INTERVENTIONS
WITH CHILDREN IN
DISSOCIATIVE FAMILIES:
A FAMILY
TREATMENT MODEL
Lynn R. Benjamin, M.A.,
Robert Benjamin, M.D.
Lynn R. Benjamin, M.A., M.Ed., is a clinical member of the
American Association of Marriage and Family Therapy in
private practice and a certified parenting educator and train-
er at Parents' Network in Fort Washington, Pennsylvania.
Robert Benjamin, M.D., is a psychiatrist and family thera-
pist who serves as Associate Medical Director of Northwestern
Institute of Psychiatry and is a consultant to its Dissociative
Disorders Program.
For reprints write Robert Benjamin, M.D., Northwestern
Institute of Psychiatry, 450 Bethlehem Pike, Fort Washington,
Pennsylvania 19034.
ABSTRACT
Interventions with children are surveyed from the literature of the
diverse fields ofMPD, play therapy, family therapy, and sexual abuse
and trauma. Within a family treatment model, play therapy and
hypnotic interventions can be useful in helping a child master the
physical, cognitive, emotional, and spiritual dimensions of trau-
ma. When parents are able to participate in the child's therapy, they
can becomea very important ally in the therapeutic process. We
emphasize rebuilding of trust in the relationship between the par-
ents and the child. It is our belief that treatment of the child-parent
subsystem of a dissociative family has the most potential to interrupt
a transgenerational chain of dysfunctional family patterns.
INTRODUCTION
Because the development of Multiple Personality
Disorder (MPD) occurs within the context of a family, it is
our experience that afamily-centered treatment model along
with individual therapy for the person in the family who has
MPD has the maximum potential to restore trustworthiness
in the family (Benjamin and Benjamin, 1992). For the pur-
pose of our discussion, a dissociative family is a family unit
in which one or more members has a dissociative disorder.
It follows, then, that when the dissociative client is a parent,
family-centered treatment must necessarily address the issue
of how to involve the children.
Kluft (1984; 1985) and many others (Braun, 1985; Sachs,
1986; Putnam, 1989) have long advocated for the assessment
of the children in a family where a parent has MPD. It has
been our experience in working with our own MPD client-
parents that most are quite concerned about the welfare and
well-being of their children. Some explicitly request clinical
54
evaluations for their children for the presence of dissocia-
tion. Others worry about the effects on their children of the
consequences of their own problems, often including numer-
ous hospitalizations, custody battles, or loss of their children
to the primary care by the other parent or a grandparent.
Many are concerned about the general effects on the child
of having a paren t with MPD. While we frequently focus specif-
ically on parenting concerns and skills in individual, cou-
ples, and group settings, we also see children themselves in
the context of our overall treatment of the family.
LITERATURE REVIEW ON THE TREATMENT
OF CHILDREN
The MPD Literature on Approaches to Children
Following Ellenberger (1970), Kluft (1984) and Fine
(1988) have written about the earliest documented case of
the treatment of a child with MPD. From 1836 to 1837, Despine
Pere treated an eleven-year-old Swiss girl, Estelle, for a con-
version disorder that paralyzed her legs. While Despine uti-
lized both individual psychotherapy and hypnotherapy, he
also recognized the role of her family in her situation.
Davis and Ocherson (1977) have written about the con-
current treatment of an MPD mother and her nine-year-old
adopted son who was referred for adjustment problems. The
authors focus on the effects of the mother's MPDon the
child's ego development: his adaptation to the separate per-
sonalities and his need to maintain sameness in a constant-
ly changing world, and his distorted perceptions and mal-
adaptive responses toward peers. They also allude to the
issue of how to explain the mother's MPD to the child.
Brown (1983) has reported the frustrating case of a
toddler who was violently abused by her MPD step-father and
the inability of the Alaskan public mental health services to
secure treatment for the step-father or support for the entire
family. Levenson and Berry (1983) have pointed out the case
of a woman with MPD who thought that her teenaged daugh-
ters would not notice their mother's shifts in personality.
The therapists observe that the daughters' manipulation of
the mother ' s amnestic periods, either to get permission from
a lenient personality to do something that the host person-
ality would have refused or to lie after doing something and
tell their mother that she had given them permission and
forgotten, demonstrated their awareness of their mother 's
changes. Additionally, each daughter assumed a half -a-
dozen names for herself.
Fagan and McMahon have written a landmark article
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BENJAMIN/BENJAMIN
(1984) on incipient MPD in children. They offer a checklist
to assess for childhood MPD, and they categorize families
according to whether or not they are "supportive", "prob-
lematic", or "pathological." They offer treatment interven-
tions that would be appropriate for each category, and they
describe their play therapy techniques for children with incip-
ient MPD.
Kluft (1984) has proposed a predictor list for child-
hood MPD along with an elaboration of five cases of child-
hood MPD. In three of the five cases, he provided family
interventions as well as individual therapy with the child. In
the following two years, Kluft (1985; 1986) wrote further
about successful treatment of children with MPD through
the use of individual therapy including hypnosis, and a vari-
ety of family interventions including family therapy and work
with family subsystems.
Kluft, Braun, and Sachs (1984) have supported family
interventions withMPD clients although they feel that often
it is impossible to be evenhandedly supportive of all family
members while at the same time maintaining a therapeutic
alliance with the MPD patient. Consequently, they advocate
individual therapy with "advocacy-oriented" family sessions.
In cases in which a parent suffers from MPD, a family ses-
sion might be utilized to explain MPD to a child, to free a
child of self-blame for a parent s MPD, and to alleviate inap-
propriate roles in the family. It might also serve as an arena
for the observation of incipient MPD in a child.
