D I S S O C I A T I O N - Beacon House

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FEBRUARY 2020Dissociationin children and teensAuthorDr Shoshanah Lyons, Specialist Clinical s/2020 Beacon House Therapeutic Services & Trauma Team All Rights ReservedWWW.BEACONHOUSE.ORG.UKFOLLOW US:@BeaconHouseTeam

Dissociation in children and teens February 2020Who is this resource for?This resource is for any adult supporting, teaching, caring for orparenting a child who uses dissociation as a way of coping withoverwhelming experience. We aim to share with you some keyideas about:What dissociation is and why it developsHow to spot dissociationHow to help a dissociative childHow to find out moreWhat is dissociation?Children who have survived experiences which were frightening, or experiences where theirbasic needs for survival and connection were not met, are vulnerable to dissociating as a wayof coping.Dissociation is a survival mechanism, andone that is so often overlooked intraumatised children. Imagine a child whois being physically abused by a parent – inthat moment of violence they cannot fightback and nor can they physically run away,but they can escape in their mind. Allhumans have a natural ability to mentally‘leave the room’ when their trauma isutterly unbearable. Babies and toddlersdissociate when they are in danger or whentheir experience is intolerable. Dissociationis vital for infants and children who aresuffering frightening things, it enablesthem to keep going in the face ofoverwhelming fear.- 2 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020What is dissociation? (cont)A child often continues to dissociate even when they are no longer in danger. Their brain cannotturn the coping strategy off. Because memories are fragmented into lots of little pieces bydissociation, children can often have a flashback to a memory, a feeling, a behaviour or a physicalpain with no understanding of why or what triggered it. This can feel disorienting and confusingfor the child – all they know is that they feel in immediate danger.The more frightening the child’s traumas were, the more likely they are todissociate; and children in ongoing danger will develop more and moresophisticated ways to dissociate.Dissociation is a separation or disconnection betweenthoughts, feelings and behaviours; and a separationbetween the mind and body. It is the mind’s way ofputting unbearable experiences and memories intodifferent compartments.For example – a child may remember a traumatic eventbut have no feelings attached to the memory; or mayshow challenging behaviour but have nomemory behind the behaviour; or suffer astomach ache but feel no anxietyunderneath it.These different parts of the child’sexperiences are of course connected,but they learn to survive by becomingunaware of the connections.- 3 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020What is dissociation? (cont)Children are usually not aware that they dissociate or ‘zone out’, and they cannot put into wordswhat is happening. From their perspective, their experiences are the same as everyone else’s.Dissociation leads to a range of behaviours which can often be misunderstood by adults as daydreamy, being a liar, or problems with concentration. In fact, dissociation is the child’s brainkeeping them safe by momentarily removing them from perceived threat in their day to day life.Dissociation is, in many ways, to be celebrated! When it was needed, it helped the child surviveunbearable moments of pain and fear.Dissociation is very often one part of a complex array of difficulties seen in DevelopmentalTrauma. For more information about Developmental Trauma please see our comprehensivearticle here www.beaconhouse.org.uk/useful-resources/.- 4 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020Are there different types of dissociation?Yes, psychologists have found that there are different types of dissociation, and each one givesthe child unique experiences. Here are some examples:No memory of long periods of time in their childhoodIn day to day life, the child may have memory lapses for seconds, minutes or hoursof timeAmnesiaA feeling that everything around them is unreal, like they are in a dreamFeeling as if other people are not real, or that they are like robots.DerealisationDepersonalisationHaving an out of body experience and looking down on themselves from aboveFeeling disconnected from their body as if their body belongs to someone elseFeeling as if they are floating awayIdentity ConfusionSpeaking in different voices with different agesFeeling as if they are losing control to ‘someone else’ inside themActing like different people from moment to momentFeeling as if there are different people inside themWhat do children and young people tell us abouthow it feels to dissociate?When children and young people recall traumatic memories, they might dissociate from thefeelings or the extent of the threat at the time, and say (or show you through their behaviour)things like:“It didn’thurt”“It didn’thappen to me”“I don’treallyremember”“I don’t carethat ithappened”“It didn’tbother me”- 5 -2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020What do children and young people tell us abouthow it feels to dissociate? (cont)Here are some quotes from children and teens which give us a clue about how it feelsto dissociate:“It’s like you are drowning, youcannot control your body, youcannot see and youcannot hear”“It’s like a part ofme that I can never reachor get to. I know it’s always thereand it can take over my body anytime, and there’s nothing I can doabout it” .