This three-part article is organized into ten sections, as follows:
When the Child is Not Safe
Working with Protective Parents To Increase a Child's Sense of Safety
Treating Dissociation in the Pretend World of Play
Play Characterizations and Abuser Personalities
The Importance of Safe Places in the Treatment of Dissociative Children
Direct Interpretation and Intervention in Dissociation of Trauma
A Common Triad of Ego-States in Abused Children
Direct Intervention with Dissociated Personalities
Fusion and Integration
The Role of Protective Parents in Treating Dissociative Children
Treating Dissociative, Abused and Ritually Abused, Children, Part I, Copyright, 2004, Ellen P. Lacter, Ph.D.
When the Child is Not Safe
Dissociative responses and defenses help children cope with ongoing abuse, lack of protection, or unsupportive home environments.
Abused children generally invest great psychological energy in defending against conscious awareness of ongoing danger in
order to preserve some ability to function and develop emotionally, academically, and socially. Although dissociative and
reality-negating defenses should be gradually modified in safe environments, such coping mechanisms should not be challenged
when needed for psychological survival.
It would be contraindicated to attempt to help a child feel safer than he or she truly is. For this reason, the therapist
should continually assess the degree of protection provided by the child's caregivers and the possibility of ongoing abuse.
Children are exquisitely sensitive to any indication that their parents or caregivers doubt whether the abuse occurred
or any indication that their parents remain attached to their abusers. Visitation with abusive parents, supervised or unsupervised,
and unsupportive families or foster-placements contribute to children feeling unsafe. No amount of therapy can make children
feel safe when they are not, in fact, safe.
In cases of suspected ongoing abuse, ongoing threats of retaliation for disclosure, or lack of support by parents-figures,
limited treatment goals can be facilitated by exploiting a child's dissociative capacity. Children may be able to express
feelings, experiences, and hopes disguised symbolically in play, sandplay, art, and writing, while avoiding disclosure and
conscious awareness of the issues being addressed.
Likewise, the therapist can indirectly communicate therapeutic messages through play, art, and metaphor, such as helping
children develop and elaborate safe places in the play room, in their inner worlds, and in their dreams for their future,
conveying anger at people who hurt other people, demonstrating empathy for hurt children and animals, spiritual messages of
hope and Gods love, compassion for the position of children afraid to tell on grown-ups, realistic information about possible
protectors (child protective workers, police, etc.), representing the availability of loving caregivers, explanations about
the blamelessness of abused children, etc.
Symbolic communication has the further advantage of being less potentially leading than direct approaches, an important
consideration in such cases which are often involved in ongoing investigations and legal proceedings, and in which civil suits
and complaints to licensing boards are a risk. In such cases, carefully chosen metaphors permit therapeutic communication
while maintaining adequate distance from the subject of child abuse, thereby limiting potential legal concerns of influence
by the therapist.
Nowhere is the issue of ongoing threat to victims' safety more troublesome than in cases of organized abuse, such as
abuse associated with Satan worship, witchcraft, and/or child sex and pornography rings (often overlapping each other). Most
victims of ritualistic abuse remain unprotected throughout childhood and develop Dissociative Identity Disorder, since abuse
by these groups usually begins early and involves intense terror, pain, and forcing children to commit acts that violate their
conscience and self-view. These Machiavellian perpetrators are sophisticated in mind control techniques and use torture to
create personalities whose function it is to ensure that the victims conscious personalities, Dont remember, dont talk, dont
tell. If these children do come to the attention of authorities, little protection is usually afforded because their disclosures
appear suspect. These sophisticated abusers stage illusions of abuse by animals, demons, space aliens, resurrections, etc.,
to ensure that childrens credibility will be destroyed as they recount these experiences. Any attempts at disclosure result
in severe punishment, both internal (by abuser-compliant personalities) and external (by the abuser group). Furthermore, ritual
crimes are so heinous, investigators often dismiss them as untrue, particularly in this age of heavy media influence by the
False Memory Syndrome Foundation.
