Treating Children with Dissociative Disorders

Attachment, Trauma, Theory and Practice

Valerie Sinason, Renée Potgieter Marks, Valerie Sinason, Renée Potgieter Marks

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000512038
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychotherapie

This book provides a comprehensive overview of research into dissociation in children and adolescents and challenges conventional ideas about complex behaviours.

Offering a new perspective to those who are unfamiliar with dissociation in children, and challenging prevalent assumptions for those who are experienced in the field, the editors encourage the professional to ask questions about the child's internal experiences beyond a diagnosis of the external symptoms. Chapters bring together a range of international experts working in the field, and interweave theories, practice, and challenging and complex case material, as well as identifying mistakes that therapists can avoid while working with children who dissociate.

Filled with practical tools and examples, this book is a vital resource for professionals to enrich their practice with children who dissociate.

Chapter 1Attachment and dissociation

Karl Heinz Brisch

DOI: 10.4324/9781003246541-2

The development of attachment is fundamental to the healthy physical, intellectual, and social development of the child. It is critically important that a child has sensitive parents who are able to perceive her signals, enable her to regulate stress and affect appropriately, and in this way anchor a secure emotional representation of the attachment in the child’s neuronal networks. Normally, children with a secure attachment have an integrated and coherent internal working model of attachment. Children with an insecure attachment also have an organised inner working model of attachment – for example avoidant or ambivalent attachment – but it is insecure; however, children with the disorganised attachment have a model in which a variety of working models of attachment coexist simultaneously. In other words, such a type of attachment tends to be dissociated.

A disorganised attachment model develops when children perceive that their parents are afraid of them, sometimes frighten and threaten them, but then collapse into a helpless state in which they are incapable of responding sensitively to their child’s signals. In essence, they do not perceive their parents as consistent, coherent entities when dealing with stressful, emotional situations in daily life. This becomes especially important when a child is under stress and frightened and is searching for a secure attachment figure for protection. If an attachment figure signals that she, too, is fearful in these situations, perhaps because she has not yet worked through her own childhood traumas, she may be triggered by the child’s normal behaviour such as crying or throwing a tantrum. Because of the parent’s own agitation or anxiety, she may not be available to provide the protection and security that her child is seeking or respond when he signals that he needs calming, security, and help with affect regulation. Under these circumstances, the child may be prone to developing a disorganised working model. Longitudinal studies involving psychological testing at the end of the second year have shown that children who exhibit a disorganised attachment pattern during the first year of infancy tend to develop symptoms of a borderline personality disorder during adolescence. As has been shown in numerous studies, dissociated self and ego-states are more frequent in such persons.

The situation becomes all the more complex when the children have been subjected to deprivation, neglect, violence in various forms, or emotional rejection during the early months of infancy. When this happens, the children may develop not only disorganised attachment but, as early as the second or third year, signs of an attachment disorder, which may manifest in promiscuous or indifferent attachment behaviour or in an attachment disorder with inhibited attachment behaviour. I have discussed other types of attachment disorders elsewhere, such as those involving addiction, role reversal, aggressive behaviour, and psychosomatic symptoms. These persons live with an internal working model of attachment that is characterised by pathological attachment behaviours.

For example, a child with an indiscriminate attachment disorder may run towards a completely unknown person when frightened and try to find protection and comfort there. We frequently encounter this sort of behaviour in children who were cared for in institutions under circumstances of great deprivation. Children with an attachment disorder do not typically vacillate between various working models of attachment with different behaviours such as seeking closeness and then running away; rather behaviours have become anchored in a pathological attachment pattern, and these behaviours have become their predominant pattern. In other words, these children live in a sort of pathological ego state that remains unchanged despite changing external circumstances, such as switches between foster parents or homes. And even if such children have received loving emotional support from adoptive parents over many years, the parents frequently report that their children continue in this indiscriminate, promiscuous pattern, for example, seeking out a stranger on the street when they are frightened or in danger. These children live in a sort of dissociated attachment state that seems to be highly resistant to external influence.

In our experience, it may require intensive inpatient psychotherapy with the aim of modelling new ways of relating in attachment relevant situations or get these children to attach to specific persons. This process is generally associated with powerful emotions and fear. As a result, these children require careful one-on-one attention to open them up to experiencing new emotions and modes of attachment in frightening situations. If the entire therapeutic team responds promptly and sensitively to these affective states, a new and more coherent attachment pattern may emerge or form. This may lead to attachment behaviours that focus on individual attachment figures and, in the best-case scenario, on adoptive or foster parents. But for this to happen, the entire family must be involved in the therapeutic process, with the parents making full use of counselling. The aim is to support and promote similar co-regulatory behaviours in the parents so that the child experiences similar responses from all attachment figures, team members, parents, and other family members.

If therapy is successful, the child becomes better able to regulate these emotions in stressful situations and less dependent on the presence of an actual attachment figure. To the extent that the child is able to self-regulate, he will be better able to integrate into groups of children in school or at the playground.

Reference

• ESTD Newsletter, 4 (4), December 2015.

