by Ellen P. Lacter, Ph.D. Copyright, 2004,

Part I
When the Child is Not Safe
Working with Protective Parents To Increase a Child's Sense of Safety
Treating Dissociation in the Pretend World of Play
Part II
Play Characterizations and Abuser Personalities
The Importance of Safe Places in the Treatment of Dissociative Children
Direct Interpretation and Intervention in Dissociation of Trauma
A Common Triad of Ego-States in Abused Children
Part III
Direct Intervention with Dissociated Personalities
Fusion and Integration
The Role of Protective Parents in Treating Dissociative Children
Bibliography

Part I
When the Child is Not Safe

Dissociative responses and defenses help children cope with ongoing abuse, lack of protection, or unsupportive home environments. Abused children generally invest great psychological energy in defending against conscious awareness of ongoing danger in order to preserve some ability to function and develop emotionally, academically, and socially. Although dissociative and reality-negating defenses should be gradually modified in safe environments, such coping mechanisms should not be challenged when needed for psychological survival.

It would be contraindicated to attempt to help a child feel safer than he or she truly is. For this reason, the therapist should continually assess the degree of protection provided by the child's caregivers and the possibility of ongoing abuse.

Children are exquisitely sensitive to any indication that their parents or caregivers doubt whether the abuse occurred or any indication that their parents remain attached to their abusers. Visitation with abusive parents, supervised or unsupervised, and unsupportive families or foster-placements contribute to children feeling unsafe. No amount of therapy can make children feel safe when they are not, in fact, safe.

In cases of suspected ongoing abuse, ongoing threats of retaliation for disclosure, or lack of support by parents-figures, limited treatment goals can be facilitated by exploiting a child's dissociative capacity. Children may be able to express feelings, experiences, and hopes disguised symbolically in play, sandplay, art, and writing, while avoiding disclosure and conscious awareness of the issues being addressed.

Likewise, the therapist can indirectly communicate therapeutic messages through play, art, and metaphor, such as helping children develop and elaborate safe places in the play room, in their inner worlds, and in their dreams for their future, conveying anger at people who hurt other people, demonstrating empathy for hurt children and animals, spiritual messages of hope and Gods love, compassion for the position of children afraid to tell on grown-ups, realistic information about possible protectors (child protective workers, police, etc.), representing the availability of loving caregivers, explanations about the blamelessness of abused children, etc.

Symbolic communication has the further advantage of being less potentially leading than direct approaches, an important consideration in such cases which are often involved in ongoing investigations and legal proceedings, and in which civil suits and complaints to licensing boards are a risk. In such cases, carefully chosen metaphors permit therapeutic communication while maintaining adequate distance from the subject of child abuse, thereby limiting potential legal concerns of influence by the therapist.

Nowhere is the issue of ongoing threat to victims' safety more troublesome than in cases of organized abuse, such as abuse associated with Satan worship, witchcraft, and/or child sex and pornography rings (often overlapping each other). Most victims of ritualistic abuse remain unprotected throughout childhood and develop Dissociative Identity Disorder, since abuse by these groups usually begins early and involves intense terror, pain, and forcing children to commit acts that violate their conscience and self-view. These Machiavellian perpetrators are sophisticated in mind control techniques and use torture to create personalities whose function it is to ensure that the victims conscious personalities, Dont remember, dont talk, dont tell. If these children do come to the attention of authorities, little protection is usually afforded because their disclosures appear suspect. These sophisticated abusers stage illusions of abuse by animals, demons, space aliens, resurrections, etc., to ensure that childrens credibility will be destroyed as they recount these experiences. Any attempts at disclosure result in severe punishment, both internal (by abuser-compliant personalities) and external (by the abuser group). Furthermore, ritual crimes are so heinous, investigators often dismiss them as untrue, particularly in this age of heavy media influence by the False Memory Syndrome Foundation.

When victims of ritualistic abuse are brought to therapy by protective parents or foster-parents, they often remain exposed to ongoing threats. Abusers may stalk them at a distance, using hand signals to threaten death, unbeknownst to protective adults, or may leave coded messages where the children will see them, e.g., graffiti on a school wall. Even when ritually abused children are currently safe, years of therapy are often needed before they can disclose or discuss such abuse. Torture and illusion may have been used to convince them that every time they hear the word "God" or a popular song, it signifies that the devil or cult members are watching them. There may have been threats to kill protective caregivers, burn down their homes, etc. (Harvey, 1993). Ritual abusers often attempt to make children believe that protective parents are part of their cult, to prevent secure attachment. Abusers may impersonate protective parents in rituals, drugging children to make them more suggestible. Cults program children to believe that their parents do not love them, are weak, and are not their real parents, but the cult is their family. A protective parent may be drugged by a cult parent, and taken to a rituals where children are forced into sexual acts with the drugged parent. Children can be tricked to believe the protective parent is a willing cult participant.

When a childs fear of continued abuse does not allay in treatment, it may be a sign that abuse is ongoing. In cases of ritual abuse, close relatives may continue to abuse the child, unbeknownst to the protective parent. Or the parent bringing the child to therapy may have dissociated personalities who are actively involved in the abuser group (cult-loyal or perpetrator alters), with no conscious knowledge of this involvement by the host personality.

Symbolic communication is particularly valuable in treatment with victims of ritualistic abuse for both clinical and legal reasons. Both child and adult victims tend to have highly developed dissociative defenses, including an elaborate imaginary inner world to where they can escape, and multiple identities that permit them to mete out the burden of their trauma, to function in the world, and to support and protect each other as would an outer network of family and friends. This dissociative capacity relies upon fantasy, symbolism, and distancing, making these clients uniquely receptive to metaphorical and symbolic communication. For instance, one personality may represent images of abuse with art media while concealing this information from the rest of the psyche.

Extreme caution must be exercised in providing legally defensible treatment in cases of suspected ritualistic abuse. These cases are complicated by disclosures of events that seem improbable because they defy reason or are too abhorrent for most to accept as true, resulting in their frequent dismissal by law enforcement, child protective agencies, and family courts. Perpetrators of organized ritualistic abuse are often sophisticated in challenging therapists' practices in civil actions and complaints to professional licensing boards, alleging that therapists influenced or contaminated a child's memory or disclosures, thereby harming the child or other family members.

In such cases, carefully chosen metaphors permit therapeutic communication while maintaining adequate distance from the subject of child abuse, thereby limiting potential concerns of influence by the therapist. For instance, if the therapist suspects a child condemns himself or herself for participating in the abuse of others, the child might be engaged in a discussion of moral dilemmas faced by victims of the Nazi holocaust, faced with choices involving survival, starvation, torture, submission, helping the enemy, etc..