Sachs (1986) has presented specific family interven-
tions as an adjunct to individual therapywhen the client
is either the child or the parent. In both cases, she insists
that any abuses to the child stop before a family interven-
tion can even be made. The parents of the MPD child can
then be helped with how to effectively nurture and disci-
pline the child. Family therapy in the case of theMPD par-
ent is aimed at validating the child perceptions of the par-
ent and helping the child to deal with the MPD parent.
Additionally, it provides an arena in which to observe the
child for possible signs of dissociation.
James (1990) has written a very specific article on the
treatment of the child with a dissociative disorder in which
she supports the formation of a strong alliance with the child
caregivers.McMahon and Fagan (1993) offer a play thera-
py approach to the treatment of MPDchildren based on
their work with sixty such children. Although their approach
is individually oriented, the case example that they present
includes the child teacher, caseworker, and foster moth-
er in the treatment.
The general trend in the MPD literature indicates that
family interventions may serve as an important supportive
adjunct to individual therapy. When a child has an MPD par-
ent, the child has a right to understand the disorder and
not feel blamed for causing it. The MPD parent can benefit
from interventions that teach healthy parenting. Children
with MPD need individual therapy to help them resolve their
traumas. Their parents may also need help with parenting
skills as the child proceeds through the therapeutic process.
Play Therapy Literature with. Traumatized Children
Mann and McDermott (1983) have outlined four phas-
es of treatment for victims of childhood trauma: 1) estab-
lishing rapport and learning how to play, 2) regression and
abreaction of trauma 3) testing of real relationships and
developing impulse control and self-esteem, 4) termination.
They also believe that concomitant, but not joint, treatment
of the parents is key to their approach.
Terr (1983) has elaborated the characteristics of post-
traumatic play which were based on her observations of the
child kidnapping victims of Chowchilla. Noteworthy are the
compulsive repetition of the play with a failure to relieve
anxiety and the contagious effect of the play on non-trau-
matized children. She advocates using four types of play ther-
apy for traumatized children: release (abreactive) therapy,
psychotherapy utilizing spontaneous play, psychotherapy uti-
lizing present or prearranged play, and play therapy utiliz-
ing corrective denouement. She (1985) also notes that par-
ents play an important role in the therapy of the traumatized
child. They may need separate sessions, participate as
observers in the child sessions, or be involved in family
treatment.
James (1989) has advocated a direct, active treatment
approach that aims at addressing the physical, cognitive,
emotional, and spiritual parts of the traumatized child. She
notes that children may engage in secret, dysfunctional behav-
iors long after a trauma is past. Unless a therapist makes an
effort to uncover such behaviors, they are unlikely to be
noticed. The involvement of parents or caregivers in a child
therapy is a key and planned intervention that helps to facil-
itate the therapeutic process.
Donovan and McIntyre (1990) have written extensive-
ly about the complexities of play and how children think,
communicate, interact, and change. Their developmental-
contextual approach appreciates both the development of
children and the familial context in which they grow. They
have adapted a parallel therapy to address both develop-
ment and context. The authors work as a team which meets
with both child and caregivers at the beginning of the ses-
sion, splits up in the middle with one therapist with the child
and the other with the parent(s), and re-unites as a group
at the end. The parallel relationship between the therapies
of child and adults forms a critical aspect of their approach.
Gil (1991) has suggested that hurt children need a safe
therapeutic environment with an early non-directive approach.
As therapy progresses, the clinician may become more direc-
tive in helping the child to face and process traumatic events.
It is important for the therapist to interrupt repetitive post-
traumatic play in order to help the child achieve mastery
over the trauma and to orient the child toward the future.
In many of Gil s case examples, she includes family contacts
and interventions to support the therapy.
Oonnor (1991) has recognized that collateral work
with parents has a place in play therapy. He conceptualizes
a variety of positions for parents: as the child therapist, as
the parent in a conjoint parent-child session, or in parallel
individual or couples treatment.
In general, play therapy approaches to traumatized chil-
dren tend to focus on the individual treatment of the child.
However, they usually acknowledge that some level of
parental or guardian involvement is necessary. At the most
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DISSOCIATION, Vol. VI. No. 1. March 1993
INTERVENTIONS WITH CHILDREN
minimal level, parents provide the history of the child and
observational data for the therapist. In contrast, Donovan
and McIntyre (1990) rest their approach on a parallel ther-
apeutic process for child and parent. As previously, stated,
Terr (1985) sees parents as playing a significant supportive
role in a childs recovery.
Child Sexual Abuse and Trauma Literature
Most authors who write about the sexual abuse of chil-
dren agree that some form of family intervention is neces-
sary either because the family is the agent of the sexual abuse
or because the family is overwhelmed by sexual abuse to the
child that has occurred outside of the immediate family
(Burgess, Holmstrom and McCausland, 1978; Sgroi, 1982;
Porter, Blick, and Sgroi, 1982; James and Nasjleti, 1983; Long,
1986; Damon and Waterman, 1986; Kempe, 1987; Jones and
Alexander, 1987; Gelinas, 1988; Friedrich, 1990). Without
changing family dynamics, the child is neither safe to stay
in the family nor able to process productively and effectively
sexual violations. Although Marvasti (1989) has offered an
essentially child-focused model of play therapy for the sex-
ually abused child, he does advise individual therapy for each
parent and group therapy for the offender.
Mowbray (1988) believes that posttraumatic therapy
for children who are victims of violence should consider
family or parental therapy as well as individual therapy. In
the case of a chronically ill child, Patterson and McCubbin
(1983) have argued that the therapeutic focus should be on
the current functioning and problem-solving abilities of the
whole family.
Without exception, the child sexual abuse authors acknowl-
edge the vital role that the family plays in a child recovery.
They include the parents in a number of family interven-
tions. Mowbray (1988), Patterson and McCubbin (1983),
specifically see family therapy as valuable in the treatment
plan.
