MULTIPLE PERSONALITY DISORDER AS AN ATTACHMENT DISORDER

Peter M. M. Barach, Ph.D.

Peter M. M. Barach, Ph.D., is a psychologist at Horizons & Milstein, 1984; Kluft, 1984b; Putnam, Guroff, Silberman, Counseling Services, Inc., in Parma Heights, Ohio. Barban, & Post, 1986; Ross, Norton, & Wozney, 1989), and anecdotal (e.g., Bliss & Bliss, 1985; Schreiber, 1973), have For reprints write Peter M. M. Barach, Ph.D., 5851 Pearl found a highly significant relationship between this diag­ Road, Suite 305, Parma Heights, Ohio 44130. nosis and patient reports of child abuse. Prospective stud­ ies have noted the development of dissociative symptoms ABSTRACT and MPD in children who were being abused (e.g., Fagan & McMahon, 1984; Riley & Mead, 1988). Descriptive theories Multiple Personality Disorder (MPD) can be viewed as a disorder of of MPD also have emphasized trauma as an etiological fac­ attachment. BowlfJy (1969, 1973, 1980, 1988) described how the tor (Braun, 1984; Braun & Sachs, 1985; Kluft, 1984b; Ross, emotionally neglected (passively abused) child detaches from inter­ 1989; Spiegel, 1986). Going beyond etiology, scientific writ­ nal and external signals that would normally lead him to search ing about MPD treatment has tended to focus on the direct for a parent; the MPD literature uses the label "dissociation"for the and indirect (i.e., reenacted) effects of childhood trauma same state which BowlfJy called "detachment." Upon the detached on the patient's transferences (Barach, November, 1987; state are superimposed the sequelae ofactive abuse. From this per­ Loewenstein, in press), cognitions (Fine, 1988), and com­ spective, many of the problematic transference phenomena in the plexity of pathology (Kluft, 1988). treatment ofMPD resultfrom reactivation in the transference ofetho­ In addition to the sadistic, invasive, ritualistic, and logically adaptive attachment behavior. The patient's difficulties in humiliating traumaticexperiencesreported byMPD patients, maintainingboundaries, periods ofsudden withdrawal, and even­ clinical material suggests that another kind of childhood tual movement through a period ofanxious attachment, represent trauma may be ubiquitous. Within the total traumatic envi­ steps towards internalization ofa secure base ofattachment. ronment (Giovacchini, 1986),another type oftrauma,which I am calling "the parents' failure to respond," profoundly INTRODUCTION influences the development of dissociative psychopatholo­ gy. Under this rubric I am including (1) the parents' failure One may view Multiple Personality Disorder (MPD) as to protect the child from abuse, and (2) the parents' ten­ an attachmentdisorder complicatedby the sequelaeofactive dencyto dissociate orotherwisedetachfrom emotionalinvolve­ abuse (specific acts which cause physical or sexual harm). ment with the child. Though physical neglect can follow When the mother (or other primary caretaker) is dissocia­ (Wilbur, 1985), the mother's chronic failure to respond to tive and detached, the child is likely to use dissociation as indications of distress or emotional need in the child is by the primary defense against the overwhelming trauma of itselftraumatic, eventually causing a corresponding detach­ active abuse. The therapist can note evidence for an attach­ ment in the child. The child's reactive detachment sets the ment disorder in nearly every aspect of the psychotherapy stage for reliance on dissociation as a response to "active of MPD. From this perspective the resolution of the attach­ abuse." ment disorder, rather than the resolution of the effects of sexual and physical trauma, causes the extended and tur­ BO~~STHEORYOFATTACHMENT bulent nature of the psychotherapy ofmore complex cases of MPD. Bowlby's theory ofattachment (1969, 1973; 1980; 1988) is a useful framework with which to understand the effects VARIETIES OF TRAUMA ofparents' failure to respond. He described the survivalvalue to the species of certain behavioral systems which increase Renewed clinical interest in MPD probably could not proximity to the mother as a predictable outcome, thereby have occurreduntil clinicians accepted that reports ofabuse protecting the infant from predators. These systems devel­ presented by adult clients were not necessarily fantasies of op gradually over the first two years of life as a result of the the Oedipal or any other variety. As Kluft (1990) succinctly infant's "interaction witl1 his environment of evolutionary stated, "The importance ofreal trauma to the development adaptedness" (Bowlby, 1969, pp. 179-180). Attachment of psychopathology is increasingly recognized" (p. 1). behaviors, such as sucking, «linging, crying, following, and NumerousstudiesofMPD patients, bothempirical (e.g., Coons smiling elicit caretaking behaviors from the mother figure.