When victims of ritualistic abuse are brought to therapy by protective parents or foster-parents, they often remain exposed
to ongoing threats. Abusers may stalk them at a distance, using hand signals to threaten death, unbeknownst to protective
adults, or may leave coded messages where the children will see them, e.g., graffiti on a school wall. Even when ritually
abused children are currently safe, years of therapy are often needed before they can disclose or discuss such abuse. Torture
and illusion may have been used to convince them that every time they hear the word "God" or a popular song, it
signifies that the devil or cult members are watching them. There may have been threats to kill protective caregivers, burn
down their homes, etc. (Harvey, 1993). Ritual abusers often attempt to make children believe that protective parents are part
of their cult, to prevent secure attachment. Abusers may impersonate protective parents in rituals, drugging children to make
them more suggestible. Cults program children to believe that their parents do not love them, are weak, and are not their
real parents, but the cult is their family. A protective parent may be drugged by a cult parent, and taken to a rituals where
children are forced into sexual acts with the drugged parent. Children can be tricked to believe the protective parent is
a willing cult participant.
When a childs fear of continued abuse does not allay in treatment, it may be a sign that abuse is ongoing. In cases of
ritual abuse, close relatives may continue to abuse the child, unbeknownst to the protective parent. Or the parent bringing
the child to therapy may have dissociated personalities who are actively involved in the abuser group (cult-loyal or perpetrator
alters), with no conscious knowledge of this involvement by the host personality.
Symbolic communication is particularly valuable in treatment with victims of ritualistic abuse for both clinical and
legal reasons. Both child and adult victims tend to have highly developed dissociative defenses, including an elaborate imaginary
inner world to where they can escape, and multiple identities that permit them to mete out the burden of their trauma, to
function in the world, and to support and protect each other as would an outer network of family and friends. This dissociative
capacity relies upon fantasy, symbolism, and distancing, making these clients uniquely receptive to metaphorical and symbolic
communication. For instance, one personality may represent images of abuse with art media while concealing this information
from the rest of the psyche.
Extreme caution must be exercised in providing legally defensible treatment in cases of suspected ritualistic abuse.
These cases are complicated by disclosures of events that seem improbable because they defy reason or are too abhorrent for
most to accept as true, resulting in their frequent dismissal by law enforcement, child protective agencies, and family courts.
Perpetrators of organized ritualistic abuse are often sophisticated in challenging therapists' practices in civil actions
and complaints to professional licensing boards, alleging that therapists influenced or contaminated a child's memory or disclosures,
thereby harming the child or other family members.
In such cases, carefully chosen metaphors permit therapeutic communication while maintaining adequate distance from the
subject of child abuse, thereby limiting potential concerns of influence by the therapist. For instance, if the therapist
suspects a child condemns himself or herself for participating in the abuse of others, the child might be engaged in a discussion
of moral dilemmas faced by victims of the Nazi holocaust, faced with choices involving survival, starvation, torture, submission,
helping the enemy, etc..
The film, Sophies Choice, illustrates one such moral dilemma. A woman pleads to a Nazi soldier to spare her life and
the lives of her two young children. He tells her she must surrender one child to the death camps. When she protests that
she can not choose, the soldier orders both children be taken. Horrified, she sacrifices one, and is plagued by her choice
for a lifetime. Organized abuser groups are equally diabolical. A child may be permitted to have only one friend in a world
of abusers, only later to be faced with the dilemma of killing an other child or watching this friend be killed.
As struggles of historical and fictional figures are discussed, hidden parts of the childs psyche may quietly receive
the therapeutic messages about human frailty, the effects of terror and the drive to survive, and that the fault lay with
abusers and not with their victims, regardless of their choices.
We must also never minimize the healing power of the therapeutic relationship itself. This one relationship, in which
the child is free to be, to express feelings and wishes, to play as he or she chooses, may be the source of all hope for future
safety and loving relationships.
An adult survivor of ritualistic abuse, whom I will call Amy, describes an experience that highlights this message. Amy
was 5 years old and had been tied down on a bed and assaulted for several days straight. Finally, she experienced herself
leaving her body, going through the headboard, and falling into soft darkness where there was a complete absence of pain.
To her left, she noticed a light and heard a woman's voice calling her name; "I'm over here, Amy, Amy, come here".
She wanted to stay in the painless darkness, but finally went to the woman. The woman stayed with her for a while. Together,
they colored pictures of Amys favorite animals. As they played, the woman said, When they do that, we do this. Amy believes
the decision within her 5-year-old heart and soul to go to the woman was a critical spiritual choice that saved her. Others
might interpret this event as a connection with the archetypical mother of the collective unconscious (in the Jungian sense),
or the fantasy product of Amys wish for love. Regardless of the psychological/spiritual interpretation, Amy found a way to
be nurtured and to play. In some cases, therapists may be powerless to protect children, or even adults, from abuse occurring
outside of our offices, but we can create a nurturing, hope-filled, even fun, environment within.