The film, Sophies Choice, illustrates one such moral dilemma. A woman pleads to a Nazi soldier to spare her life and the lives of her two young children. He tells her she must surrender one child to the death camps. When she protests that she can not choose, the soldier orders both children be taken. Horrified, she sacrifices one, and is plagued by her choice for a lifetime. Organized abuser groups are equally diabolical. A child may be permitted to have only one friend in a world of abusers, only later to be faced with the dilemma of killing an other child or watching this friend be killed.

As struggles of historical and fictional figures are discussed, hidden parts of the childs psyche may quietly receive the therapeutic messages about human frailty, the effects of terror and the drive to survive, and that the fault lay with abusers and not with their victims, regardless of their choices.

We must also never minimize the healing power of the therapeutic relationship itself. This one relationship, in which the child is free to be, to express feelings and wishes, to play as he or she chooses, may be the source of all hope for future safety and loving relationships.

An adult survivor of ritualistic abuse, whom I will call Amy, describes an experience that highlights this message. Amy was 5 years old and had been tied down on a bed and assaulted for several days straight. Finally, she experienced herself leaving her body, going through the headboard, and falling into soft darkness where there was a complete absence of pain. To her left, she noticed a light and heard a woman's voice calling her name; "I'm over here, Amy, Amy, come here". She wanted to stay in the painless darkness, but finally went to the woman. The woman stayed with her for a while. Together, they colored pictures of Amys favorite animals. As they played, the woman said, When they do that, we do this. Amy believes the decision within her 5-year-old heart and soul to go to the woman was a critical spiritual choice that saved her. Others might interpret this event as a connection with the archetypical mother of the collective unconscious (in the Jungian sense), or the fantasy product of Amys wish for love. Regardless of the psychological/spiritual interpretation, Amy found a way to be nurtured and to play. In some cases, therapists may be powerless to protect children, or even adults, from abuse occurring outside of our offices, but we can create a nurturing, hope-filled, even fun, environment within.

Working with Protective Parents To Increase a Child's Sense of Safety

It is usually a long and arduous process for a protective parent and therapist to convey to an abused child that he or she is now protected and safe. Internalization by the child of these messages inevitably occurs more slowly than the provision of safety in reality. When a child is placed with new caregivers because parents were abusive or nonprotective, internalization of safety is largely dependent on the responsiveness of the new caregivers.

Protective caregivers require support by the therapist when frustrated that their efforts to love and reassure a child have not alleviated the child's fear and fear-driven behavior. The therapist often assumes the role of teacher, educating both caregivers and children about normal psychological reactions to trauma and the course of recovery. In cases of severe abuse, parents should be forewarned that recovery is a life-long task, with fear and other symptoms surfacing in times of crisis and new developmental phases, such as beginning school, adolescence, courting, and parenting.

Parents should be counseled to limit environmental stressors that abused children may perceive as threatening. Many abused children are hypervigilant and hyper-responsive to any demonstration of anger. They react with fear and anxiety to all forms of aggression, including infrequent, modulated spankings, raised voices, or even firm assertions of behavioral limits. This creates a dilemma for protective parents; the child's behavior is poorly regulated and difficult secondary to trauma, but behavioral limits frighten the child, exacerbating behavioral problems. Parents often become exhausted as they accommodate the needs of a fearful child with minimal behavioral demands, a task that should be honored by the therapist. In many cases, no quick and easy answers exist. The therapist must collaborate with the parent in developing behavioral interventions adapted to the child's abilities and in gradually resolving the fears underlying the child's behavior.

In an attempt to feel safe, many abused children regress to infancy, a stage of development associated with constant care by a protective parent. They may resist all separations, including sleeping alone, attending school, or even being in a room apart from a caregiver. Affording time for regression can increase a child's sense of security and safety. Many young abused children benefit from pretending to be a baby again with protective caregivers, a time to be held, rocked, sung to, to suck on a bottle, and to gaze into each other's eyes. Defining this activity as a game, e.g., "Let's play Mommy and baby", reduces the child's embarrassment and decreases the parent's concern that allowing regression will cause a child to become "stuck" in infancy. Making time for this activity early in the day, or as soon as the parent and child reunite after a separation, such as a school or work day, can prevent many fear-driven behavioral problems that might otherwise occur. Parents are often surprised to discover that once a child's need for regression is temporarily met, the child moves on to more stimulating developmentally-normal activities within minutes.

Failing to provide the security required by a frightened child can result in retraumatization, an increased sense of danger, and further psychological damage. Some abused children need to sleep with protective parents or older siblings for months or years, depending on the extent of the abuse. Some children are reassured by having a cat or dog sleep with them. Room lights or night-lights can increase a sense of safety.

In cases of severe abuse of very young children, it may help to postpone commencement of school for a year. When this is not possible, children may be soothed by having transitional objects in their possession at daycare or school, including tape-recordings of parents expressing their love and that they will see them at the appointed time, coupons good for a treat on the ride home, a locket with a photograph of parent and child, etc.

Many abused children challenge themselves to overcome their fears. Four-year-old Ryan D., abused in the bathtub, eventually chose to take a bath alone, to "Do it myself". In other cases, it is difficult to discern if a child requires, or simply enjoys, the extra support. It may be possible to put this to the test. For example, a quarter can be placed under a child's pillow at night that can be exchanged to sleep with the parent, or that the child can keep if he or she sleeps alone through the night.

Case Example: Leanna J. and her Mommy Helping Each other

Leanna J., a 4-year-old victim of ritual abuse, wet her bed almost every night. She was also enuretic during the day, when she disclosed new information to her mother, and when she appeared to be remembering traumatic events. Her mother told Leanna that wetting was okay, and often put her in diapers so that bladder control was not added to Leanna's many concerns.

After 6 months of therapy and very sensitive parenting, Leanna was able to directly tell me about her frightening experiences, albeit for short periods. When her tolerance was reached, she would say, "I don't want to talk about it anymore", or, "Let's do something else".

I told Leanna I knew she had been wetting herself and asked with complete sincerity, "Leanna, do you like it better to peepee in the bathroom or in your clothes?". She said, "In my clothes, the bathroom is scary". I asked, "Did something happen in the bathroom?" She became somber, looked directly at me, and said; "The bad people put their [showed fingers] in my butt", pointing to her bottom, "and put poo-poo on my eyes, my mouth, and my nose, all over my face", making a smearing motion. She added, "and my feet", holding her foot. Her face showed disgust.