117 DISSOCIATION, Vol. IV, [\"0. 3, September 1991 Caretaking behavior aids the survival of the species in tan­ 25), children experiencingprolongedseparationscan block dem with attachment behavior. By picking up, feeding, smil­ attachmentbehaviorsand theirassociatedaffects. Once estab­ ing back and so forth, the mother brings the child closer. lished as a defensive process, detachment then becomes the Attachment behavior begins at birth (Klaus & Kennell, child's characteristic coping style. 1982) and persists through life. Once a secure attachment bond forms, the toddler uses the mother as a secure base RELATIONSlllP BETWEEN DETACHMENT for exploration (Bowlby, 1988), returning to herwhenfright­ AND DISSOCIATION ened. The older infantand toddler can draw upon the mem­ oryofa caretaker, and the knowledge thatshealways returns, My reading ofBowlby's work is that the detachment he as the basis for a feeling of security. By age five, the child describes is actually a type ofdissociation. Although Bowlby normallyhas concluded the processofinternalizingand sym­ uses the term detachment in describing howchildren respond bolizing his secure base, and is able to redirect attachment to abandonment, he is really describing a dissociative pro­ behavioronto others, andontogroups (Bowlby, 1973; 1979). cess. In its usual definition, dissociation refers to a disjunc­ Adult attachment relationships realistically mirror the situ­ tion ofthe association between related mental contents (Braun, ationwhich prevailedduring childhood; obviously, such rela­ 1986; Putnam, 1989; Ross, 1989). It is "[a] psychophysio­ tionships would be reflected in both the transference rela­ logical process whereby information-incoming, stored, or tionship and the therapeutic alliance (Bowlby, 1988). outgoing-isactivelydeflectedfrom integrationwith its usual . Bowlby (1973) identified three phases of the normal or expected associations" (West, 1967, quoted in Putnam, response to separation. The child first protests the loss and 1989, p. 6). Detachment is the same process, applied to a uses attachment behaviors to try and bring back his moth­ specific categoryofsequestered information: stimulifor attach­ er. When Mother does not return, the child seems to despair, ment behavior. but still awaits her return. Eventually he seems to detach and Detachment protects the abused child from crying out appears to lose interest. However, attachment behaviors will for help and finding out that he is alone. In traumatic situ­ return upon reunion ifthe separation hasnotbeen too extend­ ations such as "active abuse," a child feels pain, terror, and ed. Following reunion, the childwhose parenthasbeenappro­ other overwhelming feelings. Such feelings obviously make priately responsive to his attachment behaviors will often the child want his mother. But whether he fantasizes float­ cling to the parent, demonstrating anxiety at any hintofsep­ ing away and watching the abuse from somewhere else, or aration. develops alters in order to "imagine...that the abuse is hap­ Bowlby's theory provides a new perspective on clinging pening to someoneelse" (Ross, 1989, p. 55), the childdetach­ behavior, or separation