By Frances S. Waters, M.S.W.
Reprinted from The Dissociative Child: Diagnosis, Treatment, and Management, edited by Joyanna L. Silberg, Ph.D. Copyright 1996 by Sidran Institute Press. Not to be reprinted without permission of the publisher.
Effective treatment of the traumatized dissociative child includes engaging the child's family to facilitate the child's ongoing recovery from trauma. As demonstrated repeatedly (Dell & Eisenhower, 1990; Fagan & McMahon, 1984; Silberg & Waters, Chapter 6, this volume), dissociative children who make the most gains from appropriate therapy are the ones in a safe and nurturing environment with consistent parents. Consistent parenting promotes healthy attachment, provides affect modulation and containment, and helps to counteract the pessimism and demoralization learned from the child's abusive experiences. Providing the ideal environment for dissociative children is a challenge, as their behavior may be provocative, rejecting, and out of control. Many parents report that these children may seem uncaring or unattached, and parents are embarrassed by their child or adolescent's unpredictable behavior. Families are hungry for any clues that might help them understand, manage, and normalize their child's behavior.
Parents of dissociative children face many obstacles in managing their children. By learning to accept and interact with the dissociative aspects of the child, learning how to manage difficult traumatic memories, and helping the child manage his extreme emotions, the parent serves as a therapeutic collaborator in the child's treatment. With adequate knowledge, support, and commitment, parents can play an integral role in facilitating their child's recovery. Therapeutic work with parents is an essential component in the full treatment plan. Parental perseverance will facilitate the dissociative child's attainment of trust and attachment and promote the child's development into a functioning adult.
The techniques and recommendations described here are most appropriate for families that are not abusive or in severe turmoil. These are families that may have crises, temporary disruptions, or lapses in judgment, but these families are characterized by stability, commitment, and availability to the child during recovery.
Child Management Guidelines
It is difficult to anticipate the unusual family problems that may arise, with the constant interaction of patients and their alters with parents, siblings, friends and extended family. Clinicians and parents must be flexible in responding to the individual challenges of each unique dissociative child. However, the guidelines below are viewed as universally applicable to all dissociative children and may provide a framework for resolving management questions.
1. Use only non-physical forms of discipline.
A dissociative child who has been traumatized sexually or physically is very susceptible to tactile triggers related to early memories of abuse, even if the touch is an appropriate one. Incidents such as a sudden tap on the child's back may initiate a profound startle reaction, and parents may become accustomed to avoiding unexpected touches. It is important to stress to parents that purposeful hitting, pushing, spanking, or slapping are never acceptable forms of discipline for a dissociative child. These assaults to the child's body can set off a full-blown abreaction to early physical forms of abuse and strengthen the child's dissociative defenses. These children have learned aggression from their maltreatment, and physical forms of discipline may increase these aggressive and retaliatory tendencies.
Because these children are very provocative, they require parents who are well versed in appropriate child management techniques and can work out an agreed plan with the child in advance for appropriate rewards and consequences for chores and problematic behaviors. As with normal children, it is important to give consequences soon after the inappropriate behavior if possible and to employ grounding for a reasonable period of time. However, until there is co-consciousness in which the child and the alters share information and are all attentive, the parent should not expect the child to learn immediately from the behavioral interventions such as grounding and removal of privileges.
2. Use a calm, low voice when the child is out of control.
Traumatized children may have been emotionally and verbally abused by screaming, shouting, and name calling. These emotional scars are hidden scars, which can be more damaging to the child's self worth and identity than physical scars. The verbal abuse has an insidious impact on the child's sense of being as the child feels splintered, insecure, demeaned, and enraged, and may want to retaliate. Given how demanding, provocative, and unrewarding a dissociative child can be periodically, it is a most challenging task for the tired, frustrated, and angry parent to maintain a calm, low voice when the child is screaming or refusing to listen.
When a child is out of control, it may be best not to try to reason with the child, but to separate the child from the parent. The parent may send the child to his or her room with the instructions that when the child has calmed down, then he or she can come out of the room to discuss what had occurred. Sometimes it may be advisable for the parents to remove themselves from the provocative child who is attempting to incite the parent's anger. This approach would be appropriate if the parent was not worried about the child harming himself/herself or others or destroying property. The parents can go to their bedroom or to the bathroom for privacy until the provocative cycle is broken.
One parent of a DID child reported that his petite 8-year-old adoptive daughter's alter would scream in his face inches away when he was attempting to deal with her oppositional alter personality. If he yelled back, she would escalate, and the situation would quickly worsen. If he kept his voice low and calm, she was able to calm down sooner. Then, they were able to work out the conflict without a full-blown crisis.
It is very difficult for parents to separate out angry responses which their child has toward them and see their behavior as symptomatic of the abuse rather than a personal affront to them as parents. One adoptive mother, who was in a helping profession, reported to me that she could deal more effectively with her dissociative teenage daughter's angry outbursts by viewing her as a client rather than as her adoptive daughter who was resistant and fearful of attaching. Maintaining a psychological distance kept the mother from becoming entangled and embroiled with her angry, demanding, and unattached daughter. This "clinical" distance also provided some protection for the mother, who was psychologically hurt by her daughter's rejection.