I empathized with her feeling of disgust and expressed anger at those people who had done that to her, adding that they could never do those things again. I told her grown-ups should be nice to children's bodies, to their faces and feet; they should love them. I was attempting to modify her negative experience with a healing and somewhat humorous image. Leanna internalized my message. She said, "I love my foot" as she drew it to her face and kissed it. I took her foot and also kissed it. We laughed as she continued to kiss her feet.

I asked Leanna if she could think of any ways to make the bathroom feel safer. She could not. I asked if it would help to spray perfume in the bathroom, hoping this might change the setting adequately. She said no. I suggested she take a doll with her to the bathroom and reassure it that the bad people could not hurt her anymore, hoping that if she assumed a helper role, she might be less aware of her fear. This was also insufficient. I asked if she minded if her mother was there when she pee-peed and pooped. She said no. I suggested her mother go with her to the bathroom. Leanna felt this would help. I told Ms. J. about this solution. Ms. J. explained she often found Leanna had very quietly changed into fresh pajamas by morning and had pulled her sheets off her bed to avoid waking her mother. Leanna joined us and Ms. J. reassured her that she wanted Leanna to wake her at night to take her to the bathroom. Leanna began waking her mother at night to go to the bathroom and no longer wet the bed.

Treating Dissociation in the Pretend World of Play

Pretend play and dissociative inner imagery both rely on trance states, imagination, and defensive disguise and distancing. Profound dissociation, as in DID, originates in a use of fantasy that differs from normal pretense primarily in that it is so sustained and pervasive that illusion becomes confused with reality. These similarities make play and play therapy inherently suited for assessing and intervening in the unconscious world of the dissociative child. Young dissociative children naturally depict multiple aspects of self and traumatogenic experiences in play and art. Synthesis of self and resolution of trauma can proceed on a largely symbolic level (Putnam, 1997, Shirar, 1996).

Traumatogenic experiences are best gradually re-associated by beginning in metaphorical play, and progressing toward structured, abuse-focused play and direct discussion. The world of play permits dissociative children to regulate their rate of exposure to trauma via symbolization.

Materials representative of a child's severe trauma should be made available. Even if the child is not conscious of the abuse endured, or if it occurred prior to the development of narrative memory, the unconscious mind will tend to press for expression and representation of painful experiences.

In cases of ritual trauma, important toys to permit representation of trauma include cages, coffins, and boxes (used to confine); ropes and string (used to bind or pull); toy insects and snakes (placed on children to terrify them); knives and swords (used to threaten, dismember, cut, and kill animals or people and as ritual symbols); a tub and water (used in sexual abuse, near-drowning, and freezing); a doll-size toilet (childrens heads are submerged in toilets, and they are smeared with urine and feces, and forced to ingest these, as punishment for leaking information and to instill dont talk- dont tell programming); monster dolls and masks (to represent masked people and demons); figure dolls of all ages and life-size baby-dolls; toy animals, including rabbits, cats, and dogs (often sacrificed to deities and demons); a doctor kit including toy syringes (used to inject drugs to immobilize, cause internal pain, or inject the blood of cult members); play camera equipment (to depict filming of child pornography); and cloth (to represent being wrapped or gagged).

Materials should also be available that allow for representation of self-protection, reparation, protection, and nurturing. Important materials include; toy weapons, walkie-talkies, badges, (police symbols); comforting objects, soft blankets, baby bottles; vehicles for escape; hiding places; telephones to call for help; animal and human families (to represent loving, protective family constellations); and nonrepresentational materials, e.g., sand, clay, water, art supplies (these allow maximum distance/disguise of anxiety-laden material and representation of anything not available).

Unfortunately, reparative symbols are also often traumatogenic triggers for victims of ritual abuse. Toy jails may frighten children because they have been confined in cages. Symbols of law enforcement may frighten them because they have often been deliberately programmed to distrust police to prevent their seeking help. Telephones can be disturbing because they are used to contact these victims or the child is programmed to report in via phone.

Part II

Play Characterizations and Abuser Personalities

In evaluating the meaning of the play of a DID child, and in planning interventions, the therapist should consider that characters in dramas may represent figures in either the child's outer world or inner world. Or, a figure may simultaneously represent both. In DID, most traumatogenic experiences, defensive responses (e.g., identification with the aggressor), emotions, and object representations become embodied in personality states, which are then manifested in play. Aggressive figures likely portray abusers as well as personalities who behave as does the abuser. Violent themes can represent prior abuse, angry fantasies, and inner struggles between personality states. Drawings that depict retaliation against a perpetrator often, on a deeper level, reflect the childs fear of terrifying attack. Caregiving may represent external relationships or inner caregivers of traumatized baby personalities. Figures often shift characterizations within dramas, as the child often shifts identity states. For instance, a figure may initially portray an external abuser, then become the disavowed "bad" aggressive self, then represent the fearful child-self.

This multi-determined derivation of play characterizations has critical treatment implications. Until the meaning of the drama is fully elaborated, the most safe response may be to reflect the actions, feelings, and motives of all characters in the drama.

The therapist should observe the play carefully for representation of abuser personalities. Most DID children have abuser self states who take on the appearance and demeanor of the child's actual abusers. Traumatized child personalities tend to perceive them as their actual abusers. Abuser personalities often threaten bodily harm should the host remember the abuse or should disclosure be threatened. They may internally kick personalities in the head to silence them, sometimes resulting in migraine headaches. They often "keep other personalities in line" with physical punishment, not realizing that this injures the one body they share. In some cases, they have been programmed to inflict severe physical injury, placing the child at risk for suicide.

Some abuser personalities were originally created by the child as a protective measure, to ensure compliance with abusers so as not to incur their wrath. They act in a frightening manner, as did the abusers, and threaten the child with harm should any personalities consider violating the wishes of the abusers, as in disclosing the abuse, or refusing to comply with abusers directives. Their inner tyranny may continue for years after protection has been afforded since many of these personalities are often "stuck in a time warp", experiencing their abuse as ongoing.

Abuser personalities can also be self-states who were hurt at a very young age and who defend against their fear and sense of helplessness by identifying with their abusers and assuming their demeanor and behavior. They may believe the lies and promises of the abusers and buy into their abusers view of people and the world and way of life. They may be at risk of sexually or physically abusing other children or animals. They often frighten the child. They may take executive control of the childs body and consciousness and commit abusive acts while other more central personalities are amnesiac, having experienced only a loss of time.

