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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.
Bibliography
Briere, J. (1996). A self-trauma model for treating adult survivors of severe child abuse. In J. Briere, L. Berliner,
J.A. Bulkey, C. Jenny, & T. Reid (Eds.) The APSAC Handbook on Child Maltreatment, Thousand Oaks, California: Sage (pp.
140-157).
Gould, C. & Graham-Costain, V. (1994). Play therapy with ritually abused children. Treating Abuse Today, 4(2), 4-10,
and 4(3), 14-19
Harvey, S. (1993). Ann: Dynamic play therapy with ritual abuse. In T. Kottman & C. Schaefer, C. (Eds.). Play therapy
in action: A casebook for practitioners. Northvale New Jersey: Aronson. 371-415.
James, B. (1989) Treating traumatized children: New insights and creative interventions. Massachusetts: Lexington.
Kluft, R.P. (1986). Treating children who have multiple personality disorder. In B.G. Braun (Ed.) Treatment of multiple
personality disorder. (pp. 167-196). Washington, D.C.: American Psychiatric Press.
McMahon, P.P. & Fagan, J. (1993). Play therapy with children with multiple personality disorder. In R.P. Kluft and
C.G. Fine (Eds.) Clinical perspectives on multiple personality disorder (pp. 253-276). Washington D.C.: American Psychiatric
Press.
Noblitt,, J.R. & Perskin, P. (2000). Cult and Ritual Abuse: Its History, Anthropology, and Recent Discovery in Contemporary
America; Revised Edition. Westport, CT: Praeger Publishers, 1995.
Oglevie, S (1996 to 2002) Personal Communication.
Peterson, G. (1991). Children coping with trauma: Diagnosis of "dissociation identity disorder". Dissociation
Progress in the Dissociative Disorders, 4(3), 152-164.
Peterson, G. (1996). Treatment of early onset. In J.L. Spira & I.D. Yalom (Eds.) Treating dissociative identity disorder.
San Francisco: Josey-Bass (pp. 135-181).
Putnam, F.W. (1994). Dissociative disorders in children and adolescents. In S.J. Lynn & J.W. Rhue (Eds.) Dissociation:
Clinical and theoretical perspectives, (pp. 175-189), New York: Guilford.
Putnam, F.W. (1997). Dissociation in children and adolescents: A developmental perspective. New York: The Guilford Press.
Shengold, L. (1979). Child abuse and deprivation: Soul murder. Journal of the American Psychoanalytic Association, 27.
533-599.
Shirar, L. (1996). Dissociative children: Bridging the inner and outer worlds. New York: Norton.
Silberg, J.L. (Ed.) (1996a). The dissociative child: Diagnosis, treatment, and management. Lutherville, Maryland: Sidran.
Terr, L. C. (1990). Too scared to cry: Psychic trauma in childhood, New York: Harper and Row.
Terr, L. C. (1994). Unchained memories: True stories of traumatic memories lost and found. Basic Books.
Trad, P.V., Raine, M.J., Chazan, S., & Greenblatt, E. (1992). Working through conflict with self-destructive preschool
children. American Journal of Psychotherapy, XLVI(4), 640-662.
Uherek, A.M. (1991). Treatment of a ritually abused preschooler. In W.N. Friedrich (Ed.) Casebook of sexual abuse treatment.
New York: Norton. 70-92.
Waters, F.S. & Silberg, J.L. (1996a). Therapeutic phases in the treatment of dissociative children. In J.L. Silberg
(Ed.) The dissociative child: Diagnosis, treatment, and management. Lutherville, Maryland: Sidran, pp. 135-165.
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