anxiety. In contrast to traditional psy­ es from the affect. As I will show later, an abused child has choanalytic models which viewed separation anxiety as a dis­ learned to expect no help from mother because she already placement of some other fear (Bowlby, 1988), Bowlby saw had emotionally abandoned the child on a regular basis. anxious attachment as the result of real or threatened sep­ A case study demonstrates how detachment is a part of arations or temporary abandonments by caretaking figures dissociation. Rileyand Mead (1988) describe howMPD devel­ during childhood (Bowlby, 1973). When a child knows that oped between ages two and three in a girl who was being an attachment figure will be available whenever he needs a abused by her biological mother. At 14 months, before any secure base, he will develop a lifelong ability to tolerate sep­ abuse began, they noted "a strong psychological attach­ arations well, and will handle new situations confidently. ment...between the child and both guardian parents. She Lackingsuch knowledge, hewill demonstrate anxious attach­ was also able to letherparentsleave tlle roomwithoutexhibit­ ment and general apprehensiveness at new ventures. ing anxiety" (pp. 41-42). Mter visitation with the biological The availability of an attachment figure during child­ mother (andabuse) began, shestarted to cling to theguardian hood also influences the person's response to losses. When mother, would awaken during the night to be sure she was a frightened child needs his mother butultimatelyfinds that there, and was frightened when left alone with the examin­ he is abandoned and alone, he protects himself from fur­ er. In Bowlby'sframework, she showedindicationsofan inse­ ther suffering by detaching himself from any awareness of cure attachment, which is certainly understandable in light hisfeelings and needs. Summarizingstudies ofchildrenwho of having been abused when the attachment figure (the underwent prolonged separations, Bowlby (1980) noted guardian mother) could not protect or comfort her. detachment as the final stage of dealing with a separation. Eventually the child moved from anxious attachment to Duringdetachment, the childstopsemittingattachmentbehav­ defensive detachment. She developed an alter, Lila, who ior and even turns away from attachment figures when they dealt with visits to the biological family. Although she return (as Robertson's [1952] film of a two-year-old's week appeared happyand contentedwhen observedwith her bio­ longhospitalization andseparation from his parentspoignant­ logical parents, she acted as ifshe did not know herguardian ly demonstrates). Bowlby saw detachment as the result of a mother (i.e., detachment) when tlle latter made an unex­ deactivation ofthe system ofattachmentbehavior. By defen­ pectedvisit. Lila'sfascination with peek-a-boo, agamewhere­ sively excluding from awareness "...the signals, arising from in children "play" atseparation, further suggests that attach­ both inside and outside the person, thatwould activate their ment issues were salient. attachment behavior and that would enable them both to love and to experience being loved" (Bowlby, 1988, pp. 34-

