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!