Approach Considerations
Patients who are survivors of extensive childhood abuse frequently present complicated clinical dilemmas. Dissociative episodes, flashbacks, and self-destructive and suicidal impulses are common difficulties encountered by such patients.
Once the diagnosis of abuse has been made, the initial task of therapy is to detoxify the patient's environment by stopping all forms of abuse. Treatment must be geared toward trust issues, toleration of affect with the patient's understanding of himself or herself, and enabling the patient to function as effectively as possible.
If a child or adolescent is being treated, the parent or guardian must be seen. The guardian or parent must learn how to deal with the child during expression of multiple personalities or amnestic episodes.
A mental health professional with special experience in this area should provide follow-up care for these patients.
Hospital admission is indicated for children in the following cases:
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When medical or surgical condition requires inpatient management
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When the diagnosis is unclear
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When no alternative safe place for custody is immediately available
Medical Care
Encouraging healthy coping behaviors
The primary focus is to help patients learn to control and contain their symptoms. Patients must learn to deal with dissociation, flashbacks, and intense affects such as rage, terror, and despair.
Embarking on a treatment plan can be dangerous if the patient has not developed ways to tolerate the emotional turmoil that arises when uncovering traumatic memories. Until the patient can learn healthy alternatives to tolerate feelings and control behaviors, he or she cannot adequately or safely undertake the exploratory work involved in uncovering and processing memories of abuse.
Control is a major issue for survivors of abuse, and by learning new ways to control and contain their symptoms, patients no longer view themselves as victims of the past.
The emphasis is to have patients reconnect with their sense of power. Encouraging patients to design and choose which technique to use and when to use it contributes to their sense of being in charge of themselves; patients can begin to deal correctly with feelings of helplessness.
Logging and monitoring emotions
Many patients who experience loss of time through dissociation or flashbacks describe the events as being abruptly triggered. These symptoms sometimes become so severe that patients can no longer function in their usual way.
One way to help patients begin to work with their sense of unpredictability is to have them keep a log of their emotions. The patients must first identify emotions. Once they have developed the ability to identify feelings, they can monitor the intensity of each feeling.
Patients usually report a cluster of recurrent emotions such as anxiety, sadness, or rage. Quite frequently, these symptoms precede dissociation, flashbacks, self-destructive impulses, and suicidal impulses. Patients should be coached on how to intervene long before anxiety rises to a critical level. A carefully staged trauma-focused psychotherapy for dissociative identity disorder may result in improvement of symptoms. [35]
Developing a crisis plan
Identifying the cause of the anxiety is also important. Teaching patients to develop a list that ranges from simple to complex activities is helpful. Once patients become engaged in the activities, the intensity of emotions usually decreases. In addition, patients feel more in control. This reconnects them to personal strengths and the choices that can be exercised.
Most patients require time to learn new and effective coping skills. Emphasize that patients must practice new skills and techniques until they develop a sense of mastery.
If the difficulties experienced by patients with histories of abuse are directly related to the abuse experiences, definitive treatment cannot seemingly be successful without acknowledgment of these experiences. Clinicians treating such patients may collude with them in their beliefs about themselves if unaware of the existence of the traumatic etiologies of the current disturbance.
Consultations
If the reason for the dissociative disorder is likely abuse, promptly initiate appropriate medical, surgical, and mental health consultation. The law requires that a child suspected of being abused or neglected be reported immediately to CPS.
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Psychiatrist or behavioral/developmental pediatrician
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Social services representative
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Child abuse and sexual abuse (CASA) specialist
Prevention
Stopping child abuse as early as possible maximizes chances for prevention.
With suspicion of abuse, siblings should undergo full examinations within 24 hours.
