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A Model of Dissociation Based on Attachment

Theory and Research

Article in Journal of Trauma & Dissociation February 2006

DOI: 10.1300/J229v07n04_04 Source: PubMed

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 A Model of Dissociation
Based on Attachment Theory and Research
Giovanni Liotti, PhD

SUMMARY. The article offers an historical review of studies on the

role played by attachment processes in dissociative psychopathology.
The treatise proceeds from Bowlbys first insights, through Main and
her collaborators empirical studies on attachment disorganization, to
the first formulation of the hypothesis linking disorganized early attach-
ment to pathological dissociation. Recent research supporting the hy-
pothesis is then reviewed. It is concluded that infant attachment
disorganization is in itself a dissociative process, and predisposes the in-
dividual to respond with pathological dissociation to later traumas and
life stressors. Four implications of this theory are interspersed in the re-
view and are discussed in the final section: (1) pathological dissociation
should be viewed as a primarily intersubjective reality hindering the in-
tegrative processes of consciousness, rather than as an intrapsychic de-
fense against mental pain; (2) early defenses against attachment-related
dissociation are based on interpersonal controlling strategies that inhibit
the attachment system; (3) dissociative symptoms emerge as a conse-
quence of the collapse of these defensive strategies in the face of events
that powerfully activate the attachment system; (4) psychotherapy of
pathological dissociation should be a phase-oriented process focused
primarily on achieving attachment security, and only secondarily on

Address correspondence to: Giovanni Liotti, Scuola di Psicoterapia Cognitiva,

Roma, Viale Castro Pretorio, 116, 00185 Roma (Italy) (E-mail office: [email protected],
E-mail home: [email protected]).
[Haworth co-indexing entry note]: A Model of Dissociation Based on Attachment Theory and Re-
search. Liotti, Giovanni. Co-published simultaneously in Journal of Trauma & Dissociation (The Haworth
Medical Press, an imprint of The Haworth Press, Inc.) Vol. 7, No. 4, 2006, pp. 55-73; and: Exploring Dissoci-
ation: Definitions, Development and Cognitive Correlates (ed: Anne P. DePrince, and Lisa DeMarni Cromer)
The Haworth Medical Press, an imprint of The Haworth Press, Inc., 2006, pp. 55-73. Single or multiple copies
of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00
a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

Available online at http://jtd.haworthpress.com

2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J229v07n04_04 55
56 Exploring Dissociation: Definitions, Development and Cognitive Correlates

trauma work. Research studies on the psychotherapy process could test

some predictions of this model. doi:10.1300/J229v07n04_04 [Article cop-
ies available for a fee from The Haworth Document Delivery Service: 1-800-
HAWORTH. E-mail address: <[email protected]> Website:
<http://www.HaworthPress.com> 2006 by The Haworth Press, Inc. All rights
reserved.]

KEYWORDS. Attachment disorganization, controlling strategies, de-

fenses, dissociation, mental pain

Bowlby (1973) first hinted at the relationship between attachment

processes and dissociative psychopathology when he examined the
possibility that unhappy care-seeking interactions with the primary
caregivers could cause the infant to develop multiple internal repre-
sentations of self and attachment figures instead of unitary or cohesive
and secure attachments. Bowlby (1973) referred to these internal repre-
sentations as Internal Working Models (IWM). In the case of multiple
IWMs Bowlby explained that one IWM becomes dominant in regulat-
ing interpersonal perceptions and emotions, while the other IWMs re-
main segregated (or as Pierre Janet would have said, disaggregated)
from mainstream conscious experience. In stressful circumstances, the
segregated IWM may surface to regulate emotions and cognitions in a
way that is alien to the persons usual sense of self (Bowlby, 1973). In
describing a patient characterized by symptoms that we would nowa-
days term dissociative (derealization and depersonalization), Bowlby
(1979) explained the patients symptoms as the outcome of attachment
figures subtly inducing the child to disown personal, first-hand experi-
ences and instead to accept a false version of important attachment ex-
periences. Bowlbys early discussion of dissociation and attachment is
the beginning of a long line of inquiry with both empirical and theoreti-
cal implications for the understanding of dissociative psychopathology.
The first three sections of this paper summarize this inquiry. The fourth
discusses the implications of an attachment-based model of dissocia-
tion.

