Through the lens of attachment relationship: Stable DID, active DID and other trauma-based mental disorders

ABSTRACT

Some people with DID, despite years of DID-specific therapy (using the three-phase approach, ISSTD, 2011), seem unable to get better. In particular, they seem unable to remain physically safe (“Phase One”) and report continued exposure to abuse. As every fresh hurt causes fresh dissociation, their DID becomes further entrenched over time. Moreover, as dissociation makes the person more vulnerable to being re-abused, they become caught up in a vicious cycle, which further obstructs their efforts toward recovery. In this paper, I propose the existence of two distinct presentations of DID, a Stable and an Active one. While people with Stable DID struggle with their traumatic past, with triggers that re-evoke that past and with the problems of daily functioning with severe dissociation, people with Active DID are, in addition, also engaged in a life of current, on-going involvement in abusive relationships, and do not respond to treatment in the same way as other DID patients. The paper observes these two proposed DID presentations in the context of other trauma-based disorders, through the lens of their attachment relationship. It proposes that the type, intensity and frequency of relational trauma shape—and can thus predict—the resulting mental disorder. It then offers an initial (partial) classification of trauma-based attachment modes and their corresponding symptomatic sequels. The analysis and formulations presented in this paper are based on attachment theory and extensive clinical observations.

KEYWORDS:

• Active DID
• infanticidal attachment
• stable DID
• the three-phase approach
• trauma-based mental disorders

Notes

1. The clinical examples in this paper are drawn from my extensive clinical work as a therapist, supervisor, case manager and an expert witness to the court. To preserve anonymity, all identifying details have been changed and the short vignettes used as illustrations are amalgamations of frequently seen examples. The one exception is the case of Paula, which, at her own request, is reported with only minimal changes.

2. Van der Hart et al. (2006) also remark on this difficulty, see p. 217.

3. The term “attachment mode” is used throughout this paper in preference to the more widely (and interchangeably) used “attachment style,” “attachment pattern” or “attachment type”.

4. In some species, where the offspring have no direct connection to the parents (e.g., most fishes), the attachment is to the group of siblings, which offers “security in numbers”.

5. An example of minimal gaps between high intensity episodes is children who are abused by multiple perpetrators, in a “culture” of abuse and where their contact with the rest of society is restricted. These children are at the highest risk of remaining involved in a severely abusive relationship which continues into their adulthood (Middleton, 2013a)

6. Kahr even considers some cases of schizophrenia to be expression of infanticidal attachment, because the confusion of the schizophrenic discourse complies with the parental need to hide the cause of terror (the parent’s murderousness) from the world.

7. (Bowlby, 1979, 1984; Brand et al., 2013; Chu, 2011; Courtois, 2010; Dorahy et al., 2014, 2016; Hesse, 1996; Kahr, 2007; Laing & Esterson, 1964; Lidz, 1973; Main & Solomon, 1986; Middleton, 2013b; Ross, 2007; Van der Hart et al., 2006; to name but a few).

8. Nijenhuis (2015), too, suggests that the link between trauma-related structural dissociation of the personality (TSDP) and mental disorders is not random, but is ordered according to what he calls “a dimension of severity”: “TSDP postulates that the dissociation of the personality is severe in major DID, marked in most cases of minor DID, moderate in spirit possession disorder, complex PTSD… significant in simple PTSD… [and] absent to insignificant in patients with other mental disorders and in mentally health individuals” (p. 135).

9. For full discussion of the complexities of attachment in these circumstances, see Sachs, 2008 on second-generation Holocaust survivors.

10. Some non-relational trauma (e.g., imprisonment) may become relational over time, as attachment relations may develop with one’s captors.