Supporting Clients with Dissociative Identity Disorder: An Affirming Approach through Attachment and Relational Therapy for Trans+ and Queer Clients

Introduction

Dissociative Identity Disorder (DID), previously known as multiple personality disorder and not to be confused with multiplicity or plural identities, is a multifaceted and often misrepresented condition that typically originates from severe early childhood trauma. Central to understanding and effectively treating DID is the recognition that attachment disruptions and relational trauma are key factors in shaping the dissociative identities within a person. The fragmentation of self is not merely a psychological phenomenon but a survival response to overwhelming circumstances, particularly when those experiences are relational and involve caregivers. As a psychotherapist who works with trans*, nonbinary, and queer adults, adopting an attachment and relational lens is crucial in addressing these deep wounds. This perspective enables the therapist to support the client’s journey toward healing in a way that honours both their lived experiences and the intricate relationship between trauma and dissociation.

For trans* and queer individuals, the intersections of trauma, identity, and dissociation often carry additional layers of complexity. Marginalized identities, including gender nonconforming and queer identities, are frequently met with societal and familial rejection, compounding the original attachment wounds. A trauma-informed and anti-oppressive approach is vital in creating a therapeutic space where clients feel safe and affirmed in both their multiplicity and their gender identities. By acknowledging and addressing these systemic oppressions, therapists can better support their clients in reclaiming autonomy and self-compassion.

This blog post delves into how attachment theory and relational approaches can inform therapeutic interventions for clients with DID. Using a trauma-informed and intersectional framework, we will explore practical strategies for working with dissociative parts in trans*, nonbinary, and queer clients. Additionally, we will reflect on how therapists can cultivate safety, foster connection, and promote integration in therapy, particularly in light of the unique challenges that arise for clients navigating both multiplicity and marginalized identities.

Understanding Dissociative Identity Disorder through Attachment Theory

Attachment theory provides an essential framework for understanding how early relational disruptions contribute to the development of Dissociative Identity Disorder (DID). At its core, attachment theory posits that children form internal working models of relationships based on their early experiences with caregivers. These models shape not only how they relate to others but also how they perceive themselves. When children experience chronic neglect, abuse, or inconsistent caregiving, particularly from attachment figures, they are left without a secure base from which to explore the world or regulate their emotions. As a result, dissociation emerges as a survival strategy, with different identity states developing to contain unbearable emotions and memories that cannot be processed in the moment (Howell, 2011; Sinason, 2017).

The formation of dissociative parts is both an emotional and cognitive response to relational trauma. These distinct identity states, or alters, often hold conflicting memories, feelings, and perceptions that mirror the fragmented nature of the child’s early relationships. In situations where caregivers are both the source of love and protection as well as fear and harm, children may form fragmented identities to manage this dissonance. These alters serve specific functions—some may hold painful memories to protect the host personality, while others may embody anger, helplessness, or even resilience. However, this adaptive mechanism, while crucial for survival in childhood, leads to significant challenges in adulthood, as the person may experience disruptions in their sense of self, memory, and relationships (Howell, 2011).

Attachment disruptions are central to understanding the development of DID, as the attachment system—responsible for regulating emotional security—is profoundly compromised in these individuals. John Bowlby’s work on attachment highlights the importance of secure caregiving relationships in the development of a cohesive self. When these relationships are marked by fear, inconsistency, or outright abuse, the child’s capacity to form a stable sense of self is undermined. Instead, the child must develop dissociative parts as a means of psychological protection (Howell, 2011; Tohid & Rutkofsky, 2023). This results in disorganized attachment patterns, where the client simultaneously craves connection yet fears it, leading to internal fragmentation.

For therapists working with clients who have DID, it is essential to recognize that the dissociative states are not random but are often deeply intertwined with the client’s attachment experiences. Each alter may represent an aspect of the client’s relational world—some may embody the vulnerable child seeking love and care, while others may hold the rage or terror that the client was unable to express in their early relationships. Understanding this dynamic allows therapists to approach dissociative parts with empathy, recognizing that these identities were formed out of necessity to protect the client from overwhelming pain and fear (Howell, 2011; Frankish & Sinason, 2017).

Moreover, disorganized attachment patterns are not just emotional in nature; they are neurobiologically encoded. Research has shown that early attachment trauma impacts the developing brain, particularly in regions associated with emotional regulation and memory, such as the hippocampus and amygdala. Clients with DID often show altered brain activity in these regions, which further complicates their ability to integrate memories and emotions across dissociative states (Dorahy et al., 2014). This neurobiological component underscores the importance of creating a therapeutic environment that feels emotionally safe and consistent, as it helps to mitigate the hypervigilance and mistrust often present in clients with disorganized attachment histories.

