This has been the most enjoyable paper I have ever written.  Given the option, I would gladly do my dissertation on this topic with the contribution of reframing the primary caretaker/attachment figure to be the Holy Spirit, with the parent (when available) or the therapist (when no other healthy options are available) being the secondary healthy attachment figure.  Sadly, since this is a research paper and does not want my opinion, you will not read about the Holy Spirit being the best option for a secure base when healing attachment and dissociation.  But He is!!  He is the only secure attachment that you can have that will never harm you or abandon you.  Blessings, Sharon

ABSTRACT

Dissociation in children caused by trauma includes three main levels of dissociation: mild, moderate, and extreme.  This research paper compares four attachment styles, secure, avoidant, ambivalent/anxious, and disorganized to determine the role that attachment plays in the development of dissociation, prognosis, and treatment.  Using books by qualified professionals in the mental health field and scholarly journal articles published in the last ten years, the conclusion shows that attachment plays a critical role in the development and treatment of dissociation.  Results show that each child will struggle with different levels of dissociation based on individual attachment styles and how the child’s primary caretaker responds at the time of trauma.  Research further illustrates that secure attachment style can be developed in a traumatized child and healing can occur when the child is in a safe environment and involved in healthy interpersonal relationships.  Thus, the healing of attachment is an important key and primary factor in the healing of dissociation in children.

 Dissociation in Children

          Dissociation is experienced at different levels from normal to dysfunctional.  Becoming so involved in a video game that a child forgets about his surroundings is an example of normal dissociation that children may experience.  This type of dissociation does not result in a fragmentation of self, but “becomes part of the person’s story and, thus, a part of the single sense of self” (Wieland, 2015, p. 3).  However, with ongoing trauma, dissociation can move from a normal experience to severe dissociation causing difficulties that often increase as children grow up.  This paper will research mild, moderate, and extreme dissociation in traumatized children, with a focus on what role attachment plays in the development and healing of dissociation.

There are multiple factors that play a role in how a child responds to trauma and on what level they could experience dissociation.  According to Wieland (2015), without intervention the dissociation is likely to continue causing “more and more of the child’s perceptions, feelings, physical sensations, or knowledge of the world to become stored outside active awareness” (p. 3).  The fragmentation can be mild, moderate, or severe and it causes the child to have difficulty with consistent learning and maintaining consistent friendships (Wieland, 2015).  While mild dissociation does not meet the criteria of the DSM-V (2013), the distress of the child is seldom remediated unless the dissociation is addressed within therapy (Wieland, 2015).

Moderate Dissociation allows a child to “block out frightening experiences, strong emotions, body states, emotional needs, and even severe pain” (Wieland, 2015, p. 4).  The child may also experience depersonalization, feeling as if he is observing himself within the situation.  Further, the child may experience derealization, thinking the situation is not really happening, or everything around him may feel unreal (Wieland, 2015).  Although depersonalization and derealization usually starts during a frightening event, new situations can trigger the memory of the original experience on an unconscious level, resulting in the fright response being activated (Wieland, 2015).  The protective response of dissociation is triggered, and each time it occurs “the use of depersonalization or derealization to avoid distress is reinforced” (Wieland, 2015, p. 4).  A similar possible side effect is amnesia, also starting during a frightening event, but may extend to other things, including people, that remind them of the original trauma.  Hence, “some children may lose conscious awareness of small or large chunks of time” (Wieland, 2015, p. 4).  Moderate Dissociation in children may be diagnosed, based on DSM-V (2013) criteria, with Depersonalization/Derealization Disorder, Dissociative Amnesia, Other Specified Dissociative Disorder, or Unspecified Dissociative Disorder (Wieland, 2015, p. 5).

Extreme dissociation is when a child “creates” separate parts of himself to hold the emotions, physical sensations, or experiences that his conscious awareness cannot tolerate. According to Wieland (2015), it occurs when the “dissociation has moved beyond experiences of depersonalization, derealization, or amnesia to an experience of different parts of self” (p. 5).This level of dissociation occurs when the child needs to separate in order to feel safe enough to cope with the current situation (Wieland, 2015).  The dissociative self-states are separated to the point that when in a dissociated self-state, the child may not know that years have passed and he has aged, or that the original trauma is no longer a danger in his current life.  Further, he may not remember things that happened or have the knowledge gained when not in the dissociated self-state (Wieland, 2015).  Because “the child does not recognize when in one state or part that other states or parts exist,” they have “little or no control over which part is presenting at any particular moment” (Wieland, 2015).  According to the DSM-V (2013), this is referred to as Dissociative Identity Disorder (DID).

