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Attachment

Attachment Attachment, Trauma, Dissociation and Dependency

Attachment, Separation and Loss

DID/MPD Clients - Difficult to Work With?

Adult Attachment Interview classifications and corresponding patterns of infant strange behaviour

Attachment, Trauma, Dissociation and Dependency

The increase in research and understanding about “attachment” and the later life manifestations of unresolved insecure attachment will probably be the single most significant factor to influence future approaches to therapy.

The insights from attachment theory are, and will, be key to work with the issues of addressing both early life trauma and dissociation. However one area that particularly benefits from the understanding of attachment theory is in the whole appreciation of dependency and the possibility of more enlightened (and hopefully more humane) approaches to the management of the often inevitable, experiences of dependency that survivors encounter on the road to recovery.

TAG Newsletter vol.1 no.2 described the five types of attachment response in infants. Jeremy Holmes in his book “The Search for a Secure Base” describes the adult attachment interview classifications from the corresponding patterns of infant strange situation behaviour, which utilises Grice’s Maxims of conversation as part of the measure. See table 2.1 and also Grice,s maxims.

What starts to be evident is the impact of unresolved attachment on later life’s responses and relationships. When this is also considered alongside the consequences of early life trauma and abuse, together with the dissociative conditions that so often accompany such experiences it becomes clear that dependency is going to be an inevitable part of recovery.

What is required from therapy is the creative, supportive and containing elements from the therapist to enable survivors to be “accompanied” on their journey without either “fear” or “avoidance” by either the counsellor or the client of the dependency element of the relationship.

Two very helpful graphs taken from “The Journal of Trauma and Dissociation” (the official journal of the international society for the study of dissociation) in an article on “Dependency in the Treatment of Complex Posttraumatic Stress Disorder and Dissociative Disorder” by Kathy Steele, Omno van der Hart and Ellert Nijenenhuis offer a useful analysis to aid therapuitic understanding.

The first compares the characteristics of “Extreme Dependency”, “Counter Dependency” and “Secure Dependency” in relation to the different attachment types of behaviour.

The second contrasts the Countertransference Positions in relation to Dependency from an “Enmeshed”, “Distanced” and “Balanced” position.

It is well worth consulting the full article for a detailed examination of the issues, particularly in relation to DID, which this very brief reflection can not do justice to. What is clear though, is that to collude with resisting dependency is as obstructive to therapeutic recover as over enmeshment with clients can be.

Given that most counsellors (and some training courses) are preoccupied with avoiding dependency at all costs, this article provides some food for thought, and some possible guidance in considering the handling of the inevitable dependency issues that do occur in therapy and counselling particularly with survivors of early life trauma, sexual and ritual abuse.

References:

Holmes, Jeremy (2001) The Search for the Secure Base – Attachment Theory and Psychotherapy. Brunner-Routledge
Steele K, Van der Hart O, Nijenhuis ERS. 2001 Dependency in the Treatment of complex Posttraumatic Stress Disorder and Dissociative Disorders. The Journal of Trauma and Dissociation.

Mike Fisher

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Attachment, Separation and Loss

Attachment theory arose particularly from the work of John Bowlby and has been developed by Mary Ainsworth’s attempt to classify insecure attachment behaviour. Many other researchers and writers have subsequently added to our understanding of our need for attachment and the effects of disrupted attachment. Attachment theory attempts to describe a baby’s or child’s need for connectedness with its mother or caregiver.

Attachment involves a number of elements:

• closeness or proximity
• responsiveness or attunement
• consistency and reliability
• visual contact
• touch and skin contact
• duration of contact (or separation)

The provision of these elements not only enables a child to feel safe and secure but also ensure healthy functioning of its body and mind, the strengthening of its immune system and the development of its brain.

Attachment needs of the child is principally monotrophic extending possibly to a small group of specific individuals. With bonded attachment, attachment feeling will be experienced by the mother or caregiver.

