Therapy with Dissociated Youth, Using the STAR Model

Treating dissociation at times can feel like groping around in the dark. We know we are in the right ballpark, but every session can be an act of straining to interpret and understand what is being presented. Ever since I started doing treatment and parenting as a therapeutic foster parent, I wanted desperately to have a decoder ring to understand what was going on, and how to engage and respond. In my pursuit, I have connected with Fran Waters, LMSW, DCSW, LMFT to understand her STAR Theoretical Model (Waters, 2016) as a framework or a lens to make sense of what was being presented by my clients and foster children. Waters’s (2016) work was built off a model that she developed as she worked with dissociative youth.

The model that was created in order to develop a framework for understanding the mental health presentations that she was seeing in these youth. Initially, she created what she coined the Quadri-Theoretical Model which incorporated the work of attachment theory (informed by Bowlby) , developmental theory (informed by Erikson), family systems theory (informed by Satir), and dissociation theory (informed by Janet, Putnam, Van der Hart, Watkins, Silberg, and Freyd). As she was influenced by neurobiology, she adapted this model into the Star Theoretical Model (STM) because the findings were helpful in understanding the diagnostic makeup of dissociation.

The purpose of the model can be summed up as a tool that “describes pathways that either lead to, or influence the use of dissociation in children and adolescents, and it guides the assessment and treatment of children with dissociation” (Waters, 2016, p. 4). The impact this has had on my treatment of my clients is significant because the behaviors presented now made sense and were supported by the vast resources within the fields of study in dissociation, attachment, neurobiology, family systems, and developmental psychology. In order to show how the STAR model can be used for case conceptualization and treatment, I will share a vignette from one of the clients I treated. (All names and details have been changed for confidentiality purposes. Vignette inclusion was approved by the client and her family.)

A 13-year-old girl, Charlotte, came to my office with her family in order to receive treatment for what they suspected to be Dissociative Identity Disorder. The family had been through several different treatment protocols and medication regimens. In addition, their daughter experienced several hospitalizations that were ineffective in helping her stabilize and heal. Charlotte came into therapy identifying several parts of self, each with their own names, purposes, and backstories concerning their “lives” before they came to be a part of Charlotte. These parts of self came to be as a result of significant childhood sexual abuse by a peer over the course of several years. The initial assessment of this youth began with assessing the dissociative symptomatology by going through an A-DES assessment which indicated that a dissociative disorder was possible. Further assessment and clinical interviewing solidified this diagnosis. I then began to assess through Waters (2016) Sixteen Warning Signs of Dissociation, recognizing indicators of dissociation related to Charlotte’s traumatic history, moments of switching and the presence of different parts.

The next stage of utilizing the STAR model was the intervention of psychoeduction for the child and family about dissociation and communicating the treatment goal of integration. I put a special emphasis on communicating to the child’s system how “brave and strong they are”, and how “my goal was not to get rid of the parts but to help them work together”. I also spent significant time focusing on safety building so that the child and her parts knew that I was not going to harm them and would pace our work according to what she and her states could tolerate. The psychoeducation of dissociation is a crucial step because it allows the therapist to conceptualize the behaviors and symptoms for the family to make it understandable with clear guidelines for stabilization of behaviors. Assessing attachment is something done over time by tuning into the relational dynamics with the parents by including them in sessions. This can help build safety in the sessions as well because the parents are more attached to the child than the therapist, and because attachment is central to treatment. Attachment wounds and betrayal trauma must be worked on and resolved to move towards integration.

Charlotte’s relationship with her mother, while being secure at times, suffered because the abuse of a peer happened in her own home, where the child felt the parent should have protected her. This was learned in the assessment phase of treatment and during the treatment phase, I circled back to this dynamic when a part of self that primarily held the rage towards its abuser took unilateral control for a couple months. As part of therapy, Charlotte’s mother, father, and her sister (with whom there is relational disconnect as well) wrote letters to Charlotte about how they were sorry she experienced the abuse and that they wished they could have protected her and stopped those events from happening. That was a stepping-stone to ‘grease the wheels of treatment’ because that dissociative part largely wanted to disengage and stop going to therapy, due to not wanting to address the homicidal behaviors it presented with.