Chapter 2Infant attachment and dissociative psychopathologyAn approach based on the evolutionary theory of multiple motivational systems

Giovanni Liotti

DOI: 10.4324/9781003246541-3

The possibility of tracing back to infant attachment patterns the origins of mental disorders and of both healthy and untoward interpersonal styles has been of great appeal, in the past four decades, both to developmental psychopathologists (e.g. Sroufe & Rutter, 1984) and to psychotherapists (e.g. Obegi & Berant, 2008; Slade, 2008; Wallin, 2007). The interest of clinicians and researchers for the roots in early attachment patterns of clinically very relevant aspects of personality development is reflected in abundant clinical reflections and in a mushrooming of controlled studies. However, the careful examination of the rich and manifold literature on the applications to psychotherapy of attachment theory and research may be somehow disappointing to clinicians, for at least two main reasons. First, research on attachment across the life span has yielded a proliferation of different assessment procedures and different classification schemes. Second, while the phrase “attachment-based psychotherapy” is often used (Obegi & Berant, 2008), it has been authoritatively argued that although attachment theory and research may be key in informing psychotherapy, they are insufficient for devising a specific type of psychotherapy entirely based on it (Slade, 2008). One reason for this contention is that the relational dynamics on which attachment theory is focused are only one aspect of the manifold components of human relatedness that should be considered by psychotherapists in their daily practice.

This chapter will try to clarify the problems posed to the clinician by the different assessment procedures and related classification schemes used by researchers in classifying infant and adult attachment styles, and then expand on the main psychobiological (motivational) systems that, together with attachment, control, since the first years of life, human behaviour in general and human relatedness in particular. It will be argued that the nature of infant attachment patterns and of their developmental sequels are captured in a clinically more useful way when one focuses on the dynamic tensions between attachment and other motivational systems rather than on attachment alone. The implications of the important finding of two longitudinal studies – that attachment disorganization is a much more powerful predictor of dissociation than exposure to psychological trauma (Dutra, Bureau, Holmes et al., 2009; Ogawa, Sroufe, Weinfield et al., 1997) – justify the attention paid in this chapter more to disorganization of infant attachment than to the organized attachment patterns (secure, insecure-avoidant and insecure-ambivalent).

Classification schemes in the research on attachment

Much of the appeal exerted on clinicians by research on attachment follows the empirically evidenced correlation between states of mind related to attachment in the caregivers and patterns of attachment in the infants they are caring for. Infant attachment patterns are universally classified on the basis of observations in the Strange Situation Procedure (SSP: Ainsworth, Blehar, Waters & Wall, 1978) into three main organized patterns, called secure, insecure-avoidant and insecure-ambivalent (or resistant). These three organized patterns are classified according to the dimension security-insecurity in approaching the attachment figure. To them it must be added the classification of disorganized attachment, obtained by considering a dimension of coherence (organization-disorganization) of behaviour and attention (Main & Solomon, 1990; Solomon & George, 2011).

There is a strong statistical link between each pattern of infant attachment and a corresponding mental state of the caregiver assessed through a semi-structured interview called the Adult Attachment Interview (AAI: George, Kaplan & Main, 1985;). Table 2.1 summarizes in a very schematic way the results of an impressive amount of empirical research on infant attachment patterns and mental states related to attachment in the caregiver (for a meta-analysis and a review, see Bakermans-Kranenburg & Van IJzendoorn, 2009 and Van IJzendoorn, 1995).

Table 2.1 Correlations between mental states of the caregiver and infant attachment patterns

AAI coding	Adult mental state	SSP coding	Infant behaviour
Free Autonomous	Values attachment and related experiences as influential on healthy personality development. Objective (free from defences) in reporting childhood attachment experiences. Coherence of thought and discourse	Secure	Cries at separation from the caregiver and is promptly comforted at reunion
Dismissing	Devalues the influence of attachment needs in personality development. Idealizes parents but has difficulties in remembering specific childhood experiences supporting the idealization	Avoidant	Does not cry at separation and avoids actively, without behavioural signs of fear, the caregiver at reunion
Preoccupied Enmeshed	Ambivalent attitudes towards attachment relationships. Has access to specific childhood memories but shows confusion and enmeshment about their meaning and value	Ambivalent Resistant	Cries at separation, but resists to comfort offered by the caregiver at reunion (accepts it but continues to cry or displays mild aggression)
Unresolved or Hostile Helpless	Unresolved memories of attachment trauma and losses. Defective mentalization, dissociation. Either frightened and/or frightening (FF) or hostile/helpless (HH) style of caregiving	Disorganized	Simultaneous contradictory behaviour towards the caregiver (e.g. fearful every cry at separation followed by fearful avoidance at reunion three minutes later; approaches the caregiver with the head averted; freezes or collapses to the ground in the middle of an approach to the caregiver

In contrast with the universal use of the SSP to assess attachment styles in infants in their second year of life, and with the wide acceptance of the consequent classification of infant attachment into three organized patterns and a dimension of disorganization, there are different methods and different classification schemes used by researchers to categorize adult mental states related to attachment.

Besides the AAI, self-report questionnaires (Bartholomew & Horowitz, 1991; Hazan & Shaver, 1987) and the Adult Attachment Projective system (AAP: George & West, 2001) are widely used by researchers. The problem for clinicians who wish to consider the relevance for their clinical practice of the wide body of research on adult attachment is that the categories obtained through self-report measures do not have strong statistical correlation with the AAI categories (De Haas, Bakerman-Kranenburg, Van IJzendoorn, 1994; Roisman, Holland, Fortuna et al., 2007). The lack of correspondence between AAI and self-report measures of adult attachment is particularly confusing even when these diverse measure and coding systems use the same name for a category. Therefore, clinicians must be wary of using as an assessment tool a self-report questionnaire, and infer from such a way of assessing their patient’s attachment style any characteristic that has been linked to mental states related to attachment by research based on the AAI.

Let us consider an example relevant to the theme of this book. Suppose that a clinician is dealing with dissociative symptoms of a pre-adolescent child that do not seem to have their origin in straightforward violence or emotional and sexual abuse. The clinician might know that infant disorganized attach...