Mary Ainsworth developed an experimental procedure to measure the level of security experienced by children, resulting from a series of two or three minute separations from these parents. This led to the essential classification of the five types of attachment response:

1. Secure Attachment in which children show some distress at separation. On reunion they greet their parent positively, seek some comfort, contact or friendly acknowledgement but soon return to contented play. Secure babies show high levels of eye contact, vocalisation and mutuality when relating with their parents. The child is confident that the caregiver will be available and helpful in adverse or frightening situations.
2. Insecure or Avoidant Attachment in which children show few signs of distress at separation. When the parent returns, these children ignore or avoid her. They do not seek out physical contact. They are watchful of the parent and remain generally wary. Their play is inhibited. Such children show little discrimination regarding with whom they interact. They demonstrate no particular preference for either parents or strangers.
3. Insecure and Ambivalent or Resistant Attachment, in which children are highly distressed at separation and very difficult to calm down upon reunion. They seek contact but do not settle when they receive it. When reunited, they resist attempts to pacify them and continue to cry, fuss, squirm, and thrash about. However, they will run back to the parent if he or she walks away. Ambivalent children both demand parental attention and angrily resist it at the same time. Such ambivalent behaviour – displays of need and anger, dependency and resistance – is the key characteristic of this type of insecurity. When the mother reappears ambivalent children are reluctant to return to play. They can be nervous of novel situations and people.
4. Insecure and Disorganised Attachment. Children in this category show elements of both avoidant and ambivalent kinds of attachment behaviour. Upon reunion with parents they show confusion and disorganisation. They appear to lack a defensive strategy to protect them against feelings of anxiety. Sometimes these children will just freeze throughout the separation and reunion. On other occasions they may make mechanical contact but behave throughout the reunion without much show of feeling or emotion. Although the children tolerate being held they tend to gaze away. In the child’s eye, their parents are experienced as either frightening or frightened and therefore not available as a source of safety or comfort. This compounds the child’s anxiety. The infant is left with an “irresolvable conflict” to approach the attachment figure who is also the cause of the anxiety.
5. Non-attachment. This term is reserved for children who have had no opportunity to form affectional bonds with other people. This is most likely to be observed in children who have been raised in institutions from early infancy. These children typically experience many anonymous serial caregivers who may be emotionally unavailable or unresponsive. Non-attached children are profoundly developmentally impaired and have problems with social relationships, dealing with other people only on the basis of their own needs. Non-attached children experience difficulties in controlling their impulses and feelings of aggression.

Our attachment experience and response as a child will extensively affect how we relate and behave in our adult life.

Categories are taken from “Attachment Theory for Social Work Practice” by David Howe 1995.

Mike Fisher July 2001

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DID/MPD CLIENTS - DIFFICULT TO WORK WITH?

Difficult to work with? Yes, but are the main difficulties to do with the client’s dissociative states and alters, or could there be something else behind the difficulties?

• Does your client who suffers from DID/MPD also
• experience great difficulty in developing trust
• experience chaos in the transference relationship with you
• have relationship problems in general
• have a terror of abandonment and sense of emptiness and alienation
• frequently feel overwhelmed by emotions, or else numb to feelings
• have a very insecure sense of self and self-worth
• have an almost continuous sense of anxiety, when not numb
• lose the sense of ongoing relationship with you the moment she leaves you,
• and perhaps often want to phone you to make contact?

The common factor behind all these symptoms is likely to be an attachment disorder. (Bowlby, 1969) [See article on P 6 on Attachment]

Peter Barach in a paper with the title ‘Multiple Personality Disorder as an Attachment Disorder’ (1991) says ‘The therapist can note evidence for an attachment disorder in nearly every aspect of the psychotherapy of MPD. From this perspective the resolution of the attachment disorder rather than the resolution of the effects of sexual and physical trauma, causes the extended and turbulent nature of the psychotherapy of more complex cases of MPD.

The parents’ failure to protect the child from abuse and the parents’ tendency to detach from emotional involvement with the child, increases the likelihood of dissociation in the child as a way of coping with traumatic experiences. Barach quotes from a personal communication from Kluft (July 1991) ‘the attachment issues are more prominent in relatively complex patients with many alters’, and adds that ‘an awareness of attachment issues can drastically shift one’s perspective on what clinicians usually call “dependency”. So rather than perceiving aspects of the client’s difficult and demanding behaviour as being an unwelcome side-issue, it may be reconceptualised as representing the reactivation of attachment behaviour in the transference. When the client is putting enormous strain on the boundaries of the relationship it could then be recognised as an unconscious sign of hope in the client that attachment needs will be met and that he/she will not be abandoned this time.