THE FIRST EMPIRICAL STUDIES

In 1985, Main and collaborators published a preliminary report that

provided empirical evidence that some infants constructed a multiple
 Giovanni Liotti 57

and disaggregated IWM of self and of a single (often traumatized) care-

giver (Main, Kaplan & Cassidy, 1985). This research identified a new,
disorganized category of infant attachment (Main & Solomon, 1990),
which was added to the three organized categories: secure, inse-
cure-avoidant, insecure-resistant (Ainsworth, Blehar, Waters & Wall,
1978).
Disorganized attachment (DA) was coded in Ainsworths classic
Strange Situation Procedure (SSP: Ainsworth et al., 1978) when the
child demonstrated lack of orientation during attachment interactions
and/or incompatible responses to episodes of separation-reunion with
the caregiver, emitted either simultaneously or in quick succession. DA
was characterized by simultaneous approach and avoidance of the care-
giver, resulting in a lack of organization and orientation in the infants
overall attachment behavior. In comparison, secure, avoidant, and resis-
tant patterns of attachment involved a precise behavioral and attentional
strategy that was easily identifiable. DA was statistically linked to unre-
solved traumas and losses in the life of the caregivers (Main & Solo-
mon, 1990), a finding that was replicated in a large number of controlled
studies (for a review, see Lyons-Ruth & Jacobvitz, 1999; for a meta-anal-
ysis, see van IJzendoorn, 1995). Not surprisingly, the percentage of in-
fant DA classifications rose sharply from 15% in non-clinical low-risk
samples to over 70% in high risk samples (e.g., samples at risk for emo-
tional disorders, clinical samples, and family violence samples: Ly-
ons-Ruth & Jacobvitz, 1999; Solomon & George, 1999).
Main and Hesse (1990) hypothesized that infant DA is related to a
traumatized parents care giving attitude that is frightening to the child.
Children can be frightened if the caregivers attitude is violent or if the
parents attitude expresses fear. Caregivers communicating fear and ag-
gression in situations otherwise devoid of danger, yield fright without
solution in infants because the caregiver simultaneously becomes
the source and the solution of the infants alarm (Main & Hesse,
1990, p. 163). A fright without solution interaction, even when devoid
of violence or abuse, is akin to a traumatic event. Thus, fright without
solution is conceptualized here as an early relational trauma (Schore,
2003), typical of the intergenerational transmission of traumas.
Main (1991) argued that DA involves the early construction in the in-
fants mind of multiple, incoherent, disaggregated representations of
aspects of reality (the self and a single caregiver) that are otherwise rep-
resented as singular and coherent in babies with organized attachment
patterns (both secure and insecure). In response to this claim, Liotti,
Intreccialagli and Cecere (1991) performed a case-control study involv-
58 Exploring Dissociation: Definitions, Development and Cognitive Correlates

ing retrospective evidence of losses in the life of the mothers of adult

dissociative patients. They assessed mothers experiences of having a
close relative die within two years of having given birth to the pa-
tients. Retrospective evidence of loss was collected in 62% of the 46
dissociative patients compared to only 13% in the control group. Since
the losses in the life of the patients primary caregivers were arguably
unresolved in the period when the patients early attachments were
shaped, these losses may have contributed to the emergence of DA in a
disproportionately high percentage of dissociative patients.

CLINICAL HYPOTHESES

Liotti (1992, 1994, 1995, 1999) speculated about the qualitative as-
pects of consciousness in DA. Multiple, simultaneous, reciprocally in-
compatible and disaggregated representations of self and of a single
caregiver that are constructed in the same environmental-emotional
context may be matched with the well known observation that infants
older than 20 weeks respond with alarm and confusion to multiple im-
ages of mother projected in an arrangement of mirrors. While younger
infants are not troubled by simultaneous multiple perceptual images of
the mother, older infants are (Bower, 1971). This finding suggests that
the integrative power of attention, memory and consciousness increases
gradually between 6 and 18 months (Lewis & Brooks-Gunn, 1979),
during the same period in which the infants attachment bond is con-
structed. The simultaneous multiple emotional perception of self and the
caregiver in DA could exceed the integrative power of consciousness in
this developmental period, just as the multiple simultaneous visual per-
ception of the mother in Bowers experiment does. The disorganized
infant may experience an altered consciousness, akin to the trance state
that results from the multiple presentations of incompatible information
in the confusion technique of hypnotic induction (Erickson, 1964).
Early DA, thus, comprises two fundamental aspects of dissociation: an
unusual quality of conscious experience (i.e., a trance-like state) and the
simultaneous multiple representations of aspects of reality normally
construed as unitary.
On the basis of these speculations, Liotti (1992) proposed that DA
may be the first step in different developmental pathways, leading to:
(1) satisfactory adaptation (e.g., when corrective influences on the early
disorganized IWM were exerted by later secure attachment experiences
and no severe trauma intervened); (2) relatively minor disturbances im-
 Giovanni Liotti 59

