Lynne H. Harris, MA, MPH, LMHC, LPC
It’s “just a donut” became an unlikely catchphrase for my work with a client who has Dissociative Identity Disorder (DID). It started in the retelling of a routine, but fraught, Dunkin Donuts run and ended up as a way we use to signal the patient’s amygdala to turn off when it is not truly necessary.
I approach working with patients living with dissociation using a combination of Sensorimotor Psychotherapy, Eye Movement Desensitization and Reprocessing (EMDR), and ego state or parts therapy, which is grounded in Herman’s (1992) staged approach to trauma recovery. Our primary goal for the first two years has focused on overcoming chronic dysregulation in the central nervous system. I have provided psychoeducation about the Window of Tolerance (Siegel, 1999), and how trauma memory is stored differently than normal narrative memory because the parts of our brain responsible for placing a date and time stamp (hippocampus) on sensory input from the thalamus, and helping place it in a context (frontal cortex) go off line during trauma to help increase rate of reaction to a life threatening, or perceived life threatening, circumstance. I normalized how once a traumatic event happens, our brain in part stays alert to the possibility it can happen again, even while another part of the brain carries on with life—often with little or no memory of the event, thanks to our brain’s ability to compartmentalize. With complex trauma and DID, I often see a highly sensitized nervous system adapted to an unsafe world, ready to speed up or shut down with slight provocation. Using the Structural Dissociation theory (Van der Hart, Nijenhuis, & Steele, 2006), I helped her understand how parts of the personality split along the lines of action systems for socialization/procreation and defense.
To demonstrate this approach, I will present my work with Ms. X, who is a 43-year-old Caucasian woman who experienced extensive neglect, as well as emotional, physical, psychological abuse by her parents in a strictly religious family with nine siblings. She was raped by an older brother as a child. She left home in her later teenage years and married a man, 17 years her senior, who encouraged her to work as a stripper. It was after working one night in a strip club that she was kidnapped, held for 24 hours in a house, and repeatedly raped by three men when she was 19 years old. She barely survived.
When she first entered therapy, she had just been discharged earlier in the week from a 53-day inpatient treatment stay for alcohol use and suicidality. She reported having a history of alcohol use for 20 years, with a pattern of daily drinking onepintof vodka per day prior to hospitalization, and binge eating. She told me she had been “Baker-acted” three times in the past two years. She was attending SMART recovery and returning to work full time at the outset of therapy. She reported having a trauma history since childhood with repeated, life threatening experiences. In response to the question on the intake questionnaire about what was bringing her to counseling at that time she wrote: “I have survived a kidnapping and brutal rape of three men who left me for dead in 1995. Sexual abuse by ex-husband, child hood trauma”.
At the intake session, I saw signs of dissociation as we were talking. I was aware that she had not been previously diagnosed with a dissociative disorder. At first, my calling attention to the abrupt changes in her affect that accompanied switches among parts caused a negative response, indicating a need to slowly acclimate her to parts work. Much later she told me she “always knew” the parts were there and that it was weird for someone else to see it. It took her a while to get comfortable acknowledging their presence and even more time before we could study the parts of herself and how they function to help, as all parts are formed to help in some way.
One of the hardest aspects of working with adults with DID is that the present day self is often “missing in action” (Fisher, 2017). That leaves other parts to do the work of navigating day-to-day life, often with poor results. For Ms. X, a fearful child part would take over at times but be in the body of a 43-year-old adult with a job, an adult committed relationship, and two children, one with special needs. We were able to identify a seven-year-old part, a 13-year-old part, a 19-year-old part, a 23-year-old part, and a 26-year-old part, all of whom often were “in the front” and who often stepped in, especially when there was any anticipated conflict (e.g., a disagreement with her partner, or a performance issue at work). At one point, we established that she did not actually know her current adult self, and that that part appeared to be weaker, more transient, and often would go into “ostrich” mode to avoid challenging or difficult life situations. We were able to eventually observe the pattern where the adult self was hiding out, not wanting to see, and other more assertive or aggressive parts would feel the absence of the adult self and take over out of necessity.