These homicidal behaviors were a means for this perpetrator introject to protect the child by redirecting the rage on her attachment figures. That part would often state “if my parents or sister were dead then I would not have to feel like this anymore, and even if I went to jail or was sad that they were gone that feeling would go away also”. This all indicated attachment needed to be addressed to continue to work through the trauma. The influence of neurobiology is also a helpful psychoeducational piece for the parents to understand the impact of trauma with the polyvagal theory, and how stress is a mitigating factor in whether the child can stay within their window of tolerance or feel the need to rely on switching between parts. That allowed the parents to understand what was happening inside their child’s mind. Within the assessment and the treatment stages, there is always an awareness of tuning into the child’s window of tolerance and being aware of stress and how to elicit safety in therapy sessions.

If a child is resistant and non-participatory, then stress is elevated, safety is questioned and parts are presenting with a myriad of behaviors to distract and disrupt momentum in treatment. I encouraged the parents to use their new understanding of the neurobiology of trauma to adjust their parenting approach. The golden rule when treating dissociative youth in this model is ‘connecting before correcting’ (Hughes & Baylin, 2012; Siegel & Payne Bryson, 2014) because it causes the parent to become curious about the child’s behavior to understand how the trauma is playing out specific behavioral coping scripts. It also allows for attachment repair to happen in the moment of triggering. Charlotte’s different parts presented differently but they all tended to move into scripts that distanced and withdrew from family members, which led Charlotte to hide up in her room for significant lengths of time. The parents were bothered by this and wanted to correct it, but the tuning in of ‘connecting before correcting’ allowed Charlotte’s parents to move towards her and drew her out of seclusion into connection with them through cuddling, and one-on-one time.

Developmental psychology is a lens that allows for understanding where and what is going on within a dissociative child’s system. In the assessment phase, we were able to explore each of the different parts and identify developmental stages for each part. The little parts were younger developmentally and did not have the fine motor and academic skills needed for Charlotte to function in school. Therefore in several sessions, I worked on helping the younger parts identify why and when they are triggered to come out and also helped them feel comfortable staying inside when the child was in school so that they could avoid times when Charlotte switched and became lost, frightened and disoriented in school. This goal is a short-term focus to allow for stability as the goal will eventually to developmentally grow the different parts up. The younger parts need to orient to the present where the child is safe and older so that different developmental stages do not conflict with current functioning.

I worked together with Charlotte’s parental part (who took on the role of raising up one of the little’s) by helping the young part have internal space and tools to feel comfortable staying inside and also allowing for this part to have internal glasses (installed through EMDR) to help with the learning and growth process. Through this intervention, this younger part has grown to become an integral part of treatment because this part has been found to have influence or control over the perpetrator introject part of Charlotte’s system, allowing for therapeutic resistance to treatment to be mitigated. Family systems work is key to understanding the child’s internal system because their internal systems mimic the systems in their birth and adoptive homes.

Having a strong understanding of the family’s dynamics and roles helped me to understand what roles the internal parts had taken. Charlotte’s mother presented with her own trauma history and presented with a diagnosis of OCD. Charlotte’s system created a part of self that was oriented around parenting and is meticulous and controlled about the internal family and its dynamics, which seemed to mimic some traits similar to her mother’s OCD. This part had schedules, routines, educational lessons that it would force the internal family to follow through with. There is also a part of self that is predominantly image-conscious and self-focused. This part tended to take after Charlotte’s older sister, which plays in the same family patterns because Charlotte was distant and not connected to this part of self, and often remarked on hating this part. In order to work through the internal family dynamics, we helped her external family dynamics.

Charlotte would not be able to heal and integrate with her self-oriented part that mimicked traits of her sister if she did not work through the dynamics with her actual sister, and the same was true for her relationship with her mother. The reasoning can be quite symbolic and different for every child’s system, but for Charlotte, it was because each of those family members hurt her in different ways, so their behavioral scripts were wrapped up in pain and needed to grieve and unburden from those dynamics. These five pathways can provide the therapist with a concrete assessment and foundation to treat these children. It gives hermeneutics, direction, and creates open windows for stabilization, and integration to take place.

