Severe dissociative disorders (DD) are associated with high levels of impairment, treatment utilization, and treatment costs, yet relatively little systematic research has focused on treatment for these challenging patients. The goal of this naturalistic observational 30-month follow-up study of an international sample of patients with dissociative disorders was to determine if treatment provided by community providers was associated with improvements in symptoms and adaptive functioning. The patients were diagnosed with dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS). The patients and their therapists completed surveys at study entry and at 6-, 18-, and 30-month follow-up. At the 30-month follow-up, 119 of the original 226 patients completed the surveys. According to patients' reports, they showed decreased levels of dissociation, posttraumatic stress disorder symptoms, general distress, drug use, physical pain, and depression over the course of treatment. As treatment progressed, patients reported increased socializing, attending school or volunteering, and feeling good. According to therapists' reports, patients engaged in less self-injurious behavior and had fewer hospitalizations as well as increased global assessment of functioning scores (American Psychiatric Association, 2000) and adaptive capacities over time. These results suggest that treatment provided by therapists who have training in treating DID/DDNOS appears to be beneficial across a number of clinical domains. Additional research into the treatment of DD is warranted.

There is consensus that an integrated approach which addresses the clinical needs of individuals who have histories of substance abuse and psychological trauma concurrently is an acceptable and preferred approach to treatment. Several integrated models have emerged in recent years. In this paper we first define the concepts of substance abuse and psychological trauma, investigate the relationship between both and proceed to discuss why an integrated approach is most compelling. Finally, we review and critically examine the different integrated models that have been developed in terms of efficacy, effectiveness and empirical evidence. The paper concludes with suggestions on how the field can be improved.

Individuals with dissociative disorders (DDs) are underrecognized, underserved, and often severely psychiatrically ill, characterized by marked dissociative and posttraumatic stress disorder (PTSD) symptoms with significant disability. Patients with DD have high rates of nonsuicidal self‐injury (NSSI) and suicide attempts. Despite this, there is a dearth of training about DDs. We report the outcome of a web‐based psychoeducational intervention for an international sample of 111 patients diagnosed with dissociative identity disorder (DID) or other complex DDs. The Treatment of Patients with Dissociative Disorders Network (TOP DD Network) program was designed to investigate whether, over the course of a web‐based psychoeducational program, DD patients would exhibit improved functioning and decreased symptoms, including among patients typically excluded from treatment studies for safety reasons. Using video, written, and behavioral practice exercises, the TOP DD Network program provided therapists and patients with education about DDs as well as skills for improving emotion regulation, managing safety issues, and decreasing symptoms. Participation was associated with reductions in dissociation and PTSD symptoms, improved emotion regulation, and higher adaptive capacities, with overall sample | d |s = 0.44–0.90, as well as reduced NSSI. The improvements in NSSI among the most self‐injurious patients were particularly striking. Although all patient groups showed significant improvements, individuals with higher levels of dissociation demonstrated greater and faster improvement compared to those lower in dissociation | d |s = 0.54–1.04 vs. | d| s = 0.24–0.75, respectively. These findings support dissemination of DD treatment training and initiation of treatment studies with randomized controlled designs.

Little empirical evidence exists about the treatment of dissociative identity disorder and dissociative disorder not otherwise specified. Thus, we must rely on the clinical literature, which advocates a staged course of treatment. A survey of 36 international experts in the treatment of dissociative disorder (DD) was conducted to learn what treatment interventions they recommended at each stage of treatment. These highly experienced therapists recommended a carefully staged treatment consisting of three phases. In the initial phase, they advocated emphasizing skill building in development and maintenance of safety from dangerousness to self or others and other high-risk behaviors, as well as emotion regulation, impulse control, interpersonal effectiveness, grounding, and containment of intrusive material. In addition, they recommended specific trauma-focused cognitive therapy to address trauma-based cognitive distortions. They uniformly recommended identifying and working with dissociated self states beginning early in treatment. They advised the use of exposure or abreaction techniques-albeit modified to not overwhelm these complex dissociative patients-balanced with core, foundational interventions for the middle stage. The last stage of treatment is less clearly delineated and more individualized. Unification of self states appears to occur in only a minority of patients with DD. This study provides directions to pursue for future training and research on DD.

Background: Interpersonal trauma and trauma-related disorders cost society billions of dollars each year. Because of chronic and severe trauma histories, dissociative disorder (DD) patients spend many years in the mental health system, yet there is limited knowledge about the economic burden associated with DDs. Objective: The current study sought to determine how receiving specialized treatment would relate to estimated costs of inpatient and outpatient mental health services. Method: Patients’ and individual therapists’ reports of inpatient hospitalization days and outpatient treatment sessions were converted into US dollars. DD patients and their clinicians reported on use of inpatient and outpatient services four times over 30 months as part of a larger, naturalistic, international DD treatment study. The baseline sample included 292 clinicians and 280 patients; at the 30-month follow-up, 135 clinicians and 111 patients. Missing data were replaced in analyses to maintain adequate statistical power. The substantial attrition rate (>50%) should be considered in interpreting findings. Results: Longitudinal and cross-sectional analyses of cost estimates based on patient reported inpatient hospitalization significantly decreased over time. Longitudinal cost estimates based on clinician-reported outpatient services also significantly decreased over time. Cross-sectional cost estimates based on patient and clinician reported inpatient hospitalization were significantly lower for patients in later stages of treatment compared to those struggling with safety and stabilization. Cross-sectional cost estimates based on clinician-reported outpatient services were significantly lower for patients in later stages of treatment compared to those in early stages. Conclusions: This pattern of longitudinal and cross-sectional reductions in inpatient and outpatient costs, as reported by both patients and therapists, suggests that DD treatment may be associated with reduced inpatient and outpatient costs over time. Although these preliminary results show decreased mental health care utilization and associated estimated costs, it is not clear whether it was treatment that caused these important changes.