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2011-21820-002 Desarrollo Psicopatologia y Apego
2011-21820-002 Desarrollo Psicopatologia y Apego
Giovanni Liotti
APC School of Psychotherapy, Rome, Italy
232
Journal of Psychotherapy Integration © 2011 American Psychological Association
2011, Vol. 21, No. 3, 232–252 1053-0479/11/$12.00 DOI: 10.1037/a0025422
Special Issue: Disorganized-Controlling Strategies 233
developments.
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The key concept advanced to explain the link between infant DA and
caregiver’s unresolved states of mind is that these states of mind create the
base for a caregiving attitude that is frightening to the child (Main & Hesse,
1990). The unwitting rehearsal of a traumatic memory during caregiving
interactions may appear as an expression of fear in the caregiver face or
general attitude, in contexts that are devoid of danger. Another possibility
is that the unresolved trauma makes the caregiver more prone to become
aggressive toward the infant. The two possibilities are captured by the
phrase “frightened/frightening (FR) caregiving behavior” (Main & Hesse,
1990). FR caregiving behavior causes “fright without solution” in the
infant, because “the caregiver becomes at the same time the source and the
solution of the infant’s alarm” (Main & Hesse, 1990, p. 163). Fear comes to
coexist paradoxically, in the infant’s experience, with the soothing provided
by proximity to the caregiver. A study by Schuengel et al. (1999) provides
empirical support to the hypothesis that FR behavior is the main mediating
factor between the caregiver’s state of mind and the infant’s DA.
Special Issue: Disorganized-Controlling Strategies 235
attachment figure. The two systems, however, clash in any type of infant–
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caregiver interaction where the caregiver becomes at the same time the
source and the solution of the infant’s fear (Liotti, 2004). Being exposed to
frequent interactions with a FR caregiver, infants are caught in a relational
trap: their defense system motivates them to flee from the caregiver, while
at the same time their attachment system motivates them, under the
commanding influence of separation fear, to strive for achieving comforting
proximity to her or him.
Liotti (1995, 2004) suggested to use the idea of drama triangle originally
coined by Karpman (1968) in a different clinical–theoretical context. In the
drama triangle, representations of self and others shift from the prototype
of the rescuer to those of the persecutor and the victim. In the disorganized
IWM, the attachment figure is represented negatively, as the cause of the
ever-growing fear experienced by the self (self as victim of a persecutor),
but also positively, as a rescuer: the parent, although frightened by unre-
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to the child, and the child may feel such comforting availability in conjunc-
tion with the fear. Together with these two opposed representations of the
attachment figure (persecutor and rescuer) meeting a vulnerable and help-
less (victim) self, the disorganized IWM also conveys a negative represen-
tation of a powerful, evil self meeting a fragile or even devitalized attach-
ment figure (persecutor self, held responsible for the fear expressed by the
attachment figure). Moreover, there is the possibility, for the child, of
representing both the self and the attachment figure as the helpless victims
of a mysterious, invisible source of danger. Finally, because the frightened
attachment figure may be comforted by the tender feelings evoked by
contact with the child, the implicit memories of disorganized attachment
may also convey the possibility of construing the self as the powerful
rescuer of a fragile attachment figure (i.e., the little child perceives the self
as able to comfort a frightened adult).
Indirect empirical support to the above conceptualization of the dis-
organized IWM is provided by two types of research data. School-age
children who had been disorganized infants assume either caregiving (res-
cuer) or punitive (persecutor) attitudes toward their caregivers (Hesse et
al., 2003; Lyons-Ruth & Jacobvitz, 2008; Main & Cassidy, 1988). In another
series of research studies (Lyons-Ruth, Yellin, Melnick, & Atwood, 2005),
adults who reported histories of traumatic attachments and whose children
developed disorganized attachments toward them typically show multiple,
nonintegrated dramatic representations of self and attachment figures,
shifting from hostility (persecutor) to helplessness (victim) and to compul-
sive caregiving (rescuer).
