Assessing therapeutic change in patients with severe dissociative disorders: the progress in treatment questionnaire, therapist and patient measures

Figures & data

Table 1. Relationships between abilities assessed by PITQ-t, PITQ-p, and expert intervention targets.

Interventions that experts endorse using‘very often’ during at least one stage of treatment^a	PITQ-t items assessing abilitytargeted by intervention^b	PITQ-p items assessing abilitytargeted by intervention^c
Establishing safety	1, 2	12, 18, 19
Establishing/repairing alliance	5	2
Teaching/practicing grounding	8	7, 28
Educating about disorders/treatment	4	1
Diagnosing psychiatric illnesses	*	*
Teaching/practicing self-care	14	14
Developing healthy relationships	17	17
Affect tolerance and impulse control	11, 12	10, 11
Stabilizing from current stressors	6	4, 5
Teaching/practicing containment	7	6
Ego strengthening activities	3, 20	22, 24
Acceptance of DD diagnosis	4	1
Processing when and why dissociation occurs	15, 16	15, 16
Assess response to medications	*	*
CBT focused on cognitions	3, 9, 13, 20, 21, 24	3, 8, 13, 22, 23, 24, 27, 28
Awareness of emotion	10	9
Processing patient’s reactions to therapy	5	2
Stabilizing following intrusions from alleged perpetrators	6	4, 5
Cooperation with/between parts	26, 27	29, 32
Teaching/discussing attachment	^ (17, 20, 21)	^ (17, 22, 23)
Identifying/working with parts	25	30
Discussing therapeutic relationship	5	2
Awareness of body sensation	10	9
Exposure to traumatic memories/abreaction	18, 23	20, 26

^a Interventions endorsed by at least 45% of experts; Brand et al. (2012).

^b PITQ-t items 4–29 (see Table 5 for item content) are taken verbatim from PITQ items; PITQ-t items 1–3 rephrase the content of the remaining 3 PITQ items for clarity.

^c See Table 7 for PITQ-p item content.

* Not a patient-targeted ability.

^ PITQ family of measures does not explicitly query, but is very closely related to (items in parentheses).

Table 2. Therapist characteristics.

	%	(n)	M	SD	Min	Max
Gender
Female	83	(147)
Male	17	(30)
Primary Therapist Orientation
Cognitive-Behavioural	12	(22)
Psychodynamic	44	(77)
Family Systems	5	(9)
Humanistic/Experiential	14	(24)
Other	25	(45)
Treatment Settings^a
Private Practice	75	(133)
Clinic/Hospital Outpatient	31	(55)
Hospital Inpatient/Partial	4	(7)
School	2	(3)
Forensic	1	(2)
Other	7	(13)
Therapist Experience
Years in Practice		(177)	17.75	9.20	1	44
Years Treating DD		(177)	10.63	7.78	1	34
Years Treating Trauma		(177)	15.48	8.64	1	44

^a Multiple settings could be indicated.

Table 3. Patient characteristics.

	%	(n)	M	SD	Min	Max
Gender
Female	89	(157)
Male	11	(19)
Transgender	.6	(1)
Age			41.42	10.75	19	68
Race/Ethnicity
Caucasian	84	(148)
Black	3	(6)
Latino/Hispanic	5	(8)
Asian	.6	(1)
Other	8	(14)
Therapist-Reported Patient Abuse History
Was the patient neglected as a child?	67	(118)
Was the patient emotionally or psychologically abused as a child?	86	(153)
Was the patient physically abused as a child?	67	(116)
Did the patient witness domestic violence as a child?	41	(73)
Was the patient sexually abused as a child?	83	(147)
Therapist-Assigned DD Diagnosis
Dissociative Identity Disorder	75	(133)
Dissociative Disorder Not Otherwise Specified (DSM-IV-TR)	23	(41)
Other Specified DD (DSM 5)	2	(3)

Table 4. Descriptive statistics.

	M	SD	Min	Max
Measures
PITQ-t	48.86	12.39	14.83	82.07
PITQ-p	44.25	14.67	11.56	80.63
PCL-C	61.37	11.19	29.00	85.00
DES	42.00	20.08	3.21	86.07
DERS	119.41	21.53	61.00	171.00
WHOQOL-BREF Psychological Domain	8.77	2.47	4.00	16.00
WHOQOL-BREF Social Domain	10.33	3.20	4.00	17.33
Other variables
Self-harm^a	3.06	5.56	0	30
Dangerous behaviour ^b	1.03	3.03	0	30
Impulsive^c	4.11	6.52	0	30
Positive emotions^d	12.86	9.45	0	30

^a ‘On how many of the past 30 days did you purposefully hurt yourself (for example, cut yourself)?’

