Thoughts on Plurality 2.0

Plural is a term that originated online to reflect anyone who experiences life as a multiple, including:

• People who are multiple due to early childhood trauma.
• People who were multiple before they were born.
• People who are multiple but not because of trauma

An annual gathering called the Plural Positivity World Conference began in 2019 and has been held annually since that year. Originally, this conference began as a “counter-conference” to a mental health professional conference on Dissociative Disorders, also held annually. The reason it was hosted “against” the professional’s conference was to outline the following issues (which even today are still documented areas of concern in the Plural community):

1. ISSTD treatment guidelines referring to multiples as “patients” instead of “clients”
2. DSM-5 falling behind on inclusion of diagnoses such as Chronic Post Traumatic Stress Disorder (CPTSD) or Partial-DID.
3. ISSTD failing to identify functional multiplicity as a treatment option.

It’s interesting that one of the main complaints from plurals is terminology. This is because in DID support spaces we try very hard NOT to police terminology. Many DID’ers, themselves, use different different words to explain similar experiences (e.g. alter, ego-state, part, etc.). From a mental health professional standpoint, the ISSTD treatment guidelines were written for psychologists and psychiatrists who were struggling getting insurance panels to authorize for hospital and residential treatment. In this context, the term patient was appropriate.

Story time: I’m a great example of that. Prior to the updated guidelines, I was inpatient at Sheppard Pratt for my 2nd stay. I was in my individual therapy session negotiating safety with parts who were influencing the subsystems with suicidal programming. My psychiatrist interrupted our session, rushing into the room in a panic. My insurance had denied her request for more days in the program. Before she interrupted the session, she had spent all morning going up the chain with appeals until the denial was upheld. My doc was distraught. My therapist and I had to switch gears and do crisis management while planning my discharge for the next morning.

It was like opening a door to the most terrifying scene of hurt and death, and then being asked to slam it shut and forget what you saw.

For long time readers of my blog, you know the outcome of that was very bad. It was dangerous to discharge me at that time. But because “the host personality” was not suicidal — well, obviously I didn’t need 24 hour care. I wound up inpatient at a local psychiatric hospital back home immediately — I didn’t even last 24 hours before falling victim to the suicide programming. Thanks, Independence Blue Cross/Magellan Behavioral Health!

After the guidelines were written, once again I hit an obstacle in my outpatient therapy. I returned to Sheppard Pratt for my 3rd admission. At that time, I simply expected the worst case scenario was about to repeat. I still had the same insurance, so why wouldn’t it be the same outcome? I arrived on the unit in a dissociated state, going through the motions of admission, reading the program handouts, rules, and schedule. All the while preparing myself to discharge home in a day or two. Imagine my surprise when I spent 6 weeks there without issue.

During that admission, I realized first-hand how much work the ISSTD had put into providing proper care for us and other survivors with DID. They were using the proposed treatment guidelines in the program. I learned so much about actual skills I could apply to DID-specific symptoms. After 11 years of therapy and 7 over inpatient admissions (4 to DID programs), I finally felt like I had control over the dangerous storm that can be kicked up during this work.

For the purpose of this post, I’m not even going to touch #2. I’ve spoken on my twitter openly about my disgust for the politics in APA preventing updates to the DSM-5 and DSM-5-TR.

Instead, let’s talk about functional multiplicity. This is a term that originated online to mean improving internal communication, cooperation, and collaboration among parts. The clinical term for this is “integrated functioning” or sometimes just referenced as the process of integration.

Fusion, on the other hand, is an optional add-on that occurs as a final step of integration. It’s not for everyone and that’s ok. This is clear in the ISSTD guidelines. Here’s the official differentiation between the two:

“Integration is a process, as opposed to an actual event, that begins as soon as DID-focused therapy begins. To view integration simply as a time when all the internal parts come together to form a unified self does not do justice to the process.”

-Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook

Fusion is two alters coming together to form a single state.

-Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook

In a nutshell, the ISSTD supports “functional multiplicity” or “integration” or whatever you want to call it (and it’s ok to call it whatever makes sense for you). This is Phase 3 of the Triphasic Model of treatment in the guidelines. So why am I talking about this stance from the plural community that is now 3 years old? A stance that largely seems to be a moot point? Interestingly, as recent as June 2022, these opinions were still being presented to the specialists in the Dissociative Disorders community on behalf of the Plural Positivity World Conference, but now with further expansion.

The presentation included a “clinical formulation” of what someone without trauma, but experiencing themselves multiple, may include, such as:

• Reporting a very high number of alters and subsystems
• Elaborate inner worlds
• Parts who seem to have knowledge/access to inner worlds
• A high number of introjects

Although not exclusive to systems who were ritually abused, this aligns very closely to what occurs in deliberately-created DID/OSDD. Yet, the plural community is presenting to Dissociative Disorder specialists in a way that could be interpreted that a patient who reports the above are endogenic systems (without trauma).

I wish I had a better way to explain my thoughts on this. It makes me uncomfortable, at minimum. There are many more therapists joining the field of treating trauma & dissociation than ever before. ISSTD membership is exploding. A younger therapist with less experience treating DID/OSDD could make a dangerous assumption here for both themselves and a ritually abused person.

Anyway, I’m not here to say that the Plural Positivity World Conference is shit. Or they have no idea what they are talking about. The fact is bad therapy exists. The field is still largely undereducated on Dissociative Disorders. We are making progress attracting new therapists to the field and providing proper education. Yet, things like confusion between integration and fusion is still common. Many therapists still incorrectly believe the condition is rare. And other such myths.

I think it would make more sense to brainstorm with the ISSTD (and associated organizations) on way to improve access to therapy for Dissociative Disorders, including inpatient and residential treatment. Let’s work to help combat misinformation of a complex disorder. Charity and advocacy organizations for those with DID exist across the world already doing this (Beauty After Bruises, Blue Knot Foundation, and First Person Plural to name a few). They’ve already established loud voices among professional and survivors alike. Let’s amplify that. Let’s continue to support the concept of peer support in Dissociative Disorders in a way that is safe and limits the possibility of triggering. Survivors of Incest Anonymous (SIA) is a 12-step group that seems to have a blueprint for safe sharing that is working in their meetings for multiples. Is there something we can do to build off what is working there for people who want an alternative to 12 step programs?

Well, if you’re still here, thanks for reading my extremely long stream-of-consciousness. Please remember these are just our opinions and in no way do we want to come across as villainizing fellow survivor groups. Opinions that we may not agree with nevertheless come from the same poor experiences we have all had in our therapy/healing journeys. The desire to right wrongs and leave this world a better place for future survivors is admirable, and dare I say, imperative to our species growth. Let’s roll with our commonality, survivors and professionals alike, and enact change that is meaningful.