Therapy then shifted to helping Ms. X increase her felt sense of the adult self, who we referred to by age, so she would know when she was present, and to strengthen this adult part so she could remain present at all times. In essence, we shifted the relationship between the wise, adult, 43-year-old self and other parts so it worked more like an alliance in which she could hear and accept help from other parts that could be resources (e.g., “26” could lend her confidence and assertiveness) to the adult, but without loss of conscious connection to the present moment.
We have worked together for over two years.
The story of “it’s just a donut” is as follows. On a routine weekend my client went to Dunkin Donuts to get breakfast treats, as is the custom of her and her son. They always got her partner his favorite – cake donuts but with chocolate frosting on them – which is not a standard offering, and would have to be made special at her request. Every week it was the same order. One day she placed the order and the person behind the counter told her they could not make that, period. My client described that her immediate reaction was one of utter terror in her body, heart rate racing, could not talk, dissociated on the spot. She went home in what she described as a state of terror and fear and it took into the next day to calm it down. She reported this to me in our session almost a week later. We mindfully studied the body response evoked in the session by her retelling of the events, and focused on noticing the hyperarousal in her CNS as “just sensation” without attending to the contents of any thoughts or distorted cognitive schemas that were attached to it (e.g., I’m going to die, I’m in trouble, something bad is going to happen). While noticing the sensation of fear in her body, I asked her to locate where she felt it the most (in her chest) and somatically resourced that part of her body by asking if it felt ok to put a hand to chest where she felt it. I asked her to try to notice if the intensityof the feeling fit the situation at hand (“just you and me talking in my boring office”), or if it was a better fit for something that may have happened another time. My client was able to identify it was more congruent with past situations. I reframed it as a “body memory” or “sensory memory”, a form of a flashback. Then I encouraged her to cognitively explore what the actualconsequence might be when she came home without the preferred donut. We discussed how, in the donut situation, the worst case scenario was that her partner might be disappointed, or possibly angry, or that she was frustrated with the Dunkin Donut staff, but, I pointed out, none of those possibilities were life or death situations, and yet that is what her body was signaling to her. “It is just a donut”, I said, “It is not life or death”, “we are just in my office, talking”. She looked at me, clearly back in her adult self and back in the room and laughed out loud and repeated, “It’s just a donut! It’s not life or death!” We repeated it laughing. And then we joked about how we should make t-shirts with the phrase printed on it. She creatively came up with other design ideas that reflect having a highly sensitized, overactive amygdala due to repeated trauma. She later actually drew these up and showed me.
So now, when she feels the old sensation of fear escalate in her body when we are working on something that triggers the CNS defensive response, she recognizes it, puts a hand on her chest and one on her belly and says, “This is fear. This is where it lives. It’s not in my big toe”. I sometimes do it with her. I place a hand on my chest and one on my belly. Together we say “It’s just a donut. Nothing is happening now.” Sometimes, I ask her to notice specific objects in the room to help reorient and reground. A favorite is to guess the stylistic era of the fabric on the couches (we think late 80’s, early 90’s). We somatically track the reduction of nervous system arousal as the re-orientation to safety in the present moment allows the amygdala to turn off and nervous system to return to baseline functioning.
I am happy to report that she continues to recover from a lifetime of trauma and is engaged, successful in her job, and has developed a group of women friends with whom she golfs every Friday after we meet.
References
Fisher, J. (2017). Healing the fragmented selves of trauma survivors: Overcoming self alienation. New York: Routledge.
Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.
Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press.
Van der Hart, O., Nijenhuis, E. R.S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: W.W. Norton.
Lynne Harris is a consultant, trainer and licensed mental health therapist currently in private practice in Georgia and Florida. She specializes in the treatment of complex trauma and dissociation and has presented widely on the treatment of trauma. She has held various positions in the mental health field since 2000 and has worked in the health care field since 1995. For the past two years, she has served as a consultant and subject matter expert on Trauma for Voices for Florida, an organization developing the Open Doors Outreach Network serving trafficked youth and young adults throughout the state of Florida.
