Attachment and Dissociative Disorders:
Implications for Psychotherapy
ISSTD Conference
Sunday, October 17th
Mark Schwartz, Sc.D.
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611
www.castlewoodtc.com
mfs96@aol.com
1
2
2
3
Inter-Psychic Intimacy (between the couple)
vs.
Intra-Psychic Intimacy (within the individual)
4
Attachment Trauma
The psychologic distress underlying the craving is the result of
an inability to metabolize negative emotions utilizing the
attachment system (Fosha, 2003; Neborsky, 2003). Successful
therapy restores secure attachment which allows for intimate
relationships to utilize for self-soothing. Injury to the
attachment system is the result of difficulties between the
caregiver and child that results in segregated systems of
attachment and dissociated self-systems. The result is a variant
of narcissism or a false-self personality organization as a means
of avoiding the need for attachment.
5
Secure Attachment I
L.Alan Stroufe, 2000
• Because their caretakers have been routinely available to them,
sensitive to their signals, and response with some degree of reliability
(though by no means is perfect care required), these infants develop a
confidence that supportive care is available to them.
•They expect that when a need arises, help will be available. If they do
become threatened or distressed, the caregiver will help them regain
equilibrium.
•Such confident expectations are precisely what is meant by attachment
security.
•Secure Attachment (earned) with self.
6
Attachment Process in Eating Disorder and Depression
Main, 1990
Deactivation (avoidant) can be maintained through actively
diverting attention from attachment issues and distressing
childhood memories. A second major type of defensive
strategy develops when an individual perceives attachment
figures as inconsistently responsive. To maintain the
relationship with this type of caregiver, an individual
hyperactivates (pre-occupied) the attachment system to
constantly monitor the attachment figure and maximize the
output of the attachment system.
8
Disorganized Attachment
• Drawing close to the other is thus accompanied by the
expectation of re-experiencing the anxiety of unpredictable
availability, the fear that allowing oneself to ask for and
obtain care may mean giving up one’s identity and
independence.
9
Ogawa Research
• 126 children with disorganized attachment followed until age
19. Prediction of Dissociative Disorder from maternal
unavailability and disorganized attachment in the first 24
months of life was more predictive than trauma. Trauma
history did not add to the prediction, of dissociation after
disorganized attachment.
• Specifically maternal Dissociative symptoms, disrupted
maternal affective communication, maternal lack of
involvement at 12 months, significantly contributed 5 other
measures non > 19.
10
Disorganized Attachment
The difficulties encountered during the complex process of
social adjustment, poor flexibility and resilience in facing
life’s painful events, the possibility of building a sense of
self that is coherent and integrated, of producing a fluid and
coherent narration, ultimately psychopathological suffering
itself, seem to point to the attachment pattern as an
important aetiopathogenic factor.
11
Dissociation
( Liotta, 2000)
• Early dyadic processes lead to a “primary breakdown” or lack
of integration of a coherent sense of self, i.e. Unintegrated
internal working models.
• Disorganized attachment is the initial step in the development
trajectory that leaves an individual vulnerable to developing
dissociation in response to trauma.
12
“Trauma related to structural dissociation then, is a
deficiency in the cohesiveness and flexibility o the
personality structure. The lack of cohesion and integration
of the personality manifests itself most clearly in the
alteration between the vivid re-experiencing of the
traumatic event and avoidance of reminders of the
traumatic experience.”
(van der Hart et al., 2006)
13
“SELF-EMPATHY” - The internalizing
(evoking) of the attentive, validating, caring
relationship to oneself. This involves
helping the client articulate her experience
and bring it into her own internal relational
context.
Target Symptoms For “Earned Secure Attachment”
1.
2.
3.
4.
5.
6.
Turning towards other people for self-soothing and
intimacy.
Establishing a coherent narrative regarding one’s
life.
Establishing metacognitional thinking in relation to
family of origin.
Minimize idealization and family loyalties.
Establishing clarity with regards to self and self in
relation to significant others
Resolution of significant losses in one’s life.
15
Adult Attachment
1. Describe your relationship with your parents as a young child (i.e., derogation,
relevance violation, loving).
2. 5 adjectives to describe your relationship with mother/father as young child (i.e.,
idealization, dysfunctional).
3. Your first remembered separation from parent.
4. Ever frightened or worried as a child?
5. Did you tell your parents?
6. Any close relatives or loved one die?
7. How did you respond?
8. Do you think loss has had an affect on your personality?
9. What is your relationship like with your parents now?
16
Refer to Handout on
Adult Attachment
Protocol
Affect and Cognition I
Van der Kolk, Brown & van der Hart, 1989
Janet believed that traumatized individuals became
phobic about memory because they have failed to
develop narratives about their traumata, instead
experiencing posttraumatic amnesias and hyperamnesias
18
State of Mind Regarding Attachment
COHERENCE: (truthful, succinct, relevant, clean)
Steady flow of ideas, intent thoughts, feelings, clear truthful, consistent,
plausible responses, completed, but not long.
