Systemic Case Formulation, Individualized Process Monitoring, and State Dynamics in a Case of Dissociative Identity Disorder

Abstract

Objective: The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder.Methods: A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the client's dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the client's individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions.Results: For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy.Conclusion: By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and toward a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.

The Therapy Process Questionnaire ‐ Factor analysis and psychometric properties of a multidimensional self‐rating scale for high‐frequency monitoring of psychotherapeutic processes

“…A further point is a therapeutic one: Daily self‐assessments—especially when combined with electronic diaries—activate the reasoning on one's own thoughts, feelings, and behaviour (mindfulness and metacognition) and by this support self‐regulation and auto‐catalyse developmental processes. This is a mechanism of change that is reported by many patients and therapists and is also documented in case studies (e.g., Kratzer et al, ; Schiepek, Eckert, Aas, Wallot, & Wallot, ; Schiepek, Stöger‐Schmidinger, Aichhorn, Schöller, & Aas, ; Schiepek, Aichhorn, Schöller, & Kronberger, ) and in a controlled study on the effects of process monitoring on chronically addicted inpatients (Patzig & Schiepek, ). More systematic studies are needed on the psychological effects of continuous self‐reports and on the synergistic effects between monitoring other mechanisms of change.…”

Real-Time-Monitoring in der Behandlung komplexer posttraumatischer Belastungsstörung: Ein Fallbericht

“…Dynamische Prozesse lassen sich mit der Methode des Real-Time-Monitoring bei ausreichend hoher und äquidistanter Messfrequenz angemessen erfassen, analysieren und visualisieren [Schiepek et al, 2016a[Schiepek et al, , 2016b. Das Real-TimeMonitoring erlaubt es, mögliche Kontextspezifitäten von Symptomkonstellationen zu erfassen, Rückschaufehler bei der Bewertung von Therapieverläufen zu minimieren und so gewonnene Erkenntnisse direkt für ein Feedback von Therapieprozessen zu nutzen [Schiepek und Aichhorn, 2013].…”

“…Zudem ist eine Veränderung in der Komplexität einer Dynamik oft selbst ein wesentlicher Indikator für klinische Veränderungen, z.B. wenn es um die Veränderung emotionaler Instabilität bei Borderline-und/oder dissoziativen Störungsbildern geht [Schiepek et al, 2016a].…”

“…Auch der für den pathologischen Narzissmus typische dynamische Prozess des Oszillierens zwischen einem übermäßig stark ausgepräg-ten Selbstwertgefühl und extremen Minderwertigkeitsgefühlen [Morf und Rhodewalt, 2001] macht eine empirische Erfassung und theoretische Modellierung der Systemdynamik erforderlich [Schiepek et al, 2016a]. Ein diagnostisches Vorgehen, das auf der Logik eines Vergleichs von Prä-und Post-Messungen und damit implizit auf der Annahme linearer Veränderungsprozesse beruht, ist nicht in der Lage, menschliches Erleben und Verhalten in seiner Komplexität und Nichtlinearität zu erfassen [Molenaar, 2013].…”

“…Hochfrequent und äquidistant erfasste Zeitreihen und deren Analyse erlauben darüber hinaus die Identifizierung von wiederkehrenden Mustern, Phasen kritischer Instabilität und Musterwechseln im Therapieverlauf [Schiepek und Strunk, 2010;Schiepek et al, 2015Schiepek et al, , 2016a. Die Psychotherapie kann dann als Veränderung der Übergangsmuster zwischen «states of mind» konzeptualisiert werden [Beirle und Schiepek, 2002].…”