In organized ritualistic satanic abuse, as well as in some child pornography and pedophilia rings, children are forced to abuse other children as soon as they are physically capable, as young as 2 years. They are encouraged to direct their pent-up rage into abuse of more helpless victims. By design, this results in their viewing themselves as willing cult members. Faced with their capacity for abuse, many DID children, and other severely abused children, often develop keen insight, sometimes even in the preschool years, that their abusers were also victims. Theirs is a painful struggle to determine if both the abuser and self are irredeemably evil and deserving of death, or forgivably rageful and abusive, secondary to abuse.

While it is helpful to facilitate expression of anger toward figures representing actual abusers, attacks against figures representing abuser self-states are likely to make them feel threatened, hated, and condemned. While incarceration of figures representing actual abusers is an adaptive resolution depicting protection, incarceration of aggressive self-states will result in their feeling afraid and hurt and will cause greater internal polarization rather than synthesis of personality states. In protest or desperation, threatened abuser self-states may respond by retaliating against other personalities, resulting in acts of self-harm, or in acts of violence against external people.

Violent dramas should be observed and understood before determining the therapeutic response. Play interventions should aim to represent the childs psychological dilemmas and resolve them. For example, the childs violent drama may represent generalized rage toward both abusers and self. The therapist may be able to guide the drama to more clearly identify an abusive adult character, such as figures who intend harm to a frightened baby, puppy, or little frog. The therapist may also be able to help the child to choose a pro-social character with protective anger, such as a police office, a guard dog, etc. Abuser self-states have always wished they could direct their anger against their abusers. These fighters for good can then rescue the defenseless figures and take them to a safe and nurturing place, where they can subsequently provide them with protection. Their big and bad demeanor is borne of fear. Once they feel empowered and safe, they can drop this defensive posture.

The complexity of the issue of abuser self-states does not end here. Victims of organized abuse often have personalities intentionally tortured into creation to serve the abusers. Pain and terror are used to force another split, the formation of a new personality. This new part is tested for compliance to the abuser group, usually with commands to hurt another child or kill an animal. If it does not comply, the torture continues until a personality is created who is completely loyal and servile to the abuser group. It is given a name and function, e.g., reporting to the abusers. Further torture ensures its silence. These personalities are often programmed to inflict severe physical self-injury, placing the child at risk for suicide, if the abuse begins to be recalled or disclosed. These personalities comply with the abusers agenda out of terror and in the (false) hope that they will be harmed less, spared, or given a position of status and power, if they perform as they are told.

Abuser personalities defensively created by the child, and personalities intentionally created by the abuser group to serve them, both pose danger to the child should the host personality begin to recall the abuse or make abuse disclosures.

The fourth kind of abuser personality is not actually a part of the child. Victims of organized abuse may have figures in their inner worlds who function in many ways like abuser self-states, but are actually external entities "implanted" in a child's internal world through prisoner-of-war-camp-style mind control programming. These pseudo-personalities function like robots, performing limited behaviors for the abusers, such as telephoning the abuser, or entering a particular building, and have no human volition or feelings, and little real intelligence. These non-human implants are, in cases of sophisticated abusive mind control, anchored to genuinely human personality states of the child to give them the capacity for planned action. By design, removal of implants without first disarming and disconnecting them from true personalities can have severe psychological, and secondary physical, consequences. For example, the child may psychologically re-experience being shocked, suffocated, frozen, etc. In these complex cases, their removal should be done, or at least overseen, by specialists experienced in safely disabling complex mind control programming (Stephen Oglevie, 2001).

The fifth type of internal abuser is perceived in the inner world as an evil spirit of an abuser, usually attached to true personality within spiritually abusive rituals. Whether its derivation is truly spiritual, or simply perceived to be so, is an interesting spiritual and psychological question, and subject of debate among clinicians treating victims of ritual abuse. These entities play a more sinister and dangerous role than the robotic implants, since they function with the apparent motive of ensuring the continued abuse of the child, and can carry out more complex functions, such as reporters to the abuser group or punishers of the child to ensure compliance with the abusers. They can pose significant danger to the child.

The Importance of Safe Places in the Treatment of Dissociative Children

The symbolic creation of safe places in play, art, and guided imagery, is an important key to reducing the dissociative child's perception of danger in both the internal and external world. We are informed in our understanding of the nature and form of such safe places by DID adults, who tend to have complex internal landscapes with safe places, such as houses with rooms for personalities or sanctuaries with man-made or natural features. Many sequester potentially dangerous personalities in secure places where they are contained and can do no harm to other personalities or the body.

Therapists can guide DID children to enhance their internal landscapes. Child states in stark rooms can be given a fluffy blanket or stuffed animal. Internalized protective parents, caregiver personalities, and spiritual figures can bring these to the children. Protective perimeters can be created to conceal safe places from outside detection. Intra-system communication devices be installed in each room, such as intercoms or video monitors, either one-way or two-way, depending on the needs of each personality. Traumatized child personalities stuck re-living their abuse can found. Cathartic release of grief within a supportive, therapeutic relationship, especially with a protective parent, facilitates this process, but the fear and physical pain need not be relived. Horrible memories of physical pain and terror can be stored in a notebook, safe, or other object to prevent their being re-experienced. A drawing of this object can make it more usable. The abused child parts can be rescued and relocated to an internal healing place, or may be able to grow older and be brought forward in time away from their trauma. These enhancements and shifts in the internal world have surprisingly enduring, beneficial effects.

Harmful psychological or spiritual messages (claims, curses, covenants, etc.) can be rejected, refused, and renounced, and thrown in a garbage can made of art supplies. Prayer within the protective familys spiritual framework can declare these harmful messages null, void, and forever broken. These can then be replaced with true blessings.

Removal of spiritual entities can be a complex task. Clearly, there should be no attempt to spiritually remove a part of the childs true self. However, victims of ritual abuse often derive great benefit from prayer by skilled clergy and appropriately-trained therapists to spiritually separate perceived sources of evil, such as spirits of abusers, abusers ancestors, and demonic forces. Abusers trick some personalities to believe they must permit evil attachments. These parts need to be found, the abusers lies exposed, and these parts must decide to separate the evil from themselves. Help of clergy and spiritual healers specialized in working with ritual trauma is often important to discover and resolve complex abuse involving evil attachments.

