Blizard, R.A. (1997). The origins of dissociative identity disorder from an object relations and attachment theory perspective. Dissociation, 10(4), 223-229. abstract
Blizard, R.A. (1997). Therapeutic alliance with abuser alters in dissociative identity disorder: The paradox of attachment to the abuser. Dissociation, 10(4), 246-254. abstract
Blizard, R.A. (2001). Masochistic and sadistic ego states: Dissociative solutions to the dilemma of attachment to an abusive caretaker. Journal of Trauma and Dissociation, 2(4), 37-58. abstract
Blizard, R.A. (2003). Disorganized attachment, development of dissociated self states, and a relational approach to treatment. Journal of Trauma and Dissociation, 4(3), 27-50. abstract
Blizard, R.A. (2003). Why Was Dissociation Dissociated in Psychoanalysis? Journal of Trauma and Dissociation, 4(3), 27-50. abstract
Blizard, R.A. (2006). Prevention of intergenerational transmission of child abuse: a national priority. Journal of Trauma and Dissociation, 7(3), 1-6. abstract
Blizard, R.A. (2009). The role of double binds and chronic relational trauma in the genesis and treatment of Borderline Personality Disorder. In Moskowitz, A., Schäfer, I. & Dorahy, M. (Eds.) Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Wiley. abstract
Blizard, R.A. & Bluhm, A.M. (1994). Attachment to the abuser: Integrating object-relations and trauma theories in treatment of abuse survivors. Psychotherapy, 31(3), 383-390. abstract
Howell, E. F. & Blizard, R.A. (2009). Chronic relational trauma disorder: A new diagnostic scheme for borderline personality and the spectrum of dissociative disorders, in Dell, P. F. & O’Neil, J. A., (eds.), Dissociation and the dissociative disorders: DSM-V and beyond. New York: Routledge. abstract
Blizard, R.A. (1997). The origins of dissociative identity disorder from an object relations and attachment theory perspective. Dissociation, 10(4), 223-229.
Abstract: When a child is utterly dependent for survival on a parent or caregiver who is abusive, the child faces an extraordinary dilemma in finding a way to preserve the attachment to the caregiver while trying to survive terrifying abuse. Concepts from object relations and attachment theories will be integrated with current thinking about trauma and dissociation to develop a theory of why multiple identity states are created by the child to survive this paradox. According to this view, alter personalities may be understood as over-elaborations and personifications of internalized, split, self and object representations. Because of the severity of trauma, these were kept separate and dissociated in order to preserve both the self and the attachment to the "good" aspects of the caregivers while allowing the child to survive by maintaining functioning relationships with the "bad" aspects of the caregivers. Understanding the origins of these personality states in childhood object relations can help to elucidate the dynamics of the relationships within the system of personalities in adulthood. They can also clarify the purpose of reenactment of abuse, whether between two self states, or in external relationships. These principles are illustrated with a case example.
Blizard, R.A. (1997). Therapeutic alliance with abuser alters in dissociative identity disorder: The paradox of attachment to the abuser. Dissociation, 10(4), 246-254.
Abstract: Abuser alters present a dilemma in the treatment of adults with dissociative identity disorder, because they often undermine the therapy as well as re-abuse the patient. They are paradoxical because they were created to help the child survive abuse, but continue to do so by abusing the self. They were often modeled after an abusive primary caretaker to whom the child was attached. Object-relations and attachment theories clarify how creation of the abuser personality serves to preserve the attachment to the abusing caretaker. By understanding how abuser alters function to maintain attachment, contain overwhelming memories, and protect against abuse, therapists can better engage abuser alters in a therapeutic alliance. Empathy, cognitive reframing, and gentle paradoxical techniques can help host and abuser personalities become more empathic toward one another, develop common purpose, and begin integrating. By working through the transference, attachment to the internalized abusive caretaker is replaced by healthy attachment to the therapist in the therapeutic alliance.