118 DISSOCIATIO:-.l, Vol. IV, No.3, September 1991 EVIDENCE OF NONRESPONSIVITY a hoarse, eerie cry in a baby.... On tape, we see the baby in IN THE PARENTS OF ABUSED CHILDREN her mother's arms screaming hopelessly; she does not turn to hermotherfor comfort. The motherlooks distant, self-absorbed. Several sources ofdata, reviewed below, suggest that the She makes an absent gesture to comfort the baby, then gives parents ofneglected and actively abused children fail to be up. She looks away. The screaming continues for five dread­ emotionallyavailable to theirchildren. Insomeofthe sources, ful minutes on tape. In the background we hear Mrs. the relationship between the parents' failure to respond and Adelson's voice, gently encouraging the mother. "What do the child's detachment is also clear. you do to comfortMarywhen she cries like this?" [The moth­ er] murmurs something inaudible.... As we watched this Injured Children tape later..., we said to each other incredulously, "It's as if When a child is injured, varying degrees ofparentalneg­ this mother doesn't hear her baby's cries!" (pp. 104-105; the ligence can exist, ranging from complete innocence to cal­ emphasis is mine). culated sabotage. The dissociative or preoccupied parent is more likely to have a child wander away into a dangerous Psychoanalytic Case Study ofAdults Jfho situation while her attention is "otherwise engaged." Were RapedAs Children A study cited by Bowlby (1973) of children injured in Katan (1973) discussed six adult analysands who report­ traffic accidents in one section ofLondon is a case in point. ed having been raped as children. In one case, the patient's Almost two-thirds of the children had been alone; among mother, disappointed in her marriage, had turned to social younger children, more than half had been alone. Bowlby activities. Bridge was so important to her that she had little also summarized two studies of the family backgrounds of time for her children.... A succession of nursemaids took children injured in traffic accidents, and one study of the complete care of the little girl and also shared a room with families of children who had been burned. Compared to a her.... The mother['s] interestin the child concentrated on control group, the injured children in all three studies were toilet training.... The nursemaids... did not pay sufficient more likely to be unwanted or unloved, or to have a moth­ attention to the child to protect her against overwhelming er absorbed with other family problems. In such families, it sexual assaults [e.g., oralrape by the nursemaid'sboyfriend] .... would be easy for a forgotten child to wander out the door Mother frequently excited the child by inviting her into the and into the street, or to get near a hot stove. bathroom while taking a bath. These were the only times the patientrememberedgetting hermother'sattention (pp. Emotianally Detached Parents 216-217) . FurmanandFurman (1984) describedparentswho "inter­ In a second case, the patient's parents worked all day, mittently decathect" their children. These parents periodi­ and the mother "returned in the late afternoon, worn out cally seemed to withdraw from their emotional investment and irritable, to do household chores which she despised. in their children, either out of depression or as an expres­ Her patience with her children was very limited. Yelling and sion of conscious or unconscious anger. The writers often spankingwere heronlymeansofupbringing" (p. 210). When found this kind ofdysfunction in the parents of preschool­ the father fondled the child and also bit her, the mother ers who had been molested or raped. Seeming to refer to expected the child to protect herself. When the patientwas' extrafamilial molestation, they commented, "Children this five, she was orally raped at school. She recalled her moth­ young are rarely left in situations thatwill eventuate in a sex­ er saying, "She is damaged for life... nobody will ever want ual molestation if their parents have an unremitting invest­ her" (p. 212). Katan commented, "Some of my patients... ment in them" (p. 427). They also found intermittent had the tendency to expose their oWn children to the same decathexis to be common in parents whose children tend­ experience, mostly by notprotecting them when theyshould ed to "get lost." have been protected" (p. 220). Furman and Furman noted tl1at the parental dysfunc­ In treating mothers who have come for supportive ther­ tion was reflected in the child's own tendencies to withdraw apy when their children have been sexually abused, my col­ attention from others and to be on "cloud nine," which are leagues and I have found dissociative behaviors and even dissociative behaviors. In analysis, the children ofintermit­ MPD in a notably high proportion of the cases. tently decathecting parents were extremely sensitive to the analyst's withdrawal due to internal preoccupations; in my MPD Patients As Parents clinical experience, MPD patientsdemonstrate the same kind MPD patients are by definition dissociative. If it can be of sensitivity. shown that their symptomatology causes them to be inter­ Clinicians 0 bserved a similar pattern ofparental detach­ mittently unavailable to their children, they present the mentin the mothersofsomedevelopmentallydelayed infants. researcher with an opportunity to study the effects of dis­ Fraiberg, Adelson, and Shapiro (1974/1987) provide a engaged parenting on children. KIuft (1987) reported on painfully vivid description ofa dissociative mother and her the parental fitness of a group of seventy-five females with child's detachment. The mother had been grudgingly par­ MPD, based on the patients' descriptions oftheir own behav­ ented by relatives after her mother's postpartum suicide ior. In this study, KIuft did not report on the functioning of attempt, and had been sexually abused by her father and a the children. Among the,pathological parenting behaviors cousin. During a testing session, her baby begins to cry. It is found in the entire sample were "impairment due to amne-