McMahon and Fagan (1993) suggest the use of fanciful images to help DID children create internal safe places, e.g., a bird to take personalities to a safe place and an entryway like a tree stump. They suggest placing a protective guide in the sanctuary, but only after obtaining the child's commitment to protect the sanctuary to prevent any harmful parts of a child's personality system from providing a "false" guide. They reinforce the image by guiding children to experience its content and sensory elements. Shirar (1996) suggests children draw the safe place to make it more easily visualized. With children younger than 4 years, McMahon and Fagan suggest the safe place be initially represented with toys, then imagined with closed eyes to internalize the image. They suggest children visit the safe place at the start and end of sessions for continuity. Transitional objects, e.g., a special toy or stone, are used between sessions as symbols of strength. As personalities tell their stories, express and release their pain, and give up defensive identifications with aggressors, guided imagery is used to take them to the safe place inside, accompanied in imagination by whomever the child chooses, e.g., protective caregivers or even deceased relatives or pets.

Unfortunately, for many victims of organized abuse, their internal landscapes and its features, including seemingly-safe places, were mentally installed in torture-based mind-control and hypnosis for abuser control over the individuals system of personalities. Such clients are at risk for developing only contaminated new images of safety and healing. In such cases, the therapist should suggest novel helping images that contrast thematically with those the client already uses or finds alluring.

Nurturing, protective caregivers serve important functions in the play therapy process with dissociative children. Their symbolic portrayal of protective parents or socially-sanctioned protectors, such as police officers, in role play and figure play, concretizes the concepts of protection and safety, facilitating internalization of their protection. Furthermore, portrayal by nurturing caregivers of loving parental figures helps segregated and frustrated attachment strivings re-surface and find expression.

Direct Interpretation and Intervention in Dissociation of Trauma

The younger the child, the more likely inner personalities are in a process of formation rather than fixed. These fluid personalities become more separate and consolidated in response to ongoing trauma. And they become more synthesized into a coherent sense of self in response to a protective, supportive environment, at home and in therapy, that allows a child to process and "metabolize" (Peterson, 1991, p. 154) traumatogenic experiences. Since many young dissociative children have ill-defined personalities who are little more than pretend characters, when dissociative barriers are no longer needed to defend against ongoing abuse, these imaginary characters naturally find expression in child-generated play. In play, the child can manage them and gradually integrate them into a coherent whole, not unlike the process of synthesis of self in non-dissociative young children.

In cases of more fixed dissociative processes, the therapist must actively encourage expression and synthesis of dissociated affect, trauma, and personality states. Emergence of characters representing the full array of aspects of self is facilitated by the therapist empathizing with all play figures, labeling their feelings, and by introducing to dramas figures that represent self-states which the child defensively omits, such as frightened, helpless, and dependent figures, or angry and aggressive figures. When children can tolerate affect and traumatogenic experiences within the play metaphor, direct abuse-focused treatment can ensue.

A good starting point for direct discussion of dissociative responses is inquiry into how the child mentally coped during abuse episodes. Shengold, in "Child Abuse and Deprivation: Soul Murder" (1979), explained that children use "autohypnosis" to "shut off" and compartmentalize all emotion during episodes of abuse. Children report blocking out abuse experiences by doing multiplication tables, focusing on a spot on the wall, leaving their bodies, flying away, changing to another television channel in their mind, imagining being elsewhere (the beach, amusement parks), or having another personality take over, one who "goes away" when the episode of abuse is over, etc.

Shengold (1979) explained that use of autohypnosis tends to become chronic in response to chronic abuse. Both children and their caregivers should be helped to understand that dissociative defenses were adaptive during abuse, but are no longer helpful. They cause discontinuity of experience, fragmentation of sense of self, intrusive posttraumatic symptoms (as dissociated feelings and self-states "push" for expression into consciousness), anxiety, and dysregulation of behavior, including possible self-harm or reenactment of abuse.

Gradual interpretation of autohypnosis and other dissociative defenses helps clients recapture and express emotions "shut off" during the abuse. This process of recapturing inner experience is essential to synthesize affect and thought, and to restore a sense of self and personal history. Shengold (1979) explains:

...the patient must know what he has suffered, at whose hands, and how it has affected him. The means he uses to not know, to deny, must be made fully conscious; the patient must give up his defenses of massive isolation and compartmentalization; often, one must analyze the use of autohypnosis to accomplish this. (p. 555)... Only when knowing involves a free range of feeling is brainwashing undone... Avoiding denial and tolerating rage [are] achieved together (p. 544).

Structured, abuse-focused play facilitates the process of re-association of abuse-related memories and feelings. Children can be asked to stage the scenes of their abuse, then choose dolls to "be" themselves, their abusers, and others who were involved. Tolerance of affect is facilitated by focusing initially on the doll representing the child, rather than directly on the child. The therapist can speak directly to the doll, allowing the child to answer for it, asking about the doll's inner experience while being abused, including inquiry into the use of defensive dissociation. In time, the child will be able to discuss these feelings without masquerading behind a doll.

This process is guided by the principals of gradual exposure and Briere's "intensity control" (1996). When the "therapeutic window" is exceeded, Briere explains that the individual's internal protective mechanisms are overwhelmed, resulting in what he terms "anti-abreaction". This retraumatizes, floods the individual with anxiety, and consolidates, rather than allays, defensive processes. The dissociative child's creative capacity can be used to regulate this process. For example, a metaphor of an internal volume dial can be used to "turn down" anxiety and fear (Silberg, 1996c). Or containers, such as a box or bag, can be used to "store" anxiety-producing memories and feelings during reassociation and between sessions (Shirar, 1996).

While anti-abreaction retraumatizes, properly-timed abreaction has significant therapeutic value. When the child (or adult) feels "held" in the therapeutic relationship, "grounded" in present-day reality, and has internalized that he or she is finally safe from the abuse, a cathartic release of sadness, grief, and anger, rather than a sense of re-living and re-traumatization, can occur in the telling of abuse. Ideally, a protective and nurturing caregiver will be present to soothe the child during this process. If there is no appropriate support person, the therapist often fulfills this function, including hugging the crying child. Until this intense affect is released, it tends to "push" for expression, often resulting in episodes of violence, oppositionality, tantrums, and regressive "melt-downs". Once this intense affect is released, these subside (see The Magic Castle for a mothers biography of her adoptive son who experienced intense behavioral dysregulation prior to his recovery of ritual abuse memories.)