plying only an increased propensity toward dissociation (e.g., both ab-

sence of later traumas and of corrective relational experiences); or
(3) dissociative disorders (e.g., because of later traumas confirming and
amplifying the dissociative features of early DA). In later papers, Liotti
(1995, 1999, 2000, 2004) proposed an attachment-based model of the
dissociative disorders and of other trauma-related disorders that involve
dissociation, such as Borderline Personality Disorder (BPD) and com-
plex Post-Traumatic Stress Disorder (PTSD). Liotti (1995, 1999, 2000)
suggested that the dynamic shifts among the multiple, dramatic and re-
ciprocally disaggregated representations of the disorganized IWM
could be captured, in a clinically useful way, through the metaphor of
Karpmans (1968) drama triangle. In the drama triangle, the interac-
tions between the main characters oscillate between the reciprocal pro-
totypic roles of the powerful benevolent rescuer, the equally powerful
but malevolent persecutor, and the helpless victim.
IWM in infancy relies on implicit memory (Amini, Lewis, Lannon,
Louie, Baumbacher, McGuinnes & Zirker, 1996); that is, memory that
does not require language or consciousness. During development, part
of the formerly implicit IWM may become explicit and enter both in the
consciously held meanings attributed to attachment needs and into the
narratives of autobiographic memory. Once the attachment system is
activated (attachment is related to an inborn evolved control system
that is activated by distressing experiences throughout the life span:
Bowlby, 1969/1982), the IWM guides both attachment behavior and the
appraisal of attachment emotions in self and others. The literature on at-
tachment (for reviews, see Cassidy & Shaver, 1999) provides abundant
evidence that the secure IWM leads to positive appraisals of ones own
attachment emotions, and expectations that ones need for help and
comfort will be met by significant others as a legitimate request. An in-
secure organized IWM (avoidant or resistant) leads to negative apprais-
als of attachment emotions, and expectations that ones need for help
and comfort will be met as a nuisance (avoidant attachment) or as intru-
sive or in an unpredictable way (resistant attachment). The disorganized
IWM leads to multiple, contradictory, reciprocally disaggregated (i.e.,
fear without solution) appraisals and expectations.
The metaphor of the drama triangle suggests that a disorganized child
construes attachment interactions as shifting representations of both the
attachment figure and the self as each others persecutor, rescuer and
victim. The child represents the attachment figure negatively, as the
cause of the childs ever-growing fear, and positively, as a rescuer. The
caregiver, notwithstanding the frightening attitude caused by unre-
60 Exploring Dissociation: Definitions, Development and Cognitive Correlates

solved traumatic memories, is usually willing to offer comfort to the

child; thus, the child may feel comfort in conjunction with the fear. The
IWM of DA also conveys a negative representation of a powerful, evil
self meeting a fragile or even devitalized attachment figure (persecutor
self, held responsible for the emotional distress and the fear expressed
by the attachment figure). Moreover, the child may represent both the
self and the attachment figure as helpless victims of a mysterious, invis-
ible source of danger. Finally, because contact with the child may have
comforted the distressed caregiver, the implicit memories of DA may
also convey the possibility of construing the self as the powerful rescuer
of a fragile adult.
The three positions of the drama triangle correspond to the three main
types of alternate ego states or personalities (alters) in the Dissociative
Identity Disorder (DID): persecutor alters, protective alters that act as
rescuers in the face of the patients limitations, and child (victim) alters
that preserve memories of having been the helpless victims of abuse
(see Ross, 1989, for a clinical discussion of the prevalence of these three
types of alters in the vast array of dissociated ego states observed in
DID). In the psychotherapy process, the metaphor of the drama triangle
provides a unitary explanation, related to the dynamics of a single moti-
vational system, for the quickly shifting multiple transferences that are
typical in dissociative and borderline patients psychotherapy. That is,
multiple transferences are regarded as different but interrelated mani-
festations of the same underlying mental state: a frightened, desperate,
often unconscious longing for help (Liotti, 1995).
Other clinicians have proposed different ways of conceptualizing the
influence of DA in psychotherapy with dissociative and borderline pa-
tients that are compatible with the hypothesis of the drama triangle. In
more traditional psychodynamic terms, the expectation of dramatic
shifts in the attitudes of the caregivers, reflecting the patients experi-
ence of early DA, has been linked to the simultaneous operations of sa-
distic (persecutor role of the drama triangle) and masochistic (victim
role) defenses in interpersonal relationships (Blizard, 2001). These de-
fenses produce a relational dilemma that hinders the therapeutic pro-
cess: it seems impossible to the patient to achieve both self-protection
and protective closeness (Blizard, 2001). The patient may then oscillate
between dependence on the therapist as rescuer, and avoidance of the
therapist as persecutor (phobia of attachment alternating with morbid
dependency: Steele, Van der Hart & Nijenhuis, 2001, pp. 83 ff).
While Liotti focused on disaggregated representations of self and
caregiver typical of DA, Fonagys research concentrated on the possi-
 Giovanni Liotti 61

