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Case Study

Treating the Dissociative Child: The road back from the ultimate loss of self

By Joyanna Silberg

She wasn’t responsive to my voice or my soft touch. Her face was pale, her body was limp, her breathing was rhythmic and shallow. Should I call the medics, I wondered, or have her mother carry her out of my office? Luckily, she was my last client for the day, so I had time to figure out what to do with this unresponsive teen. I was seeing dissociation in its extreme form: the body shutting down in a “freeze” position, the way some wild prey respond when threatened by a predator. But what in our session had 17-year-old Trina perceived as “predatory”?

Though there had been a casual conversation about college plans and a boyfriend, there had been no talk of her early sexual abuse memories with a grandfather with whom she no longer had contact. After three years of treating her for dissociative behaviors, including sudden regressions, amnesia, and dazed states, I thought we’d moved beyond such an extreme response to stress on her part.

Trina was demonstrating a “dissociative shutdown,” a symptom often found in children faced with a repeated, frightening event, such as being raped by a caregiver, for which there’s no escape. Over time, this response may generalize to associated thoughts or emotions that can trigger the reaction. Although the child’s body may be immobilized, her mind remains active and can invent solutions, often retreating into an imaginary world, where bad things aren’t happening. With time and practice, the mere thought of needing to escape a situation may trigger a self-induced hypnotic retreat, along with a primitive freeze response.

According to Bruce Perry, senior fellow of the ChildTrauma Academy in Houston, these kinds of episodes are best understood as a dysregulation of the central nervous system’s opioid systems, which have been repeatedly activated by extreme stress. This response then becomes an enduring “trait,” so that small reminders of trauma can stimulate these dramatic alterations in consciousness. Perry points out that medical professionals often are puzzled by this kind of shutdown and may diagnose it as “syncope of unknown origin,” “conversion reactions,” or “catatonia.”

Working with dissociative children and teens can be unnerving for therapists, particularly in view of such extreme symptoms. A basic theoretical understanding of dissociation can demystify even this kind of sudden in-session event. But as important as it is to have a theoretical understanding of what’s happening, a clinician needs a pragmatic, strength-based, problem-solving focus to feel prepared to treat such entrenched dissociative reactions in children and teens.

Most children experiencing dissociation don’t have as little control as Trina did at this juncture. Usually, signs of dissociation can be as subtle as unexpected lapses in attention, momentary avoidance of eye contact with no memory, staring into space for several moments while appearing to be in a daze, or repeated episodes of short-lived spells of apparent fainting. As they move along an intensity spectrum, some young clients may have alterations in identity, with sudden regressions or rage-filled episodes, and little awareness of their behavior.

There’s still little consensus about how dissociation develops in traumatized children, but it’s been linked to disorganized attachment, often characterized by blank looks, avoidant eye gaze, and shifting affect. Frank Putnam, director of the Mayerson Center for Safe and Healthy Children at Cincinnati Children’s Hospital, has theorized that, while most infants learn to shift flexibly between emotional states over time, trauma-based states are marked by inflexibility and impermeability. According to psychologist Silvan Tomkins, children learn to rely on “affect scripts,” sequences of automatic behaviors that help them avoid experiencing such painful affects as fear, shame, or disgust—the kind of deeply disturbing feelings aroused during sexual abuse or other traumatic experiences with caregivers. The traumatized child learns to avoid overwhelming emotional pain through dissociation. As a consequence, these children can fail to develop the basic building blocks of identity and consciousness.

The reversal of dissociative states requires a therapeutic relationship in which the child can feel safe and clearly distinguish between the present environment and the traumatic past, while developing the deep, embodied conviction that the future doesn’t have to mirror what he or she has already been through. From years of experience working with children like Trina, I knew that my job was to help her discover alternatives to her avoidance response, understand and learn to tolerate its triggers, and find ways to override the automatic physiological escape tendency over time.

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1 Comment

  • Comment Link Monday, 21 January 2013 12:14 posted by Micki McDonough

    This is a beautiful example of outstanding therapy, a therapist who trusts her client and a client who trusts her therapist. It doesn't get any better.