Five year old Luke was referred to therapy by his kindergarten teacher due to his disruptive behavior in the classroom and his constant refusal to follow rules. When I asked him what had happened at school before coming to see me, he was perfectly capable of giving a narrative of the facts. When I asked whether he knew what had caused him to behave in such a way, he said in a very confident manner: “When I´m bored I feel kind of a monster inside my chest that wants to come out and get some fun. I know I don’t have a monster but this is the way I feel with Miss Cecilia. She is so boring. She doesn´t allow me to get fun, she only wants me to sing her stupid songs.” Had Luke been a dissociative child the answers to these questions might have been quite different. He might have shown amnesia for his behavior, or had blurred memories of it. He might have answered ‘I don´t know’ to the question about the trigger, or might have felt that the monster was really inside of him, taking control over Luke´s behaviors without him being able to stop it, and yet not knowing what caused the monster to behave like that. The Inside-Outside technique (Baita, 2015) was developed to assist a little dissociative girl in curiously exploring her internal experience while she was seen by her siblings – in the outside world- as a crazy girl, a situation that was very upsetting for her. This is a common experience for dissociative kids: their behaviors and reactions might be baffling for those surrounding them, even though they make a lot of sense for the child´s internal experience. The big challenge is that most of the time, the child is also unaware of what has caused their behavior or reaction, and is often unable to properly communicate their feelings and concerns. When the child is in a safe situation, the present keeps triggering memories of their past that intrude into their daily life, and they cannot gain control over it. Through the use of the Inside-Outside technique the clinician can assist the child, along the course of therapy, to increase:
- self observation – What is going on inside of me right now?;
- self awareness – What part of me is reacting like this right now?;
- self monitoring – How intense is what I´m feeling right now? What do I want to do when I feel like this?; and
- self reflection – when I feel like this I behave…; when I remember my Daddy hurting me, I feel like, and I think …; when my mommy hugs me, something inside of me wants to hurt her because I recall when I was hurt) (Waters, 2016)
The technique is very simple and can be used from the first meeting with the child and throughout the entire therapeutic process. To begin, the clinician draws a big circle on each side of a white sheet of paper, and starts with a very simple explanation that serves both the purposes of introducing the technique and providing some psychoeducation: Did you know there are some things outside your head that everyone can see? Here the clinician encourages the child to answer with the things everyone can see on her head (eyes, mouth, nose, etc.). Then the clinician keeps moving along with the explanation: And did you know there are some other things stored inside your head that you are the only person in this world who can see or listen to? Most kids will give answers like the skull or the brain and in that case the clinician can say something like: Yes, you are right, inside your head there is the skull and the brain, however a doctor can take a picture of both of them, and in that case he would also be able to see what is inside your head… but do you think the Doctor’s pictures would show a feeling or a thought, or even a memory? The idea of this first part of the introduction is to allow the child to get in contact with the fact that she or he has feelings, thoughts and other experiences that are unique and personal, and outside others´ awareness. Then the clinician proceeds: Some of the things that happen to us can be easily seen by others, like if you have tears someone might think you’re sad. But the person who is with you doesn´t know what causes your sadness. The only one who really knows what’s going on is you. You are the only person who knows about your sadness that is stored inside of you. I have here this piece of paper with a big circle on each side. Would you please draw on one side what everybody can see outside your head? …OK, good. And now, would you please draw on the other side of the paper all the things that only you know are inside your head, and might be worrying or bothering you? This could help me understand you and help you better. This is the only starting point. From now on the clinician can use this technique for multiple purposes, and asking countless questions related to past, present or future experiences: Do you remember what was inside your head when your Daddy used to do these things to you? What´s inside your head right now when you are telling this to me? What would you like to have inside your head when you grow older? What´s inside your head when you think of that/when you feel… (sad, angry, mad)? Being able to reflect upon their own behavior, feelings and thoughts is an important step for the self regulation of a chronically traumatized and dissociative child. And the uses of this technique are certainly unlimited! References
- Baita, S. (2015): Dalma (4 to 7 years old) – “I´ve Got All My Sisters with Me”: Treatment of Dissociative Identity Disorder in a Sexually Abused Young Child. In Wieland, S. (ed.) Dissociation in Traumatized Children and Adolescents. Theory and Clinical Interventions. Second Edition. (pgs. 41-88). New York, Routledge.
- Waters, F.S. (2016): Healing the fractured child. Diagnosis and Treatment of Youth with Dissociation. New York, Springer Publishing Company.
*A Spanish Language version of this article will be available on ISSTD Website under Spanish Language Resources.