Over the past two decades, psychiatrists and therapists have moved beyond a reflexive belief in fusion therapy as the gold-standard treatment for DID, but many are still convinced that all plurality must fit neatly into the medicalised DID or OSDD-1 model to be valid, even if they are loath to push fusion in the way they used to.

The medical model does fit some systems; nevertheless, it is not universal. Here are three reasons why this kind of thinking doesn’t always work:

  1. Under the structuraldissociation model of DID, people are born without an integrated sense of self; a unitary self-concept arises later in childhood. For people who have experienced severe trauma at a young age, a integrated self-concept never emerges. We don’t know, however, whether other contributors may cause systems to have discrete identities. More research – especially cross-cultural research – is needed to understand how self-concepts change across the lifespan. It’s premature to claim that these interpretations of multiplicity, whether trauma-based or not, are the final word.
  2. Everyone experiences trauma differently, so what may be traumatising for one person may not be for another. For example, verbal abuse may prevent the creation of an integrated self in one case, but not in another. We used to see ourselves as entirely non-trauma-based in part because we didn’t think our traumatic experiences – verbal abuse, emotional neglect, early physical neglect, bullying – were bad enough. Although trauma is associated with more obvious events like rape, war and torture, bullying, psychological abuse and religious indoctrination can also leave lasting scars.
  3. Plurality is not intrinsically pathological. For DID to be diagnosable under the DSM-5, it has to cause significant distress in someone’s life, which is a departure from previous versions that considered the presence of multiple selves a disorder with or without distress. Systems may need help to manage daily life, get along with one another and process traumatic memories, and all these tasks are possible while remaining separate people. The emphasis on an idealised singular self, the treatment of newly formed system-members as ‘alters’ or ‘parts’ of a self that never existed in the first place, and the emphasis on fusion therapy are further reasons for our reluctance to connect our plurality with past traumas. The idea of being a mere ‘dissociated part’, rather than being a proper person with opinions, feelings, values, philosophies and preferences, was and is a bit insulting. We’d like to have our existence acknowledged and work through our traumas; these goals are not mutually exclusive.