A Common Triad of Ego-States in Abused Children

Although dissociative children tend not to have multiple, well-defined, separate, dissociated personalities (Peterson, 1996), I have encountered a number of abused children with three specific types of partially dissociated personality ego-states. The first personality is the most functional ego state, the one generally in executive control, and the one that is generally presented to others. It is age-appropriate, but socially avoidant or superficial, and has little affective charge. The second embodies frustrated attachment strivings and is very dependent and regressed when alone with loving caregivers. The third is heavily identified with the child's abuser. It has intense rage and affective memories of trauma, becomes explosive with little provocation, and may reenact abuse against others. Perceived as largely ego-alien, it is often symbolized by a predatory animal, an evil entity, a "bad" self, or a voice that issues commands of violence. A child struggling with his aggression aptly describes the influence of his abuse-derived aggressive ego-state: "When I try not to do what the 'Good Memory' tells me to do, the 'Bad Memory' has strong magic, and then it pulls on the 'Good Memory', and both of them tell me to do bad things" (Trad, Raine, Chazan, & Greenblatt, 1992, p. 648).

The dependent and abuser ego-states "hold the keys" to early trauma, losses, and related affect. The job of the therapist is to work through the characterological and defensive resistance of the "front" personality to re-associate traumatogenic material.

Compassionate interpretation of the process by which fear fuels identifications with abusers, and normalization of this as a response to abuse, help the front personality feel safe to acknowledge the existence of abuser self-states and help abuser self-states come out of hiding. Nonjudgmental guidance in anger modulation help abuser self-states manage aggressive and abusive impulses. Explanations that this defensive posture is no longer necessary can help them to relinquish this defensive posture and to re-direct destructive anger constructively or to let it go. They will eventually be willing to assume a benign prosocial function, e.g., a "guard" against external threats or protector of the younger, dependent, personality.

Inclusion of loving caregivers in therapy sessions facilitates the expression of the dependent ego-states and associated fears of loss. The therapist should commend the child for reaching out for love and for expressing needs unmet in early abusive and neglectful environments. When the child attempts to deny dependency needs and to detach from primary caregivers, caregivers should be encouraged to initially provide the "glue" for the relationship, despite the child's overt rejecting behavior. In therapy, parent and child can be taught to "play baby" with rocking, blankets, and even bottles. They should be assigned "homework" to continue this play at home, perhaps at the start of the day to meet attachment needs before separating to go to school, and upon reunion after school. Or the parent and child can decide another plan to maintain their bond, such as a morning or bed-time routines, watching television cuddled up together, one-on-one outings, or play sessions.

Intense feelings of jealousy rooted in fear of rejection and loss are likely to arise in traumatized dissociative children when caregivers show love to other family members, particularly younger children or babies. This often precipitates acts of violence against younger siblings. These childrens feelings of fear and anger should be interpreted and normalized in view of their abuse and losses. They must be helped to learn to express attachment needs directly, both verbally (asking for help and attention) and in proximity-seeking (crying, hugging). They must be helped to verbalize their fears of loss and rejection, and to express their sense of rage and unfairness about their abuse, neglect, and/or abandonment. When they feel safe to adaptively express their needs and fears, and receive comforting and support, they will be less likely act out in rage when threatened.

Children who become anxious discussing abuser self-states may be willing to represent them initially in art and play. These depictions can appear evil and powerful and children may perceive them as both frightening and enticing. The therapist must not react with fear nor reject these figures as evil. Instead, the child must be helped to understand the origins of their rage, redirect this rage toward their abusers, and gradually facilitate expression of trauma-related fear, helplessness, and grief. When abuser-states act out destructively, more direct interpretation and intervention are generally required to help children re-associate their trauma and regulate their behavior, as in the following case.

Case Example: Jody A. and the Monster in her Heart

Jody A. was abandoned by her mother at one year of age and placed with a distant relative where she was molested for two years by an adult male in the home.

At the age of 3 years, Jody was placed in her first foster-home. Shortly after being placed, and long before she first disclosed her sexual abuse, she reenacted this abuse with some younger children. When confronted, she initially denied it, but then said, "I just did it cause I felt like it". Jody's foster-mother deprived her of an outing. Jody responded with, "I wish you were dead", and paced her room all night. The next day, Jody seemed in a trance and said, "You know what a voice told me to do last night? It told me to kick you". This was the first statement of many about a voice or monster telling her to hurt, kill, or cut up the foster-mother and her baby daughter, or to burn down the house.

When treatment began, Jody was 6 years old and in her fifth foster-placement. She was defiant with her foster-mother, externalized blame for all problem behavior, and was mean to her foster-siblings. When questioned about the "monster", she said it was not real and that other children had given her that idea. In time, she said the monster lived in her heart and periodically spoke to her or "did" things. She generally minimized its effect.

In her sixth placement, Jody's problem behaviors became more dire. She placed a large knife in the crib of her infant foster-brother. And she punched other children when jealous of attention given them by her foster-mother. When confronted with these behaviors, she accused her foster-mother of lying and abusing her. If adults in authority doubted her, she became verbally belligerent or attempted to flee. If restrained, she fought tooth and nail to escape.

Jody was initially successful in gaining substantial adult sympathy for her protests of innocence and accusations of abuse by her foster-mother. Only after losing this placement and a month of residential treatment in which her aggressive behavior resurfaced, did all adults in authority understand her potential for violence and deceit.

True exploration of the origins of her violence began when I had to physically restrain Jody to prevent her from bolting out of the therapy office. She disclosed that the monster in her heart "makes me do bad things". When told, "Many abused children want to kill people sometimes", she easily and flatly acknowledged having wanted to kill her molester, her second foster-mother, her younger foster-sister, and infant foster-brother. Then, she became suddenly startled by what she had just revealed, and said she did not want to kill her foster-brother; she just wanted to make him stop crying. I focused on the events preceding her giving the baby a knife, which Jody again denied. Ignoring her protests, I said, "I know you hate yourself for what you did. I am going to help you understand why you did it and to do other things when you are angry or sad".

Jody slowly began to explore the feelings preceding her acts of violence. She began to express anger at her mother and molester in play, art, and direct dialogue. She recalled that her molester frightened her with a knife and began to understand the origins of her impulses involving knives and cutting. She was eventually able to tell me that when her infant foster-brother cried, and when her foster-mother went to him, she felt painfully jealous and wished she was the baby. She grieved that, "It's not fair" that her mother used drugs and gave her away and that she was horribly molested.

Jody was given a small sketch pad for drawing her angry feelings as an alternative to violent acting out. She brought this pad to sessions filled with scribbled-over pictures of her molester and her mother. In time, she told me that the monster in her heart was her molester and she did not want to be like him anymore.

Finally, one day, Jody arrived at therapy, looked me straight in the eye, and announced; "I don't want to hurt anyone anymore cause then they'll have anger in them like me, I don't want to be like him [her molester], I don't want to go to jail, I don't want to be like someone like my mother who does drugs". She meant it.