COLLABORATIVE:
Speaker appears to value attachment relationships and experiences
CONSISTENCY:
Descriptions of relationships with parents are supported by specific
memories.
19
Metacognitional
Metacognition means treatment of one’s mental contents
as “objects” on which to reflect, or in other words
“thinking about one’s thinking.” Distinct skills
contribute to its characterization, such as the ability to
reflect on one’s mental states, elaborating a theory of the
other’s mind, decentralizing, and the sense of mastery
and personal efficacy.
20
Intra-Relational
• Relatedness
1.
2.
3.
4.
5.
6.
Fostering empathy for dissociated parts of self.
Tracking of intra-relational patterns – internal abandonment, ridicule.
Understanding survival function of parts of self.
Resolution of internal conflicts.
Internal witnessing, reduces shame and aloneness.
Affect regulation between internal dyads.
• Emotional Processing
7.
Recognition that different parts of self encompasses different defense strategies, divergent
emotions and divergent attachment schemes.
• Meta Therapies
8.
Recognition that different parts of self encompasses different defense strategies, divergent
emotions and divergent attachment schemes.
21
Attachment Therapy for Groups: Concepts and Methods
Week 1: Idealization and Family Loyalty
Definition: Idealization – the discrepancy between the overall picture or presentation of the parent and the readers
inferences regarding actual behavior of the parent.
Week 2: Rejection and Neglect
Definition: Define rejection and neglect by AAI standards
•
Reject – child goes to attachment figure with tender feelings and emotions and parents turns away the child’s
expression of the emotions “I’ll give you something to cry about…”
•
Neglect – parent is physically available but inaccessible emotionally/psychologically unavailable
Week 3: Loving Behaviors
Definition: The attachment figure is dedicated to the development of the child as a person and is emotionally supportive
and available. Loving behavior vs. instrumental love vs. non-loving behaviors.
Week 4: Involving and role reversal
Definition: Define involving and role reversal by AAI standards
•
Involving – parent uses child attachment system to become the object of the child’s attention
•
Role reversal – more severe form of involving behavior; the parent uses the child in the role of a spouse or parent, for
their own emotional needs
22
Attachment Therapy for Groups: Concepts and Methods
Week 5: Caretaking behaviors
Involving behavior on the part of our “caretakers” (parents, other attachment figures) can lead us into unhealthy caretaking behaviors in our
relationships. Ex. From Alcoholics Anonymous language – Alcoholic as dependent, partner as codependent
Definition: Caretaking behaviors deceptively (to self and others):
• Keep people in a dependency relationship with you
• Keeps you from dealing with your own issues
• Require that everyone you care for must conform to your set of rules and norms about their life
• Look good and proper on the surface but in reality are a subtle way of manipulating others to keep them under your control
• Make you valuable to others who need your assistance, rescuing and help.
Week 6: Caretaking vs. Supporting behavior
Definition: Review from Week 5
Week 7: Involving Anger
Definition: Involving anger is the reason that when a thing happens in relationship, all the past hurt comes in and it feels as if it is a
continuation or what always happens.
Involving anger sounds like this… “ she was always trying to make me into a little doll that was always doing what she wanted, and she
dressed me that way, and for awhile I acted that way, but I’m onto her now and I know what she’s up to and I’m sorry but I am not your
little baby doll anymore.”
Often longer, but even though it’s a short passage it would score a 6/9 for involving anger on the AAI
Week 8: Passivity
Partial Definition: The speaker appears unable to prevent sounds or phrases from arising while unable to specify it’s presumed intent or
content
23
Therapist >
SELF
Parts > Protectors > Exiles
First Level
Second Level
Intra-Psychic Intimacy
Secure Attachment with Self
Attachment Therapy for Groups: Concepts and Methods
Week 1: Idealization and Family Loyalty
Definition: Idealization – the discrepancy between the overall picture or presentation of the parent
and the readers inferences regarding actual behavior of the parent.
Purpose: How dismissive clients idealize their family-harmful effects for treatment
Intervention: Role played a mini-AAI:
Can you give me three adjectives regarding relationship with a parent and then specific
supporting memories? (3 glowing adjectives with very little specific memories)
When you were upset as a child what would you do? (Not go to parents due to their unloving
behaviors)
How do you think your overall experiences with your parents have affected your adult
personality? (either is hasn’t or they made me stronger)
Expressive: 3 chair expressive Narrative concerning struggle with family or parental loyalty; 1st
chair-the loving nurturing parent, 2nd chair-the polar opposite behavior of the parent, 3rd client.
