When Dissociating Isn’t Enough

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!

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Photo by June Liu on Unsplash

Anticipating Life After Integration

It Is Possible

Truth. It does happen! People are able to integrate their dissociated personalities that have been separate for a very long time behind an amnestic curtain. And true, it takes many years in psychotherapy with a skilled clinician for this process to complete itself thoroughly. This being stated, not all persons with Dissociative Identity Disorder (DID) will move forward after long-term treatment with a single, unified personality. That is their choice in the event that integration of solidified ego states (aka-alter personalities) does not ever spontaneously occur. Sometimes a person’s internal system will opt for co-consciousness with a sense of respectful agency for internal personalities. People living without multiplicity (roughly 99% of the general population) may have understandable trouble with this notion. And surely for persons living with internal multiplicity, the concept of integration can be scary.

Passing The Vibe Test

My first DID client, Darlene**, was a surprise to me, as is the case for most clinicians not steeped well enough in graduate school courses and supervised professional experience in the treatment of the dissociative disorders. Darlene was a physician in her late 40s who knew she was a multiple when she arrived self-referred to my private practice. She had stopped therapy for several years after moving to a different city post-residency. Right away after Darlene’s intake appointment, I began seeking consultation with a DID expert and sought further educational experiences regarding complex trauma and dissociation to continue to treat her in my private practice.

It was initially very difficult work for me to keep my countertransference in check; often I privately found myself feeling both sad and enraged while thinking about the injustices she had experienced as a child. As Darlene unpacked her life history to me, I learned that her alcoholic father used her for sex from the ages of three through thirteen, and then… “he lost interest in me.” Darlene’s mother knew all along and did nothing to protect her. Living in a chaotic household also rife with domestic violence and poverty, Darlene made it out of impoverishment by earning an academic college scholarship and doing quite well in her studies. She paid her way through medical school by prostituting her body. Being a sex worker was the job of one of her alters inside. During her college years, another alter personality would go to bars occasionally and pick fist fights with men after they came on to her. By the time Darlene had entered into treatment with me, she had made peace somewhat with the different ways of being herself inside, but she had no access to consciously embodying the vulnerable feelings she and I made note of early on. The streaming tears running down her straight face… she would cry and not know where the tears came from, who inside was crying, or even what crying tears felt like emotionally.

It seemed as though Darlene had invested much self-esteem in her disaffected presentation and high career accomplishments. Even though I had tried to help her understand it wasn’t necessary to recount her early life troubles at the onset of therapy, she soldiered through telling me about her shocking history. Thankfully I passed the vibe test as her new helper because I didn’t appear to be easily rattled as she later told me. I was actually surprised that confronting her trauma so early on in treatment via the history taking process didn’t derail or destabilize Darlene’s adaptation to daily life, but it was clear to me the price she (the one out front) paid for consciously knowing much of her story.

For many years we worked together in therapy to understand how and why she had come to live dissociated inside and function under such overwhelmingly stressful circumstances beginning as a toddler. Developing internal multiplicity was how “her body-mind’s wisdom” survived and adapted thereafter. We worked together over time to understand the alliances and divisiveness amongst and between her alter personalities, respectively, to create a more peaceful and collaborative internal system, updated for the current life circumstances. We worked through Darlene’s disgust toward some of her alters, and their corresponding mistrust and rage toward Darlene too. When the time was right, we intermittently addressed her traumatic wounding, so that she could know and understand her felt sense of pain, release it, and come to a new understanding of its meaning in the context of whom she intended to become for all of her selves. It certainly was not a linear process. We needed to toggle between trauma confrontation, and containment of her internal discomfort coupled with building emotional tolerance and other skills building for years.

Creating Heart Space For A New Normal

Toward the end of her therapy (a period of more than a year or so), we began discussing what life would be like after integration of her system of personalities. In Darlene’s case, all of her alters integrated before the last year of therapy, save for two of them. She retained co-consciousness with a sense of personal agency with these two. The first one she created initially for the purpose of functioning optimally at work when there was an emergency, and the other alter personality would come forward for running marathons and training. It’s quite interesting that her system thought it best to retain these two personalities as separate and distinct, the only ones created outside of experiencing clear defensive threat. During our many discussions about life after integration, we talked about how Darlene would use her time/energy management because there came to be an emerging massive internal silence and solitude--which was a very big change. I held space for Darlene as she mourned the loss of many alters, and she decided to make meaning of these changes by feeling into a sense of them in her heart space. They had not been banished, “killed off” or died; their functions were now to support the body in a different way, a way that felt right for her. In one of our later sessions Darlene remarked, “I don’t have multiple personality disorder anymore. I’m a family of three loved ones inside now.”