Since then, Jody has been in one placement for almost three years. She has had only one incident of aggression when she hit her foster-mother in defiance. She no longer dissociates her anger into other personality states nor does she blame a "monster" in her heart for her actions.

Part III

Direct Intervention with Dissociated Personalities

Jody was able to synthesize the anger embodied in her abuser-self state with no need to work directly with that ego-state as a separate entity. However, there is a general consensus in the DID literature that children with more well-developed personalities require direct intervention with alter personalities to synthesize dissociated aspects of self. Until a child gains at least co-consciousness and cooperation between distinct personality states, the child is prone to episodes of intrusive reexperiencing of trauma, regression, abuse reenactments, and often, abusive behavior toward others.

Treatment of childhood DID is modeled largely after treatment of adult DID and is described in depth in Putnam's book, "Dissociation in Children and Adolescents" (1997), Silberg's book, "The Dissociative Child: Diagnosis, Treatment, and Management" (1996a), Shirar's book, "Dissociative Children: Bridging the Inner and Outer Worlds" (1996), and in a number of noteworthy journal articles and chapters (James, 1989; Kluft, 1986; McMahon & Fagan, 1993; Peterson, 1996; Putnam, 1994). Since I have treated children with only partially dissociated inner identities, I draw upon these sources and my treatment of adult DID to highlight a few important considerations in the treatment of DID in children. The above sources are essential in guiding treatment with DID children due to the complexity of the disorder and the severity of abuse involved.

Early in treatment, the therapist must directly and patiently intervene in the frightening illusions that traumatized personalities experience as real. Gentle explanations can help personalities stuck in trauma realize that they are no longer being abused, but exist in the present and in a safe place. The host or internal self-helpers can be asked to convey this information to them, or these parts can be invited to look through the eyes of the host to see protective caregivers, their safe home, the therapist, and therapy office. Guided imagery can be used to rescue traumatized child personalities from the their abuse. A spiritual helper within the childs belief system (e.g., an angel or God), a protective parent, or an internal self-helper, can go into the site of the abuse, remove the abusers and their implements of abuse, pick the children up, hold and comfort them, and relocate them to internal places of safety and healing. James (1989) suggests therapists substitute adaptive rituals for abusive rituals in ritual trauma cases, e.g, praying about the ultimate power of God and good over evil.

The mechanisms underlying the child's defensive creation of dissociated personalities must be gradually interpreted and made conscious. James (1989) suggests therapists talk with children about everyone having many different feelings and aspects of self, followed by exploration of what would happen if the child claimed them all.

Personalities' names often provide clues to their roles in coping with trauma, such as names of feelings, kinds of abuse endured, or attributes assigned by abusers. However, therapists generally need to develop significant rapport with a personality before asking permission to know his or her name. Names of dissociated identities are often fiercely guarded by dissociative children, due to shame, or because not being able to be identified, or called upon, helps them hide from their abusers.

James suggests that therapists help children "own" split-off parts of self and gain control over dissociative processes "by acceptance and gradual reference to the dissociative split as being his creation and being part of him" (p. 110). She cautions us not to treat identities as more separate than they actually are to preclude creation of more dissociation. She suggests therapists attempt to contract with children not to create new personalities while in therapy. Similarly, Silberg (1996c) suggests therapists talk with, or about, other personalities through the presenting personality, rather than encourage abundant switching in treatment. Putnam (1997) also warns against "engaging dissociative identity shifts as if they were discrete alter personality states" (p. 293):

Alter personality states should only be engaged directly as discrete psychological entities (e.g., called out by name) when it is clear that they are behaviorally distinct, express strongly held convictions of separateness, and play an identifiable role in a child's or adolescent's symptoms and behaviors across several domains or contexts. At this point, they are sufficiently crystallized that it is highly unlikely that they will remit spontaneously (p.293).

Other forms of chronic or generalized dissociation should also be interpreted. Terr (1990) discusses a case of a physically abused 7-year-old boy with defensive, generalized bodily self-anesthesia. Over 3 weeks of therapy, she explained to him that numbing himself worked at the time he was beaten, but was dangerous now; "If Frederick went on deadening himself, he might expose his body to danger. Everybody needs pain" (p. 93). Within two weeks, the child experienced pain when a child jumped on him at school.

To begin to synthesize the DID child's sense of self, the therapist should maintain a stance of compassionate interpretation of the protective function each personality served in coping with the abuse. The "host" or presenting personality is likely to experience persecutory and abuser personalities as intrusive and dangerous, and often wishes they would go away. The therapist should help them consider their helpful functions. Questions such as; "Did that part make sure you did what the abuser wanted so you would not get hurt worse?" can help children accept personalities who averted retaliation by ensuring compliance . Asking; "Did that part help you be mad and strong when you were scared or sad?can help them understand and accept parts who identified with the abusers.

These superficially hostile personalities are likely to "listen from inside" to these exchanges since they are usually more aware of the experiences of the host than vice versa ("directional awareness", Putnam, 1997). The therapist's compassion gives them hope, helps them become less self-condemnatory, and increases their communication with the host.

The host is also likely to fear the sadness and fear of the young internal traumatized children, sometimes manifested by desperate crying or screaming. The therapist must help children tolerate and re-associate in manageable doses the traumatic memories these personalities hold of their shared life.

Shirar (1996) and Silberg (1996a) offer a number of techniques to help children re-associate split-off parts of the psyche. Play, art, and role-play are used to identify the purposes and conflicts between personalities, and expression of disavowed self-states, such as anger or fear. A particularly communicative part can serve as a "connector" (Shirar, p. 158) for the inner personality system. The child can write letters to personalities asking to know more about them and their feelings. A "Book of Parts" (Shirar, 1996, p. 159) can be made with a page reserved for each personality, with new information added as it is learned (Silberg, 1996a). Shirar suggests children make a diagram of parts, or draw "their inside world where the parts live" (p. 159). They may depict which personalities are connected, where separations exist, and how personalities "switch" and gain executive control. Often, personalities are offshoots of other personalities, created in succession, as the abuse escalated.

As personalities become co-conscious, the work of cooperation, negotiation, and redefinition of roles can begin, followed by learning to share their abilities and functions with each other. Silberg (1996a) explains that since DID children tend to have more fluid boundaries between personality states than in adult DID, they more easily respond to simple suggestions, such as asking the host to please ask a particular personality to listen or do something. She suggests that the therapist, parent, and child arrange cue words to elicit an agreed-upon personality to come out and assume control when needed or to signal particular personalities to regroup and cooperate. Children also can learn to use code words to alert caregivers to internal dissonance and their need for help.

