatment of those with such barriers, the fundamental goal of therapy is the same: to support the healing of the early childhood trauma that gave rise to the dissociation and its attendant alters.Good DID therapy involves promoting co­-consciousness. With co-­consciousness, it is possible to begin teaching the patient’s system the value of cooperation among the alters. Enjoin them to emulate the spirit of a champion football team, with each member utilizing their full potential and working together to achieve a common goal.Returning to the patients that seemed to lack amnestic barriers, it is important to understand that such co-consciousness did not mean that the host and alters were well-­coordinated or living in harmony. If they were all in harmony, there would be no “dis­ease.” There would be little likelihood of a need or even desire for psychiatric intervention. It is when there is conflict between the host and/or among alters that treatment is needed.
The case of a patient with dissociative identity disorder follows:Cindy, a 24-year-old woman, was transferred to the psychiatry service to facilitate community placement. Over the years, she had received many different diagnoses, including schizophrenia, borderline personality disorder, schizoaffective disorder, and bipolar disorder. Dissociative identity disorder was her current diagnosis.Cindy had been well until 3 years before admission, when she developed depression, "voices," multiple somatic complaints, periods of amnesia, and wrist cutting. Her family and friends considered her a pathological liar because she would do or say things that she would later deny. Chronic depression and recurrent suicidal behavior led to frequent hospitalizations. Cindy had trials of antipsychotics, antidepressants, mood stabilizers, and anxiolytics, all without benefit. Her condition continued to worsen.Cindy was a petite, neatly groomed woman who cooperated well with the treatment team. She reported having nine distinct alters that ranged in age from 2 to 48 years; two were masculine. Cindy’s main concern was her inability to control the switches among her alters, which made her feel out of control. She reported having been sexually abused by her father as a child and described visual hallucinations of him threatening her with a knife. We were unable to confirm the history of sexual abuse but thought it likely, based on what we knew of her chaotic early home life.Nursing staff observed several episodes in which Cindy switched to a troublesome alter. Her voice would change in inflection and tone, becoming childlike as ]oy, an 8-year-old alter, took control. Arrangements were made for individual psychotherapy and Cindy was discharged.At a follow-up 3 years later, Cindy still had many alters but was functioning better, had fewer switches, and lived independently. She continued to see a therapist weekly and hoped to one day integrate her many alters.
Of course, I should have known the kids would pop out in the atmosphere of Roberta's office. That's what they do when Alice is under stress. They see a gap in the space-time continuum and slip through like beams of light through a prism changing form and direction. We had got into the habit in recent weeks of starting our sessions with that marble and stick game called Ker-Plunk, which Billy liked. There were times when I caught myself entering the office with a teddy that Samuel had taken from the toy cupboard outside. Roberta told me that on a couple of occasions I had shot her with the plastic gun and once, as Samuel, I had climbed down from the high-tech chairs, rolled into a ball in the corner and just cried. 'This is embarrassing,' I admitted. 'It doesn't have to be.''It doesn't have to be, but it is,' I said.The thing is. I never knew when the 'others' were going to come out. I only discovered that one had been out when I lost time or found myself in the midst of some wacky occupation — finger-painting like a five-year-old, cutting my arms, wandering from shops with unwanted, unpaid-for clutter.In her reserved way, Roberta described the kids as an elaborate defence mechanism. As a child, I had blocked out my memories in order not to dwell on anything painful or uncertain. Even as a teenager, I had allowed the bizarre and terrifying to seem normal because the alternative would have upset the fiction of my loving little nuclear family.I made a mental note to look up defence mechanisms, something we had touched on in psychology.