Family Therapy Literature
Beezley,Martin and Alexander (1976) have focused
extensively on therapy for parents in an abusive family. They
see parents as needing individual, marital, and group ther-
apies. Figley (1988) also sees the family as key in its support
for victims of trauma.
Boszormenyi-Nagy and Ulrich (1981) have specifical-
ly addressed the inclusion of children in their contextual
approach to family therapy. Having children present graph-
ically demonstrates to the family the transgenerational
nature of family problems. The presence of children func-
tions as a therapeutic leverage. Contextual therapy postu-
lates that children are entitled to have a trustworthy rela-
tionship with their parents. Consequently, parents are
accountable for making sure that children are treated in a
fair and trustworthyway. Family therapy with children occurs
in such a way that a trust-building between parents and child
is fostered rather than the therapist engaging in" child ther-
apy." For example, the therapist may ask the child to describe
the problem that he sees the family as having and how the
child has tried to make the family situation better. The ther-
apist then may acknowledge the child act of giving to the
family and facilitate the parentsacknowledgement of the
child contribution. The parents crediting of the child begins
to build trust between parents and child by noticing the child
efforts at giving. The parents can then be encouraged to
take parental responsibility for working out problems and
not leave the child to silently believe that he has responsi-
bility for making family problems better.
Zilbach (1986) has written specifically on the integra-
tion of children into family therapy. Although she chroni-
cles how many of the early family therapists including
Ackerman, Satir, Minuchin, and Whitaker worked with
young children in their treatment approaches, she also notes
that the amount of documentation of their work with young
children is scant. She sees children as serving critical func-
tions in family therapy: providing access to hidden family
problems by making them visible through their communi-
cations or symptoms, being "allies" to the therapist and "direct
explainers" of family mechanisms, bringing developing fam-
ily problems to the attention of the therapist, and helping
the therapist to understand how the whole family operates
so the therapist can model behaviors that might be useful
to the family. She encourages the specific use of play mate-
rials such as a bop bag, paper, crayons, clay, and puppets to
facilitate the expression of childrensfeelings.
In the family therapy literature, Sachs, Frischholz and
Wood (1988) have addressed the marriage and family treat-
ment of MPD in two specific circumstances: when the MPD
client is a child and when the MPD client is a parent. When
the MPD child is the client they offer six guidelines: estab-
lish safety for the child, develop a consistent and nurturing
environment for the child, develop functional communica-
tion in the family, develop appropriate boundaries, prevent
the triangulation of the child, and establish family rules,
expectations and consequences. Alternatively, when the fam-
ily therapy focus is around an MPD parent, the therapist needs
to identify the effects of the MPD on the children, assess chil-
dren for dissociation, help the children learn to relate to
the MPD parent, identify stressors in the environment which
cause the MPD parent to dissociate, establish boundaries,
and establish a strong parental subsystem.
Overall, the family therapy literature acknowledges that
everyone in a family, including children, are affected by fam-
ily problems. Zilbach (1986) notes that although family ther-
apists, in general, see the importance of children, many train-
ing programs in family therapy omit instruction in how to
directly include children in treatment. Zilbach herself fills
that void with her contribution on working with young chil-
dren in family therapy. A number of authors in the family
treatment field see parenting counseling as a specialized
intervention. Notably, Contextual Therapy views parents as
accountable for building trust in relationships with children
by caring for them in appropriate ways without the expec-
tation that children take care of the parents. With its empha-
sis on the ethical dimension in therapy, it focuses on fair-
ness in relationships and on a transgenerational transmission
of appropriate giving from parent to child (Boszormenyi-
Nagy and Ulrich, 1981).
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BENJAMIN/BENJAMIN
THE IMPORTANCE OF WORKING WITH CHILDREN
IN DISSOCIATIVE FAMILIES
The foregoing discussion of the literature indicates that
the MPD literature, the play therapy literature, the sexual
abuse and trauma literature, and the family therapy litera-
ture all con tribute to supporting the notion that family inter-
ventions have a place in therapy. In our own work with MPD
clients, we believe that a family approach as well as individ-
ual treatment enhances the treatment at both a systemic
level and an ethical level. Further, we assert that within that
family context, treatment of the child-parent subsystem has
the most potential to interrupt a transgenerational chain of
dysfunctional family patterns. Of course, in cases where the
clinician has reason to believe that either physical or sexu-
al abuse of the child is presently occurring, it is necessary to
first stop the abuse before any meaningful treatment can
proceed. The therapist is obligated to report the abuse to
the appropriate authorities according to the legal guide-
lines which exist in that particular jurisdiction. We attempt
to help families deal with the course and consequences of
the reporting as a planned intervention incorporated into
the fabric of the work with the family.
In dissociative families, children may or may not have
MPD themselves. However, they always play an important
role in the family treatment. Even if the children are not
directly included in the therapy of the MPD client-parent,
they, nevertheless, are affected by individual or marital inter-
ventions. At the very least, developing children notice that
there are problems in the family. They are often perplexed
by the switches of the MPD parent. As therapy proceeds, they
may be further confused by the shifts in behavior that occur
in the identified client, in the client ' s partner, and in the
relationship between the partners. Further, Putnam and
Trickett (1993) suggest that dissociation may be transmit-
ted transgenerationally by environmental mechanisms and
that parents and children may mutually stimulate dissocia-
tive behavior in each other.
When a main caregiver has MPD, a child may come to
feel that it is his role to take care of the parent or he may
feel that he is to blame for the MPD. In a previous article
(Benjamin and Benjamin, 1992) , we have enumerated a num-
ber of potential risks that face children of MPD parents. First,
there is the risk of physical or emotional abuse or neglect.