Silberg (1996a) suggests that the therapist and host negotiate with abuser and persecutory parts to accept limits on physical expression of rage against others, and limits on punishment of other personalities (self-harm), within a "No Harm Deal". Aggressive personalities are usually willing to modify their behavior, assume new prosocial functions and names, and cooperate with the rest of the system once they realize they are safe. Abuser parts often agree to more modulated expression of aggression when asked to consider the that a less intense response is required in their current life.

Shirar (1996) suggests that intra-system communication devices be installed within the child's imagistic inner world. These may be telephone lines, roads, meeting rooms, etc. Many personalities initially require one-way communication to regulate their degree of exposure to the expressions of other parts. They may want to listen without being heard, to open channels to only particular parts, and to "shut off" incoming or outgoing information as needed. While trauma is being processed, non-involved parts can be guided to got to a remote safe place to not have to listen to the painful material. Intra-system communication can be used to increase behavioral regulation. Contracts against harm to self and others can be arranged through such communication systems. Behavioral expectations for home and school can be communicated to all personalities as well.

Fusion and Integration

Fusion, a blending of two or more personality states, tends to occur spontaneously throughout treatment, particularly in children, as trauma-related memories and feelings are re-associated and dissociative defenses are less necessary. Fusion is part of the larger, gradual process of integration, the emergence of a cohesive self-representation (Shirar, 1996; Waters & Silberg, 1996). Some controversy exists about whether integration into a single identity is necessary, or whether individuals can function equally well with a few co-conscious personalities who cooperate well together. The latter approaches normal adaptive functioning, in which an individual knowingly assumes many roles throughout the day in his or her work and personal life. I believe that at therapist should not communicate an investment in integration as a primary treatment goal, but as a decision that belongs to the child (in agreement with Gould and Graham-Costain, 1994). For many DID adults, final resolution includes keeping a few key personalities who function well together.

The processes of personality fusion and eventual integration into a coherent sense of self can often be expedited by direct therapeutic intervention toward these ends (James, 1989; McMahon & Fagan, 1993; Peterson, 1996; Silberg, 1996a). In the same way that the child created personality states to sequester traumatogenic effects of abuse (memories, affect, cognitions, somatosensory perceptions, identifications), the child can be helped to re-unite these aspects of self, generally by following the same path in reverse. For example, if a child created "Jane" to contain the sexual abuse trauma, and Jane in turn created 10 personalities to divide the burden of this escalating trauma, those 10 personalities will be likely to blend into Jane before integrating into a cohesive whole. The same child may have assigned "Mary" to bear the effects of her physical abuse, from whom eventually stemmed 12 more personalities to share that burden. Those 12 personalities would likely fuse back through Mary upon resolution of the trauma of physical abuse.

Since DID personality systems rely upon an imagistic internal world, the work of fusion and integration is perfectly suited to play, art, guided imagery, metaphor, and stories. These methods concretize the fusion process, helping it "stick". For example, a child can be asked to represent a group of personalities with dolls. When ready, "offshoot" personalities may choose to join a more primary personality. This may be represented by dolls bestowing toy props on the more central personality that symbolize their contributions. They may then hug, and finally combine into the primary doll. Art, objects, and metaphors that symbolize a multi-faceted, functional whole (e.g., trees, quilts, sports teams, etc.) can also be used to represent and encourage integration. Waters and Silberg (1996), Shirar (1996), McMahon and Fagan (1993), James (1989), and Kluft (1986) provide many illustrations of these methods.

The Role of Protective Parents in Treating Dissociative Children

In cases of highly dissociative children, loving caregivers serve critical therapeutic functions both within therapy and at home, often functioning as co-therapists if adequately sensitive and psychologically-minded. Shirar (1996, p. 174) writes, "Parents, therapist, and the child's own parts become the therapeutic team that will bring healing to the child and to the family."

Parents must be given a "crash course" in the psychodynamics and subjective reality of dissociative children. They must be educated in the dissociative basis of disruptive behaviors typical of these children, e.g., regressive clinging, outbursts of anger, "melt-downs", and amnesia-based lies, stealing, and forgetfulness. They must be helped to react non-punitively, while nonetheless working toward increased intra-system cooperation. They must be helped to understand, accept, and work with all personalities rather than rejecting the difficult ones, which only increases their sense of isolation, helplessness, and destructive acting out. For example, they must be taught that identification with the aggressor is a defense and that sexualized personalities helped the child to cope with frequent sexual assault more easily than did personalities who felt overwhelmed with disgust or terror.

Dissociative children often regress to infancy in fixated, traumatized baby personality states, seeking to fulfill their interrupted attachment needs to internalize parental love and protection. They usually have extreme separation and stranger anxiety, and long to be held, rocked, sung to, sucking on a bottle, and gaze into the loving parents eyes. Time should be made to interact with these parts based on their psychological/emotional age and associated needs, rather than the childs chronological age. Some severely abused, dissociative children need to sleep with protective parents for months or years. Others are reassured by having a pet sleep with them. Room lights or night-lights can increase a sense of safety. In some cases, commencement of school should ideally be postponed for a year while these needs deep psychological are being met.

Many dissociative children are at high risk for self-harm or abuse to others. Safety plans must be developed, ideally with the child's cooperation. Very young and severely traumatized children often have little ability to control harmful impulses arising from their personalities until the needs of these states are addressed, a lengthy process. In such cases, caregivers must provide constant supervision, especially around siblings and other children. School attendance may even need to be postponed to ensure the safety of the other students.

In cases of ritual abuse, the caregiver should be educated about ritual trauma reminders and mind control programming triggers to reduce their occurrence in the childs environment. These vary from child to child and are often discovered based on the childs responses. They often include satanic and witchcraft holidays, traditional holidays, ritual objects (e.g., crosses and chalices), animals, songs, colors (red for blood, brown for feces, almost any color for programming), fairytale stories and characters, phrases, churches, police, firemen, characters in horror movies, etc. (For a more complete compilation of ritual trauma reminders, see Gillotte, 2001, and Gould & Graham-Costain, 1994)

Ideally, the parent creates a therapeutic environment at home that permits a child to reveal feelings, fears, personalities, and the nature of abusive episodes as the need arises. The availability of toys and art materials facilitates this process. Much treatment can occur at home with a loving caregiver, replete with tears and hugs, as the therapist serves as a guide for both parent and child.

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