Applying Attachment Theory in Therapy

Applying an attachment-based framework to the treatment of DID requires a focus on rebuilding the client’s capacity for secure attachment within the therapeutic relationship. The therapist must serve as a “secure base,” offering consistent, predictable, and non-judgmental care that contrasts with the client’s early experiences of caregiving. This involves being attuned to the client’s emotional states, responding with empathy, and allowing space for dissociative parts to emerge without fear of rejection or shame (Howell, 2011; Tohid & Rutkofsky, 2023).

In practice, this means acknowledging the different roles that dissociative parts play within the client’s internal system and understanding how these roles are tied to the client’s early attachment experiences. For example, a part that holds feelings of rage may have emerged in response to an abusive caregiver, while a childlike part may still long for the love and safety that was never consistently provided. Therapists must carefully navigate these dynamics, offering validation to all parts of the client’s identity and helping them understand how their dissociative system served to protect them (Frankish & Sinason, 2017).

Additionally, working through attachment-related trauma involves helping clients rebuild their internal working models of relationships. Many clients with DID have internalized beliefs that they are unworthy of love or that relationships are inherently dangerous. These internal models must be challenged and reframed within the safety of the therapeutic relationship. Over time, as the therapist provides a consistent and secure attachment, clients can begin to internalize new, healthier relational patterns that allow for greater integration of their dissociative parts (Howell, 2011).

For trans* and queer clients, this process is further complicated by societal attachment disruptions—such as family rejection or societal invalidation—that compound their early relational trauma. These clients often struggle with intersecting issues of identity and belonging, making it even more essential for therapists to adopt an anti-oppressive framework that affirms their gender and sexual identities. By doing so, therapists help trans* and queer clients build new, affirming attachment relationships that honour all aspects of their identity, both dissociative and otherwise (Howell, 2011; Tohid & Rutkofsky, 2023).

Understanding Relational Approaches to Supporting Clients with DID

Relational therapy centres the therapeutic relationship as a primary vehicle for healing, making it an effective approach for clients with Dissociative Identity Disorder (DID). This approach is rooted in the idea that the relationship between therapist and client mirrors the early relational experiences that shaped the client’s attachment patterns. For clients with DID, whose identities have fragmented as a result of chronic trauma and relational disruption, the therapeutic relationship offers an opportunity to experience safety and trust in a way that may have been absent in their early development (Howell, 2011). The therapist becomes a model for secure attachment, providing consistent, non-judgmental care that helps clients rebuild their ability to trust others and, ultimately, themselves.

Co-creating Meaning in Therapy

In relational therapy, healing is co-constructed between the therapist and client. This is particularly crucial for individuals with DID, who often experience internal fragmentation not only in their identities but also in their ability to make sense of their experiences. Each dissociative part, or alter, may hold different perspectives, memories, and emotions that need to be acknowledged and integrated into a coherent narrative. The therapist’s role is to help the client bring these disparate parts into dialogue with one another, co-creating meaning from the client’s complex internal world (Howell, 2011).

Relational therapy allows for this meaning-making process to happen within the therapeutic relationship itself. By engaging with the client’s dissociative parts and helping them communicate, the therapist fosters an environment where the client can begin to understand how each part functions in their overall system. Howell (2011) highlights the importance of coconsciousness, a state in which multiple parts of the client’s identity are aware of each other’s presence and experiences. Coconsciousness is a critical goal in the therapeutic process, as it allows for greater harmony within the system without the need for complete integration or fusion of identities.

The Therapist as a Secure Base

A core tenet of relational therapy is the idea that the therapist acts as a “secure base” from which the client can explore their internal world. For clients with DID, whose early attachment relationships were marked by fear, inconsistency, or outright abuse, the therapist provides a new relational experience—one that is grounded in safety, stability, and care (Howell, 2011). This consistent presence helps to counteract the client’s internalized beliefs that relationships are inherently dangerous or that they are unworthy of love and support. Over time, the client begins to internalize this new relational model, which supports the healing of attachment wounds and the reintegration of dissociative parts.

This process is particularly important for trans* and queer clients, who may have experienced additional layers of relational trauma due to societal rejection or familial invalidation of their gender or sexual identity. The relational therapist must be acutely aware of the societal context in which their client’s dissociation developed, particularly in terms of how external oppression interacts with internal fragmentation. For example, a client may have parts that internalize societal transphobia or homophobia, resulting in self-destructive behaviours or a rejection of their own identity. The therapist’s role in these cases is to affirm the client’s gender identity and provide a safe space where all parts of the client, including those that may hold self-critical or shame-based beliefs, can feel seen and validated (Tohid & Rutkofsky, 2023).