Because alters may switch to do caretaking, children may
experience a sense of unpredictability and inconsistency
toward them. They may feel confused if the MPD parent suf-
fers from bouts of amnesia or emotionally abandoned if the
MPD parent spends large amounts of time focused inward
instead of listening to the needs of the child. The child may
experience lengthy or periodic physical separations from
the parent if the parent needs hospitalization. The sense of
unpredictability in the parent may discourage the child from
bringing peers home to play, and, thus, inhibit the child's
social development. The behaviors themselves of the child
may unwittingly evoke overwhelming feelings in the parent
that cause him to withdraw from or hurt the child. The child,
who observes the parent's instabilities, may feel overly
responsible for the parent or for younger siblings if the par-
ent is unavailable. Additionally, a young child may feel to
blame for the parent ' s illness. Often an MPD parent has other
complicating problems such as alcoholism, eating disorders,
depression, suicidal behaviors, or phobias. The child finds
a way to cope with those other obstacles as well.
Kluft has published a striking article (1987) in which
he has studied the parental fitness of seventy-five mothers
with MPD. Implicit in the results of the study is a concern
for whether or not the children of mothers with MPD are
receiving an adequate childrearing experience. Of the total
number of mothers, he found that 38.7% were "competent
or exceptional"; they did what was good for the child and
best for the family, avoided switching in front of the child,
and achieved co-consciousness across personalities or devel-
oped collaborating personalities to do the parenting. Another
45.3% were labeled as "compromised or impaired"; they had
MPD symptoms that interfered with their parenting, behaved
against the best interests of the child, neglected the needs
of the child, parentified the child, and practiced some form
of psychological abuse. Finally, 16% of mothers were "gross-
ly abusive"; they inflicted harm on the child, physically dam-
aged the child, failed to protect the child from injury, or
sexually exploited the child. Summing up his categories,
61.3% of the mothers were behaving in ways which were like-
ly to harm the children to a lesser or greater extent. The
interventions that Kluft proposed for the abusive mothers
were: agency or legal interventions, ongoing supervision includ-
ing parenting skills, intensive psychotherapy for the MPD
mother specifically for her MPD, treatment and follow-up
for her children, and supportive therapy and education and
advice for the caretaking partners. We see in these sugges-
tions a clarion call for efforts to help these mothers and their
children.
In Kluft 's four-factor theory of causality of MPD, he
describes the kinds of traumatic events that can overwhelm
a child's non-dissociative defenses and to the part that care-
givers play in the evolution of MPD in the child (1984). In
addition to sexual abuse, extreme physical abuse, aban-
donment, neglect, and psychological abuse, other life expe-
riences that are overwhelming are: the loss or death of sig-
nificant others, witnessing a murder, an accident or carnage
of war, receiving serious death threats, cultural dislocation,
being caught between embattled parents in a divorce situa-
tion, being treated as if the child is the opposite gender, or
excessive observation of the primal scene. Most of these sit-
uations either involve the family directly in the trauma or
else rely on the family to mediate the effects of external trau-
ma. Kluft (1984) labels the family's inability to process the
trauma or protect the child as Factor 4: "Inadequate provi-
sion of stimulus barriers and restorative experiences by sig-
nificant others, for example, insufficient `soothing - (p.15).
When a traumatized child is neither protected nor helped
to process trauma within the family, the child may go inside
him/herself to find soothing and comfort.
This notion of a parent neither providing a stimulus
barrier nor processing traumatic events with a child can be
viewed from two ends of the telescope when working with
families. On the child side, a lack of protection or soothing
may be a risk factor in the development of MPD in a child.
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DISSOCIATION, Vol. VI, No. 1, March 1993
INTERVENTIONS WITH CHILDREN
From the parental lens, an MPD parent who has not had the
protection and soothing from her own parent may have dif-
ficulty giving it to her non-MPD children because she has
not experienced it herself. The inability of a parent to mod-
ulate affect states in herself may hinder the parental task of
modulating affect states in children (Cole and Putnam, 1992;
Nathanson, 1993). Additionally, Frederick (1985) points out
that children of a traumatized parent are affected by the
parent 's traumatization. Children are upset when they per-
ceive their parent as unstable. Other authors have written
about this phenomenon of contagion of trauma (McCann
and Pearlman, 1990; Dyregrov and Mitchell, 1992; Figley
and McCubbin , 1983; Figley, 1985; Donaldson and Gardner,
1985; Terr, 1985; Maltz and Holman, 1987; Courtois, 1988;
Figley, 1988; Carroll, Foy, Cannon and Zweir, 1991; Harris,
1991).
In a study of psychic trauma in children who have wit-
nessed the homicide of a parent, Eth and Pynoos (1985)
emphasize that trauma affects children differently at different
developmental stages. Cognitive, social and emotional devel-
opment may be altered as traumatized children struggle to
manage schoolwork, play, and interpersonal relations. They
recommend early treatment interventions to prevent mal-
adaptive trauma resolution. Terr (1985) asserts that child-
hood trauma leads to cognitive-perceptual difficulties and
the collapse of early developmental achievements. Fish-
Murray, Koby, and van der Kolk (1987) report that abuse
affects the accommodative capacity of the child which may
lead to an inability to self-correct. Fine (1990) further observes
that abuse may also interfere with assimilative capacity which
may result in cognitive distortions. Briere (1992) discusses
both the impact of abuse on the survivor ' s inner experience
(e.g., cognitive distortions, altered emotionality, dissocia-
tion, and impaired self-reference) and on interpersonal rela-
tions (e.g., disturbed relatedness, avoidance, co-dependent
relationships and borderline tendencies) . Cole and Putnam
(1992) offer a developmental model of the effects of incest
on children and conclude that incest interfereswith the devel-
opment of self and social skills in children in a way that
increases the risk of severe psychopathology. Moreover,
Putnam and Trickett (1993) assert that traumatized chil-
dren suffer serious physical/biological, psychological, and
social consequences.