^b ‘How many times in the past 30 days have you done something that in retrospect was dangerous enough to kill you?’

^c ‘On how many of the past 30 days did you do something very impulsive (spending sprees, lost your temper and really shouted at someone, threatened to or actually harmed someone else, driven far too fast, done anything against the law, etc.)?’

^d ‘On how many of the past 30 days did you feel some good feelings even if it was for a brief period (e.g. happiness, contentment, joy)?’

Table 5. PITQ-t item-total statistics.

	Corrected Item-Total Correlation	Cronbach’s Alpha if Deleted
1. (R) Engages in self-injurious behaviour (e.g. cutting, burning) or suicide attempts	.37	.91
2. (R) Engages in potentially self-damaging acts such as abusing substances, purging, shoplifting, driving unsafely	.24	.91
3. (R) Identity is strongly tied to being a victim of abuse	.09	.92
4. Understands that they have a dissociative disorder (DD) and generally acknowledges that this diagnosis is accurate	.40	.91
5. Able to maintain a strong treatment alliance and, when there are disruptions to the alliance, able to work productively to repair it	.46	.91
6. Knows and uses self-soothing strategies (e.g. any type of calming strategy that is not used explicitly to contain PTSD symptoms or prevent dissociation) when they are needed	.56	.90
7. Knows and uses containment strategies (e.g. hypnotic or imagery techniques used to contain intrusive PTSD symptoms) when they are needed	.54	.90
8. Knows and uses grounding techniques to prevent self from going numb, zoning out, having amnestic lapses when they are needed (e.g. techniques such as muscle contractions, movement, or touching an object to avoid dissociating)	.47	.91
9. Keeps oriented in the present (i.e. does NOT get confused about past and present)	.46	.91
10. Shows good awareness of his/her emotions and feels his/her body sensations	.68	.90
11. Shows good affect tolerance (can feel emotions without getting overwhelmed)	.69	.90
12. Shows good impulse control (e.g. can feel angry or depressed without acting it out)	.50	.91
13. Is aware that the trauma was not his/her fault	.50	.91
14. Manages daily functioning well (e.g. managing hygiene, maintaining a home, paying bills)	.37	.91
15. Has continuous awareness of behaviours, that is, the patient does not report time loss or other signs of amnesia (e.g. no behaviours done out of their awareness, no possessions for which they can’t recall how they obtained them, etc.)	.55	.90
16. Able to deal with stressful situations without dissociating	.61	.90
17. Able to maintain healthy personal and professional relationships with other people	.61	.90
18. Able to experience grief stemming from trauma-related losses	.56	.90
19. Has found ways to make life feel meaningful and rewarding	.66	.90
20. Has a generally positive view of him/herself	.69	.90
21. Has a generally positive view of other people	.56	.90
22. Able to experience sexual intimacy without difficulties such as intense shame, flashbacks or dissociation and with some pleasure	.23	.91
23. Able to tolerate doing trauma focused abreactive work (i.e. able to express intense affect about past trauma, talk in detail about traumatic events, as well as explore the meaning, impact, and conflicts related to trauma)	.52	.91
24. Has awareness that all dissociated self-states are part of himself/herself and share one body (i.e. does not believe one alter can ‘kill’ another and survive the suicide)	.41	.91
25. Knows parts and understands their functions (i.e. what purposes they serve, such as helping manage feelings related to trauma)	.56	.90
26. Shows good internal communication and cooperation among parts	.63	.90
27. Has reliable co-consciousness with all parts	.58	.90
28. Has integrated at least two parts/self-states	.33	.91
29. Has integrated all parts and no longer experiences amnesia, voices, passive influence or other signs of identity fragmentation	.37	.91

(R) = reverse scored.

Table 6. PITQ-t and PITQ-p correlations with measures and variables of interest and significance of comparative strength of PITQ-t and PITQ-p correlations with measures and variables of interest.