 Assessments and Attachment Models

          Early assessments for Dissociation must be approached carefully and with an open mind because the child needs to feel safe with the treatment provider before revealing the trauma.  Hence, the evaluator needs to “give the child the sense that any information that is shared is acceptable, and there will be no judgement or overreaction if traumatic information is revealed” (Silberg, 2013, p. 33).  When trauma is revealed during an assessment, the evaluator needs to glean how the child views himself and the meaning of the traumatic event from the child’s perspective.  For example, does the child perceive it to be his fault, think it will always continue to happen, or believe it occurred because he is essentially flawed and allowed it to happen?  According to Silberg (2013), these are important questions to assess because “how the child made sense of the event has the greatest impact on the child’s subsequent symptomatology” (p. 33).  She further explains the need to understand how the child’s own symptoms and behaviors are used to adapt after the trauma.  Does his mind go blank to avoid remembering, is he stealing to handle rage, or fighting with classmates as a way to regain a sense of power?  Processing these questions in early assessment helps the child to know you “believe there is a logical meaning to that behavior”, removing the need for judgement and providing “a logical path to remediation” (Silberg, 2013, p. 34).

It is also important for a therapist to understand the “common classes of symptoms among dissociative children and teenagers” (Silberg, 2013, p. 35).  This can be accomplished by using a variety of checklists, such as the “Child Dissociative Checklist, the Adolescent Dissociative Experiences Scale, or the Child Dissociative Experiences Scale/Posttraumatic Stress Index” Silberg, 2013, p. 35).  Additionally, Silberg (2013) provides a table of Symptom classes that include “Perplexing Shifts in Consciousness, Vivid Hallucinatory Experiences, Marked fluctuations in knowledge, moods, or patterns of behavior and relating, Perplexing memory lapses for one’s own behavior or recently experienced events, and Abnormal Somatic Experiences” (p. 36).  Each class catalogues common symptoms and organizes them into related groups that can be used as a structured interview checklist.

Finally, attachment models must be understood for proper treatment of dissociation and integration, especially in the severe cases of dissociation that meet the requirements of being classified as Dissociative Identity Disorder (DID).  According to Hart (2013), “DID can be regarded as an attachment disorder” because parental neglect and relational trauma can cause detachment from signals “that would activate their attachment behavior that would enable them to love and experience being loved” (p. 304). Attachment plays a critical role in how the child will respond to a traumatic event and if dissociation will become the child’s way of dealing with the trauma and things that trigger memories of the trauma in the future (Wieland, 2015).  Research shows that “dependable attachment bonds, wherein the caregiver responds promptly and appropriately to the positive and negative states of the child, are vitally important to the child’s development of his or her coping capacities” (Baker, 2010, p. 79).  For example, when a caregiver is available to model regulatory processes by “rocking a crying baby, laughing with a happy baby, and soothing a fussy baby” the child starts to expect that uncomfortable states can be soothed (Silberg, 2013, p. 149).  Accordingly, interaction with an attentive caregiver who models these regulatory processes enables the child to learn to self-regulate.  However, Silberg (2013) explains that when “early caregiving is unresponsive to overwhelming affect in the developing child, the child may be left with emotional arousal that vacillates between extremes of over-arousal and under-arousal” (p. 149).  A child who is unable to self-soothe will look for other ways to regulate their mood such as self-harm to release endorphins, or destructive acts to hurt the people whose attachment they fear they have lost (Silberg, 2013).

Attachment Styles

          There are four common attachment styles known as secure attachment, avoidant attachment, ambivalent/anxious attachment, and disorganized attachment.  First, a secure attachment with a primary caregiver creates a “good enough” environment for the “internalization of positive object relations and a secure integrated sense of self” to develop (Baker, 2010, p. 79).  Secure attachment not only occurs with the physical presence of the attachment figure, but also the child’s “belief that the attachment figure will be available if needed” (Cassidy & Shaver, 2008).  God created the framework of secure attachment to occur in infancy, providing a secure base from where the child can safely explore his world and know that his needs would be met.  When a traumatic event happens in the life of a securely attached child, the caregiver “can provide sensitive care and a sense of protection, keeping the child from experiencing “fright without solution” (Cassidy & Shaver, 2008).

Second, when avoidant attachment style is seen, the insecure-avoidant infants often grow to become dismissive adolescents.  The avoidant infant plays independently, paying more attention to his toys than his mother, not showing concern when she leaves the room, and ignoring her when she returns (Straus, 2017).  Avoidant children focus on the external world instead of internally or on their caregivers.  They are also more aggressive and engage in more negative interactions with peers than securely attached children (Straus, 2017).  Furthermore, because they are distant, “adults view them more negatively and discipline them more often, thus reinforcing their untrusting assumptions about not being able to rely on others (Straus, 2017, p. 18).  As adolescents, they are dismissive of attachment-related experiences and ignore or deny the needs that might trigger the need for an attachment system.  Likewise, they will “compartmentalize negative emotions to avoid the frustration and distress caused by the unavailability of attachment figures” (Straus, 2017, p. 18).

Third, when ambivalent/anxious attachment style is seen, insecure-ambivalent infants often grow to become preoccupied adolescents.  These infants lack confidence that the attachment they long for will be available because their mothers are “insensitive and inconsistently responsive to their signals” (Straus, 2017, p. 20).  These babies very much want to be held, but when united with their mothers, they reject close contact and won’t allow soothing to occur.  According to Straus (2017), this happens because they are angry that they don’t get picked up enough and anxious from not being able to anticipate how their mothers will respond to them.  Ambivalent children are at higher risk for developing separation anxiety, be more socially withdrawn, and struggle to make friends.  As adolescents, they make excessive demands for attention, feel incapable of self-soothing, and become entirely dependent on others for comfort (Straus, 2017).  Unfortunately, in their desperate attempts to have their attachment needs met, they “tend to have volatile and unsatisfying relationships” (Straus, 2017, p. 21).

