Treating Dissociative, Abused and Ritually Abused, Children, Part III
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Treating Dissociative, Abused and Ritually Abused, Children, Part III, Copyright, 2004, Ellen P. Lacter, Ph.D.

Direct Intervention with Dissociated Personalities

Jody was able to synthesize the anger embodied in her abuser-self state with no need to work directly with that ego-state as a separate entity. However, there is a general consensus in the DID literature that children with more well-developed personalities require direct intervention with alter personalities to synthesize dissociated aspects of self. Until a child gains at least co-consciousness and cooperation between distinct personality states, the child is prone to episodes of intrusive reexperiencing of trauma, regression, abuse reenactments, and often, abusive behavior toward others.

Treatment of childhood DID is modeled largely after treatment of adult DID and is described in depth in Putnam's book, "Dissociation in Children and Adolescents" (1997), Silberg's book, "The Dissociative Child: Diagnosis, Treatment, and Management" (1996a), Shirar's book, "Dissociative Children: Bridging the Inner and Outer Worlds" (1996), and in a number of noteworthy journal articles and chapters (James, 1989; Kluft, 1986; McMahon & Fagan, 1993; Peterson, 1996; Putnam, 1994). Since I have treated children with only partially dissociated inner identities, I draw upon these sources and my treatment of adult DID to highlight a few important considerations in the treatment of DID in children. The above sources are essential in guiding treatment with DID children due to the complexity of the disorder and the severity of abuse involved.

Early in treatment, the therapist must directly and patiently intervene in the frightening illusions that traumatized personalities experience as real. Gentle explanations can help personalities stuck in trauma realize that they are no longer being abused, but exist in the present and in a safe place. The host or internal self-helpers can be asked to convey this information to them, or these parts can be invited to look through the eyes of the host to see protective caregivers, their safe home, the therapist, and therapy office. Guided imagery can be used to rescue traumatized child personalities from the their abuse. A spiritual helper within the childs belief system (e.g., an angel or God), a protective parent, or an internal self-helper, can go into the site of the abuse, remove the abusers and their implements of abuse, pick the children up, hold and comfort them, and relocate them to internal places of safety and healing. James (1989) suggests therapists substitute adaptive rituals for abusive rituals in ritual trauma cases, e.g, praying about the ultimate power of God and good over evil.

The mechanisms underlying the child's defensive creation of dissociated personalities must be gradually interpreted and made conscious. James (1989) suggests therapists talk with children about everyone having many different feelings and aspects of self, followed by exploration of what would happen if the child claimed them all.

Personalities' names often provide clues to their roles in coping with trauma, such as names of feelings, kinds of abuse endured, or attributes assigned by abusers. However, therapists generally need to develop significant rapport with a personality before asking permission to know his or her name. Names of dissociated identities are often fiercely guarded by dissociative children, due to shame, or because not being able to be identified, or called upon, helps them hide from their abusers.

James suggests that therapists help children "own" split-off parts of self and gain control over dissociative processes "by acceptance and gradual reference to the dissociative split as being his creation and being part of him" (p. 110). She cautions us not to treat identities as more separate than they actually are to preclude creation of more dissociation. She suggests therapists attempt to contract with children not to create new personalities while in therapy. Similarly, Silberg (1996c) suggests therapists talk with, or about, other personalities through the presenting personality, rather than encourage abundant switching in treatment. Putnam (1997) also warns against "engaging dissociative identity shifts as if they were discrete alter personality states" (p. 293):

Alter personality states should only be engaged directly as discrete psychological entities (e.g., called out by name) when it is clear that they are behaviorally distinct, express strongly held convictions of separateness, and play an identifiable role in a child's or adolescent's symptoms and behaviors across several domains or contexts. At this point, they are sufficiently crystallized that it is highly unlikely that they will remit spontaneously (p.293).

Other forms of chronic or generalized dissociation should also be interpreted. Terr (1990) discusses a case of a physically abused 7-year-old boy with defensive, generalized bodily self-anesthesia. Over 3 weeks of therapy, she explained to him that numbing himself worked at the time he was beaten, but was dangerous now; "If Frederick went on deadening himself, he might expose his body to danger. Everybody needs pain" (p. 93). Within two weeks, the child experienced pain when a child jumped on him at school.