Charlotte’s system improved significantly when stabilization and safety were achieved by utilizing these 5 pathways in the STAR theoretical model. It also allowed for clarity when treatment became a challenge and Charlotte was resistant. The model helped me interpret and identify a perpetrator introject and understand the impact of the family and attachment dynamics in play. The STAR Theoretical Model (Waters, 2016) is a comprehensive and directional primer and approach to treating dissociative clients.

References: Hughes, D. A., & Baylin, J. (2012). Brain-based parenting: The neuroscience of caregiving for healthy attachment. New York, NY: W. W. Norton. Siegel, D., & Payne Bryson, T. (2014). No-drama discipline: The whole-brain way to calm the chaos and nurture your child’s developing mind. New York, NY: Random House. Waters, F. S., (2016). Healing the fractured child: Diagnosis and treatment of youth with dissociation. New York, N.Y., Springer Publishing Company.

DID Game Review: Who Am I: The Tale of Dorothy

This is a very fun post to write!

Mostly because it’s one of the few times DID or dissociation is handled and communicated with care and knowledge. Typically in the media DID is usually negative, or a gross misrepresentation of the disorder.

This post is a review of a short game that is available on steam or in the google play store for 1.99$. As soon as I found out about it I wanted to explore and I was not disappointed.

The concept of the game is akin to a choose your own adventure story revolving around the life of a teenage girl named Dorothy who has DID. She was adopted after being separated from her parents for reasons revealed throughout the game.

I love this because dissociation and DID are so prevalent in foster care and adoption but so misunderstood. It’s one of my passions to help foster and adoptive families identify and work through dissociation.

You initially walk through a tutorial that explains the game and how to play. What is revealed is that you interact with Dorothy in a dream space, and you as the user play as Dorothy’s therapist trying to help her solve daily life struggles and the triggered traumatic past that comes up from the daily experiences- this includes the activity and actions of the parts when they take control.

You are given limited attempts each time you enter the dream space to talk with Dorothy or one of her 3 parts Alice, Gretel, and Cindy (metaphors of fairytales are prevalent through the game).

The goal of the game is to help keep Dorothy’s stress low and manageable related to the concept of the Window of Tolerance, and to build the “integrity” of the parts with the hope that once their integrity is full they will integrate with Dorothy.

Each of the parts has their own story arcs related to the trauma that they were birthed out of. One of the story arcs is towards integration, and the other towards disintegration.

All of the parts are considered littles in the game which is an intriguing stance the game took because dissociative research disagrees about this but some believe that all parts are littles even the ones that act older because they were created at the time of the trauma (depending on when the parts were created).

Alice is shown as a younger part that identifies with Alice in Wonderland who encapsulates the derealization of dissociation. This part wants to protect Dorothy by having her escape reality to Wonderland. This is such a spot on representation that it is heartwarming to see how they careful developed the parts in the game.

Gretel is shown as slightly older and the part that holds the rage and anger of the trauma and also seems to take on some qualities of a perpetrator introject because its fixation on violence and blood which mirrors the behavior of the abuser. This part also has another quality of rage-filled parts- protective posture over littles. Gretel sees Alice as an innocent child needing protection from monsters (parents).

Cindy is what could be deemed as the ANP (Apparently Normal Part) this part seems to compensate for perceived weaknesses in Dorothy by being social, outgoing, popular. This part seems to be quite vain at times but throughout the narrative can be key in lowering stress, and being mindful of the depression or anger that is taking over Dorothy.

As I played this game I had to fail a lot to understand the dynamics and what the game developers wanted you to do to maintain Dorothy and her parts because it is much more nuanced in the therapy room and what works for one client does not work for another.

So my first attempt was to try and connect with the different parts depending on what storyline was being told. Within that connect there is an exploration I tried to buy into such as their interests and what they perceived. This was a total failure. It became clear that spending too much dialogue space on the different parts increased Dorothy’s stress and quickly got me stuck answering the parts in ways that decreased their integrity.

I eventually became successful by having the strategy of primarily speaking with Dorothy, and then engaging mindfully with the part that was involved in the particular narrative that the story found itself.