be emphasized, does not imply that children who have been disorganized
infants constantly show, during their development, disassociated, utterly
incoherent, and dysregulated mental states in their interactions with other
people. On the contrary, before they reach school age, almost all children
who have been disorganized in their infant attachments develop an orga-
nized behavioral and attentional strategy toward their caregivers. Research
data suggest that a majority of DA children achieve such an organization
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cope with the shattered states brought on by the activation of the disorga-
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Since the publication of Main’s (1991) seminal paper stating the pos-
sibility of multiple and incoherent IWM of a single attachment figure, a
number of theoretical and clinical studies advanced the hypothesis that
infant DA may be the first step in developmental pathways characterized
by less than optimal or even frankly defective capacity for mental integra-
tion of emotional-interpersonal information (Fonagy, 1999; Fonagy et al.,
1995; Liotti, 1992, 1993, 1995, 1999; Main & Morgan, 1995). These studies
argued that DA attachment is a risk factor in the development of disorders
implying dissociative processes and/or borderline features. A few research
studies lent support to the hypothesis (Carlson, 1998; Liotti, Pasquini &
The Italian Group for the Study of Dissociation, 2000; Ogawa et al., 1997;
Pasquini, Liotti, & The Italian Group for the Study of Dissociation, 2002;
West, Adam, Spreng & Rose, 2001). However, later empirical studies and
critical reviews on the role of DA in developmental psychopathology
suggest that its influence may be widespread and extended to developmen-
tal itineraries leading to different syndromes besides those showing explicit
240 Liotti
strategies stemming from infant DA may further explain how disorders not
explicitly involving dissociative symptoms may be based on the dissociative
processes characterizing the IWM of DA. As far as the IWM is kept at
brake by a controlling punitive strategy, for instance, developmental path-
ways stemming from a latent tendency toward dissociation may involve
abnormal aggressive dominance in interpersonal relations (that may be-
come a risk factor for antisocial personality disorder) rather than frankly
dissociative symptoms. On theoretical grounds, therefore, different itiner-
aries of personality development may be started by early DA (Liotti, 1992).
1. Infant DA is not followed by pathological developmental pathways,
because of socially rewarding controlling strategies (e.g., controlling care-
giving strategies) or later corrective relational experiences that bring the
formerly disorganized IWM toward attachment security. This is likely to be
a frequent occurrence in the life of people who had been disorganized in
their infant attachments, as suggested both by epidemiological consider-
ations (DA is a frequent occurrence in samples from low-risk families) and
by research findings suggesting that infant DA is not significantly predictive
of psychopathology in preschool years (e.g., it does not seem to predict
externalizing disorders in preschool children: Keller, Spieker & Gilchrist,
2005). As long as the defensive controlling strategies are in place, and the
attachment system is not activated in any strong an prolonged way, there
is no theoretical reason to expect that the disorganized IWM manifests its
dissociative features and its link with memories of fright without solution.
2. Controlling strategies and persistent inhibition of the attachment
system may pave the way to developmental processes leading to adolescent
or adult personality disorders that do not involve dissociative experiences.
This is particularly likely to happen if no adverse life event (e.g., traumas,
separations and losses) causes the collapse of the controlling strategies
during personality development, but the type of controlling strategies is not
socially acceptable (e.g., controlling punitive). The personality disorders
stemming from these developmental pathways may be occasionally com-
plicated by dissociative and/or anxiety symptoms when patients are con-
fronted with stressors that activate the attachment system. It is noteworthy
that these symptoms may subside quickly if the patient is able to resort to
the controlling defenses (i.e., with aggressive-punitive interpersonal behav-
Special Issue: Disorganized-Controlling Strategies 241
ior or with a compulsory caregiving attitude), but they tend to recur every
time a distressing life event activates the attachment system again.
3. Traumatic events may repeatedly impinge on a disorganized
attachment system during development, causing the collapse of the
controlling strategies, the reactivation of the disorganized IWM, and the
dissociative experiences contingent upon such a reactivation. It is argu-
able that this line of development plagues the mental growth of children
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living in maltreating families and constitutes a major risk factor for the
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Relational Dilemmas
the widely diffused notion that having two therapists operating in two
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tina, & Farina, 2008). Only when they are organized as “one-team interven-
tions” (Bateman & Fonagy, 2004) can parallel integrated treatments offer
precious opportunities for corrective relational experiences that do not require
in advance the use of mentalization capacities but can foster these capacities.
Resistance to Change
M. I’m not going to tell you anything anymore. What is the purpose
when I am worse than ever?
T. Then I’ll advance an hypothesis. In the last session you said you
were considering divorce. Maybe this is not an easy decision to take.
Maybe the prospect of separating and living on your own caused anxiety.
In the past, we noticed that when you are afraid of something, particularly
afraid of loneliness, you tend to become somehow aggressive toward
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people in general.
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CONCLUDING REMARKS
1
This episode has been reported to me by my Colleague, Dr. Fabio Monticelli, from the
transcript of a psychotherapy session. I gratefully acknowledge his help in my search for a
concise example of the integrative power of attachment theory while exploring resistance to
change in psychotherapy. Data concerning the patient have been disguised so as to make it
impossible to identify her.
248 Liotti
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