119 DISSOCIATIO~, Vol. IV, 1\0. 3, September 1991 MPD AS AN ATTACHMENT DISORDER

sia" (20%), "abdication ofparenting by alters" (17.3%), and ized by extrafamilial incest, their parents tend to have been "affective absence" (5.3%). Due to amnesia and the wish to "intermittentlydecathecting" (detached), unloving, orentire­ please the interviewer, these percentages may be too low. ly rejecting. When parents have been detached from their Sixteen percent of the mothers admitted to having physi­ children (or unavailable to protect them from injury, as in cally or sexually abused their child, or failed to protect the the case ofLila [Riley & Mead, 1988]), the children demon­ child from physical injury. Kluft classified over 45% of the strate the pattern Bowlby called detachment: an active turn­ mothers as "compromised/impaired"; although they were ing away from the abandoning parent, and a withdrawal to not abusive, their symptoms interfered with their function­ a dissociated state. As parents, they often reenact the par­ ing as mothers, or they failed to act in the best interests of enting they received:' they are unable to protect their own the children. children from abuse, and they dissociate when their chil­ Kluft (1984a) discussed one childwith MPD whose father dren need them. was dissociative and whose motherhadMPD. Although there was no evidence of abuse by either parent, the child pre­ TRANSFERENCE PHENOMENA REFLECTING sented a classic MPD picture (with amnesia); the precipitat­ THE PARENTS' FAILURE TO RESPOND ing event was a near-death by drowning. Kluft did not dis­ cuss the specific parenting style to which the boy had been Given the presence ofdetachment as a dynamic in MPD exposed. patients and their parents, one would expect to find many Coons (1985) found a significantly greater percentage representationsand reenactmentsofattachment-related issues ofemotional disturbance in the children ofMPD patients as in the treatment of MPD. The attachment issues are more compared to the children of a matched sample of non-dis­ prominent in relatively complex patients with many alters sociative psychiatric patients. Although the study did not (Kluft,July, 1991, personal communication). An awareness specifically explore the parenting styles ofthe MPD patients, of attachment issues can drastically shift one's perspective "eightofthe nine emotionallydisturbed children had moth­ onwhatcliniciansusually call "dependency."Thus, Putnam's ers who continued to dissociate and/or were poorly moti­ (April, 1990) description ofintrusive abuse, leading to a lack vated for therapy" (p. 160). ofboundaries, as "the core problem" in MPD, changes to an Though the available data is sparse, the existing studies awareness that the alternation between intrusion/assaultand suggest that parental dissociation is associated with child­ abandonment is the core problem. hood psychopathology. Attachment issues sometimes become evident through the use of detachment in early sessions. Because MPD MPD Patients'Description ofParental Failure to Respond patients often enter therapy feeling that no human can be Wilbur's (1985) description ofnon-nurturingabuse sum­ trusted, they use various protective mechanisms to get the marizes the emotional and physical neglect that many MPD help they need without having to develop a sense of trust. patients describe. Putnam et al. (1986) found that over 60% Some patients will immediately produce child alters who of their case series of 100 MPD patients reported extreme seem to trust and cling to the therapist, but they are quick­ neglect in childhood. ly replaced with distant or hostile alters who protect the per­ Any therapistworkingwith MPD patients hearsdailyexam­ sonalitysystem from the expected assault. Using attachment ples ofparental non-responsiveness. Whether these memo­ behavior as a framework, one can reconceptualize this ries reflect literal events or merely symbolize the patient's sequenceas representing the reactivation ofattachmentbehav­ emotional experience, they show the prevalence ofneglect ior in the transference. as a themein the emotionallife ofMPD patients. Manypatients Early in treatment, when the patient is often flooded by report that their mother was periodically depressed to the signals thatsuggest thatinternal and external danger is close point ofbeing bed-ridden, was hospitalized for depression, at hand, the need for an attachmentfigure is strong. Bowlby and/or received ECT. One patient's mother "always burned wouldremind the therapistthatattachmentbehavioris elicit­ all the food," having been so dissociative that she lost time ed by fear, and that the frightened person seeks proximity whenever she tried to cook. Some parents rarely attended to an attachmentfigure. Thus, there arefrequentemergencies, schoolfunctions, showinglittle interestin academic progress. phone calls, requests for extra sessions, requests for hospi­ Commonly, patients report that their mothers pushed them talizations or medication (symbolic feeding). Alternatively, away orpunished themwhen they cried, told them that their patients run from their attachment wishes by self-destruc­ problems were insignificant, or locked them in their rooms tive behaviors or by dropping out of treatment. When they or a closet until they stopped crying. One patient reported later re-enter treatment, they commonly say that they felt that her mother sat and watched television while her father they were "getting too close." raped another child in the next room. Caretaking behavior, as well as attachment behavior, is ethologicallydetermined. Notunexpectedly then, the attach­ Summary ofthe Evidence ment behavior of child alters can readily elicit caretaking Several converging data sources (in addition to what behavior from the therapist. The therapist new to MPD may patients have remembered) indicate that abused children be surprised by the intensity of his wish to respond to the commonly receive preoccupied, dissociative parenting. attachment behaviors of the child alters. This behavior When children have been injured in accidents, or victim- sequence has usually been discussed in the MPD literature