“The voices“When I go, I’m gone.are always there. TheyI like it there.I’m safe”chatter, they decide thingsfor me, they make me say anddo things and they tell mewho I can trust”- 6 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020What to look out for – how can you spot dissociation?Unable to do tasks and follow instructions – like a learning exerciseat school, or getting ready to leave the house at home. They mightappear slowed down, physically still, unsure of themselves.A glazed look in their eyes or a blanking out (this canlook like a daydream, zoning out or sometimes even a‘pseudo-seizure’)Extreme mood changes without any obvious trigger.One minute they might appear safe and calm, the nextminute they might appear frightened, angry, sad or anyother emotion.Depersonalisation – the child may have an out of bodyexperience, yet not think anything of it. They mightexpress that something that happened “was not me”,or that their body is not their own: “my legs did it, itwasn’t me”. This may also lead to behaviours such aswetting and soiling, because their brain and body arenot talking to each other.Feeling numb and dead inside – children might bepresent and aware of their surroundings, but feelExtreme behavioural or appearancecompletely numb on the inside; emotionally cutchanges without any obvious trigger. Thereoff, disconnected and empty. They can feel ‘hardmight be changes in their voice, dress,to reach’ to adults when they are in this zone.handwriting, hair, or facial expression.- 7 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020What to look out for – how can you spot dissociation?Regressed behaviour – theMemory loss – the childchild might suddenly start tomight lose memory for thingsact much younger than theythey have said or done; theyare through their voice,might also lose memory forlanguage and behaviour.certain skills, such as doingYou might have the sense thatup their laces or doing joinedthey ‘look and feel’ youngerup handwriting.all of a sudden.Denial of misdemeanours – children might sincerely deny thatthey have done or said something wrong because they have nomemory of it, even if you saw it with your own eyes.There may be a history ofmedically unexplainedphysical symptoms, whichcome and go over time andwhich cause real pain ordistress.Saying “we” or “they” –The eyes roll or flutter asMany children who dissociateself-harm as a way of 'wakingthemselves up’ or 'calmingthey switch from being inthe ‘here and now’ to beingin a dissociative mode.dissociative children feelas if they are ‘multiple’.They might sayspontaneously “we don’tlike that” or “they said no”,which is a way of referringthemselves down’. Self-harmto themselves as multiplecan be a form of selfregulation.The child might seemdistracted by internalConfusion andvoices, or you might noticedisorientation –that they are having athe child may appear confused about the time, day, where theyconversation with a voiceare and who they are.that nobody else can hear.- 8 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020Dissociative partsChildren who dissociate tend to have different dissociative ‘parts’within them. You can imagine this like a mobile phone with lots ofapps, and each app does something useful and a little differentyet it is their collective abilities which make up the overallfunctioning of the phone.There are lots of other metaphors for multiplicity, acouple of ideas are:NestingDollsMasksRainbows- 9 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020Dissociative parts (cont)Dissociative parts can be seen as helpful, because each one serves a purpose in the fightfor survival. Some parts, might, for example:Sometimes, children who are dissociative don’t know about all of their parts and it can feellike the parts have a mind of their own. One role that supportive adults have is to helpchildren see that their parts were once useful, and should be welcomed, celebrated andaccepted – even if some of them are no longer needed. Over time, those parts that are notneeded anymore can be helped to settle.- 10 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020How adults can support dissociative children and young peopleGENERAL PRINCIPLES FOR HOW TO SUPPORT A CHILD WHO DISSOCIATESHelp them to see that while theyneeded their strategies in the past,they can now learn to let them gobecause they are safe. Let them knowthat they can’t do this alone, and thatthey will be helped to do this by theadults around them.Let them know, in many differentcreative ways, that they are safe now.Children do need to be held accountable fortheir actions when they are dissociated,however, try to avoid punishment andshame inducing adult responses (these onlyincrease the child’s dissociation)Give them gentle feedback aboutUse language which accepts and celebratestheir different dissociative parts and thewhat they did and said when theyare dissociated, but do so in a nonshaming, non-blaming way.way in which they have learnt to cope.- 11 -2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020How adults can support dissociative children and young people (cont)GENERAL PRINCIPLES FOR HOW TO SUPPORT A CHILD WHO DISSOCIATES (CONT)Help the child’s importantTry not to feeladults to understandparalysed by thewhat they are seeing, thisabsence of obviousincludes parents/carers,triggers. Dissociativeteachers, extended familyand trusted friends. Sharethis resource if thatwould help.If you can spot triggers, do what you can to prevent orreduce them. If they cannot be avoided, give the childsome information so that they can understand what willchildren are oftentriggered by internalfeelings and sensationswhich are hidden tothe outside. Just knowthat there is a trigger,and that they needhelp to feel safe again.happen and why.We can often worry that talking about dissociation with young people might make itworse. However, young people tell us that they feel relieved and better for talking about it.They need help to understand what is going on, and to find words to express theirexperiences. Download our dissociation cards from www.beaconhouse.org.uk/usefulresources/ to help you have conversations with young people about their experiences ofdissociation.