To begin to synthesize the DID child's sense of self, the therapist should maintain a stance of compassionate interpretation of the protective function each personality served in coping with the abuse. The "host" or presenting personality is likely to experience persecutory and abuser personalities as intrusive and dangerous, and often wishes they would go away. The therapist should help them consider their helpful functions. Questions such as; "Did that part make sure you did what the abuser wanted so you would not get hurt worse?" can help children accept personalities who averted retaliation by ensuring compliance . Asking; "Did that part help you be mad and strong when you were scared or sad?can help them understand and accept parts who identified with the abusers.

These superficially hostile personalities are likely to "listen from inside" to these exchanges since they are usually more aware of the experiences of the host than vice versa ("directional awareness", Putnam, 1997). The therapist's compassion gives them hope, helps them become less self-condemnatory, and increases their communication with the host.

The host is also likely to fear the sadness and fear of the young internal traumatized children, sometimes manifested by desperate crying or screaming. The therapist must help children tolerate and re-associate in manageable doses the traumatic memories these personalities hold of their shared life.

Shirar (1996) and Silberg (1996a) offer a number of techniques to help children re-associate split-off parts of the psyche. Play, art, and role-play are used to identify the purposes and conflicts between personalities, and expression of disavowed self-states, such as anger or fear. A particularly communicative part can serve as a "connector" (Shirar, p. 158) for the inner personality system. The child can write letters to personalities asking to know more about them and their feelings. A "Book of Parts" (Shirar, 1996, p. 159) can be made with a page reserved for each personality, with new information added as it is learned (Silberg, 1996a). Shirar suggests children make a diagram of parts, or draw "their inside world where the parts live" (p. 159). They may depict which personalities are connected, where separations exist, and how personalities "switch" and gain executive control. Often, personalities are offshoots of other personalities, created in succession, as the abuse escalated.

As personalities become co-conscious, the work of cooperation, negotiation, and redefinition of roles can begin, followed by learning to share their abilities and functions with each other. Silberg (1996a) explains that since DID children tend to have more fluid boundaries between personality states than in adult DID, they more easily respond to simple suggestions, such as asking the host to please ask a particular personality to listen or do something. She suggests that the therapist, parent, and child arrange cue words to elicit an agreed-upon personality to come out and assume control when needed or to signal particular personalities to regroup and cooperate. Children also can learn to use code words to alert caregivers to internal dissonance and their need for help.

Silberg (1996a) suggests that the therapist and host negotiate with abuser and persecutory parts to accept limits on physical expression of rage against others, and limits on punishment of other personalities (self-harm), within a "No Harm Deal". Aggressive personalities are usually willing to modify their behavior, assume new prosocial functions and names, and cooperate with the rest of the system once they realize they are safe. Abuser parts often agree to more modulated expression of aggression when asked to consider the that a less intense response is required in their current life.

Shirar (1996) suggests that intra-system communication devices be installed within the child's imagistic inner world. These may be telephone lines, roads, meeting rooms, etc. Many personalities initially require one-way communication to regulate their degree of exposure to the expressions of other parts. They may want to listen without being heard, to open channels to only particular parts, and to "shut off" incoming or outgoing information as needed. While trauma is being processed, non-involved parts can be guided to got to a remote safe place to not have to listen to the painful material. Intra-system communication can be used to increase behavioral regulation. Contracts against harm to self and others can be arranged through such communication systems. Behavioral expectations for home and school can be communicated to all personalities as well.

Fusion and Integration

Fusion, a blending of two or more personality states, tends to occur spontaneously throughout treatment, particularly in children, as trauma-related memories and feelings are re-associated and dissociative defenses are less necessary. Fusion is part of the larger, gradual process of integration, the emergence of a cohesive self-representation (Shirar, 1996; Waters & Silberg, 1996). Some controversy exists about whether integration into a single identity is necessary, or whether individuals can function equally well with a few co-conscious personalities who cooperate well together. The latter approaches normal adaptive functioning, in which an individual knowingly assumes many roles throughout the day in his or her work and personal life. I believe that at therapist should not communicate an investment in integration as a primary treatment goal, but as a decision that belongs to the child (in agreement with Gould and Graham-Costain, 1994). For many DID adults, final resolution includes keeping a few key personalities who function well together.