120 D1SS0CLmo~,Vol. IV. ~o. 3. September 1991 - BARACH

from the equallyvalidviewpointofcountertransference-based to remind her of the therapist during a vacation, but the violations of the patient's boundaries (e.g., Barach & ability ofthe object to evoke a sense ofsecurity tends to wane Comstock, November 1990; Chu, 1988; Greaves, 1988). after a few days; in other words, detachment sets in. Eventually, the therapist realizes that any caretaking behav­ Iftreatment progresses well, a few alters begin to devel­ ior must be applicable to the needs ofthe system as a whole. op a sense of security in their attachment, which may then While the tendency ofsome MPD patients to violate the spread throughout the system ofalters as integration nears. therapist's boundaries has usually been understood as the Atfirst, the attachmentbondis concrete in natureand requires transference reenactment of abuse (Barach, November picturing the therapist, fantasizing about the therapist, hav­ 1987; Loewenstein, in press), boundaryviolationsalso reflect ingimaginaryconversationswith the therapistas issues come the reactivation of attachment behavior within the trans­ up, talking to other people about the therapist, etc, The tra­ ference. For example, some patients monopolize the ther­ ditional derogatory term used for this period of the thera­ apist's answering machine, spend hours in the therapist's peutic work is dependent, or regressed. waiting room, leave notes on the therapist's car, drive by the In the conceptualframework ofattachmenttheory, such therapist's house, etc. developments are an extremely positive sign, showing that There are positive and negative aspects to this kind of . the patient has entered a period ofanxious attachment. As acting out. The positive aspect, as Winnicott (1965) point­ Bowlby (1969, 1973) noted, anxious attachment following ed out, is the patient's hope that the original trauma can be detachment is a sign that defensive exclusion of the need corrected, that this time she will not be abandoned. The for proximity to an attachment figure has been breached; reactivation ofattachment behavior also raises the possibil­ anxious attachment thus indicates a departure from the use ity that the adult patient may eventually develop an internal of dissociation as a defense mechanism. Gradually, but not sense of security in her attachment and will not need to always steadily, the patient begins to find the therapist to be detach (i.e., dissociate) in response to internal and exter­ a secure base to which she can return when frightened. The nal demands. As Greaves (1989) said, "the external refer­ patient's nascent sense of security then makes the stress of ence point ofthe therapist becomes a place offocus for the abreactive work bearable. Often the patient begins to make patient'semotionsin the externalobjectworld, hence a vehi­ major gains in self-confidence at this time. The therapist cle of eventually-integrated experience" (p. 225). should not discourage attachment, but should maintain his The negative aspect to the reactivation of attachment attitude of empathic neutrality. He should encourage the behavior is that the patient may see the therapist's empath­ patient to express wishes for dependence and attachment ic neutrality as an abandonment which is more real than just as he encourages expression of all other feelings, but transferential, therebywrecking the therapeutic alliance. The he should not endeavor to gratify those wishes other than patient often unconsciously perceives the therapist as unre­ by his steady, nonjudgmental, mirroring presence. sponsive, as her mother was. To protect herselffrom antic­ Not all MPD patients seem to be able to develop a secure ipated future abandonments, the patient may then move base for attachment. Some seem to get stuck in the period into a state of detachment, often by calling upon an intel­ ofanxious attachment, while others, staying with the use of lectualizedornumbalter. The expression ofdissociatedanger detachment, never invest in the therapeutic alliance. Many which eventually follows, accompanied by further demands of these patients demonstrate the pattern which Kernberg (Barach & Comstock, November, 1990), can push the ther­ (1984) called malignant narcissism. apist into detachment or retaliation. Anger at the departed However, as many MPD patients move toward integra­ attachmentfigure is a common response to separation,which tion, they gradually develop an internalized sense of secu­ may have the function of overcoming obstacles to reunion ritywhich is much less dependenton the actual or imagined and making it less likely that the attachmentfigure will leave presence ofthe therapist. The feeling ofinternal security is in the future. But repeated experiences of separation and available to the personality system as a whole, and patients loss are likely to elicit malicious, dysfunctional anger from will often make forward strides in their lives which they pre­ the one who has been left, weakening the attachment bond viously feared to attempt. instead ofstrengtheningit (Bowlby, 1973). Indeed, the MPD patientwho is furious at the therapist's unwillingness to ful­ CliNICAL EXAMPLE fill every demand is often terminated, medicated, or hospi­ talized-in otherwords, "sentaway" inone manneroranoth­ Ann (a pseudonym) came into treatment complaining er. of chronic anxiety. She was having panic attacks in numer­ Early in treatment, MPD patients usually demonstrate ous situations in which she could find no objective external either separation anxiety or detachment when a therapist danger. With people she was either seductively compliant leaves for vacation. I cannot recall any MPD patientwho has or sarcastic; she left the impression that she could "take or ever been able to retain positive feelings over an extended leave" the people in her life, including the therapist. She absence without separation anxiety (the fear that the ther­ made little eye contact and did not seek comfort when dis­ apist will not return) or detachment. Many MPD patients tressed. In other words, the clinical picture showed detach­ find that they are unable to picture the therapist in their ment. As treatment progressed, Ann described dissociative mind when he is out oftown or out ofthe office. Some ther­ symptoms. Gradually th,e diagnosis of MPD was made. apists have resorted to giving the patienta transitional object Annwas sure thatthe therapistwouldforget herin between