Working with Protective Parents To Increase a Child's Sense of Safety
It is usually a long and arduous process for a protective parent and therapist to convey to an abused child that he or
she is now protected and safe. Internalization by the child of these messages inevitably occurs more slowly than the provision
of safety in reality. When a child is placed with new caregivers because parents were abusive or nonprotective, internalization
of safety is largely dependent on the responsiveness of the new caregivers.
Protective caregivers require support by the therapist when frustrated that their efforts to love and reassure a child
have not alleviated the child's fear and fear-driven behavior. The therapist often assumes the role of teacher, educating
both caregivers and children about normal psychological reactions to trauma and the course of recovery. In cases of severe
abuse, parents should be forewarned that recovery is a life-long task, with fear and other symptoms surfacing in times of
crisis and new developmental phases, such as beginning school, adolescence, courting, and parenting.
Parents should be counseled to limit environmental stressors that abused children may perceive as threatening. Many abused
children are hypervigilant and hyper-responsive to any demonstration of anger. They react with fear and anxiety to all forms
of aggression, including infrequent, modulated spankings, raised voices, or even firm assertions of behavioral limits. This
creates a dilemma for protective parents; the child's behavior is poorly regulated and difficult secondary to trauma, but
behavioral limits frighten the child, exacerbating behavioral problems. Parents often become exhausted as they accommodate
the needs of a fearful child with minimal behavioral demands, a task that should be honored by the therapist. In many cases,
no quick and easy answers exist. The therapist must collaborate with the parent in developing behavioral interventions adapted
to the child's abilities and in gradually resolving the fears underlying the child's behavior.
In an attempt to feel safe, many abused children regress to infancy, a stage of development associated with constant
care by a protective parent. They may resist all separations, including sleeping alone, attending school, or even being in
a room apart from a caregiver. Affording time for regression can increase a child's sense of security and safety. Many young
abused children benefit from pretending to be a baby again with protective caregivers, a time to be held, rocked, sung to,
to suck on a bottle, and to gaze into each other's eyes. Defining this activity as a game, e.g., "Let's play Mommy and
baby", reduces the child's embarrassment and decreases the parent's concern that allowing regression will cause a child
to become "stuck" in infancy. Making time for this activity early in the day, or as soon as the parent and child
reunite after a separation, such as a school or work day, can prevent many fear-driven behavioral problems that might otherwise
occur. Parents are often surprised to discover that once a child's need for regression is temporarily met, the child moves
on to more stimulating developmentally-normal activities within minutes.
Failing to provide the security required by a frightened child can result in retraumatization, an increased sense of
danger, and further psychological damage. Some abused children need to sleep with protective parents or older siblings for
months or years, depending on the extent of the abuse. Some children are reassured by having a cat or dog sleep with them.
Room lights or night-lights can increase a sense of safety.
In cases of severe abuse of very young children, it may help to postpone commencement of school for a year. When this
is not possible, children may be soothed by having transitional objects in their possession at daycare or school, including
tape-recordings of parents expressing their love and that they will see them at the appointed time, coupons good for a treat
on the ride home, a locket with a photograph of parent and child, etc.
Many abused children challenge themselves to overcome their fears. Four-year-old Ryan D., abused in the bathtub, eventually
chose to take a bath alone, to "Do it myself". In other cases, it is difficult to discern if a child requires, or
simply enjoys, the extra support. It may be possible to put this to the test. For example, a quarter can be placed under a
child's pillow at night that can be exchanged to sleep with the parent, or that the child can keep if he or she sleeps alone
through the night.
Case Example: Leanna J. and her Mommy Helping Each other
Leanna J., a 4-year-old victim of ritual abuse, wet her bed almost every night. She was also enuretic during the day,
when she disclosed new information to her mother, and when she appeared to be remembering traumatic events. Her mother told
Leanna that wetting was okay, and often put her in diapers so that bladder control was not added to Leanna's many concerns.
After 6 months of therapy and very sensitive parenting, Leanna was able to directly tell me about her frightening experiences,
albeit for short periods. When her tolerance was reached, she would say, "I don't want to talk about it anymore",
or, "Let's do something else".