3. When discussing with the dissociative child consequences, ask the child to have "all your parts (alters, fragments, ego states) watch and listen" so everyone is aware of the undesirable behavior and consequences.
The parent's goal is to encourage the child to develop co-consciousness by requesting that the child's alters, ego states, or fragments watch and listen when the parent is instructing the dissociative child.
Parents should not assume that the child and the alters, fragmented personalities, or ego states are aware of the discussion following an inappropriate behavior, even when the child has expressed co-consciousness, because the alters may be "sleeping" or preoccupied with some other activity internally. Several dissociative children whom the author has treated stated that a helpful alter (one who has a positive influence) was "sleeping," even when it was agreed that all alters were to be attentive.
Another common dilemma with parents is managing the dissociative child's aggressive behaviors, e.g., hitting, swearing, breaking objects, when the child reports that the alter who committed the offense quickly disappeared leaving the host personality "holding the bag." These alters may "go into hiding" to escape from listening to the reprimand. To avoid or minimize this from occurring, the parent needs to make reference to the child and alters, if known, or "to any and all parts" that were involved in the misbehavior to be aware of the consequences decided. For example, the father can say to his dissociative daughter, "I want you and your parts to watch and listen while we talk about what just happened, and decide how it should be handled. Everyone needs to listen so they know the consequences."
Due to dissociative features, these children need frequent reminders about the rewards and consequences of unacceptable behaviors. Parents should not assume that the child will remember and learn from one incident to another what is acceptable and unacceptable behaviors. Until the child is further along in treatment in which amnestic barriers have eroded, and there is coconsciousness and cooperation, he or she will require continuous discussion of expectations, rules, and consequences.
4. No matter who was out or internally influenced the child at the time of the inappropriate behavior (alter, fragmented personality, ego state), the child still has to be held responsible for his or her behavior.
It is my general position that the dissociative child needs to be accountable for his or her behavior. Understandably, this will present conflicts of responsibility and ownership of behavior in the initial phase of therapy in which the identification of the dissociative system is unknown and amnestic barriers are still present. Therapist and parents can use judgment and flexibility in determining the degree of the child's accountability for inappropriate behavior by weighing many factors.
One critical factor to weigh in determining consequences is this question: "Is this behavior linked to a traumatic incident which the child is remembering and therefore acting out?" For example a child's inappropriate sexual behavior with a peer or a much younger child may be rooted in his or her own unresolved trauma. It is important that the therapist explores with the child the underlying dynamics and the motives of the behavior. The therapist assists the child to deal with the traumatic memory of sexual abuse and stresses to the child the serious legal and social consequences of sexually inappropriate behavior. The therapist, then, helps the parent understand the motives of the child's behavior.
Nevertheless, the parent would need to set up necessary environmental precautions to prevent or greatly reduce the opportunity for the child to sexually engage with or abuse another child, such as playing only in supervised areas, prohibiting sleepovers, or allowing only structured activities with peers outside of the home. These restrictions give the child the message that the sexually inappropriate behavior is unacceptable, and the child will have to learn ways to control future sexual impulses in order to be allowed more freedom with peers.
5. When the child denies a witnessed, problematic behavior, the parent gives the firm message that the child needs to sort out with the alters what occurred as the parent provides an understanding atmosphere.
Even though dissociative children are encouraged by parents and therapist to engage in coconsciousness and cooperation, the child may not always have an awareness of a destructive behavior exhibited by an alter. Restrictions should be accompanied by the strong message that the patient needs to do an internal check to find out what role an alter may have played in the behavior. This encourages inner communication, the eroding of amnestic barriers, and cooperation. The child's task is to learn to work together with the alters to control any impulses.
When a parent is faced with a child's denial of a witnessed behavior, the parent should calmly instruct the child to go to his or her room and explore internally what may have occurred, and later they will discuss the behavior and consequences. One astute adoptive mother of an 8-year-old DID girl told her when conflicts occurred between her and her alters, "It's not up to me to fix it. You have go inside and fix it!" The adoptive mother understood her limits and encouraged her daughter to fix her conflict with her alters, and to arrive at an agreed solution. This approach worked well to minimize jealousy, competition, and resentment among the child's alters, and to encourage communication, cooperation, and conflict resolution with them.
Another factor in evaluating the child's denial and accountability for his or her actions is to consider if the child is manipulating to avoid responsibility for behavior by blaming an alter for the actions. The author knew one 10-year-old DID girl who would frequently try to fool the author and the child's parents by pretending to be her male alter in order to blame him for her misbehavior. When she learned that it did not matter if it was her or her male alter, but that there were clear consequences for the misbehavior, her attempts to deceive her parents and the author decreased. In addition, her male alter was instructed to come out and take control, if needed, to prevent the child from getting into trouble and being grounded. The child and her alters had to work out together a way to deal with projection of blame, internal conflicts, and accountability for the misbehavior.
6. The therapist, child, and parent confer and identify internal helpers who are requested to assume control if the child or an alter attempts to engage in destructive or abusive behavior.
