by Nel Walker
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
The common factor behind all these symptoms is likely to be an attachment disorder. (Bowlby, 1969)
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!
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.
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