When I navigated the darkest spots of the story there is some triggering content. SPOILER: Such as the reason that Dorothy was adopted was that she entered care when her father killed her mother due to an affair she was having. Along with the darkness comes dark ways of thinking from Gretel, who is fixated in the blood and evil that came from the abusers.

There is an element that is creepy to the game from the music to some of the images of Gretel, especially her final disintegration which was her taking primary control over the body and being consumed with rage, and the trauma causing switching back and forth between the above faces.

Ultimately the lessons that the game tries to teach moving towards integration are beautiful such as trusting the love of her adopted family, advocating for her needs, reaching out to her new parents to clarify assumptions that she has about how they are acting, and finding self-confidence.

The biggest and only thing I would take issue within the game is the fact that integration is portrayed as the parts of self no longer being needed and going away. This is not what happens for DID clients, instead, integration is the unification of the parts- all being present and working together simultaneously once the traumatic past has been unburdened and processed. These parts are still there and experienced, but amnestic barriers once promulgated by the withheld memories are no longer causing the disintegration.

Overall, this game is wonderful and gives hope that people can engage with a healthy representation of DID and understand its traumatic roots and how to engage and help those in need.

Final Spoiler: The game ends when Dorothy turns to you and identifies you are not a therapist but actually another part of her that helped her through the journey. This is a beautiful sentiment but the goodbyes seem unnecessary.

Please support Onaemo Studios and buy Who Am I: The Tale of Dorothy!

The Armor of Self

Whenever I am working with my dissociative clients, I am on the lookout for better ways to communicate and help them and their parts work together.

One concept that is often very hard to navigate with clients is that of integration.

Integration has the connotation that multiple become one.

This has implications that usually is uncomfortable for my clients.

I hear…

“I don’t want my parts to go away”

“I don’t want to only be singular it feels unnatural”

“I don’t think I need to be integrated into one”

I believe there is a lot of confusion when it comes to the idea of integration.

My opinion is that it stems from a faulty misconception of the anatomy of personality. From dissociative clients and from nondissociative clients.

Our beliefs about personality impact the interpretation of integration, and as a result impact treatment and healing for dissociative clients.

If our starting point is that the anatomy of personality is singular, and trauma causes multiplicity then the idea of integration is removal or melding into a singular again. I will represent this framework by this formula:

Singularity Framework

Personality Formula: Singular Self + Trauma= Multiplicitous Self  (S+T=M)

Integration Formula: Multiplicitous Self + Integration= Singular Self  (M+I=S)

 

This framework has innate fears built into it for the dissociative client because it implies that health and healing in treatment is a movement away from the multiplicity to the singularity.

If however, your belief about the anatomy of personality is multiplicitous then trauma’s impact on the self is merely about the disunification or the disintegration of the multiplicitous self. I will represent this framework by the following formula:

Multiplicity Framework

Personality Formula: Multiplicitous Self + Trauma= Disintegrated Multiplicitous Self  (IM+T=DM)

Integration Formula: Disintegrated Multiplicitous Self + Integration= Integrated Multiplicitous Self (DM+I=IM)

This framework solves the problematic innate fears of the singularity framework but replaces the innate fear with that of the fear of normification of the dissociative experience which can feel invalidating.

There are pros and cons to each perspective and I am sure there are variants that could be crafted, but for all intents and purposes of this post, I will leave it at the two I have delineated.

I advocate for the Multiplicity Framework because I have found it to be more conducive to healing for my clients. Out of this framework, I have found that conceptualizing this framework into an analogous metaphor is necessary to make the message of the framework useful and adaptable for treatment.

This is where the Armor of Self comes in.

I will flesh this idea out in a conceptualized vignette I had with a client. For clarity, the client’s name is Charlotte (changed for anonymity) and in the session, I was interaction with one of her little parts that identify as being 3 years old. The different parts I will label by P1, P2, P3, P4, etc.

P2: “P1 keeps pushing us to act, sound, and be more like Charlotte, but I don’t want to be completely like Charlotte. I know that P1 knows more than me because he is older, and he acts like he’s in charge because he tells everyone what to do, but I don’t want to be completely like Charlotte.”