bility that traumatic early attachment experiences hinder Theory of

Mind, reflective self and mentalization (Fonagy, 1991, 2002). Deficits
in these mental functions arising from traumatic early attachments are
obstacles to the conscious integration of disaggregated (dissociated or
split) mental states, and can therefore intervene in the genesis both of
BPD (Fonagy, Target, Gergely, Allen & Bateman, 2003) and of
dissociative disorders (Fonagy, 2002).

FURTHER EMPIRICAL STUDIES

The clinical hypotheses regarding the links between DA and dissociative

psychopathology encouraged further empirical investigations. For in-
stance, clinical hypotheses prompted Main and collaborators to make
detailed analyses of the phenotypic similarities between dissociative
symptoms and (1) the behavior of disorganized infants during the SSP;
and (2) the features of the narratives provided by the disorganized chil-
drens caregivers during the Adult Attachment Interview (AAI: Hesse,
1999). These similarities suggested that dissociative processes may
play a causal role both in SSP behavior and in AAI narratives (Ly-
ons-Ruth, 2003; Main & Morgan, 1996). Hesse and van IJzendoorn
(1999) provided empirical evidence supporting the causal relation be-
tween dissociative processes and unresolved mental states as assessed
by the AAI.

The Minnesota Longitudinal Study (MLS)

The Minnesota Longitudinal Study (MLS) provides evidence that

early DA increases vulnerability to pathological dissociation throughout
personality development (Carlson, 1998; Ogawa, Sroufe, Weinfield,
Carlson & Egeland, 1997). The MLS involves a non-clinical sample of
168 young adults whose attachment patterns were assessed in their sec-
ond year of life. The group that had infant DA showed higher mean dis-
sociation scores as young adults than those with other types of early
attachment patterns (Ogawa et al., 1997). Within this disorganized
group, those who faced later traumas during childhood and adolescence
had significantly higher mean dissociation scores than those who did
not face later trauma. This finding provided empirical support for
Liottis (1992) hypothesis that dissociative psychopathology is the out-
come of infant DA facilitating dissociative responses to childhood trau-
mas.
62 Exploring Dissociation: Definitions, Development and Cognitive Correlates

Carlson (1998) found that early DA was linked not only to higher rat-
ings of dissociative behavior on the Teacher Report form of the Child
Behavior Checklist both in elementary and high school, but also to
self-reports of dissociative experiences on the Dissociative Experi-
ence Scale at age 19. Three adolescents in the MLS had developed
dissociative disorders at the time of Carlsons inquiry; all of them had
been disorganized in their infant attachment to a primary caregiver
(Carlson, 1998). Lyons-Ruth (2003) emphasized findings in the MLS
that suggest an equal or even more relevant role of early DA with re-
spect to later childhood traumas, in causing dissociative psycho-
pathology.

Retrospective Report Studies

Extending a previous retrospective study examining the etiology of

dissociation (Liotti et al., 1991), a group of Italian researchers con-
ducted two multi-center case-control studies, involving 52 dissociative
patients, 66 BPD patients, and 146 psychiatric non-dissociative con-
trols. They found support for the hypothesis that losses and severe trau-
matic events in the lives of the dissociative patients mothers that took
place from two years before to two years after the patients birth were
risk factors for the development of dissociative disorders (Pasquini,
Liotti & The Italian Group for the Study of Dissociation, 2002) and
BPD (Liotti, Pasquini & The Italian Group for the Study of Dissocia-
tion, 2000).