The processes of personality fusion and eventual integration into a coherent sense of self can often be expedited by direct therapeutic intervention toward these ends (James, 1989; McMahon & Fagan, 1993; Peterson, 1996; Silberg, 1996a). In the same way that the child created personality states to sequester traumatogenic effects of abuse (memories, affect, cognitions, somatosensory perceptions, identifications), the child can be helped to re-unite these aspects of self, generally by following the same path in reverse. For example, if a child created "Jane" to contain the sexual abuse trauma, and Jane in turn created 10 personalities to divide the burden of this escalating trauma, those 10 personalities will be likely to blend into Jane before integrating into a cohesive whole. The same child may have assigned "Mary" to bear the effects of her physical abuse, from whom eventually stemmed 12 more personalities to share that burden. Those 12 personalities would likely fuse back through Mary upon resolution of the trauma of physical abuse.

Since DID personality systems rely upon an imagistic internal world, the work of fusion and integration is perfectly suited to play, art, guided imagery, metaphor, and stories. These methods concretize the fusion process, helping it "stick". For example, a child can be asked to represent a group of personalities with dolls. When ready, "offshoot" personalities may choose to join a more primary personality. This may be represented by dolls bestowing toy props on the more central personality that symbolize their contributions. They may then hug, and finally combine into the primary doll. Art, objects, and metaphors that symbolize a multi-faceted, functional whole (e.g., trees, quilts, sports teams, etc.) can also be used to represent and encourage integration. Waters and Silberg (1996), Shirar (1996), McMahon and Fagan (1993), James (1989), and Kluft (1986) provide many illustrations of these methods.

The Role of Protective Parents in Treating Dissociative Children

In cases of highly dissociative children, loving caregivers serve critical therapeutic functions both within therapy and at home, often functioning as co-therapists if adequately sensitive and psychologically-minded. Shirar (1996, p. 174) writes, "Parents, therapist, and the child's own parts become the therapeutic team that will bring healing to the child and to the family."

Parents must be given a "crash course" in the psychodynamics and subjective reality of dissociative children. They must be educated in the dissociative basis of disruptive behaviors typical of these children, e.g., regressive clinging, outbursts of anger, "melt-downs", and amnesia-based lies, stealing, and forgetfulness. They must be helped to react non-punitively, while nonetheless working toward increased intra-system cooperation. They must be helped to understand, accept, and work with all personalities rather than rejecting the difficult ones, which only increases their sense of isolation, helplessness, and destructive acting out. For example, they must be taught that identification with the aggressor is a defense and that sexualized personalities helped the child to cope with frequent sexual assault more easily than did personalities who felt overwhelmed with disgust or terror.

Dissociative children often regress to infancy in fixated, traumatized baby personality states, seeking to fulfill their interrupted attachment needs to internalize parental love and protection. They usually have extreme separation and stranger anxiety, and long to be held, rocked, sung to, sucking on a bottle, and gaze into the loving parents eyes. Time should be made to interact with these parts based on their psychological/emotional age and associated needs, rather than the childs chronological age. Some severely abused, dissociative children need to sleep with protective parents for months or years. Others are reassured by having a pet sleep with them. Room lights or night-lights can increase a sense of safety. In some cases, commencement of school should ideally be postponed for a year while these needs deep psychological are being met.

Many dissociative children are at high risk for self-harm or abuse to others. Safety plans must be developed, ideally with the child's cooperation. Very young and severely traumatized children often have little ability to control harmful impulses arising from their personalities until the needs of these states are addressed, a lengthy process. In such cases, caregivers must provide constant supervision, especially around siblings and other children. School attendance may even need to be postponed to ensure the safety of the other students.

In cases of ritual abuse, the caregiver should be educated about ritual trauma reminders and mind control programming triggers to reduce their occurrence in the childs environment. These vary from child to child and are often discovered based on the childs responses. They often include satanic and witchcraft holidays, traditional holidays, ritual objects (e.g., crosses and chalices), animals, songs, colors (red for blood, brown for feces, almost any color for programming), fairytale stories and characters, phrases, churches, police, firemen, characters in horror movies, etc. (For a more complete compilation of ritual trauma reminders, see Gillotte, 2001, and Gould & Graham-Costain, 1994)

Ideally, the parent creates a therapeutic environment at home that permits a child to reveal feelings, fears, personalities, and the nature of abusive episodes as the need arises. The availability of toys and art materials facilitates this process. Much treatment can occur at home with a loving caregiver, replete with tears and hugs, as the therapist serves as a guide for both parent and child.


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