Me: “You are apart of Charlotte but you bring to the table strengths and uniqueness that the other parts do not”.

P2: “Like how I can make the shadows go away? Like how I can make P3’s anger and desire to hurt people go away?”

Me: “Yes! Exactly, you do something that none of the other parts can do, you also have the strength of joy and sociability that Charlotte struggles with.”

P2: “I know I help Charlotte with that, and I know that we need to work with P3 so he doesn’t want to hurt Charlotte’s sister, but I am only 3 and am not strong enough. I am not like P1 and P4 who are really strong”

Me: “Well, what if you thought about Charlotte as someone who has to battle through the ups and downs of life. Someone that may be weakened because of the abuse that she experienced. In order for her to be strong enough to face each day she needs each one of her parts to be like her armor. She needs all of her armor on at the same time to be as strong as possible to face difficulties in her life. If she only has a shield she cannot push back the darkness, and if she only has a sword to push back the darkness she is vulnerable to the darknesses attacks. This is what I mean when it comes to integration. We need all of Charlotte’s armor to be strong (healthy protection) and equipped (co-conscious) in order for her to be as strong (healthy) as possible to face any adversity or stress in her life.

P2: “That makes a lot of sense and maybe if I am co-conscious with P4 I can be strong enough to work through the unhealthy protection of P3”.

Me: “You got it!”

I hope this metaphor is helpful in understanding the multiplicity framework of integration because I think the way we shape our narrative and beliefs is crucial in the journey of healing.

Because our brains are powerful, and whatever our brains believe they will make happen.

 

 

You Decide

Ever since I was a kid I always heard the question…

What do you want to be when you grow up?

My initial thought was always I want to be an astronaut…and to my chagrin as I grew up I realized that an astronaut career meant an incredible amount of math and math and I do not get along.

What’s so telling about my journey towards growth and what I have heard from others is that this is the most common question posed to us during development.

This question has everything to do with what you do with your life.

I think this focus does us all a disservice because whether it’s losing a job, trauma, or mental health struggles doing is not always possible or priority.

This focus on production or action often times is not grounded in something deeper. Doing is not altruistically good. If our actions do not flow out of character than our actions often times are reactions or lacking in depth.

Intentionality is a huge struggle for those who have experienced trauma. They are stuck in fight or flight which predisposes their physiology to react instead of act with measured intentionality. Also, they can have parts of self that are stuck in the past which makes intentionality in the present a challenge.

While this is all true our physiology and feelings are not the truest reality and do not need to dictate who we become or how we act.

My suggestion for our western society is we need to change our questions for children and (due to the lack) adults. The question we hammer into our kids should be…

What type of person do you want to become?

This reorientation is a shift from doing to being and it brings the focus of conversation with children around virtues and character.

Children and adults need to understand that the type of person you become is the one that you are practicing to be every minute. Without intentionality about building character, we all slide into our predispositions or the shadow parts of ourselves.

We start focusing mostly on our individualized fears “am I loveable enough?” “will I be rejected?” “will I be taken advantage of?”, which causes us to build a reactive character fixated on self-preservation.

I believe if we shift our focus it can have a lot of positive change for the mental health field.

I hear language within my therapy office like “I can’t do that” or “I do not have the motivation”, but the issue for my clients is not that I have this list of things I want them to do, but what I want them to be aware that what they are doing is influencing who they are becoming. 

I do not want to give my clients tons of work and burden them, but I do want to help them evaluate what they are doing, and subvert or change those patterns. The reason is that no matter who I talk to they all have an aspect of themselves that they want to transform or change.

They see certain things in their character that they do not like or want because it does not match the person who they thought they were.

Patterns and habits (chosen or forced on them by trauma) are the reasons that there are these aspects of their character that they are not satisfied with.

I believe that we all deep down have a true self that exudes an idealized character and set of virtues, but because we do not know how to live in tune with that self we cope with life out of pandering to our hurts.

Becoming is not an act of developing something we do not have but cultivating and strengthing our connection to what we do have. 

A bodybuilder does not grow new muscles through working out, they just develop and increase what they already have.