- 12 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020How adults can support dissociative children and young people (cont)TOP TIPS FOR HELPING A CHILD WHO HAS DISSOCIATEDYour main goal when helping a dissociated child is to ground the child back to the ‘hereand now’ and help them to feel safe. You can do this in many different ways, here are a fewideas:Use eye contactUse a calm, low, slow voice.Use their name, remind them they are safe and where they are (“Sarah, you are at home,it’s me – mum”)Use gentle, simple grounding questions (“Sarah, can you tell me where you are? What isyour name? How old are you?”)Use gentle touch (such as placing your hand on their knee or their hand)Use potent smellTurn on some musicGive them something to eat or chew, or something to drinkGet them moving. E.g. help them to stand up and walk around, throw a cushion to and fro.Ask them questions about their surroundings (“Sarah, what can you see? what can youhear? what can you smell?)Take them outside and walk on the grass - preferably in bare feetIf you have a pet, ask them to stroke itFor teens, a mobile phone can be the connective bridge between adissociative moment (‘then and there’) and the present (the ‘here andnow’). If your young person has a mobile and you know they have beentriggered or are feeling vulnerable, send them regular grounding messagesto help them stay present. You can download some free grounding textmessages from www.beaconhouse.org.uk/useful-resources/ .Remember: The nervous system works in a sequence. Young people often move intofight/flight/freeze as they transition back to being fully present. If they start ‘fighting youaway’ or ‘wanting to avoid’ what just happened you are on the right path. If you can bringin playfulness, humour and laughter then you have turned on their social engagementsystem and they will be back in the room with you.- 13 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020How adults can support dissociative children and young people (cont)THE ROLE OF ASSESSMENT AND THERAPYIf you suspect a child uses dissociation, it is important to seek out a full psychologicalassessment with a practitioner who is a specialist in trauma. The practitioner will be able toconfirm whether the child is dissociating, and they will also be able to map out theinteraction between the dissociation and other aspects of their complex trauma. It is onlythrough a robust assessment that a child’s therapeutic needs can be identified.Therapy for dissociative children can be very helpful, if they are living in a safe and stablehome. There are useful guides written by the ESTD for the assessment and treatment ofchildren and adolescents with dissociative symptoms and dissociative disorders (2015).Therapy goals might include:To establish safety for the child, and to reduce the likelihood of the re-enactment oftraumaTo teach them about dissociation, and how they have learnt to survive. Downloadour dissociation cards from www.beaconhouse.org.uk/useful-resources/ to helpyou have conversations with young people about their experiences of dissociation.To help them develop skills in managing their emotions without turning todissociation as regularly or as severely.To help them communicate their needs, and to identify when they are dissociatingso that they can stay grounded more and more over time.To process and make sense of any explicit or body memories they have about theirtrauma- 14 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020How adults can support dissociative children and young people (cont)THE ROLE OF ASSESSMENT AND THERAPY (CONT)Therapy tends to integrate a range of therapeutic approaches (there is no ‘one sizefits all'); and is phased and long-term. Including the parents/carers and extendednetwork is an important part of developing a therapeutic web around the child.- 15 2020 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Dissociation in children and teens February 2020About the authorsIf you would like to reference this resource, please use the following credit:Dr Shoshanah Lyons, Beacon House Therapeutic Services and Trauma Team(www.beaconhouse.org.uk/useful-resources) February 2020You are welcome to contact the author on: [email protected] out moreBOOKSThe Simple Guide to Complex Trauma and Dissociation: What It Is and How to Help (Simple Guides)by Betsy de Thierry, 2020Dissociation in Traumatized Children and Adolescents by Sandra Wieland, 2015EMDR Therapy and Adjunct Approaches with Children: Complex Trauma, Attachment, andDissociation by Ana M. Gomez, 2012Treating Chronically Traumatized Children: Don't let sleeping dogs lie! By Arianne Struik, 2019The body keeps the score, by Van der Kolk, 2015WEBSITESwww.pods-online.org.uk - PODS has a wealth of information about dissociation and its treatmentwww.isst-d.org - International society for the study of trauma and dissociationwww.estd.org - European society for trauma and dissociationwww.childtrauma.org - Dr Bruce Perry’s research about developmental trauma- 16 2019 Beacon House Therapeutic Services & Trauma Team All Rights Reserved

Here are some quotes from children and teens which give us a clue about h o w it f e e ls to disso cia te : “ T h e v o ic e s a r e a l w a y s t h e r e . T h e y c h a t t e r , t h e y d e c id e t h i n g s f o r m e , t h e y m a ke m e s a y a n d d o t h in g s a n d t h e y t e l l m e w h o I c a n t r u s t ”