Fostering Communication Between Dissociative Parts

An essential component of relational therapy is helping clients with DID foster communication between their dissociative parts. Dissociative parts often operate in isolation from one another, with limited or no awareness of each other’s existence. This fragmentation can lead to significant challenges in the client’s ability to function, as vital information—such as memories or emotional responses—may be “locked” in certain parts of the system and inaccessible to the host personality (Howell, 2011).

The therapist’s role in fostering communication between parts is to encourage dialogue and cooperation within the client’s internal system. This requires careful attunement to the client’s shifting states, as different parts may emerge in response to different triggers or relational dynamics. For instance, one part may hold traumatic memories of abuse, while another part may function as a protector, shielding the client from emotional pain by maintaining distance from those memories. By facilitating communication between these parts, the therapist helps the client build internal cohesion, reducing the need for dissociation as a defensive strategy (Howell, 2011).

For clients who identify as gender diverse, the multiplicity of their dissociative parts may resonate with the fluidity of their gender identity. In these cases, it is crucial for the therapist to honour the client’s multiplicity, both in terms of their dissociative identities and their gender identities. Rather than pushing for a singular, cohesive sense of self, relational therapy embraces the complexity and fluidity of identity, allowing clients to explore how their different parts contribute to their overall experience of self (Tohid & Rutkofsky, 2023).

The Role of Empathy and Mutual Recognition

A cornerstone of relational therapy is the therapist’s ability to engage in mutual recognition with the client. This concept, drawn from object relations theory, refers to the therapist’s capacity to see and validate the client’s subjective experience while also maintaining their own subjectivity (Benjamin, 2018). In the context of DID, mutual recognition is particularly important, as it allows the therapist to engage with each dissociative part as a distinct subject, worthy of recognition and empathy.

Mutual recognition fosters a sense of dignity and agency in the client, helping them to feel that all parts of themselves are valuable and deserving of care. For clients with DID, who may have internalized feelings of shame or worthlessness, this recognition is a powerful counterbalance to the fragmentation and isolation they experience. Moreover, for trans* and queer clients, mutual recognition extends to their gender and sexual identities, reinforcing the importance of an affirming and inclusive therapeutic space (Howell, 2011; Tohid & Rutkofsky, 2023).

Practical Applications for Trans*, Nonbinary, and Queer Clients

When working with trans*, nonbinary, and queer clients who have Dissociative Identity Disorder (DID), it is vital to adopt an intersectional approach that considers not only their experiences of trauma but also the impact of their gender identity on their mental health. These clients often face compounded layers of societal and relational trauma, which shape both their dissociative identities and their understanding of self. Therapy, therefore, must be a space where all aspects of their identity are validated and integrated into the healing process. Below are key strategies that can help therapists provide effective, affirming care to trans*, nonbinary, and queer clients with DID:

Affirming Gender Identity and Dissociative Parts

For trans* and nonbinary clients, the relationship between their gender identity and dissociative parts can be complex. Different parts may have conflicting feelings about gender, especially if the client has experienced familial rejection or internalized transphobia. These dissociative parts may hold different narratives about the client’s identity, some of which may align with the client’s gender, while others may reflect the gender assigned at birth due to early relational experiences.

For example, one part may identify strongly with the client’s gender identity, while another part might cling to the gender identity they were raised with, especially if it was tied to their sense of safety or acceptance during childhood. These dynamics can create internal conflicts, where parts of the self feel at odds with one another. In therapy, it is crucial for the therapist to affirm the client’s gender identity and explore how each part relates to it. This means validating all parts of the client, including those that may hold onto past identities or express discomfort with gender transition (Tohid & Rutkofsky, 2023).

By affirming the diversity of experiences within the client, therapists help build trust and create a space where each part of the client feels seen. This is particularly important for trans* and nonbinary clients who may have faced invalidation not only in their families but also in the wider world. Therapy becomes a place where all aspects of the client’s identity, including gender and dissociative parts, are respected and honoured.

Addressing Internalized Oppression

Trans* and queer clients often internalize oppressive societal messages about their worth, which can manifest in dissociative parts that hold self-destructive or shame-based beliefs. These beliefs may stem from a lifetime of navigating environments where their identity was marginalized, leading to the development of protective parts that internalize shame or self-criticism in an attempt to avoid further harm.

According to Howell (2011), working with these parts requires a gentle, compassionate approach. These parts may have developed as a defense mechanism, believing that by holding onto self-destructive beliefs, they are protecting the client from external rejection or punishment. For example, a part may internalize transphobia or homophobia as a way of preventing the client from expressing their true self, thereby reducing the risk of societal backlash or familial rejection.