Furthermore, authors in the MPD literature have noted
the transgenerational nature of dissociative disorders. Kluft
(1984) has found MPD in one or both parents of 40% of his
childhood MPD patients. Braun (1985) has studied eighteen
cases of MPD in which dissociative phenomena were found
in the family histories of all eighteen. In a study of twenty
patients with MPD, Coons (1985) has found that children of
MPD mothers had a 39% incidence of diagnosable psychi-
atric disturbances including 9% with MPD. Such evidence
adds to the urgency of assessing all children of parents who
have MPD. A number of authors (Kluft, 1984, 1985; Braun,
1985; Sachs, 1986; Putnam, 1989) advocate for routine assess-
ment of the children of MPD parents.
Based on the foregoing studies, it seems evident that
there is an increased risk of children of MPD parents receiv-
ing less than adequate parenting. In addition, the MPD client-
parents themselves may have trouble with parenting skills
58
based on the lack of competent role models from their own
families of origin. This conclusion is implied in Kluft ' s (1984)
Factor 4 which states that inadequate provision of stimulus
barriers or restorative experiences to children by significant
others in the face of overwhelming trauma is an essential
element in the etiology of MPD. As traumas in minor, if not
in major ways, are ubiquitous in the everyday life of a child,
it follows that many parents with MPD may be woefully unpre-
pared to help their children cope if their own coping skills
are based solely on their experiences of how they have been
parented in their own childhoods. Consequently, our ther-
apeutic interventions take two forms: 1) to work directly with
the child to help the child process his or her experiences,
both in terms of handling life events and relating to a par-
ent with MPD (if that is the circumstance); 2) to work indi-
rectly with the child by teaching the parent how to help the
child process experiences.
Thus by both methods, we are seeking to provide the
stimulus barrier and soothing thatwill protect the child from
becoming or remaining dissociative, and/or from continu-
ing in the transgenerational chain of dissociative
pathology.
Rationales for Working with Children
To summarize the various rationales for working with
children in dissociative families, we feel that they include:
1) Children are often affected by the dissociation of a
parent.
2) Children need to be observed and assessed for dis-
sociation or other signs of maladaptive behavior.
3) MPD parents are often concerned about the effects
of the MPD on the child.
4) MPD parents are often concerned about the effects
of the child's current life situation (custody battle,
alternative caregiver, abusive situation outside the
family) on the child.
5) An MPD parent often benefits from watching the
therapist interact with the child. The therapist can
model both nurturing and limitsetting behaviors.
The therapist can demonstrate appropriate bound-
aries in an interactive rather than a didactic way.
6) The therapist can empower the MPD parent to relate
well to her children by participating in sessions with
them. Confidence in parenting has the potential to
become a self-esteem enhancing resource for the
MPD client.
7) Work with parents and children provides therapeutic
leverage for the therapist.
8) Strengthening the parental subsystem deparentifies
the child. It shifts accountability for parenting to
the parent.
DISSOCL1T10N, Vol. V1. o. l. Mardi 1993
BENJAMIN/BENJAMIN
9) Work with parents and children builds trust in their
relationship and restores a fair balance of giving
from parent to child.
The last three points draw heavily on contextual prin-
ciples (Boszormenyi-Nagy and Ulrich, 1981) which we have
discussed at length in a previous paper (Benjamin and
Benjamin, 1993a).
TREATMENT GOALS IN WORKING WITH CHILDREN
Within the context of our family-centered treatment phi-
losophy for MPD, we have five goals in working with chil-
dren:
1) To restore healthy interactions and enhance rela-
tionships between child and parents and child and
siblings.
2) To increase mastery and control in the child's life
through a combination of nurturing and empow-
ering messages, activities, and techniques.
3) To help the child resolve trauma(s) with trauma-
based play therapy (Terr, 1983, 1985; Gil, 1991; James,
1989) , activities such as storytelling (Gardner, 1992) ,
or frank hypnotic interventions (Rhue and Lynn,
1991; Kluft, 1984, 1985a, 1985b, 1991; McMahon
and Fagan, 1993).
4) To promote a sense of wellness and normalcy for
the child.
5) To help the child connect to family, peers, and the
larger community through participation in relevant
experiences based on the child's talents and inter-
ests (e.g. sports, art classes, dance, etc.).
TYPES OF INTERVENTIONS
Our work with children always involves the parents to
some degree. We agree with James (1989) who notes that
the involvement of parents is not a breech of confidential-
ity. Rather, it is a planned intervention. James justifies parental
participation for many reasons: children spend more time
with their parents than in therapy, parental involvement lessens
secrecy and shame, acceptance by parents promotes self-
acceptance in the child, it insures parental cooperation, it
allows for the strengthening of attachment of the trauma-
tized child to the parent. Filial play therapy (Guerney, 1983)
includes parents in the therapeutic process in order to specif-
ically teach and model parenting skills. Unlike filial thera-
py, however, which first places a parent behind a one-way
mirror to watch the therapist interact with the child and
then allows the parent to interact with the child while the
therapist observes, we usually prefer to have the parent in
the same room with the child and therapist as the child plays.
In that way, the parent can participate directly in the pro-
cess of the play therapy. The therapist is then able to observe
and later process with the parent the parent's reactions to
the play of the child. Not only can the therapist be helpful
specifically in the parenting area, but such interactions fre-
quently stir up a well of more general psychodynamic and
family of origin issues for the MPD client that can be pro-
cessed in individual sessions.
The type of involvement that we have with children
varies from family to family. Often, we have a few sessions
with the children of an MPD client-parent to look for signs
of dissociative symptoms or other problem behaviors. In those
cases, we spend part of the session with parents and child
and part with the child alone. If further child work is indi-
cated, we include the MPD parent as much as is possible for
him or her in the session with the child. In cases in which
the parent is able to remain in a child's session without overt-
ly switching or experiencing flashbacks or numbing, the par-
ent is welcomed to join in the play therapy of the child. In
instances in which the parent is unable to participate for the
entire session, the parent participates for ten minutes at the
beginning of the session and five or ten minutes at the end.