Blizard, R.A. (2001). Masochistic and sadistic ego states: Dissociative solutions to the dilemma of attachment to an abusive caretaker. Journal of Trauma and Dissociation, 2(4), 37-58.
Abstract: A theory describing the development of alternating, dissociated, victim/masochistic and perpetrator/sadistic ego states in persons who grew up with abusive primary caretakers will be proposed and a paradigm for treatment will be derived from the theory. Alternating ego states can be observed throughout the spectrum of dissociative disorders, from Borderline Personality to Dissociative Identity Disorder. Dependence on an abusive caretaker creates a series of relational dilemmas for the child. To maintain attachment, abuse must be dissociated, but to protect the self from abuse, need for attachment must be disavowed. Disorganized attachment may result. Incompatible internal working models, using parallel masochistic and sadistic defensive strategies, may be developed and elaborated into ego states. Masochistic and sadistic defenses are ultimately maladaptive, because they require dissociation of need for either self-protection or attachment. Each defensive attempt at resolving a relational dilemma leads to another impasse, a change in defensive strategy, and perhaps a shift in ego state. When alternating ego states are understood as evolving from defensive schemas developed to negotiate the dilemmas of attachment to an abuser, the following therapeutic techniques can be derived: 1. identifying adaptive needs and maladaptive defenses, 2. interpreting ego state switches as attempts to resolve relational dilemmas, 3. gradually bridging dissociation between states, 4. using transference and countertransference to understand relational patterns, and 5. cultivating more adaptive interpersonal skills within the therapeutic relationship.
Blizard, R.A. (2003). Disorganized attachment, development of dissociated self states, and a relational approach to treatment. Journal of Trauma and Dissociation, 4(3), 27-50.
Abstract: Disorganized (D) attachment, and the double-bind characteristics of the relationships that foster it, form a basis for theoretical approaches to understanding the development of alternating, dissociated self states with incompatible, idealizing/devaluing or victim/persecutor, models of attachment, such as are observed in borderline personality and dissociative disorders. This model proposes that the double binds inherent in abuse by a primary caretaker are likely to generate two or more, dissociated self states, with contradictory working models of attachment. In contrast, because dissociated states ensuing from extra-familial trauma can be expected to have been constructed primarily around fear, all parts of the self will operate according to the same attachment paradigm. Because relationships within the family of origin appear at least as important as trauma in the development of dissociated self states, this has important implications for treatment of child abuse survivors. D attachment may result from several parental behaviors: abuse, neglect, frightening, intrusive or insensitive manner; and disrupted affective communication. Longitudinal research demonstrates that D attachment in infancy predicts dissociation in childhood and early adulthood. Theoretical models describing the relationships among D attachment, the development of segregated internal working models of attachment, and the emergence of dissociated self states will be discussed. A relational approach to therapy calls for consideration of attachment issues in creating the frame for therapy and tailoring treatment to the individual trauma survivor. The therapist can serve as a relational bridge between dissociated self states, allowing the patient to internalize a working model of the therapeutic relationship. This interaction provides a vehicle for integrating dissociated self states and opportunity for development of more flexible, adaptive models of being with others.
Blizard, R.A. (2003). Why Was Dissociation Dissociated in Psychoanalysis? Journal of Trauma and Dissociation, 4(3), 27-50.
We so often find that for our patients, experiences that are overwhelming and incomprehensible have been minimized, marginalized, denied, disavowed or dissociated. The most incomprehensible experience for our patients, and thus most likely to be dissociated, is having been abused by someone to whom they were strongly attached, such as a parent. As clinicians and scholars, we are vulnerable to the same defenses, and history has shown that many have grasped eagerly at alternative explanations both for patients reports of abuse and for the dissociative symptoms ensuing from such trauma. These rationalizations made it possible for many psychoanalysts to explain away memories of abuse as fantasy, thus relieving them of the need to acknowledge that memory for objective events can be dissociated.