The author has instructed alters to be "watchers" and to take over, if needed, to prevent the child from engaging in destructive or aggressive behavior. Parents need to be aware who the "watchers" are and encourage them to take executive control or warn the parent if the child is going to engage in destructive or abusive behavior.
7. The therapist, parent, and child confer and agree on modified treatment techniques to be employed at home for safe discharge of feelings. The child is rewarded with an agreed-upon privilege. Traumatized children need safe and varied methods to express and discharge their feelings. Frequently they have rage, which may be expressed in violence toward their family members, peers, or property. Providing acceptable discharge of such rage can minimize these destructive episodes. Arranging in advance privileges for safe discharge of intense feelings will encourage the child to employ these techniques.
The following are some suggested bargains that the parent can negotiate with a dissociative child to help with expressing anger:
- punching a pillow or punching bag to earn points toward a toy;
- drawing a picture of their feelings and ripping it up to earn points toward renting a video;
- making a snow sculpture symbolic of feelings and then smashing it to earn the privilege of a favorite bedtime snack;
- making a sand sculpture symbolic of feelings and stepping on it to earn the privilege of inviting a friend over;
- making a clay figure symbolic of feelings, and smashing it to earn points toward the privilege of ice skating, roller blading, or roller skating;
- running down the driveway or around the block three times a week to discharge anger to earn the privilege of attending a favorite sports event;
- using an exercise machine to expel anger in exchange for time playing a computer game;
- shooting baskets to expel anger in exchange for watching a favorite television show that day;
- journal or write poetry about feelings three times a week in exchange for going to a movie.
- Most importantly, verbalizing to the parent the anger felt and requesting parent's help in processing thoughts and feelings in exchange for spending special time with the parent.
Each family needs to evaluate what opportunities are available and acceptable in their home environment to express rage. One family, who resided in a rural area, agreed on a creative solution for their adopted 10-year-old DID girl. She was permitted to go to the woodshed, which also contained garbage cans, and shake them, scream, and swear. She understood that this was the only place in which she was allowed to use vulgarities toward the abusers who had sworn at her profusely. Another devoted adoptive mother who also resided in a rural area would make use of her quarter-mile driveway when her 8-year-old DID daughter would become rageful at bedtime. The mother would bundle up her daughter and march her up and down the driveway until her daughter was able to calm down and verbalize her anger, hurt, and fears. Then the mother would rock her daughter and put her to bed.
The therapist and parents need to review techniques which they find acceptable and agreeable and permit their child to voice what she is willing to do to safely discharge negative feelings. Children can suggest creative techniques that adults might have overlooked. Children need to decide with parents what rewards would be meaningful to them when they use appropriate expression of unpleasant feelings instead of destructive behaviors.
8. Therapist, parent, and child agree on code words or symbols to signify the presence of intense, and uncontrollable feelings, thoughts, and behaviors. It is advisable for the therapist, parent, and dissociative child to select code words or symbols which can be verbalized by the child, parent, therapist, teacher, and other appropriate adults to signify that the child is in need of quick stabilization. Code words or symbols can be used for the following purposes:
- The child may be experiencing intense and uncontrollable feelings, thoughts, and behaviors which could result in destructive behaviors.
- The child may be experiencing a flashback of a traumatic memory and needs to be reoriented to the present.
- The child may be dealing with conflicts with alters over executive control of the body or over a desire to hurt someone or oneself.
- The child may be disoriented and switching personalities and needs to maintain coconsciousness and cooperation.
The expression of code words or symbols can be a quick way to halt the escalation of serious behaviors without exposing the child to humiliation in front of peers or other adults. This is an intervention tool to redirect the child to being appropriately oriented and under control.
The code words "get it together" have been used by parents, teachers, and therapists with DID and DDNOS children who appeared disoriented and had uncontrollable switching of alters or ego states influencing the child to act developmentally inappropriate, exhibit extreme mood switches, or experience difficulty in performing needed tasks, e.g., homework or chores. This word signified to the child and his or her parts the need to come together in co-consciousness and cooperation.
The symbolic word "spike" was used by a DID child to report to her parents when she was experiencing intense feelings or new memories. Sometimes her parents would use the word when they suspected that their daughter was having a new memory, saying, "Are you having a spike?"
One child used the symbolic word "bubbles" to signify when he felt that he was "going to burst" with overwhelming emotions and might hurt himself or someone else. For one child the symbol of the child's hero figure, Power Ranger, was employed to reorient the child to the present when the child was experiencing a flashback. The hero figure was seen as the child's protector who gave the child the emotional support to come back to the present environment because his hero was watching over him. In order for code words or symbols to be effective, the child and alters should select the code words or symbols and agree to comply with the use of them. Sometimes children may become resistant or oppositional to using them. A frank discussion with the child about effective ways to help him to have control over himself to spare him any embarrassment or a long discussion may be required to regain the child's commitment to responding to the code words or symbols. Hypnotherapy (Kluft 1985b) may be employed to instill code words to help stabilize the child, if the child is agreeable to this technique.
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