121 DISSOCLHIOl\. Vol. IV. No.3. September 1991 MPD AS AN ATTACHMENT DISORDER

sessions and when he took a vacation. In other words, she Barach, P.M., & Comstock, C. ( lovember, 1990). TheeJJectsofalter­ expected thatshewould disappearfrom the therapist's mind ing the treatment frame during ongoing treatment ofmultiple personality as she had disappearedfrom her mother's. The first attempt disorder. Presented at the Fifth Conference of the International to establish a continuity of attachment came from a child Society for the Study of Multiple Personality/Dissociative States, alter who asked the therapist to keep a small toy that was Chicago. important to her. She could picture in her mind that the Bliss, E.L., & Bliss,]. (1985). Prism: Andrea swodd. New York: Stein toy was still with the therapist, even though she could not & Day. yet imagine that her mental representation stayed with him. Ann was highly sensitive to the therapist's momentary wan­ Bowlby,]. (1969). Attachment and loss: Vol. 1: Attachment. New York: dering of attention. She tended to become more detached Basic Books. and numb when this would occur. Eventually, Ann's sudden detachment sometimes alerted the therapist to the fact that Bowlby,]. (1973). Attachment and loss: Vol. 2: Separation: Anxiety and his thoughts had begun to wander, and was a helpful indi­ anger. Middlesex, England: Penguin Books. cator that countertransference issues needed exploration. Mter abreactive work began, Ann went through a peri­ Bowlby,]. (1980). Attachmentand loss: Vol. 3: Loss: Sadness and depres­ sion. Middlesex, England: Penguin Books. od of making numerous calls to the therapist. These calls, at reasonable hours, were usually not crisis calls (suicide, Bowlby,]. (1988). A secure base: Parent-child attachment and healthy intrusive flashbacks, self-mutilation, etc.). Rather, theyreflect­ human development. ew York: Basic Books. ed moments of separation anxiety, when the patient want­ ed to check ifthe therapist "was still there." Listening to the Braun, B.G. (1984). Towards a theory ofmultiple personality and therapist's answering machine later sufficed. The patient other dissociative phenomena. Psychiatric Clinics ofNorth America, also used imagined conversations and interventions from 7, 171-193. the therapist (pictured in great detail and involving age­ appropriate comforting of the relevant alters) to cope with Braun, B.G. (1986). Issues in the psychotherapy of multiple per­ situational transitions and anxieties. At times, Ann had sud­ sonality disorder. In B.G. Braun (Ed.), Treatment ofmultiple person­ ality disorder (pp. 1-28). Washington, DC: American Psychiatric Press. den upsurges of denial concerning parental abuse; these tended to occur when she strongly feared losing the attach­ Braun, B.G., & Sachs, RG. (1985). The development of multiple ment bond to her parents. Her internalized sense of self­ personality disorder: Predisposing, precipitating, and perpetuat­ confidence developed and she found friends, a careerdirec­ ing factors. In RP. Kluft (Ed.), Childhood antecedents ofmultiple per­ tion, and more willingness to try new ventures. sonality (pp. 37-64). Washington, DC: American Psychiatric Press. Ann did not work directly on material related to her mother's failure to respond until after the active abuse had Chu,].A. (1988). Ten traps for therapists in the treatment of trau­ been processed. She allowed herself to feel much younger ma survivors. DISSOCIATION, 1(4), 24-32. than ever before in the treatment, accompanied by intense sadness and mourning. She used her internal "secure base" Coons, P. (1985). Children of parents with multiple personality disorder. In RP. Kluft (Ed.), Childhood antecedents ofmultiple per­ and the therapist as supports for her mourning, no longer sonality (pp.151-165). Washington, DC: American Psychiatric Press. needing the therapist to quell separation anxiety. Although she felt intense sadness, she did not dissociate from it or Coons, P.M., & Milstein, V. (1984). Rape and post-traumatic stress detach from those around her; she knew why she was sad, in multiple personality. Psychological Reports, 55, 839-845. and accepted these feelings as her own. Fagan,]., & McMahon, P. (1984). Incipient multiple personality SUMMARY in children: Four cases. fournal ofNervous and Mental Disease, 172, 26-36. Though the effects of active abuse on the etiology of Fine, e.G. (1988). Thoughts on the cognitive perceptual substrates MPD are important, attachment issues are the central part of multiple personality disorder. DISSOCIATION, 1(4),5-10. of the disorder. Just as the mother's failure to respond to and protect her child affect every developmental task, so do Fraiberg, S., Adelson, E., & Shapiro, V. (1987). Ghosts in the nurs­ attachment issues affect every aspect of the treatment. The ery: A psychoanalytic approach to the problems ofimpaired infant­ achievement of an internalized secure base allows the MPD mother relationships. In L. Fraiberg (Ed.), Selected writings ofSelma patient to abandon dissociation as a coping style, so thatshe Fraiberg. Columbus, Ohio: Ohio State University Press. (Original can feel a part of her world. • work published 1975.)