Lastly, when disorganized attachment style is seen, insecure-disorganized infants often grow to become fearful-unresolved adolescents.  While avoidant and ambivalent/anxious attachment styles are seen in dissociation, disorganized attachment is by far the most prevalent.  Straus, (2017) states, “the frozen trancelike states we see in disorganized-type infants may be the precursor to dissociative ‘blanking out’ in childhood” (p. 22).  She further says, “they tend to be the least trusting, most impaired, and dissociative of all” (Straus, 2017, p. 22).  These infants are often parented by parents with their own history of severe trauma, “began life in orphanages, or with brutally abusive or unpredictable substance-addicted parents who were, impossibly, both the source of security and fear” (Straus, 2017, p. 21). These children have significant trouble with friendships, academic ability, and diminished self-confidence.  Overall, this attachment style is “highly correlated with dissociative coping as a defense” (Straus, 2017, p. 22).

Treatment

            When treating dissociation, treatment goals at each level of treatment should include creating secure attachment to aid in the resolution of dissociation (Wieland, 2015).  The first stage of treatment typically involves stabilization and symptom reduction.  In this stage, the primary goal is to establish “a positive therapeutic relationship enabling the individual to work through the fear (phobia) of attachment and the fear (phobia) of attachment loss” (Wieland, 2015, p. 30).  Additionally, in extreme dissociation, this must occur with each of the self-states, bringing each self-state that does not understand time has passed or the situation has changed, into the awareness that they are now safe in their present world.  If a child can recognize the changes that keep him safe, he can learn to shift from behavioral reactions to past trauma, such as dissociation.  Over time, he can learn to respond to what is happening in the present situation in new ways through positive interpersonal interaction with a therapist and engaged caretaker (Wieland, 2015).  These positive experiences create “healthier firing within the brain, inter-connective firing” that eventually allows memories to be integrated (Wieland, 2015, p. 26).  It is only when all self-states feel safe that the child can enter the second stage of therapy and begin to process the trauma.  Processing the trauma includes sharing the trauma memories of each split off self-state with the core-self and coming to accept that the trauma of the self-states belongs to the core-self (Wieland, 2015).  In the third stage, integration occurs and the integrated whole self learns “adaptive coping skills and the information that may have been missed during times of dissociating” (Wieland, 2015).

It is outside the scope of this paper to discuss the details of therapeutic interventions that lead to integration and secure attachment models for traumatized children.  Nonetheless, the basic principle of the therapeutic relationship appears to extend across all relative treatment models.  Secure attachment is the framework of healthy children thus this must be available for healing of dissociation to transpire.  Ideally, the primary relationship in which attachment skills are learned is with the caretaker, and “one of the main goals of treatment is to help the family learn how to provide the safety and trust the young client needs” (Silberg, 2013, p. 56).  Yet, for some children, “parents will never achieve the psychological skills to provide the unconditional love these children require, the relationship with the therapist may be their only opportunity to experience a relationship based on respect and nurturing” (Silberg, 2013, p. 56).

In conclusion, research shows that the attachment style of the child plays an important role in the predictability of a child developing dissociation as a coping skill to deal with traumatic events.  Determining the attachment style of the child provides a starting point for the therapist to address the unmet needs of children who do not have a secure attachment with a primary caretaker.  A child must feel safe and understand that his current situation has changed; then healing from traumatic memories can occur within a therapeutic environment.  Developing secure attachment can happen as positive interpersonal interactions occur with therapists and caretakers, allowing the child to develop a sense of trust, and safety.  This diminishes the need for dissociation and with completed treatment, can allow children to live full, productive lives that bring glory to God.

 

References:

Baker, K., (2010). From “it’s not me” to “it was me, after all”. Psychoanalytic Social Work, 17, 79-98. doi:10.1080/15228878.2010.512263

Cassidy, J., & Shaver, P. R. (Eds.). (2014). Handbook of attachment: theory, research, and clinical applications. Retrieved from https://ebookcentral-proquest-com.ezproxy.liberty.edu

Hart, C., (2013). Held in mind, out of awareness. Journal of Child Psychotherapy, 39, 303-318. doi.org/10.1080/0075417X.2013.846577

Silberg, J.L. (2013). The child survivor: Healing developmental trauma and dissociation. Retrieved from https://www-taylorfrancis-com.ezproxy.liberty.edu/books/9781136821189

Straus, M. B. (2017). Treating trauma in adolescents: development, attachment, and the therapeutic relationship. Retrieved from https://ebookcentral-proquest-com.ezproxy.liberty.edu

Wieland, S. (Ed.). (2015). Dissociation in traumatized children and adolescents: Theory and clinical interventions. New York, NY: Routledge.