On occasion, therapists from outside our own practice
request an evaluation of a child of their MPD client. In that
case, we interview the parents together for one or two ses-
sions in order to get a family history and genogram, and a
developmental history of the child. Then we meet with the
parents and child for several sessions. During those sessions,
we spend about half the session alone with the child.
Alternately, if two therapists are available, we split the treat-
ment into two rooms so that one therapist meets primarily
with the child while the other spends further time separately
with the parents gathering additional history and building
rapport. Later, all reconvene to review the session together
briefly. Usually, further time is then spent with both thera-
pists talking with the parents while the child or children
remain in a nearby waiting room. If this feedback to the
parents cannot be done immediately, then a separate ses-
sion is arranged within a few days to accomplish this pur-
pose. Sometimes we then continue the treatment of the child
while the MPD parent remains in individual therapy with
another therapist. In that event, if it is appropriate and agree-
able with the primary therapist, we encourage the MPD moth-
er to join our MPD mothers ' group (Benjamin and Benjamin,
1992) and the spouse to join our Partners and Parents' group
(1993b). We are also available to meet separately with the
parents for parenting counseling if this seems indicated. Again,
it is in cooperation with the client's primary therapist.
Another possibility which occurs is that one or both
parents continue in parallel therapy with one of us while the
other therapistworks with the child. This is the method advo-
cated by Donovan and McIntyre (1990). We find this
approach to be a powerful and useful method. However, it
has some practical drawbacks. It requires extraordinarily close
collaboration between the therapists, and it presents a finan-
cial problem in that two services are being rendered by two
therapists. The latter results in either a double bill for the
client-family or else a sharing of a single fee between the two
therapists.
Sometimes we are asked to do an evaluation of a child
for court. Although one child who we originally evaluated
59
DISSOCIATION. Vol. VI. No.1, March 1993
INTERVENTIONS WITH CHILDREN
for child abuse has remained in treatment with us for over
five years, we have since modified our own policy toward
legal cases subsequent to that experience. Because we strong-
ly believe in the Contextual Approach (Boszormenyi-Nagy
and Ulrich, 1981; Gelinas, 1988) that mandates that the ther-
apist show multidirected partiality to all family members includ-
ing the ones who are absent but directly affected by our
interventions, we see legal advocacy as antithetical to our
philosophy of the practice of psychotherapy. It runs the risk
of putting the child into a split loyalty situation between the
therapist and the adversarial parent in custody disputes.
Therefore, we now explain to prospective clients that we will
consider either working with them therapeutically or else
serving as an expert witness, but we will not agree to be in
both roles on a given case.
Our preferred method of working is with the members
of an entire family. If after an evaluation of a child, it seems
that therapy work with the child is indicated, we will offer
to see the child within the context of the family. That means
that one of us treats the MPD parent individually, one of us
treats the non-MPD parent, each parent is in a group for
mothers with MPD or for parents or partners, and the child
has play sessions preferably with the MPD parent present.
SPECIFIC MODALITIES WITH CHILDREN
Play Therapy
A discussion of play therapy necessitates a brief digres-
sion about the function of play in a child's life. Erikson (1963)
views play as a child's effort to master reality: "I propose the
theory that the child's play is the infantile form of the human
ability to deal with experience by creating model situations
and to master reality by experiment and planning" (p. 222).
O'Connor (1991) sees particular elements as typifying play
behavior: it is intrinsically complete without needing exter-
nal rewards, it is aimed at making use of objects, it does not
proceed with a conscious goal on the part of the child, it
absorbs the child's awareness to the point of loss of self-con-
sciousness, it is fun, it is variable and flexible depending on
the situation and the child, and it does not occur in new or
frightening situations. He regards the goal of play therapy
as " the reestablishment of the child 's ability to engage in
play behavior as it is classically defined " (p. 6). It does not
matter that the therapist and child engage in behavior that
may not be called "play" along the way to the goal. Treatment
is complete when a child has the ability to play in a joyous
way.
However, the secretive and compulsive play of trau-
matized children (Terr, 1983) is not fun. It may, instead, be
an attempt to master an experience of trauma. Trauma affects
children cognitively, emotionally, physically and spiritually
(James, 1989), and, by extension, interferes with the nor-
mal processes of self and social development (Cole and
Putnam, 1992) . Play therapy with traumatized children (Terr,
1983; Mann and McDermott, 1983; Fagan and McMahon,
1984; James, 1989; Gil, 1991) utilizes play to help children
master the trauma, and, ultimately, to free children to con-
tinue the processes of normal development.
Like James (1989), our style is direct and open. With
60
the parents present, we explain the purpose of our meet-
ing. We usually begin sessions with the child and parents
together reviewing what has happened during the week at
home, at school, in the neighborhood. Where possible, we
invite a parent to stay to be a part of the child's play thera-
py session as explained previously.
A number of play therapists (Mills and Crowley, 1986;
James, 1989; Gil, 1991) advocate the use of multidimensional
strategies with children that address physical, cognitive, emo-
tional, and spiritual aspects. The play materials and activi-
ties that we provide in our office address each of these devel-
opmental areas as well. To this list, we would add hypnotic
interventions which do not fit neatly under any of the other
categories.
The Physical Aspect
Materials for physical use include balls of all sizes and
textures, various bop bags, a large karate kicking bag, and
a velcro ball "dart " game. Children use these props to make
up their own physically appealing games. One child method-
ically and ritually blew up a small bop bag in each session
over a period of months, punched it until he was exhaust-
ed and the bag either deflated from a hole or the sandbag
weight inside burst. He would then take a scissors, cut out
the sandbag (which he called the "heart") and drape the
bag over his head like a cape. The same child, in a late stage
of his treatment, punched and kicked the indestructible karate
bag repetitively over many sessions in a trance-like way while
the therapist intoned the elements of a hypnotic integra-
tion ceremony to help him coalesce his alter personalities.