Client sits any or all chairs and acts out all three parts.
25
Attachment Therapy for Groups: Concepts and Methods
Week 2: Rejection and Neglect
Definition: Define rejection and neglect by AAI standards
• Reject – child goes to attachment figure with tender feelings and emotions and
parents turns away the child’s expression of the emotions “I’ll give you something to
cry about…”
• Neglect – parent is physically available but inaccessible emotionally/psychologically
unavailable
Intervention: Clients discuss these experiences in their childhood
Expressive: Expressive around scene where child was rejected or neglected. Work
with parts around this. Have self validate feelings.
26
Attachment Therapy for Groups: Concepts and Methods
Week 3: Loving Behaviors
Definition: The attachment figure is dedicated to the development of the child as a
person and is emotionally supportive and available. Loving behavior vs.
instrumental love vs. non-loving behaviors.
Intervention: Hakomi exercise: Bring to mind a loving individual in your life that you
are willing to share with peers. Get in groups of 3-4. Each person gets 7 minutes to
speak about this person with no interruption or feedback. When everyone shares, the
last 7 minutes is for the small group to give feedback concerning how each person’s
story had an impact on them.
Group reconvenes and shares their experience of focusing on loving people and
behaviors in their lives. If time permits, write down as many loving behaviors as
possible and place them in the rating categories of the AAI loving scale.
27
Attachment Therapy for Groups: Concepts and Methods
Week 4: Involving and role reversal
Definition: Define involving and role reversal by AAI standards
• Involving – parent uses child attachment system to become the object of the child’s attention
• Role reversal – more severe form of involving behavior; the parent uses the child in the role of
a spouse or parent, for their own emotional needs
Intervention: Pre-determined client shares a narrative regarding parental involving behavior.
Questions for discussion:
• What function do they serve?
• Where do these behaviors lead to (present strategies)?
• What can you do now (to step away from caretaking behavior)?
Expressive: Laura
28
Attachment Therapy for Groups: Concepts and Methods
Week 5: Caretaking behaviors
Involving behavior on the part of our “caretakers” (parents, other attachment figures) can lead us into
unhealthy caretaking behaviors in our relationships. Ex. From Alcoholics Anonymous language – Alcoholic
as dependent, partner as codependent
Definition: Caretaking behaviors deceptively (to self and others):
• Keep people in a dependency relationship with you
• Keeps you from dealing with your own issues
• Require that everyone you care for must conform to your set of rules and norms about their life
• Look good and proper on the surface but in reality are a subtle way of manipulating others to keep them
under your control
• Make you valuable to others who need your assistance, rescuing and help.
Intervention: Make a list of caretaking behaviors from the group and allow discussion as needed. Have clients
answer the following (in writing):
1.) What caretaking behaviors do I engage in? 2.) What purpose does this role serve for me personally and/or
emotionally? 3.) How does this practice look like healthy behavior? 4.) How is it not healthy behavior for me
and what are the consequences? 5.) Where/how did this behavior originate in my life?
Expressive: Laura
29
Attachment Therapy for Groups: Concepts and Methods
Week 6: Caretaking vs. Supporting behavior
Definition: Review from Week 5
Intervention: Caretaking demonstration acted out by staff – three scenarios, and
discussion of each.
1. Typical caretaking by clients in group
2. Consequences of using your voice with a caretaker (shows what “strings” are
attached)
3. Appropriate resolution of issue between caretaker and the usually dependent person
who decided to use their voice.
Expressive: Laura
30
Attachment Therapy for Groups: Concepts and Methods
Week 7: Involving Anger
Definition: Involving anger is the reason that when a thing happens in relationship, all the past
hurt comes in and it feels as if it is a continuation or what always happens.
Involving anger sounds like this… “ she was always trying to make me into a little doll that
was always doing what she wanted, and she dressed me that way, and for awhile I acted that
way, but I’m onto her now and I know what she’s up to and I’m sorry but I am not your little
baby doll anymore.”
Often longer, but even though it’s a short passage it would score a 6/9 for involving anger on
the AAI
Intervention and Expressive:
1. Revisit – a scene from more recent adult life with an attachment figure (someone you care
about, have emotions that could become vulnerable around) where a disproportionate amount
of anger arose within you, seen in what you said or what you thought in the moment.
2. Reinterpret (the anger) – break the scene down, view it in slow motion and see what parts are
activated and find the origin of the involving anger. Attend to the angry parts as well as the
injured parts that the angry one(s) protect.
31
Attachment Therapy for Groups: Concepts and Methods
Week 7: cont.
Intervention and Expressive:
3. Reevaluate the actions and intentions of the parties in the present scene from this new
metacognitive perspective.
