When Dissociating Isn’t Enough
A wise and more experienced colleague said to me once, “You can’t expect someone to just stop dissociating and do something else more beneficial for their wellbeing when they don’t feel safe enough to stop dissociating. They need to find safety first within that dissociated state to come out of it.” Essentially, somebody who relies on soothing and safety within a dissociated ego state has nowhere else to go-inside the mind/body or outside that is adequately safe or soothing enough to regulate the nervous system.
Safety First
A wise and more experienced colleague said to me once, “You can’t expect someone to just stop dissociating and do something else more beneficial for their wellbeing when they don’t feel safe enough to stop dissociating. They need to find safety first within that dissociated state to come out of it.” Essentially, somebody who relies on soothing and safety within a dissociated ego state has nowhere else to go-inside the mind/body or outside that is adequately safe or soothing enough to regulate the nervous system. The original threat of danger may have passed years ago, yet the motivation to continue dissociating can remain undeniably strong with a widening set of threat triggers over time. This unfortunate situation is the catch-22 many traumatized people face.
High Stakes
One of my newer clients, Loida, is repeatedly caught in this conundrum during our outpatient sessions. She is barely hovering inside the appropriateness of an outpatient level of care and is just a suicidal plan or pill overdose away from her sixth stint in residential treatment in her young adult life. Loida’s parents have vowed to kick her out of the family home if she overdoses one more time, so the stakes are high for her newest outpatient treatment efforts (this time with me).
“DBT therapists have told me to take a cold shower, or hold ice cubes when I begin to dissociate. That’s awful, and my pain feels invalidated. My little girl inside needs attention and comfort. Late at night when I’m alone in my room I cry for hours, and I feel so alone and desperate. I don’t even know why I feel this way!”
Loida hadn’t allowed herself to remember yet about any kind of abuse. I tried seeing whether she had a collaborative relationship with her little girl way of being, “Can you go inside now and see if you sense her, maybe look into her eyes?”
“I hate her and she hates me. And I want to kill her and she wants to kill me. And there’s no relief and I get confused and I dunno and I dunno are you safe? Are you gonna be mean? Are you gonna are you gonna are you gonna leave me too like the five other therapists have? ….” Loida’s speech tone began to trail off as the other way of being Loida became evident. I knew then where our work had to start.
Could I Even Handle This?
This is an excerpt from my first session with Loida as she was enacting for me her trauma story which she didn’t even know about yet in a narrative fashion, just being able to recount spontaneously in a very regressed, nearly collapsed child ego state. Marshalling my nearly quarter century of clinical experience, I wondered to myself whether I could even handle her presentation after just 15 minutes into the intake session. My efforts at helping her to ground in her five senses were met with prolonged blank stares and uncontrollable crying jags. I was in the presence of a severely traumatized and dissociated individual who could find no safety in her present dissociated state.
Starting in the second session, her child ego state began usurping session time with more unstable emotionality, a paucity of speech that was almost inaudible, balling up on my blue pleather couch clutching throw pillows to cover her face.
“I’m here. I’m listening, and I sense your pain. I’m Christine, your helper. Can I ask adult Loida to talk to me please?”
Crying, lots of loud crying came in response to my request. Then the words with an outstretched arm from beneath the pillow fort, “I need a hug. I need a hug. I need a hug. I need a hug. I need a hug….”
A Rocky Road
Here was my opportunity to help her, not by hugging her but by using my voice presence to meet her in her desperate and dissociated way of being herself in that moment. I was still unsure whether her presentation was descriptive of Dissociative Identity Disorder (DID) or Other Specified Dissociative Disorder (OSDD), but I did know one thing for certain. If I gave into becoming her substitute caretaker by giving her a hug, this kindness would not be therapeutic. I would be colluding with her dissociated state that has avoided learning how to trust the adult version of herself inside for soothing and comfort. But there was another complication. The Loida who engages with adult daily life had a personality adaptation that was highly unstable too, Borderline Personality Disorder (BPD).
How does a therapist stay empathic to a relationally traumatized client like Loida and still deliver the standard of care ethically? Understandably, Loida needs a felt sense of caring and safety with me. She certainly does not feel that within herself.
It’s been a rocky road experience for both of us, Loida and me. Carefully negotiating the therapeutic relationship within the treatment frame has kept her out of a higher level of care (residential) so far, and is also what she struggles so mightily with session after session. Heels dug in, Loida’s little girl ego state desperately wants caretaking in the form of hugs, assisting her out of my office while she’s mostly collapsed into a dissociative state. She relies heavily on me and hates me simultaneously for seeing what she needs and not giving it to her in the way she demands it. I am staying the course to help her tolerate her wildly uncomfortable feelings while living in an adult body that must play by the rules of adult life. My gut tugs at me from time to time, “But am I being mean when my clinical judgment is to refrain from touching her in any way?”
“I promise I won’t see you as a man who’s scary if you give me hugs at the end of sessions. My other therapist gave me hugs as part of a reward system. That was mean, but it’s better than nothing at all!”
“I’m committed to helping you find safety and soothing in whatever way you experience yourself….without my hugs, Loida. I’ll help you find safety within yourself…as long as it takes. We’ll do this together, me and you.”
