1. Disorganized attachment, trauma- related disorders and the therapeutic relationship Giovanni Liotti Scuola di Psicoterapia Cognitiva Roma (Italy)

2. Main theme of the presentation Developmental psychopathology may provide the psychotherapist with models of mental disorders that help devising effective interventions Disorganized attachment (DA) during infancy and/or childhood may be involved in the genesis of trauma-related disorders (Complex PTSD, BPD, Dissociative Disorders, and other disorders that have traumatic memories among their antecedents) These disorders often involve fragmentation of the sense of self (dissociation)

3. Structure of the presentation Summary of empirical evidence on the genesis of early attachment disorganization Review of evidence linking early disorganized attachment to adult psychopathology An attachment based model of the development of disorders related to complex* trauma (* repeated and unavoidable) Reflections on some implications of these empirical studies for the psychotherapy of people with a fragmented self

4. Research on early D.A. (Disorganized Attachment) Infant D.A. is statistically linked to caregiver’s: unresolved traumas and/or losses non-integrated hostile and helpless representations of self and the attachment figures aggressive, frightened and dissociative caregiving behaviour (genetic influences play a moderating role)

5. Theories on the genesis of attachment disorganization conflict between two inborn control systems, attachment and fight-flight  fright without solution (Main & Hesse, 1990) early relational trauma  abnormal construction of the stress coping system in the infant’s right brain ( Schore, 2003 ) flickering switch mechanism in the infant contingency detection module  dissociative type of attention (Koos & Gergely, 2001)

6. Sequels of infant attachment disorganization proneness toward dissociative experiences (Ogawa et al., 1997) deficits in emotion regulation, stress- coping capacity and control of impulses (Schore, 2003) mentalization deficits (Fonagy et al., 2003) risk factor in the development of a wide range of DSM mental disorders ( Levy, 2005; Liotti 2004) controlling strategies

7. D.A. and psychopathology If early D.A. is essentially a disaggregated way of processing socio- emotional information … … then it may be more often linked to disorders characterized by severe dissociation, splitting among ego states and fragmentation of the self (than to other psychiatric disorders)

8. Studies on traumas/losses in the life of adult patients’ mothers AAI studies cannot reliably assess the early attachment pattern of the responder (as evidenced by longitudinal studies  Grossmann, Grossmann & Waters, 2005). Studies of traumas/losses suffered by the patients’ mothers in the 2 years before and after the patient’s birth may provide better hints at the specific role of infant DA in the genesis of adult pathologically disaggregated mental states

9. Traumas/losses in mothers and mental disorders in offspring Mothers of adult BPD and dissociative patients (cases) report two times more traumas/losses than mothers of other psychiatric patients (controls) in the 2 years interval around the patients’ birth (Liotti et al., 2000; Pasquini et al., 2002) Mother’s losses and children’s traumas act as independent risk factors, (each of them increases vulnerability to dissociative disorders) The statistical difference between cases and controls disappears if the control group comprises schizophrenic patients (Miti & Chiaia, 2003)

10. DA and psychopathology: a neo- dissociationist hypothesis DA is an essentially dissociative process It may direct development toward a high number of mental disorders Many mental disorders are based on the disruption of integrative processes, but only a few are characterized by explicit symptoms of dissociation or of other types of non- integrated mental functions (e.g. splitting) Other risk factors, besides DA, must intervene in the genesis of disorders characterized by fragmentation of the self  traumas

11. Not only early attachments Bowlby’s metaphor: branching railways lines Any untoward itinerary stemming from early attachment insecurity can be gradually reversed pointing at mental health, and any favourable pathway can be left behind, due to later negative influences, to follow the railroads leading to psychopathological developments.

12. Early DA and later traumas (1): genesis of the fragmented self the quality of pre-existing attachments (IWMs) is an important factor in children’s capacity to cope with trauma traumas suffered at the hand of attachment figures throughout childhood and adolescence have a damaging effect on the quality of existing attachments and IWMs

13. Early DA and later traumas (2): genesis of the fragmented self A pre-existing DA instigates dissociative reactions to traumas Traumas inflicted by family members are likely to cause fright without solution throughout childhood, and therefore to reinforce disorganization of earlier attachments, or to induce anew DA, both toward the abuser and toward other family members who fail to protect the victim (betrayal trauma: Freyd, 1997)

14. Early DA and later traumas (3): genesis of the fragmented self The IWM of DA is intrinsically dramatic (fright without solution) and un-integrated Trauma  pain  activation of the attachment system  secure IWM  successful coping Trauma  pain  activation of the attachment system  disorganized IWM  peritraumatic dissociation  cumulative effect  fragmentation of the self

15. A closer look at the IWM of DA a structure of implicit memory, hardly accessible to consciousness represents unpredictable, uncontrollable, and frightening caregivers’ responses, and… …switches in the child’s state of mind that are equally uncontrollable and oscillate between the polarities of craving for protective closeness, defensive rage, fright without solution and helplessness. tendency to invert the direction of the attachment relationship

16. Defences against the mental state of DA : controlling strategies (1) Before reaching school age, disorganized children develop organized behavioural/ attentional strategies, aimed at controlling their caregivers and deactivating the attachment system. These strategies may be uncerstood as a defence from the unbearable experience of fragmentation Two main types of controlling strategies: Controlling-punitive (domineering) Controlling-caregiving (inverted attachment)

17. Defences against the mental state of DA: controlling strategies (2) The defensive inhibition of the attachment system… …obtains through the activation of another inborn motivational system: Care-giving system (controlling-caregiving strategy) Social ranking system (controlling-punitive strategy) {Sexual mating system?}  (oedipal defences)

18. Collapse of controlling strategies and experience of fragmentation When separations, losses and traumas activate the attachment system, the inhibiting influence of other social motivational systems is overpowered: the controlling strategies collapse. Clinical symptoms characterized by fragmentation of the self emerge.