AAI Studies

Other studies that support the link between DA and dissociative

psychopathology involve the use of the AAI in clinical samples. Two
categories of AAI transcripts related to infant DA, the unresolved (U)
and the Cannot Classify (CC; Hesse, 1996), are particularly interest-
ing for the study of dissociation. The U coding reflects unresolved
memories of traumas and losses emerging during the AAI. The CC cate-
gory is coded when they express deeply divided states of mind concern-
ing attachment. CC interviews portray a dismissing attitude toward
attachment in the first half of the transcript, and a preoccupied state of
mind concerning attachment in the second half (or vice versa), without
any hint that the respondent is aware of the change in attitude during the
interview. These interviews cannot be classified as dismissing or
 Giovanni Liotti 63

preoccupied and they obviously do not portray a secure state of mind

concerning attachment. Most CC interviews are also rated high for un-
resolved traumas and/or losses (Hesse, 1996; Steele & Steele, 2003). In-
terestingly, participants whose interviews are coded CC have infants
whose attachment is coded as disorganized in the SSP. U and CC codes
are particularly frequent in clinical, dissociative and borderline samples
however they are not rare in non-clinical, low-risk samples. This hints at
the presence of sub-clinical but clearly problematic dissociative pro-
cesses in the general population.
Several studies point to links between U or CC coding and
dissociative symptoms. West, Adam, Spreng and Rose (2001) found
that dissociative symptoms were more frequent among 69 adolescent
psychotherapy patients whose AAI was coded U or CC (disorganized
group) compared to a control group of 64 adolescent psychotherapy pa-
tients whose AAI coding was unrelated to DA. Barone (2003) found a
significantly higher percentage of U coding in the AAI of BDP patients
in a comparison to a non-clinical control group. Steele and Steele
(2003) reported preliminary findings of a clinical study of dissociative
patients involving the AAI that show a high percentage of CC inter-
views in this clinical population.
When used with patients suffering from DID, the AAI regularly elic-
its multiple narratives, and sometimes multiple narrating voices, in the
same individual (Steele & Steele, 2003). These multiple narratives re-
flect distinct ego states, or personality organizations, each with a differ-
ent mental state concerning attachment. Not infrequently in this clinical
sample, a switch in ego state signals the narration of a horrifying history
of abuse suffered at the hand of an attachment figure that is not accessi-
ble to the preceding ego state. Steele and Steele (2003) call attention to
an important observation: while psychic pain certainly accompanies
the recall of the abuse per se, this pales in comparison to the much
greater pain that accompanies the recall of being betrayed by trusted
caregivers and siblings (Steele & Steele, 2003, pp. 116-117). That is,
the memory of an attachment figure who fails to protect the child from
the abuse perpetrated by another member of the family may be more
painful than the memory of the abuse per se. From an attachment theory
perspective, the abused child is forced by the inborn propensity to pre-
serve the attachment relationship and to trust the caregiver and may
therefore collude with a parents denial of the abuse perpetrated by an-
other member of the family: this collusion implies dissociation of the
traumatic memory (Bowlby, 1988, pp. 99-118; Freyd, 1997).
64 Exploring Dissociation: Definitions, Development and Cognitive Correlates

Besides the U and CC, a new coding system for the AAI promises to
be of great interest in the study of the relations between DA and dissoci-
ation (Lyons-Ruth, Yellin, Melnick & Atwood, 2003). In the attempt to
account for those instances of disorganized infant attachment that are
not linked to caregivers unresolved (U) mental states (a substantial mi-
nority in the first AAI-SSP studies), Lyons-Ruth and her collaborators
developed a system for coding separately AAI interviews reporting
multiple and non-integrated mental states both in self and in the attach-
ment figures, but not unresolved memories of traumas and losses. The
disaggregated mental states are alike to the drama triangle, being char-
acterized by hostility (persecutor), helplessness (victim) and compul-
sively caregiving (rescuer) attitudes toward parents (Lyons-Ruth, 2003;
Lyons-Ruth et al., 2003). The code for these disaggregated representa-
tions of self and the attachment figures is called hostilehelpless
(HH). Preliminary findings of researches using the new system indicate
that HH codes are linked to the vast majority (over 90%) both of infant
DAs in the SSP and of borderline diagnoses in a clinical sample com-
paring dysthymic and BPD patients (Lyons-Ruth et al., 2003; Melnick,
Lyons-Ruth, Hobson & Patrick, 2003).