I told Leanna I knew she had been wetting herself and asked with complete sincerity, "Leanna, do you like it better
to peepee in the bathroom or in your clothes?". She said, "In my clothes, the bathroom is scary". I asked,
"Did something happen in the bathroom?" She became somber, looked directly at me, and said; "The bad people
put their [showed fingers] in my butt", pointing to her bottom, "and put poo-poo on my eyes, my mouth, and my nose,
all over my face", making a smearing motion. She added, "and my feet", holding her foot. Her face showed disgust.
I empathized with her feeling of disgust and expressed anger at those people who had done that to her, adding that they
could never do those things again. I told her grown-ups should be nice to children's bodies, to their faces and feet; they
should love them. I was attempting to modify her negative experience with a healing and somewhat humorous image. Leanna internalized
my message. She said, "I love my foot" as she drew it to her face and kissed it. I took her foot and also kissed
it. We laughed as she continued to kiss her feet.
I asked Leanna if she could think of any ways to make the bathroom feel safer. She could not. I asked if it would help
to spray perfume in the bathroom, hoping this might change the setting adequately. She said no. I suggested she take a doll
with her to the bathroom and reassure it that the bad people could not hurt her anymore, hoping that if she assumed a helper
role, she might be less aware of her fear. This was also insufficient. I asked if she minded if her mother was there when
she pee-peed and pooped. She said no. I suggested her mother go with her to the bathroom. Leanna felt this would help. I told
Ms. J. about this solution. Ms. J. explained she often found Leanna had very quietly changed into fresh pajamas by morning
and had pulled her sheets off her bed to avoid waking her mother. Leanna joined us and Ms. J. reassured her that she wanted
Leanna to wake her at night to take her to the bathroom. Leanna began waking her mother at night to go to the bathroom and
no longer wet the bed.
Treating Dissociation in the Pretend World of Play
Pretend play and dissociative inner imagery both rely on trance states, imagination, and defensive disguise and distancing.
Profound dissociation, as in DID, originates in a use of fantasy that differs from normal pretense primarily in that it is
so sustained and pervasive that illusion becomes confused with reality. These similarities make play and play therapy inherently
suited for assessing and intervening in the unconscious world of the dissociative child. Young dissociative children naturally
depict multiple aspects of self and traumatogenic experiences in play and art. Synthesis of self and resolution of trauma
can proceed on a largely symbolic level (Putnam, 1997, Shirar, 1996).
Traumatogenic experiences are best gradually re-associated by beginning in metaphorical play, and progressing toward
structured, abuse-focused play and direct discussion. The world of play permits dissociative children to regulate their rate
of exposure to trauma via symbolization.
Materials representative of a child's severe trauma should be made available. Even if the child is not conscious of the
abuse endured, or if it occurred prior to the development of narrative memory, the unconscious mind will tend to press for
expression and representation of painful experiences.
In cases of ritual trauma, important toys to permit representation of trauma include cages, coffins, and boxes (used
to confine); ropes and string (used to bind or pull); toy insects and snakes (placed on children to terrify them); knives
and swords (used to threaten, dismember, cut, and kill animals or people and as ritual symbols); a tub and water (used in
sexual abuse, near-drowning, and freezing); a doll-size toilet (childrens heads are submerged in toilets, and they are smeared
with urine and feces, and forced to ingest these, as punishment for leaking information and to instill dont talk- dont tell
programming); monster dolls and masks (to represent masked people and demons); figure dolls of all ages and life-size baby-dolls;
toy animals, including rabbits, cats, and dogs (often sacrificed to deities and demons); a doctor kit including toy syringes
(used to inject drugs to immobilize, cause internal pain, or inject the blood of cult members); play camera equipment (to
depict filming of child pornography); and cloth (to represent being wrapped or gagged).
Materials should also be available that allow for representation of self-protection, reparation, protection, and nurturing.
Important materials include; toy weapons, walkie-talkies, badges, (police symbols); comforting objects, soft blankets, baby
bottles; vehicles for escape; hiding places; telephones to call for help; animal and human families (to represent loving,
protective family constellations); and nonrepresentational materials, e.g., sand, clay, water, art supplies (these allow maximum
distance/disguise of anxiety-laden material and representation of anything not available).
Unfortunately, reparative symbols are also often traumatogenic triggers for victims of ritual abuse. Toy jails may frighten
children because they have been confined in cages. Symbols of law enforcement may frighten them because they have often been
deliberately programmed to distrust police to prevent their seeking help. Telephones can be disturbing because they are used
to contact these victims or the child is programmed to report in via phone.
Treating Dissociative, Abused and Ritually Abused, Children, Part II