Attachment Relationships & Developmental Trauma Disorders: Nuances and Treatment

Abstract
Evidence is mounting that complex PTSD, borderline (BPD) and narcissistic (NPD) personality disorders, and severe dissociative disorders (DD) are not caused by trauma alone, but by a combination of chronic interpersonal trauma and disrupted attachment. This workshop is designed to expand the understanding of attachment theory, from the lens of developmental psychology to clinical applications, in the treatment of dissociation and complex trauma.

We will introduce background information about attachment theory and the different ways of measuring it, beginning with an outline of the three major organized attachment categories, and multiple sub-categories within these major classifications. There will be an in-depth focus on discreet and global disorganization states and how they are recognized and approached clinically. Examples from research and clinical experience will be provided to illustrate the theoretical content, with an emphasis on disorganized strategies, culminating in a brief discussion on extreme cases of patients who are “Unattached.” The workshop will demonstrate how to recognize attachment clues embedded in the discourse within the therapeutic relationship and how to ‘hear’ implicitly encoded states of mind about attachment, including past and present loss, traumatic events, and ongoing activation of hostile and/or helpless states of mind. It is equally important to appreciate the dynamic nature of attachment behaviors and how they can shift during clinical treatment. The clinical pitfalls that may arise when therapist’s and patient’s internal working models of attachment collide or entangle during times of stress will be explored.

We will then focus on chronic relational trauma and insecure or disorganized attachment and how these interact to create the characteristics of Developmental Trauma Disorder (DTD) and cPTSD. We will review the antecedents and characteristics of DTD in children, and cPTSD, BPD, NPD and DD in adults. Disorganized attachment may foster dissociated representations of self and other, as well as the strategies needed for negotiating relationships. Dissociation of traumatic experiences may in turn contribute to fragmentation of internal representations of relationship patterns. We’ll explore the implications for integrating treatment of trauma and dissociative symptoms with therapy for disorders of abilities to form relationships. We will demonstrate the applications of attachment theory to relational therapies, including transference and countertransference dynamics. Because dissociated self-states play essential roles in maintaining attachment, self-protection, and the integrity of self-structure, the importance of carefully pacing the integration of dissociated memories and self-states will be emphasized.

Clinical examples will illustrate how disorganized attachment can lead to alternating, dissociated self-states, from the partially dissociated ego states evident in BPD, to the personified states with full amnesia seen in DID. This range of dissociative symptoms is seen in DTD, cPTSD, BPD and NPD, and the spectrum of dissociative disorders. Therapy vignettes will demonstrate how to integrate alternating self-states. The workshop will conclude with open questions and discussion with the participants. Through lecture/discussion, we will move the invisible internal working models of attachment relationships into the visible therapeutic interaction.

Timed Outline
5 Minutes - Overview and Objectives
15 Minutes - Attachment Assessments and Major Organized Classifications
5 Minutes - Disorganized Attachment Classifications
5 Minutes - Assessment Measures
30 Minutes - Adult Attachment Interview and Classifications
20 Minutes - Subclassifications
10 Minutes - Q&A
30 Minutes - Break
15 Minutes - Intro to attachment in personality & dissociative disorders
15 Minutes - Developmental Trauma Disorder - DTD A precursor to BPD, NPD, DID
30 Minutes - Why dissociated states form: Attachment to an abusive caregiver, relational dilemmas
30 Minutes - Borderline and Narcissistic Personality Disorders
90 Minutes - Lunch
30 Minutes - Unresolved Examples
10 Minutes - Hostile Helpless and AAI
20 Minutes - Dissociation, Attachment and Therapeutic Implications
30 Minutes - Break
30 Minutes - Treating victim and perpetrator self-states – the relational bridge
30 Minutes - Identifying double-binds and intervening in shifts between self-states
30 Minutes - Recognizing self-state shifts in role-play of therapy sessions