Child-Caregiver Interactions Responsible for DA

In the last decade, a number of empirical studies have provided sup-

port for Main and Hesses (1990) hypothesis that the relationship be-
tween unresolved states of mind in the caregiver and DA in the infant
was mediated by frightened and frightening parental behavior. Home
based observations of mother-infant interactions showed that infant dis-
organized behavior immediately followed mothers abrupt expressions
of fear, worried absorption in internal states, or rage (Hesse, Main,
Abrams & Rifkin, 2003). These studies provided some disquieting ex-
amples of disturbed parent-infant interactions in low-risk samples and
illustrated how parents attitudes can induce fright without solution and
dissociative reactions in the infant even when the parents behavior did
not constitute maltreatment in the usual sense of the term. For instance,
while seemingly trying to soothe the infants cry, an unresolved parent
approached her child from behind and slid both hands around the in-
fants neck. Other parents froze with a dead stare, unblinking in the
face of the infants cry for help. Some parents manifested a paradoxi-
cally deferential attitude toward the infant. Still others seemed to seek
comfort from the infant, in a patent inversion of the attachment relation-
ship (Hesse et al., 2003).
 Giovanni Liotti 65

Childhood Sequels of Infant DA

There is evidence that, in the absence of further traumatic experi-

ences, parents and children involved in the type of interaction that leads
to infant DA tend to develop more organized and coherent strategies for
daily exchanges over the ensuing two to four years. These strategies,
however, do not correct the underlying disorganization. In order to un-
derstand how these strategies are developed, it is useful to keep in mind
that human interpersonal relationships are regulated by different evolved
inborn dispositions. At least five different behavioral/motivational sys-
tems, with an inborn evolved basis, regulate attachment (care-seeking),
care-giving, social ranking, sexual mating and cooperative types of be-
havior (Gilbert, 1989, 2000; Liotti, 1994, 2000).
Two prospective longitudinal studies (reviewed by Lyons-Ruth &
Jacobvitz, 1999, pp. 532-533) demonstrated the shift from disorganized
interaction between infant and parent to a later type of child organized
behavior toward the caregiver. Over 80% of school-age children who
were classified as disorganized in infancy displayed either punitive-
dominant or care-giving behavior toward the attachment figure. These
two attitudes have both been subsumed under the heading controlling
because through either of them the child can exert active control on the
parents attention and behavior.
Controlling strategies imply that children, in their relation with par-
ents, assume a role which is usually considered more appropriate for a
parent with reference to a child (Main & Cassidy, 1988, p. 418). Chil-
dren who exert control over the parent through a care-giving strategy
seem to have inverted the usual direction of the attachment interaction,
as if they have activated the care-giving motivational system instead of
the attachment system (Solomon & George, 1999). Children who con-
trol the parent through punitive-dominant strategies activate another
inborn behavioral/motivational system to substitute for the normal op-
erations of the attachment system. Namely, they activate the evolved
system that regulates interactions aimed at defining the reciprocal roles
of dominance and submission in the social group (identified by etholo-
gists as the social-ranking system: Gilbert, 1989). Thus, the interaction
of controlling-punitive children with their parents is regulated more of-
ten by an aggressive striving for dominance than by care-seeking
(Sloman, Atkinson, Milligan & Liotti, 2002).
Controlling strategies may be interpreted as a defensive process,
safeguarding the childs family relationships from disorganization at
the expense of abnormally frequent inverted care-giving or competitive
66 Exploring Dissociation: Definitions, Development and Cognitive Correlates