We all need to develop a greater vision for the people that we are deep down, and not let the hurts of life cause us to fixate on our hurts, fears, and insecurities.

We get to choose our stories.

We do not have to be the victim.

We do not have to live a life in the shadow of trauma.

We do not have to be the abuser.

We can cultivate an understanding of self, and create rhythms that keep us in tune to that reality.

We can focus on being instead of doing.

We can live with intentionality instead of reactivity.

We can reflect on our lives and choices and ask

“What type of person do I want to become?”

“What lies am I believing that keeps me out of sync with my true self?”

“What truths do I need to live into in order to stay in tune with a life of character and virtues?”

 

The Balance of the Window of Tolerance

 

 

The Window of Tolerance (WOT) is a term that was created by Dan Siegel to describe a person’s ability to regulate the emotions that they are feeling. When certain experiences are too painful or overwhelming it kicks us out that window of tolerance and we become stuck in that emotional state unable to return to baseline easily.

There are obvious correlations to working with dissociation that is important to glean from the window of tolerance.

I am not interested as much with describing all the facets of the Window of Tolerance because frankly, Lori Gill, RP, MACP explained it concisely here.

What my focus is pertaining to the WOT is that we have to have awareness and approaches to engage and develop a clients window.

To borrow some language from Nassim Nicholas Taleb (2012) the WOT is not a “fragile” thing but an “antifragile” one.

What do I mean by this?

Well, truthfully I think we all see mental health from a fragile or unbreakable binary that causes practitioners, parents, and clients to be so delicate in their approach to work within the WOT that we must walk on eggshells. So we need a third way of viewing people’s mental health capacities.

So what does it mean for something to be antifragile?

“A property of systems that increase in capability, resilience or robustness as a result of stressors, shocks, volatility, noise, mistakes, faults, attacks, or failures” (Taleb, 2012, p. 430).

This concept is a huge third way perspective on mental health, which is not a foreign concept to health in general.

Think about muscle development, in order to increase strength there must be resistance and stressors. I would say that the same is true for mental health, but I am not a masochist that thinks trauma is necessary for development. I do think that if we are never exposed to adversity, difference, or stress we are doomed to be kicked out of our limited WOT.

How this concept pertains to dissociation is that these clients need resistance to their predisposition. In order to correct or adjust an imbalance in disconnection, there must be the discipline of connection/grounding.

This resistance through connection or grounding will inevitably cause stress, and go against the flow of disconnection and the goal of the therapist is to encourage and initiate exercises that cause the client to push against that flow.

Like any healthy exercise, the person engaging in them or their personal trainer must be attuned to the person’s threshold so that the person does not overexert or pull a muscle. Same is true for mental health, it is not about speed, quantity, progress but about pacing, quality, and small goals.

I want to reject the need to be afraid of challenging a client with uncomfortable exercises or activities for dissociative clients and mental health clients in general because they are not fragile, but antifragile and dependent on the resistance to grow stronger.

I think the best imagery for this is one that Dan Siegel utilized in his book Aware (Siegel, 2018)

Imagine that there are two containers that hold water one small and one large.

Imagine that every difficult or painful struggle one goes through is a spoonful of salt that is put in the containers.

 

Our Window of Tolerance is the container of water.

If we treat our WOT as fragile we will have a small container and the experiences that we go through with cause that water to become untenable or unuseable making out WOT not reliable or useful.

But, if we treat our WOT as antifragile trying to discipline, exercise, and develop that container making it larger than each experience will only make the water taste refreshing and stable for use.

We need a flexible, strong, and resilient window of tolerance to be able to face reality as difficult as it may be so that we can overcome adversity and continue to grow.

This is the trajectory of dissociative clients, they must build their window of tolerance to the point where they can face the past, the pain, the trauma so that they can overcome and become stronger than the adversity so that the past does not dictate their wellbeing anymore.

 

 

References:

SIEGEL, D. M. (2018). AWARE: The science and practice of presence – a complete guide to the groundbreaking wheel of awareness meditation program. PENGUIN Books.

Taleb, N. N. (2012). Antifragile: Things that gain from disorder(Vol. 3). Random House Incorporated.