Therapists can help clients unlearn these harmful beliefs by gently challenging the narratives held by these parts and fostering self-compassion. This process involves helping clients recognize that these beliefs, while protective in the past, no longer serve their well-being. By validating the pain and fear that these parts carry, therapists can guide clients towards a more compassionate and affirming relationship with themselves, encouraging parts to release the need for self-punishment (Tohid & Rutkofsky, 2023; Howell, 2011).

Fostering Connection and Communication Between Parts

A key therapeutic goal when working with clients with DID is fostering communication and cooperation between dissociative parts. Clients with DID often experience their parts as isolated from one another, with limited awareness of each other’s experiences. This internal fragmentation can lead to difficulties in functioning, as important emotions, memories, or information may be inaccessible to the part currently in control.

For trans* and queer clients, this fragmentation may also extend to their gender identity. Different parts may have different understandings of the client’s gender, and fostering communication between these parts can help create a more integrated sense of self. Howell (2011) describes how coconsciousness—when multiple parts are aware of each other’s presence and experiences—can lead to greater internal harmony and reduce the need for dissociation as a defense mechanism.

Therapists can guide clients in listening to the voices of their parts, fostering a sense of cooperation and mutual support between them. This process may involve facilitating dialogue between parts that hold conflicting views on gender or other aspects of identity. For example, a part that is deeply connected to the client’s assigned gender at birth may need to communicate with a part that embodies the client’s chosen gender identity. Through this dialogue, parts can begin to understand and support each other, creating a sense of internal unity that allows the client to navigate both their dissociative identities and their gender identity with greater ease (Howell, 2011).

Trauma-Informed Care for Complex Identities

Clients with DID often have histories of profound relational trauma, including childhood abuse, neglect, and significant attachment disruptions. For trans* and queer clients, these traumas are often compounded by societal discrimination, making it essential for therapists to adopt a trauma-informed approach that is also sensitive to issues of gender and sexual identity.

In a trauma-informed framework, safety, trust, and empowerment are paramount. Therapists must create a therapeutic space where clients feel secure in exploring their dissociative parts without fear of judgment or retraumatization. This includes being aware of how societal trauma—such as transphobia, homophobia, or racism—intersects with the client’s personal trauma, and ensuring that therapy remains a place of safety and affirmation (Tohid & Rutkofsky, 2023; Howell, 2011).

Trauma-informed care also involves recognizing that dissociation was a survival strategy for the client and honouring the adaptive function it served. Rather than pathologizing dissociation, therapists can frame it as a creative response to unbearable circumstances. By helping clients understand how their dissociative parts helped them survive, therapists foster a sense of gratitude and compassion for these parts, encouraging clients to integrate their identities in a way that supports healing and growth.

Working with trans*, nonbinary, and queer clients who have DID requires an intersectional, trauma-informed approach that affirms both their dissociative identities and their gender and sexual identities. By validating the client’s gender identity, addressing internalized oppression, fostering communication between dissociative parts, and creating a safe, trauma-informed therapeutic environment, therapists can help clients navigate the complexities of both multiplicity and marginalized identities. Through this compassionate and affirming approach, therapists support clients in healing from trauma, integrating their dissociative parts, and embracing their full selves.

Conclusion

Supporting clients with DID through attachment and relational approaches offers compassionate and affirming ways to healing, particularly for trans*, nonbinary, and queer clients. By addressing early attachment wounds and fostering communication between dissociative parts, therapists can help clients navigate multiplicity with greater self-awareness and self-compassion. The relational aspect of therapy provides a model for secure attachment, allowing clients to build trust in themselves and others as they work toward greater integration. This holistic approach, grounded in empathy and attunement, honours both the complexity of dissociation and the resilience of marginalized identities, offering a path to healing that embraces the full scope of each client’s lived experiences.

Continue the Convo

If the ideas in this blog resonate with you, I warmly invite you to connect with me. Whether you’re a therapist seeking guidance on treating dissociative identity disorder or someone navigating multiplicity and looking for support, I’m here to help. You may book individual therapy sessions or peer consultations online. Be sure to bookmark this blog for future insights, reflections, and updates.

References

Dorahy, M. J., Brand, B. L., Sar, V., et al. (2014). Dissociative identity disorder: An empirical overview. Australian and New Zealand Journal of Psychiatry, 48(5), 402-417. https://doi.org/10.1177/0004867414527523

Frankish, P., & Sinason, V. (2017). Holistic therapy for people with dissociative identity disorder. Routledge.

Howell, E. F. (2011). Understanding and treating dissociative identity disorder: A relational approach. Routledge.

Tohid, H., & Rutkofsky, I. H. (2023). Dissociative identity disorder: Treatment and management. Springer.