interactions (Liotti, 2004). The defensive activation of another motiva-

tional system in response to a disorganized IWM of attachment, how-
ever, should not necessarily be construed as a purely intra-psychic
process. Rather, empirical observations suggest that caregivers atti-
tudes influence the childs defensive use of motivational systems sub-
stituted for the attachment system (e.g., Hesse et al., 2003). Parents who
show FF behaviors toward their (disorganized) infant children also dis-
play an unusual array of submissive, care-seeking or even sexualized
behaviors (Hesse et al., 2003).
The competitively aggressive, inverted care-giving or sexualized in-
teractions between child and parent limit the influence of the IWM on
the childs current thought, emotion and behavior by substituting for the
activation of the attachment system (Liotti, 2000, 2002). These interac-
tions, however, do not cancel the disorganized IWM from the childs
mind. The disorganized IWM becomes manifest again when the childs
attachment system is activated by conditions that are able to overcome
the relative inhibition. For instance, 6 year old controlling children ap-
peared well oriented and organized in their thinking, behavior, and at-
tention until they were shown pictures from a Separation Anxiety Test
(Hesse et al., 2003). These pictures portrayed situations that activated
the childs attachment system (e.g., parents leaving a child alone). Once
the system was activated, the controlling strategy collapsed, and the
children revealed their underlying disorganization by providing inco-
herent, unrealistic, catastrophic narratives in response to the pictures.
This illustrated an important process in the pathogenesis of trauma-re-
lated disorders based on a disorganized IWM. The relative inhibition
of the attachment system through the defensive activation of other
equally inborn motivational systems (the care-giving, the social-rank-
ing, and/or perhaps the sexual system, as may occur in some sexually
abusive families) was suspended under the influence of a powerful
stressor. The coherence of thought, emotion and behavior that was se-
cured by the defensive motivational systems disappeared. The intrinsi-
cally dissociative IWM of DA intervened (together with the emotions
evoked by the stressor) in determining the dissociative response. This
type of pathogenic process may explain the intriguing cases of delayed
manifestation or exacerbation of dissociative disorders years after the
original traumatic experience without any repetition of the original
trauma. In order to bring out previously latent dissociative tendencies,
any event that could either strongly activate attachment needs or invali-
date controlling strategies may be sufficient (Liotti, 2004).
 Giovanni Liotti 67

IMPLICATIONS OF AN ATTACHMENT BASED MODEL

OF DISSOCIATION

The model of dissociative psychopathology emerging from attach-

ment theory and research cannot solve the age-old problem, whether
the self is not a pristine unity but an entity achieved by integration of
simultaneous psychological existences, or the self is a pristine unity
but uses defenses which have the effect of dysunification (Rycroft,
1987, p.198). One cannot prove false the hypothesis that DA is the re-
sult of archaic defenses against the unbearable mental pain of fright with-
out solution, and that these defenses yield fragmentation of a previously
unitary self already present at birth. It seems, however, more plausible
that DA reflects not the outcome of defenses, but an intersubjective fail-
ure of the integrative processes that normally create a unitary sense of
self during the first year of lifea self that is absent at birth.
The prevailing contemporary theories of neonatal consciousness
(e.g., Meares, 2005; Schore, 2003; Stern, 1986) suggest that in the
self-organizing brain (Edelman & Tononi, 2000) of newborn infants in-
tegrative processes that tend to create a unitary sense of self and later on
a unitary self-representation are already operant, but only at the im-
plicit, radically intersubjective level of mental processes. During the
first year of life, the self-organizing brain realizes such a tendency and
yields a unitary self-representation only in securely attached infants
and, to a lesser degree, in organized insecure attachments. In DA, the
tendency to integrate multiple information into a unitary self-represen-
tation fails. This implies that a dissociative mind (Howell, 2005) emerges,
at the beginning of life, in conjunction with operations of the attachment
system, not in moments of the infant-caregiver interactions that are reg-
ulated by a motivational system different from attachment. Dissociative
phenomena never arise as a function of the only other inborn interper-
sonal system that, alternating with the attachment system, is active since
the very beginning of life: the cooperative and intersubjective system
regulating parent-infant play and proto-conversations (Trevarthen, 1974).
The care-seeking-caregiving interactions between disorganized in-
fants and their parents are heavily influenced by dissociative processes
and are linked to the caregivers unresolved traumas and losses. Care-
givers dissociation interacts in a self-perpetuating loop with the ongo-
ing dissociative processes in the infants mind. Dissociation, at least at
the beginning of life, appears therefore to be grounded in interpersonal,
dialogic processes (Lyons-Ruth, 2003) rather than in intrapsychic de-
68 Exploring Dissociation: Definitions, Development and Cognitive Correlates

