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Case Study - Page 2

Handling the Emergency

When I asked Trina’s mother to come into my office, she first gently shook her daughter, saying “Trina, session is over” in a singsongy, motherly tone. No response. In a quiet, hypnotic tone, I suggested to Trina that she’d find herself growing more and more awake, ready to face hard roadblocks in her life. No response. Then Trina’s mother and I decided to call 911. Her mother, apparently accustomed to this strange behavior, was surprisingly calm. When the medics took Trina to an emergency room, I expected that she’d wake up as they transferred her to the stretcher and then the ambulance, but she didn’t.

Two hours later, my cell phone rang. It was Trina. “Dr. Soybean (her playful name for me),” she implored, “Please tell the hospital doctor that I don’t need psychiatric admission, and that I’m not crazy!” As relieved as I was to learn that she’d awakened from her dissociative slumber, I saw a great opportunity to move her forward therapeutically. Whenever my child clients ask me for something, I find a way to ask them to do something in return that will be a therapeutic advance for them. So I asked Trina to come to my office first thing in the morning, and explained that if she could successfully describe what happened right before her dissociative shutdown, she could avoid the hospitalization. If, however, she was unable to uncover the feelings that led to this self-defensive reaction, it would make sense for her to go the hospital after the session. Trina agreed to this.

The next session centered on the kind of “fishing expedition” often required with dissociative patients. Blocked from the feelings that usually help people string together a coherent narrative explaining their experiences, dissociative clients’ responses often appear as mysterious to them as they do to others. Trina remembered that we’d talked about her high-school science project, her ambition to be a biochemist, and a boyfriend she was outgrowing. I suggested that something else in our conversation had awakened her old feelings of being helpless, frozen, and unable to move forward. She acknowledged that was true, but remained mystified about what had triggered the old sense of being trapped.

I asked her to focus on that feeling of being trapped and as Trina got in touch with it, she became agitated and nearly mute. As she struggled, I modeled slow, rhythmic breathing and softly said, “Breathe with me. We’ll get through this together.” She took my cue and followed my slow breathing. “Where are you feeling this in your body I asked?”

“In my chest—it’s tight,” she said.

I used a familiar image to help her counter the sense of constriction in her chest. “Let’s imagine together that you’re out in the woods near your house and breathing the fresh fall air,” I said. We stayed with this image for about five minutes, and then I redirected her.

“Whatever’s happened, we can work together so you can handle it. We can find a solution, no matter how scary the trap feels.” I’ve learned that blocked memory usually returns when the therapist provides safety and confident reassurance that the information is tolerable, so I asked, “If you had to guess who it was about, would you guess your mother, your boyfriend, or your father?” Sometimes “guesses” allow the unconscious mind to express itself.

“I don’t really know,” she said, “but if I had to guess, it would be about my father,” she said.

“Something he did or something he said?” I wondered with her.

“I don’t know,” she said, “but he always says stupid things to me, so he probably did say something.”

“Think about your father saying stupid things, and tell me what you feel,” I said.

“My chest feels tight” she said, “and I feel trapped.”

“You aren’t trapped,” I reassured her. “Your whole life is ahead of you. Every day you’re more and more free. Soon you’ll be 18, and have the freedoms of an adult.” My comment about her future, which she faced with both anticipation and anxiety, was right on target.

“That’s it!” she said, “I remember.”

Trina’s parents were divorced, with joint custody. With a shaking voice, she told me that her father had threatened to withdraw college funding if she didn’t agree to overnight visits at his house, where her early abuse had occurred. She’d visited him willingly over the years when he put no real pressure on her, but the controlling nature of his new demand aroused the hopeless feeling she’d experienced when her grandfather’s abuse had seemed so inescapable. The overwhelming fear she’d experienced the day before seemed to encapsulate a central dilemma faced by all child survivors, now heightened by her approaching transition to adulthood: could she grow up, go to college, and be normal? or was she stuck forever in the traumatic past? It was crucial to find a way to support her belief that she could move on in life and escape the traps of her past.

Now that Trina had explained her dilemma, we began to brainstorm practical solutions, discussing ways she could stand up to her father. Ultimately, she decided she’d like me to serve as an intermediary to help him understand why presenting his demand in this authoritarian way triggered her old symptoms. In a subsequent session, I told him how she experienced his attempt to influence her through his control of her college money. He insisted he hadn’t really intended to withhold the funds, he was only emphasizing to her that he “could.” In a subsequent family session, with my prompting and direction, he promised her he’d pay for college, and that he’d never use this threat again. For her part, Trina promised him she’d visit him as her schedule allowed. She never experienced that degree of dissociative shutdown again.

Follow-Up

Over time, Trina learned to believe that the brighter future she dared imagine for herself was possible. Her treatment revolved around learning to combat her automatic tendency to dissociative avoidance and repeated recommitment to her belief in a positive future, whatever challenges she faced in her life. Through her college and postgraduate education, she succeeded, using her skills in affect tolerance, identifying emotional triggers, and self-awareness to navigate dismissive teachers, rude boyfriends, and even the tragic death of a close friend. She stayed in my practice for six years, maturing from a frightened, avoidant girl who had trouble attending school to an aware, insightful survivor.

Today, Trina is an accomplished medical professional, married, with a young child of her own. When asked about her recollections of her early treatment, she says, “Yes, I was a weird kid, but you knew what to do about it.” She quickly changes the subject, but proudly shows me pictures of her new son, who she assures me is developing beautifully, “without dissociation or other wacky stuff.”

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