The Cognitive Aspect
Quite a bit of direct discussion happens in the play-
room between therapist and child, therapist and parent, and
parent and child. For instance, a child who is going through
the separation and divorce of his parents may need reas-
surance that his upset and loyalty feelings toward both par-
ents are very normal. The parents may also need counsel-
ing on how to cooperate about rearing the child as they go
through a divorce process. Storytelling and metaphors (Mills
and Crowley, 1986; Gardner, 1992) are often used to help
a child both understand and master his situation. Puppets
(Burgess, Holmstrom, and McCausland, 1978) can be uti-
lized to initiate a non-threatening story. They take the direct
focus off of the child and allow the child, therapist, and par-
ent to talk in an indirect way that may be less intimidating
or embarrassing than direct conversation. We find the use
of puppets to be a very powerful and effective technique that
we employ extensively in work with children. We maintain
a large collection of colorful and engaging puppets, primarily
in the form of interesting and whimsical animals. They are
used both formally in a puppet theater stand and informally
and spontaneously to interact with the child.
Hypnotic Interventions
Formal hypnosis has been used with traumatized chil-
dren to help the child master the trauma, to alleviate symp-
toms, and to retrieve information (Kluft, 1991). Storytelling
techniques have been used to create hypnotic inductions
DISSOCIATION, Vol. I I, No.I, March1993
BENJAMIN/BENJAMIN
(Olness and Gardner, 1988) . Hypnotic techniques have been
used to help sexually abused' children find a safe context,
restore personal power, reduce feelings of self-blame, shame
or brokenness, to promote a sense ofwellness, and to resolve
sexual issues (Rhue and Lynn, 1988). Kluft (1991) cautions
that before resorting to formal hypnosis with a child, the
therapist take into account the child's ego functions, cog-
nitive and psychodynamic development, coping styles, the
family's attitude toward hypnosis, and whether or not a hyp-
notic intervention might later contaminate forensic testi-
mony. As Green (1985) notes, traumatized children often
present as hypervigilant, frozen, and mistrustful, hardly a
promising combination for formal hypnosis. Hilgard and
LeBaron (1984) explain thatveryyoungchildren (from about
three to six years) engage in "protohypnosis", pretend play
which is guided by language. They cannot engage in formal
hypnosis because their limited cognitive abilities interfere
with typical,hypnotic suggestions and tasks and they cannot
engage in the internal elaboration of fantasy. Usually they
keep their eyes open just as they would as they engage in
pretend play. Hypnotic ability of the type we are able to rec-
ognize, describe, and measure begins to rise at about five
years and peaks between nine and twelve years.
Children who dissociate have discovered an autohyp-
notic way of coping with trauma and reducing their own
stress. It makes sense that hypnosis, which has a link to dis-
sociation, might be an intervention of choice with dissocia-
tive children (Kluft, 1991). In our own sample of children
who appear to have MPD, we have used formal hypnosis spar-
ingly with elementary school-aged children as part of the
larger treatment plan, to increase mastery, identify alter per-
sonalities, and facilitate integration. More frequently, how-
ever, we have used hypnotic or "hypnoidal " (Linden, 1993)
techniques to increase a child 's sense of safety and mastery.
These techniques capitalize on the child 's ability to be absorbed
in fantasy play. Once involved in the pretend play of the
child, the therapist can send messages of safety, strength,
control, and mastery.
The Emotional Aspect
This realm includes all of the play therapy materials
and activities that encourage exploration and expression of
feelings. James (1991) offers a wealth of interactive activi-
ties with children to help them label and get in touch with
feelings. In our practice, the many art supplies such as paper,
paints, markers, crayons, pencils, clay, glue, feathers, imita-
tion gems, pipe cleaners, etc. encourage children to express
feelings. Mills and Crowley (1986) have devised the helpful
technique of having a child and the child's parents draw
what the problem as they see it looks like, drawing what life
will be like when the problem is resolved, and then drawing
how the child can best solve the problem.
The use of sand tray (Kalff, 1980; De Domenico, 1988;
Dundas, 1990) allows the child to project feelings and expe-
riences onto the sand. The tactile use of the sand can help
to soothe a child (Gil, 1991). Some children merely finger
the sand at first, others play out repetitive simple scenes, and
other make elaborate constructions in the sand. Our obser-
vation is that over the course of therapy, a child's capacity
to create scenarios in the sand increases. The children choose
the figures that they wish to use in the sand and create a
scene. They are asked to explain the scene and then two still
instant photos are taken. One stays with the therapist and
one goes home with the child. One child created a sand tray
of a male figure in a boat being attacked on all sides by clawed
creatures (crabs, lobsters, and sharks). The child put sand
in the figure's mouth. This child was in the middle of a hos-
tile custody battle and was scheduled to appear before a
judge to say whether he wanted to live with his mother or
his father.
In addition to the sand tray, children create scenes on
the rug with figures, vehicles, and props (dolls, furniture,
bugs, dinosaurs, fish, snakes, cars, trucks, trains, a futuristic
" Star Wars" type ship, etc.) One school-aged child, whose
parents were divorcing, repetitively created scenes of car
accidents in which all the participants were hurt and bro-
ken.
The Spiritual Aspect
Traumatized children have suffered many losses. When
they have a parent who has been traumatized as well, the
parent may have trouble passing on a sense of life's mean-
ing to the child. James (1991) believes that children can be
given the message that they have something of value inside
of them that no one can take away. The therapist can uti-
lize the specific religious affiliation of the family to encour-
age spirituality and connection to universal values. The spir-
itual dimension can also be appreciated in the power and
beauty of nature. Mills (1991) encourages keeping natural
wonders such as stones, gems, and shells in the office.