Furman, R.A., & Furman, E. (1984). Intermittent decathexis-a REFERENCES type of parental dysfunction. IntemationalJournal ofPsychoanalysis, 65, 423-433. Barach, P.M. (November, 1987). Transference reenactments of child abuse in the treatment ofmultiple personality disorder. Presented at the Giovacchini, P.L. (1986) .Developmentaldisorders: The transitionalspace Fifth Conferenceofthe InternationalSociety for theStudyofMultiple in mental breakdown and creative integration. Northvale, ew Jersey: Personality/Dissociative States, Chicago. Aronson.

122 .. DISSOCLUIOX, \'01. 1\'.1':0. 3, September 1991 BARACH

Greaves, G.B. (1988). Common errors in the treatment of multi­ Spiegel, D. (1986). Dissociation, double binds, and post-traumat­ ple personality disorder. DISSOCIATION, 1(1),61-66. ic stress inmultiple personalitydisorder. InB.G. Braun (Ed.), Treatment ofmultiplepersonality disorder (pp. 61-77). Washington, DC: American Greaves, G.B. (1989). Precursors of integration in the treatment Psychiatric Press. of multiple personality disorder: Clinical reflections. DISSOCIA­ TION, II, 224-230. West, LJ. (1967). Dissociative reaction. In A.M. Freeman, & H.I. Kaplan (Eds.), CompTehensive textbook ofpsychiatry (pp. 885 - 899). Katan, A. (1973). Children who were raped. Psychoanalytic study of Baltimore: Williams & Wilkins. the child, 28, 208--224. , Wilbur, C.B. (1985). The effect of child abuse on the psyche. In Kernberg, O. (1984). Severepersonality disorders: Psychotherapeuticstrate­ R.P. K1uft (Ed.), Childhood antecedents ofmultiple personality (pp. 21­ gies. New Haven: Yale University Press. 35). Washington, DC: American Psychiatric Press.

Klaus, M.H., & Kennell,].H. (1982). Maternal-infant bonding (2nd Winnicott, D.W. (1965). Psychotherapy ofcharacter disorders. In Ed.). St. Louis: C.v. Mosby. Winnicott, D.W., The maturational processes and the facilitating envi­ ronment: Studies in the theory ofemotional development (pp. 203-216), K1uft, RP. (1984a). Multiple personality in childhood. Psychiatric ,New York: International Universities Press. Clinics ofNorth America, 7, 121-134.

K1uft, RP. (1984b). Treatment of multiple personality disorder. Psychiatric Clinics ofN01th America, 7, 9-29.

K1uft, RP. (1988). The phenomenologyand treatmentofextreme­ ly complex multiple personalitydisorder. DISSOCIATION, 1(4),47­ 58.

K1uft, R.P. (1990). Introduction. In R.P. K1uft (Ed.). Incest-related syndromes of adult psychopathology (pp. 1-10). Washington, DC: American Psychiatric Press.

Loewenstein, RJ. (in press). Post-traumaticand dissociative aspects of transference and countertransference in the treatment ofmul­ tiple personality disorder. In RP. K1uft & C.G. Fine (Eds.), Clinical perspectives onmultiplepersonality disorder. Washington, DC: American Psychiatric Press.

Putnam, F. (1989). Diagnosis and treatment ofmultiplepersonality dis­ oTder. New York: Guilford Press.

Putnam, F. (April, 1990). MPD: Guidelines for a treatment plan that works. Presented at the Fifth Regional Conference on Multiple Personality and Dissociative States, Akron, Ohio.

Putnam, F.W., Guroff,jJ., Silberman, E.K., Barban, L., & Post, RM. (1986). The clinical phenomenology of multiple personality dis­ order: A review ofl00 recent cases.Journal ofClinical Psychology, 47, 285-293.

Riley, RL., & Mead,]. (1988). The development of symptoms of multiple personality disorder in a child of three. DISSOCIATION, 1(3),41-46.

Robertson,]. (1952). A two-year-old-goes to hospital [Film]. New York: New York University Film Library.

Ross, CA (1989). Multiple personality disorder: Diagnosis, clinicalfea­ tures, treatment. New York: john Wiley & Sons.

Ross, CA, Norton, G.R., & Womey, K. (1989). Multiple person­ ality disorder:Ananalysis of236cases. CanadianJournalofPsychiatry, 34,413-418.

Schreiber, F.R (1973). Sybil. Chicago: Henry Regnery.

123 D1SS0CLUIQi\. Vol. IV. No.3. September 1991