The plan going forward included a new definition of self-care without loads of internal energy spent on dealing with the dynamics of internal victim, rescuer, and perpetrator. Darlene was taking the risk to make new friends and develop new interests. For the first time in her life she was able to feel soothed by physical touch from a massage therapist. These kinds of endeavors met the challenge of the new and voluminous space that she acknowledged inside her. There were no more warring voices or crying from inside to manage. Darlene no longer had the adrenaline rush from flashbacks, or the spacey high from endorphins dumped into her system from dissociating—she worked hard in her therapy to leave those automatic, reliable escapes behind her. She was able to let go of hooking in to key drama-inducing people. Saving it for one of our last regular sessions, Darlene told me she was worried that I would suggest she stop running long distance and training for marathons due to the endorphins her body was gifted after long runs. We had a big, hearty laugh together over that one as I grinned, “Hell no! Keep on running the marathons, Darlene. You’ve earned those endorphins fair-n-square each time you intentionally push through together!”

Where To Turn For More Information

I feel fortunate to have assisted Darlene and her others inside on their journey in therapy, and I will always hold a special place in my heart for them. I also hold deep respect for all persons who find a way to overcome overwhelming obstacles to embody their own mental health. If you would like information about the understanding and treatment of complex trauma and dissociation, please visit the International Society for the Study of Trauma and Dissociation (ISST-D) website by clicking the button below.

**Note: Disguised identity information of my actual client has been used.

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Trauma Bonding and Dissociative Coping

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.

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Photo by Aimee Vogelsang on Unsplash

What’s at the Heart of Trauma Resolution

When is it trauma?

So many of us have brushed aside the notion of being traumatized because our self-image, our self-talk, our reliable defensive stance in life don’t allow us to reflect inside. “It was my fault. I shouldn’t have been dressed that way. Maybe then they wouldn’t have followed me outta that bar and beaten me up…” is what I heard one new client referred by the Victim Witness Assistance Program tell me when speaking about their most recent hate crime.

My client didn’t consider themself a victim, and they were proud of that. I respected their personal experience of the beating, and I knew their take on it was protective for them. My understanding of their beating (which I didn’t share with them at intake) was that they had likely dissociated from the vulnerable feelings and sensations that were a part of the beating in that dark parking lot. While this client presented a more obvious story of trauma that therapy could, and would resolve, other traumas are less obvious…yet just as devastating to the mind-body psyche.

Interestingly, conscious awareness at the time of traumatic experience is not a prerequisite for people to [subconsciously] register experience as traumatic. At clinical intake, the psychotherapist may hear, “My childhood? Mine was just great. Wonderful parents! Funny thing though…I don’t remember anything specific about it now that you ask.” Only many sessions later may the therapist begin to discover the client’s abusive/neglectful childhood if there is one. This kind of dissociative process happens automatically as a built-in survival mechanism attendant to the human condition. Why? -----because we are built to cordon off that which we cannot metabolize consciously. And kids are especially susceptible to dissociating when life gets to be too taxing for their burgeoning personal psychology in the midst of abuse and/or repeated experiences of emotional neglect.

My client who had been beaten up did not begin to consciously register their trauma until they sensed it was safe enough with me to explore this possibility within a paced, therapeutically shared internal journey. Resolution of trauma came quite slowly. After careful clinical interviewing, it became apparent to me that this client had Dissociative Identity Disorder (DID), and we worked through a serious history of early trauma extending up to the present at age 21 years. Their trauma healing process took a handful of years altogether in therapy with me.

When does the trauma response cease to be triggered? 

Skilled therapeutic intervention is key to resolving trauma, and fortunately there is not just one method or modality to accomplish resolution of traumatic experiences! At the heart of mental/emotional trauma resolution is therapeutic memory reconsolidation as articulated by Bruce Ecker’s (2018) methodology literature review. Healed trauma cannot be re-triggered. It’s permanently gone. Erasure of memory’s traumatic aspects connected to the declarative (aka, factual) and episodic recall is complete. This is fantastic news!

At present, there are ten different therapy modalities that have the backing of published scientific research explaining therapeutic memory reconsolidation. Check the list out here.  These distinct therapies provide a framework for established best practices in the field of trauma psychology. The International Society for the Study of Trauma and Dissociation (ISST-D) has treatment guidelines for adults which can be found here, and for child treatment of trauma, the guidelines can be viewed here. Working within these guidelines leaves ample room for applying the various treatment modalities alluded to above. FYI, please look them up!

To be frank with you, in my early years of treating Complex PTSD and DID, I hardly knew how to recognize what the heart of the matter was with these clients! I definitely contributed to the well-known statistic of DID clients being in therapy for an average of seven years before being given an accurate diagnosis of DID.  Fortunately, I found ISST-D via one of my mentors, and my confidence in working with traumatized clients has blossomed over the years. I now utilize the treatment modality of EMDR as a framework with nearly all of my clients, and it requires a specialized, advanced application with traumatized persons. If you are a client needing trauma-informed care, or if you are a psychotherapist treating trauma, aren’t we so fortunate as seekers and deliverers of therapy at the current time when trauma truly can be healed! Please share this blog with anyone you know who may benefit.

Ecker, B. (2018). Clinical translation of memory reconsolidation research: Therapeutic methodology for transformational change by erasing implicit emotional learnings driving symptom production. International Journal of Neuropsychotherapy, 6(1), 1–92. doi: 10.12744/ijnpt.2018.0001-0092