Bowlby (1969, 1973) suggests that anxious attachment following detachment is a sign that defensive exclusion of the need for proximity to an attachment figure has been breached. The anxious attachment indicates a departure from the use of dissociation as a defence mechanism.

As therapists, counsellors, and those involved in the care and treatment of those suffering from DID, we cannot ever meet needs to the extent the client’s internal system is demanding. So a stormy relationship may develop, or at least one where strong ambivalence is expressed and where the client may perceive the therapist as being as unresponsive as her mother was. Reactive anger and further detachment may result, which together with needy approaching behaviour, may become cyclical causing great strain on the therapeutic relationship. The therapist should not discourage the client’s attachment behaviour, but aim towards an attitude of empathic neutrality. With some clients such a therapeutic relationship can help significantly towards healing attachment wounds but many other survivors of severe early abuse are simply unable to develop a relationship that is strong enough to facilitate their healing. ‘A therapeutic relationship is limited by its very nature and boundaries in what it can compensate for. As van der Kolk puts it, “It is the wrong person, in the wrong place at the wrong time”.’ (Steele, 2000)

There are new understandings filtering slowly through from the areas of neuroscience which are informing psychotherapy practice and have the potential to be very helpful with clients who have suffered deficits such as abandonment or neglect in the period from 0 – 2 years, the time when healthy attachment experiences would be laying down vital foundations for the well-being of the sense of self in the brain.

Two useful tools that I have been bringing in to my practice are ‘Core-Imaginal-Nurturing’ (Steele, 2000), and Affect Management Skills Training (Omaha 2000). They use visual imagery tied in to body sensation, in order to help build something of the missing structures, and provide internal , accessible experiences of containment and safety.

Resolving disturbing memories, and facilitating harmony between alters, is, of course, vital, but much attention I believe needs to be given to attachment issues continuously throughout the therapy. I suggest that we keep our thinking wide open to understanding each client’s difficulties, and not be restricted by the status that DSMIV recognition gives to the diagnosis of DID. In an interview, Bessel van der Kolk, who was some years ago involved in putting together the diagnostic criteria that predated the Diagnostic and Statistical Manual (DSM), said that ‘the whole thing got unified into what I think is a crazy DSM system where people believe that all these categories actually exist. All of these differentiations were conveniences by committees to say “okay let’s more or less figure out, group these people together for now,” and now all these things exist.’

By the way ‘attachment disorder’ is not mentioned in the DSM!

References

Barach, P.M. (1991) Multiple Personality Disorder as an Attachment Disorder. Dissociation, 4, 117-123.
Bowlby, J. (1969). Attachment and Loss: Vol. 1: Attachment. New York: Basic Books
Bowlby, J. (1973) Attachment and Loss: Vol. 2: Separation, Anxiety and Anger. Middlesex, England: Penguin
Omaha, J. (2000) Affect Management Skills Training. Chemotion Institute, P.O. BOX 528 Chico, CA, USA.
Steele, A. (2000) Therapy from the right side of the brain: a role for EMDR with imaginal nurturing in the treatment of early neglect. Paper submitted for publication.
Van der Kolk, B. (2001) In an interview Trauma and PTSD: Aftermaths of the WTC Disaster. Published on internet.

Nel Walker

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Adult Attachment Interview classifications and corresponding patterns of infant strange behaviour

Taken from “The Search for the secure base by Jeremy Holmes 2001

Sources - Adapted from Hesse (1999)
Notes - Descriptions of the adult attachment classification system are summarised from Main et al(1985) and from Main and Goldwyn (1984a.1998a) Descriptions of infant A,B,C categories are summarised from Ainsworth et al (1978) and the description of the infant D categories summarised from Main and Soloman (1990). Data from Main (1996)

Notes to accompany the above table.

H. P. Grice’s maxims of conversation

1. Maxim of Quantity – All the necessary information is given; no unnecessary information is given.
2. Maxim of Quality – Information is true, not false or misleading.
3. Maxim of relation – Information given is relevant to the goal of the conversation.
4. Maxim of manner – The communication is clear, brief and orderly; ambiguity and obscurity is avoided.

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