4. Release – the anger towards the appropriate targets (e.g. two chair work)
5. Revise – imagine a scene in the near future where involving anger could rear it’s ugly head…
6. Rewrite – the script in coherent and collaborative form and read it aloud.
7. Reintegrate
32
Attachment Therapy for Groups: Concepts and Methods
Week 8: Passivity
Partial Definition: The speaker appears unable to prevent sounds or phrases from arising while unable to
specify it’s presumed intent or content.
One of the most surprising finds in early AAI’s was an implied passivity of though processes manifested by:
• Overtly vague expressions suggesting an inability to find words or focus on a topic
• Failure to complete sentences and lapse into silence or start a new one
• Odd words or phrases added to the end of sentences
• Wandering to irrelevant topics with no apparent reason
• Indeliberate use of child speech or parental style of speech
• Pronoun confusion between self and parent in recounting past episodes
• These are not dysfluencies and common space fillers like “you know” or “like”…
A hand reaches for a book, hesitates, then grabs it is a restart. A hand that reaches for a book and changes
direction and grabs a glass is a redirection. These are also common in conversation. But a hand that reaches
for a book, stops, then drops limp on the table is analogous to a sentence which is passive.
33
Burdens
The concept of “burdens” is brilliant in its widespread
application. It sidesteps the need to compare, contrast, count
symptoms to diagnose, and postulates instead more of a “no
one escapes unscathed” framework. Thus, “burdens” can
encompass beliefs, feelings, and energetic residue of events
and experiences that overwhelmed the internal and/or external
accessible resources of the organism and its attachment
environment at the time, thereby creating constraint.
34
Every deep desire, every powerful emotion, gives a trail
into the unconscious. Usually there is only one-way
traffic: outbound, toward the world of sensation and
action. But we can follow the trail to its source by going
against the current. With this desire to go against desire,
to buck the demands of biological conditioning, the
journey of self-realization begins in earnest.
Meditation in Action
Eknath Easwaran
35
In I.F.S., the more unburdening of these
“legacy” and personal burdens, the more
space for Self to re-enter. Decreasing
compartmentalization leads to an increase
in metacognitive capacities and
establishment of a coherent, cohesive
narrative.
36
Scanning
And as I count back not from 7 to 6, you’ll be able to begin to move back
safely and comfortably through the years, and from 6 to 5 now, (just
continuing back and allowing your mind to begin to scan, much like the
tuner on a radio dial, just looking for any strong signal indicating some
significant event) and continuing back – from 5 to 4 – back through more
and more years, and allowing your mind to continue to scan through the
years just looking for any strong signal – and 4 to 3 – and as your mind
move s toward some strong signal indicating some significant event,
you’ll be able to focus in and talk about where you are and what’s
happening. You’ll be able to stay with that event as long as you want and
then move on to the next strong signal. And now from 3 to 2 (pause) and
2 (short pause) to 1 – And just allowing your mind to move toward some
significant event and as you focus in, just talk about where you are and
what you’re aware of.
37
Stuckpoints
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
How am I avoiding remembering?
How am I avoiding feelings?
How am I avoiding talking about it?
How am I minimizing?
How am I avoiding focusing on enjoying parts of life?
How am I avoiding noticing triggers that cause me to hurt
self?
How am I avoiding dealing with current life stresses?
How am I still protecting those who hurt me?
How am I avoiding being close to others?
What secrets have I not yet discussed?
How am I fighting my therapist and working my program?
38
Schema-Focused DX of Personality Disorders
Other Directedness
Emphasis on self-denial
people pleasing, over
emphasis on needs and
opinions of others
SCHEMAS: self sacrifice
approval and recognition
seeking
Hyper-Criticism &
High Expectations
In areas of performances
& achievement,
hypercritical, high
expectations for
achievement, shames or
unloved for inadequate
performance.
Subjugation &
Inhibition
Over-Protection &
Over-Involvement
Over controlled by others
restrained emotionally
inhibited, rule-bound
given little freedom of
expression
SCHEMAS: Subjugation,
over control, punitiveness
SCHEMAS: unrelenting
standards, failure, error
Disconnection &
Rejection
In area of intimacy &
closeness, child is
emotionally deprived,
socially isolated, made to
feel bad, unlovable
Over-Indulgence
Spoiled, undisciplined
Parents over involved in
life situations, fostering
dependence, discouraging
autonomy, enmeshing,
worried, over concerned
with danger
SCHEMAS:
Dependence/incompetence
, vulnerability to harm and
illness enmeshment.
Lack of Safety & Stability
Mistreated, abused, lied to, betrayed, manipulated,
humiliated, abandoned, environment characterized by
instability, unpredictability, danger.
SCHEMAS: mistrust and abuse
SCHEMAS: emotional
deprivation, social
isolation
39