Patient “Kathy” is a 32 year old female who has had 17 prior admissions to acute care psychiatric facilities for suicide attempts and self-mutilation. She reported hearing voices and losing periods of time for which she could not account.
Diagnosis Dissociative Identity Disorder, Post Traumatic Stress Disorder, Depression.
Referral Kathy was referred by her therapist for immediate admission for treatment of her self-mutilation, dissociative identity disorder and post traumatic symptoms.
Barriers to Treatment Kathy has been repeatedly self abusive by cutting her arms with razor blades, burning herself with cigarettes and masturbating with sharp objects.
History According to her account, Kathy’s childhood was characterized by two alcoholic parents who exhibited violence toward each other and Kathy. They divorced when Kathy was 5 and Kathy lived with her mother and a series of “stepfathers” who physically and sexually abused her. Kathy’s mother confirmed much of this abuse in sessions with Kathy’s therapist. Kathy was first hospitalized at age 13 following a Tylenol overdose. Shortly thereafter she refused to go to school and lived on the streets where she traded sex for food and shelter. Kathy was picked up by the juvenile authorities and spent the next 4 years in a residential program as a ward of the state.
Kathy’s behavior improved with the structure; she completed high school and got a secretarial job. She married at age 20, but soon after began to have problems. Kathy’s husband reported that she was extremely moody and would often become hysterical during sex. Kathy began having “flashbacks” of sexual abuse and became extremely depressed. She was hospitalized repeatedly during the next 10 years receiving diagnoses of schizo-affective disorder, bipolar mood disorder and borderline personality disorder.
Kathy had seen her current therapist for six months at the time of admission. A clinical interview conducted by this therapist revealed that Kathy often heard “mean voices in her head” and “children crying.” Kathy reported that she cut on her arms and abdomen to “relieve the internal pressure and stop the bad feelings.” Kathy said she frequently lost periods of time and would find herself in strange places not remembering how she got there. Upon request, the therapist was able to talk to an alter personality, Julie, who said that she helped Kathy during times of stress. Kathy’s therapist requested admission to a Ross Institute program following an excerbation of self mutilatory behavior and threats of suicide.
Course of Treatment An integrated team approach, consisting of psychiatrists, masters level therapists, case managers, direct care staff and Kathy, developed a master treatment plan which included individual and group psychotherapy. In individual therapy, Kathy and her therapist worked on identifying the alter personalities who were suicidal or self injurious, orienting them to the present, encouraging them to talk about their feelings and reframing them as positive and helpful. Kathy also worked with her therapist on problem solving and coping skills and practiced these new behaviors with peers on the unit. Kathy received a variety of specialized group therapies designed to address her defenses, anger and cognitive distortions. With these new skills she learned in the Trauma Program, she would not have to rely so much on dissociation as a coping strategy.
In groups, Kathy found safe ways to manage and discharge her anger and was able to talk openly about the difficulties her dissociative disorder created in her daily life. Cognitive distortions such as “I can hurt or kill the body and not die myself” and “It was my fault that I was abused” were recognized and corrected both in groups and in individual therapy. Education groups helped Kathy learn about her disorders and feel less isolated.
Through the course of treatment Kathy began to appreciate the protective role her dissocation played during childhood, and she began to accept her parts as parts of herself. She was able to partly revers her self-blame, and therefore be less depressed, suicidal and hopeless. Kathy was soon able to be discharged to the Trauma Day Program where she could practice her new skills in an outpatient setting.
Discharge Kathy was discharged to the Ross Institute Day Program, a partial program dedicated to the treatment of trauma disorders. Since Kathy was referred from another state, she was assisted in finding safe housing near the hospital. In the Day Program, Kathy was given many opportunities to practice her new coping skills and to learn effective strategies for independent living.
The above patient information is a composite of patients treated in the program.