The Right Approach
It takes a specialized treatment approach to serve clients as traumatized as Loida is, and it can be tedious for both in the treatment dyad. The standard of care for highly traumatized clients means much more than simply a “trauma informed approach.” If you would like more information about this topic and how to find a therapist trained to help with complex trauma and dissociation, visit ISST-D.org. The International Society for the Study of Trauma and Dissociation (ISST-D) has excellent resources for the public to understand complex trauma via podcasts and a national therapist directory. They also have a professional program that trains therapists how to specialize in the treatment of complex trauma and dissociation; I highly recommend it!
Trauma Bonding and Dissociative Coping
The International Society for the Study of Trauma and Dissociation (ISST-D) has standard of treatment guidelines and therapist referral sources that are publicly available at www.isst-d.org. If you know someone who is in an abusive home atmosphere, please give them information about how they can seek help. If it is a child, please contact a mandated reporter of abuse, such as a school official.
Tu Te Calme!
I had never witnessed anything like this scene before, yet I’ve heard similar (and more severe) first-hand accounts of this nature when people make their way into therapy. One of those moments I’ll never forget--apparently helpless to do anything but affront the blatant abuses with my burning stare, I almost immediately regretted my inaction.
Last week I was traveling in Costa Rica and had visited its most popular national park near the town of Manuel Antonio. I was next in line to enter the two-stall women’s restroom that had an open entryway. There was a young girl probably five or six who suddenly made a loud fuss aimed at her mother who was next to the washbasin.
The mother’s was jarringly louder and shriek-like than the young girl’s protests, “Tu te calme! Tu te calme!” pinballed in the pink cement interior as she boxed the little girl’s ears—twice! Shockingly, it seemed I was witnessing a well-practiced motion. The woman glanced out at me before asserting her right hand along her side, and the brown-pig-tailed girl silently obliged her little fingers into her mother’s stronghold. Just as suddenly as she had protested near the washbasin, this small girl had been screamed at to be calm while she was being physically and emotionally abused! Within one second after her ear-boxing, this little one adjusted herself into a slight smile with glazed-over eyes as she walked out of the restroom in a kind of lock step with her mother. Something tells me that this sort of mother-daughter exchange had happened many times before with them.
Then an older girl with a dour face, maybe nine or ten, peered out of the restroom’s threshold with furrowed brow spying on her mother and sister (I assume) who absorbed into the nearby sea of tourists exiting the national park. As she lost sight of them within a couple of seconds, the taller sister flashed a panicked face, began running after the pair, and caught up with them just outside the entrance. With jerky and erratic motions, the mother’s left arm seemed to signal her older daughter to scramble toward the right side of her younger sister’s back. And then they were lost.
Trauma and Dissociation
I was really jolted out of my vacation mode having witnessed this abusive scene because who expects to see something like this in public on a beautiful day? I had the urge to confront the mother, but I held myself back. I don’t speak French. Who would I report the abuse to anyway? And if I had done something, anything to let these sisters know that there was an adult who would stand up for them, I could have been placing the girls in much greater jeopardy later when the mother was free from public view. I hate to imagine what happens to those girls in private with their mother.
What I saw unfolding before my eyes with these sisters likely was a desperate coping pattern, the need to attach to their mother at any cost. These girls developmentally do not have the capacity to make sense of their traumatic experience, and they do not have the choice to physically disengage and find safety from their abusive world. There is no perspective yet to put abuse into an appropriate context for their lives, no appropriate assignment of responsibility for the abuse (rightfully resting with the mother).
When the source of care and comfort is also the abuser, this makes for disorganized attachment to the caretaker that mirrors the chaotic behaviors and other unhealthy communications from the caretaker-abuser. Unfortunately, children naturally resort to desperate coping measures in these circumstances by dissociating from their traumatic experience because they cannot psychologically or emotionally handle them, and they cannot physically leave.
Dissociative Identity Disorder
In abusive home atmospheres, children cannot integrate their different ways of being in the abusive milieu into their consciousness. When abuse is severe, begins before the age of five years and is ongoing throughout childhood, dissociative coping often can develop into Dissociative Identity Disorder (DID). Lesser forms of dissociation do not organize a fragmented personality structure around dissociative coping and can be seen in milder forms, such as derealization of the environment, or depersonalization of the body when stressed or triggered. Usually these lesser forms of dissociation are correlated with less severe trauma histories.
While the story of these two unfortunate girls is all too similar to abuse around the world, there is help and treatment for those suffering from current trauma and/or past abuse. Many people do not find relief through treatment until they are adults, and children who are removed from their abusive home environments also incur the pain of longing for their abusive caretakers due to trauma bonding.
What You Can Do
The International Society for the Study of Trauma and Dissociation (ISST-D) has standard of treatment guidelines and therapist referral sources that are publicly available at www.isst-d.org. If you know someone who is in an abusive home atmosphere, please give them information about how they can seek help. If it is a child, please contact a mandated reporter of abuse, such as a school official. Thank you for reading my blog and thereby raising awareness on the phenomena of trauma and dissociation.
Photo by Aimee Vogelsang on Unsplash