	PITQ-t	PITQ-p	rtp	t	df	p	99% CI
Measures
PCL-C	−.41**	−.47**	.50**	.81	174	.42	−.12–.22
DES	−.29**	−.42**	.50**	1.97	174	.05	−.04–.31
DERS	−.35**	−.67**	.50**	5.51	174	<.001**	.16–.48
WHOQOL-BREF Psychological	.45**	.64**	.50**	−3.21	174	<.001**	−.35–-.04
WHOQOL-BREF Social	.22**	.28**	.50**	−.76	174	.45	−.24–.13
Other variables
Self-harm^a	−.37**	−.34**	.50**	−.49	174	.62	−.21–.14
Dangerous behaviour^b	−.31**	−.20**	.50**	−1.40	174	.16	−.29–.09
Impulsive^c	−.23**	−.21**	.50**	−.22	174	.83	−.20–.17
Positive emotions^d	.21**	.31**	.50**	−1.39	174	.17	−.28–.09

^a–d: See Table 4.

* p < .05 (2-tailed), ** p < .01 (2-tailed), r_tp = correlation between PITQ-t and PITQ-p.

Table 7. PITQ-p item-total statistics.

	Corrected Item-Total Correlation	Cronbach’s Alpha if Deleted
1. I have been diagnosed with a dissociative disorder and agree that this diagnosis is correct	.17	.92
2. I collaborate well with my therapist and, when there are problems between us, I talk to my therapist about them so that we can resolve them together	.36	.92
3. I am compassionate and fair with myself, that is, I respond to myself with as much empathy as I would show someone else in the same situation	.52	.92
4. I’m aware of the thoughts, feelings, and body sensations that indicate I’m getting anxious or overwhelmed	.44	.92
5. I use relaxation techniques (such as relaxation exercises, safe place imagery, music) to safely help myself relax and feel better when I begin to get anxious or overwhelmed	.54	.92
6. I manage intrusive memories and flashbacks using containment strategies (imagery techniques used to contain and manage PTSD symptoms)	.50	.92
7. I use grounding techniques when I need to prevent myself from going numb, zoning out, or losing time (Examples: focus on my surroundings, pay attention to my five senses, tense and relax my muscles)	.45	.92
8. If I begin to confuse the past with the present, I notice this and work to see differences between how things are now versus how they were when I was being traumatized	.54	.92
9. I am aware of my emotions and body sensations	.58	.92
10. I am able to feel my emotions without getting overwhelmed	.60	.92
11. I am aware of, able to think about, and can control my impulses (Example: I can feel angry or depressed without doing something unhealthy)	.52	.92
12. I reach out to treatment providers if I have difficulty controlling severe unhealthy impulses despite using recovery-focused coping skills (e.g. grounding, past vs. present, containment)	.41	.92
13. I know that the traumas that I experienced were not my fault	.59	.92
14. I manage everyday life well (Examples: I regularly eat, bathe, pay bills on time, etc.)	.58	.92
15. I am able to account for all that I do that is, I don’t ‘lose time’ or find evidence of having done something I do not remember	.55	.92
16. I am able to deal with stressful situations without dissociating	.57	.92
17. I am able to maintain healthy personal and professional relationships	.57	.92
18. I value my physical well-being, and do not do things that hurt my body (Examples: I don’t cut or burn my body or attempt suicide)	.53	.92
19. I value my health and do not do things that put me at risk (Examples: I do not abuse drugs, throw up after eating, drive unsafely, have unsafe sex, etc.)	.48	.92
20. I am able to experience sadness and grieve the losses related to trauma	.62	.92
21. Life feels meaningful and rewarding	.58	.92
22. I have a generally positive view of myself	.64	.92
23. I have a generally positive view of other people	.37	.92
24. My sense of myself includes many important things beyond having been traumatized	.57	.92
25. I am able to experience sexual intimacy without intense shame, flashbacks, or dissociation, and with some pleasure	.27	.92
26. I can explore the meaning and impact related to the traumas I experienced, I can feel and express the emotions related to these traumas	.59	.92
27. All parts of myself know that we are part of the same person and that we share one body	.42	.92
28. All parts of myself are oriented to the present (know what day, month, and year it is)	.47	.92
29. I pay attention to and am curious about what different parts of myself are feeling	.58	.92
30. I’m aware of which parts of myself are contributing to my actions	.50	.92
31. All parts of myself know and can independently use recovery-focused coping skills (e.g. grounding, past vs. present, containment)	.42	.92
32. All parts of myself communicate and cooperate well	.53	.92

Items 3, 4, 12, 28, and 31 reflect capacity targets introduced in the PITQ-p.

Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., … Putnam, F. W. (2012). A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 490–500. doi:10.1037/a0026487

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