fenses against mental pain. This statement does not rule out the possibil-
ity that individual risk factors play a role in dissociation. It asserts,
however, that individual (genetic, neurological) risk factors can yield
pathological dissociation only through the mediation of dialogical pro-
cesses such as those of DA. The reader interested in the interplay be-
tween interpersonal processes, individual genetics and brain functions
in the genesis of DA may profit form consulting recent papers by
Buchheim and George (in press), Henninghausen and Lyons-Ruth
(2005), and Schore (2003).
The inborn tendency of mental operations toward unity does not dis-
appear in disorganized infants. Before they reach school-age, the major-
ity of children who were disorganized infants achieve a unitary type of
interpersonal behavior toward their caregivers and a unitary, albeit un-
stable, self-representation (Lyons-Ruth & Jacobvitz, 1999, p. 532 ff).
These children attempt to control the relationship with caregivers
through attitudes that are typical of parents toward their babies (domi-
nant-punitive or care-giving attitudes). The emerging controlling strat-
egy is based on the inhibition of the attachment system through the
activation of a different interpersonal motivational system (see para-
graph 3.4.). Childrens behavior may be interpreted as a defense against
the unbearable feeling of disorientation and disorganization linked to
fright without solution. Thus, the child behavior serves as a defense
against dissociation (which in turn should be interpreted as a primarily
intersubjective process), rather than dissociation serving primarily as a
defense against mental pain. Whenever mental pain activates the attach-
ment system, the dissociative processes linked to the disorganized IWM
emerge in consciousness and disrupt the integrative power of con-
sciousness, as the consequence of a collapse or failure of the defensive
controlling strategies rather than as a primary defense against mental
pain. Thus, an attachment-based model of dissociation supports Janets
rather than Freuds view on the unity of the self: unity of self-represen-
tation, rather than being pristine, is achieved though integrative pro-
cesses, and defenses do not play a primary role in fragmentation of the
self throughout childhood. Dissociation may be secondarily used as a
defense against mental pain in later developmental stages. Secondary,
intrapsychic and defensive use of dissociation may occur when the im-
plicit knowledge of dissociative mental states that originally were
intersubjective becomes the basis for avoiding unpleasant experiences
in a difficult environment, e.g., by absorbing oneself in a trance-like
state.
 Giovanni Liotti 69

An attachment-based model of dissociation fits with a phase-ori-

ented, contextual psychotherapy for the dissociative disorders where
trauma-work is secondary to achieving security in the therapeutic and
other significant interpersonal relationships (e.g., Courtois, 1997; Gold,
Elhai, Rea, Weiss, Masino, Morris & McInich, 2001; Liotti, Mollon &
Miti, 2005). Therefore, future research on the process of phase-oriented
psychotherapy could test some predictions of the attachment-based the-
ory of dissociation. An example is the prediction that dissociative pa-
tients typically show, in their behavior toward the psychotherapist,
multiple representations of self-with-other that shift among the poles of
the drama triangle (Liotti, 1995). Another example is the prediction that
particularly intense decreases of metacognitive capacity accompany
moments when multiple transferences emerge (Fonagy, 1999; Liotti,
2004). Controlled studies that test these predictions are feasible: prob-
lematic mental states, such as the non-integrated representations of the
drama triangle, and transient changes in metacognitive capacity can be
both reliably assessed in transcripts of therapeutic sessions (Semerari,
Carcione, Dimaggio, Falcone, Nicol, Procacci & Alleva, 2003a,
2003b).
Researchers and clinicians still lack methods for reliably assessing
the activation and de-activation of motivational systems (attachment,
caregiving, competition, sexuality) within the therapeutic relationship.
Thus, the critical prediction of the attachment-based model of dissocia-
tionthat dissociative experiences of clinical relevance are contingent
upon the activation of the attachment systemcannot be empirically
tested within the therapeutic relationship, for the time being, in any
systematic way. However, careful analyses of the interpersonal con-
texts in which dissociative symptoms first appear in patients lives
could provide support for this and other attachment-based predictions.
For example, the attachment-based theory of dissociation predicts that
the interpersonal contexts in which dissociative symptoms first appear
will be characterized by (1) losses and actual or expected separations
from attachment figures; (2) creation of new bonds implying attach-
ment; (3) lack of appropriate soothing responses to any type of stressor
intervening in the patients life, including traumatic stressors; (4) life
experiences that invalidate defensive strategies based on compulsive
care-giving or compulsive competition for social rank. The theory also
predicts that controlling interpersonal strategiesbased on compulsive
care-giving, competition for social rank or sexual seductivenesswill be
typically adopted by dissociative patients in periods of their lives when
their explicit dissociative symptoms remit spontaneously. Data from
70 Exploring Dissociation: Definitions, Development and Cognitive Correlates

empirical studies based on these predictions could lend support to the

hypothesis that dissociative symptoms emerge not only as a reaction to
traumatic experiences, but also through the mediation of a disorganized
IWM that becomes active whenever mental pain activates the attach-
ment motivational system.

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