19. DEVELOPMENTAL PSYCHOPATHOLOGY OF DA X FF and/or HH Caregiver Disorganized Attachment Multiple IWM + Fright without solution Controlling Strategies Attachment Deactivation Collapse of controlling strategies (e.g. traumas, separations, etc.) Reactivated Attachment Fright + dissociative symptoms Intergenerational transmission Externalizing or internalizing disorders

20. clinical example Diana, 33, a physician, daughter of a woman suffering from bipolar disorder  Att. Dis. Remembers incest throughout adolescence and adulthood Controlling-caregiving toward mother, firmly believes having successfully prevented father abusing of sister (6 years younger) Professional vocation linked to compulsive care-giving Recurrent depressive episodes (  self-prescribed antidepressants), but no dissociative symptoms until 32 Dissociative symptoms (depersonalization, hypnagogic hallucinations) emerge when sister reveals she needs psychotherapy because father abused her sexually during her childhood The need for personal therapy is accompanied in Diana by almost delusional fantasies of rejection and danger

21. Relevance for psychotherapy Symptoms related not only to intrapsychic defences from painful memories, but also to: Multiplicity of non-integrated, dramatic representations of self-with-other Hindered “mentalizing” capacities Complex relational dilemmas All the above problems are contingent upon the activation of the attachment system (they may subside when interactions are governed by another motivational system)

22. An understanding of the therapeutic relationship Whenever multiple shifting transferences and mentalizing deficits are noticed during clinical dialogues, they are attributed to attachment needs directed toward the therapist. Fright without solution and the dissociated, dramatic IWM of AD underlies this extremely problematic expression of attachment needs This explains the repetition of typical relational dilemmas in the therapeutic relationship

23. Relational dilemmas Avoidance of attachment feelings toward therapist, obtained by rehearsing punitive or sexualized controlling strategies Alternating “phobia of attachment” and clinging, insecure dependency (Steele et al., 2001) Memories of frightening interactions with attachment figures are dissociated in order to preserve the attachment relationship. At the same time, attachment feelings are disavowed to protect the self from anticipated repetition of abuse (Blizard, 2001) Searching for the meaning of symptoms fosters the patient’s sense of mastery/security, but at the same time may arouse terrifying memories of attachment trauma (Holmes, 2004)

24. Ugo’s relational dilemma: (first part) Ugo, 27, primary pulmonary hyperten. (4 years life expectancy) Previously diagnosed BPD, U begins new psychotherapy  “ I wish to know who I am before I die” U states on session 1 he’ll refuse heart and lung transplant (because of suffering in the prospect of unlikely positive outcome). T empathizes saying he understands U’s position U idealizes therapist’s (T) empathic listening and comments Moist, cold hands at the end of every session U’s suicidal ideation escalates. From session 48, U says he decided to kill himself (therapy is still seen as a very positive experience). Frightening OBE, Out of the Body hallucinatory Experience: U sees a figure (himself) with a knife, going to kill him.

25. Ugo’s relational dilemma: (second part) T takes the OBE experience as evidence of disorganized attachment in the therapeutic relationship. Plans a classical intervention aimed at showing that he values U’s life without becoming unduly solicitous or looking “frightened” (which would further activate the patient’s attachment system and re- traumatize the patient  repetition of attachment trauma). During session 51, T opposes the idea of suicide, saying it is illogical to value a relationship more than one’s own life. Asks for U’s decision to stay alive in order to continue therapy. Furious, U refuses to decide pro-life. States T has ruined the only opportunity he ever had of “real dialogue”. Says he’ll quit treatment. T reacts by confirming next appointment. A sequence of three sessions (all in the same vein) follows.

26. Ugo’s relational dilemma: (third part) At the end of session 54, T became aware that Ugo’s hand had been warm and dry since the end of session 51  U had been very anxious during all the “idealizing” sessions, even before the beginning of suicidal ideation (  since session 1, U had been unconsciously testing T’s concern for his life, and until session 51 T failed the test) U’s response to T’ s intervention allowed for U resorting to a controlling-punitive strategy, able to re-organize his thoughts and feelings while he felt attachment feelings toward T U may have intuited T’s new understanding: on the following session, he said he’ll continue treatment  Insight on mother suicidal threats. Treatment continued until 3 years later, when U died while he was hospitalized, waiting for transplant (he had accepted to be enrolled in the waiting list for transplant)

27. Benefits of parallel, integrated interventions Modulation of separation anxiety and therefore of the intensity of activation of attachment needs linked to disorganization The “secondary” therapist may examine critically the multiple, dramatic, negative transference with the first (“primary”) therapist The primary therapist feels supported from the secondary therapist  less likely repetition of early relational trauma (meeting a frightened/frightening attachment figure) Witnessing cooperation on equal grounds between two attachment figures