FAMILY INTERVENTIONS
Parent-Child Sessions
In our model, parents are vitally involved in the child's
therapy. A major goal of our approach is to empower the
parent to relate successfully to the child: to nurture, soothe,
set limits, and be aware of boundaries. In cases in which the
parent has been the perpetrator of abuse, we work with the
parent individually to help the parent reach a comfort level
of addressing the abuse directly with the child. Over sever-
al sessions, the parent explains that he/she was wrong, that
the child was hurt, and that the parent deeply regrets hav-
ing hurt the child. In cases where the parent has MPD, we
have worked extensively with the offending alter (s) and invit-
ed the alters (with preparation of the child) to the playroom
to deal directly with apologizing to the child.
Sibling Interaction
Frequently, siblings attend a child 's play therapy session.
Such sessions give the therapist valuable data on sibling inter-
actions. The therapist can observe how the parent interacts
with the other children in contrast to the index child.
Frequently, sibling rivalry is an issue. In a particularly dra-
matic example of the importance of including the siblings,
when a mother with MPD and her eight-year-old child were
together, the child presented with florid MPD symptoms which
mirrored the mother's. The child's three-year-old brother
61
DISSOCIATION, Vol. VI, No, 1, March 1993
INTERVENTIONS WITH CHILDREN
attended a number of sessions in which he dominated and
distracted her mother's attention by his exuberant behav-
ior. Eventually, the child-client renounced the MPD symp-
toms as feigned in imitation of her mother. She admitted
that her real problem was her anger at her mother for her
prolonged hospitalization which left her stuck for extend-
ed periods of time with her younger brother. Her imitation
of her mother was an effort to win her mother ' s approval
and divert her mother 's attention from her brother.
Family Therapy
Often the entire family or subsystems of families attend
sessions. Family sessions allow the therapist to invite per-
spectives from all family members. Problem behaviors at home
maybe dealt with in family sessions. One family came togeth-
er after the mother with MPD had sexually fondled her school-
aged son. After a session of parallel therapy in which one
therapist worked with the parents and one worked with the
child, both therapists, the parents, and the child convened.
The child showed the parents a puppet show that he had
made up which depicted the abuse. At the end, he showed
what the boy would do if the fondling occurred again. His
mother reassured him that it would not happen again and
his father was alerted that his child needed protection.
TRANSFERENCE AND COUNTERTRANSFERENCE
Donovan and McIntyre (1990) note that interpretation
of "transference relationships" in psychotherapy with young
children can be counterproductive and represent an intru-
sion by the therapist. However, O'Connor (1991) broadens
the context by looking at the emotions, thoughts, and behav-
iors that the child and therapist bring into therapy. He fur-
ther examines the emotions, thoughts, and behaviors that
the child has, that as a result of therapy, enter the child's
ecosystem. In a similar way, the therapist has emotions,
thoughts, and feelings with regard to the child's larger ecosys-
tem. Three types of transference that O 'Connor sees on the
part of the child are: the child treating the therapist as par-
ent, the child seeing the therapist as omniscient and all-pow-
erful, and the child taking behaviors from the therapy ses-
sion into the larger ecosystem (e.g. the child who becomes
dependent in therapy becomes clingy at home). All of these
transference problems may be addressed with the parents.
According to O'Connor, types of therapist counter-
transference include: wanting to "save" the child and the
child ' s ecosystem, anger and frustration if the child does not
improve, and an attitude of blaming the parents and seeing
them as failing the child.
Gil (1991) adds that abused children, because of their
experiences ofviolation, may experience feelings of distrust,
fear, rage, and longing toward the therapist. They may be
confused because the therapist does not hurt them. The
therapist, in turn, may desire to be nurturing even in the
face of attacking behavior by a child. Ultimately, Gil relates,
the attacking behavior may elicit other responses in the ther-
apist.
We have found that Avery important for us to stay ground-
ed with a particular treatment philosophy in order to avoid
common countertransference responses to traumatized chil-
dren and their families. In our case, we combine and inte-
grate both psychodynamic and family therapy approaches
(Nichols, 1988). More specifically, our family approach is
heavily influenced by the contextual ideas of Ivan Boszormenyi-
Nagy (Benjamin & Benjamin, 1993a) James (1991) suggests
constructing a metaphor to describe the therapeutic pro-
cess to a child. Similarly, we believe that it is important for
the clinician to have a vision of the goals and the purpose
of the treatment. Our own metaphor is that we are tour guides
to family health and functioning. We know the destination
of the journey, but the individuals in the family must decide
on the course of the trip and set the pace. By the end of the
journey, parents are empowered to care for their children,
children do not have responsibility for their parents, indi-
vidual traumas are resolved, and children can continue the
process of development facilitated by their own families or
caregivers. Ultimately trust is restored in the family.
CONCLUSION
Within afamily treatment model, play therapy and hyp-
notic interventions can be useful in helping a child master
the physical, cognitive, emotional, and spiritual dimensions
of trauma. In cases in which a parent is abusive toward a
child, the abuse needs to stop and the damage needs to be
contained, apologized for, and re-processed. The child
needs opportunities to deal with the damage directly and in
play. If possible, trust in the relationship between child and
parent needs to be rebuilt. When a child has been trauma-
tized outside the home, direct discussion and play therapy
that is geared to help the child process and master the trau-
ma is necessary. When parents are able to participate in the
child's therapy, they can become a very important ally in the
therapeutic process. In child-parent sessions, individual ses-
sions, and couples' sessions, they can learn how to care for
their children by learning how to listen, how to encourage
play, how to help a child process problems, how to set lim-
its, how to be sensitive to boundaries, and how to go about
exploring and solving childrearing problems. The parents'
commitment to involvement in the child's therapy is a major
step toward ethical accountability on the part of the parents
to the child's well-being and to the well-being of future gen-
erations. 
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