In working with traumatized parents, we sometimes observe a real disconnect between the parent and young child, despite the determination of the parents to be caring and protective. Some of these children become caretakers of their parents, while others learn to get attention through negative behavior. Often, there is alternation between solicitous and contrary behavior, laying the foundation for borderline personality and dissociative self-states (Blizard, 2003; Lyons-Ruth, 1999). If there is neglect or trauma, these children may develop dissociative disorders (Liotti, 1992, 1999). For all of these reasons, long-term, relationship-oriented treatment of abused or dissociative caregivers can have significant preventive effects on the mental health of their children and grandchildren.
Blizard, R.A. (2006). Prevention of intergenerational transmission of child abuse: a national priority. Journal of Trauma and Dissociation, 7(3), 1-6.
An ounce of prevention is worth a pound of cure. This maxim is no more true than in the treatment and prevention of child abuse. Research on, treatment for, and prevention of child abuse and related disorders should be the highest priority for our nation (Freyd et. al., 2005). Failure to prevent and treat severe, chronic childhood abuse comes at tremendous cost to society and to the individuals and families affected. In addition to lost work and medical care for eating disorders, self-injury and stress-related illness (Whitfield, 1998), treatment may require years, including intensive outpatient psychotherapy, possible repeated hospitalizations or substance abuse treatment, and family therapy for affected partners and children. Studies increasingly show that persons incarcerated for substance abuse and violent crimes have long histories of neglect and abuse, all of which comes at great financial cost to society and emotional cost to their families. Perhaps the greatest loss is to the children of abuse survivors.
Blizard, R.A. (2009). The role of double binds and chronic relational trauma in the genesis and treatment of Borderline Personality Disorder. In Moskowitz, A., Schäfer, I. & Dorahy, M. (Eds.) Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Wiley.
The essence of borderline personality disorder (BPD) has been something of a conundrum. It has been variously conceptualized as 1) on the border with psychosis, 2) a level of personality organization more pathological than neurosis, 3) a pattern of unstable and intense relationships, and 4) a complex traumatic stress disorder. In the DSM-IV (APA, 1994), BPD can be defined by a wide variety of symptoms, suggesting widely differing disorders and levels of severity. The DSM-IV briefly acknowledges the presence of dissociative or psychotic-like symptoms and a history of childhood abuse, neglect and loss, while it emphasizes the instability of relationships, self-image and affect. What has not been recognized until recently is the prevalence of childhood trauma and the pervasiveness of dissociative processes in persons with BPD. Trauma-based dissociative processes may underlie most of the symptoms described in the diagnostic criteria for BPD, including the apparently psychotic symptoms. More important, dissociation based in the double binds inherent in chronic relational trauma may account for the essential characteristic of BPD, the instability of identity, affect, behavior and relationships. In BPD, acute, episodic impairment in reality testing is based on dissociative symptoms such as illusions, disorientation and flashbacks. A more pervasive and essential form of impairment of reality testing seen in BPD is based on polarized, severely distorted perceptions of self and others. These distortions may be patterned on the quality of attachment relationships with dysfunctional caregivers in childhood.
Blizard, R.A. & Bluhm, A.M. (1994). Attachment to the abuser: Integrating object-relations and trauma theories in treatment of abuse survivors. Psychotherapy, 31(3), 383-390.
Abstract: Attachment to the abuser often occurs when the primary caretaker of an abuse survivor was abusive. Attachment and object-relations theories help to explain this attachment and can inform the treatment of survivors. These theories are integrated with current knowledge of post-traumatic stress disorder and dissociation to explain the defenses used by survivors to maintain attachment to the abuser and to clarify patterns of attachment in survivors’ adult relationships. This integration of theories informs the pacing of treatment and offers insight into transference and counter transference issues.
Howell, E. F. & Blizard, R.A. (2009). Chronic relational trauma disorder: A new diagnostic scheme for borderline personality and the spectrum of dissociative disorders, in Dell, P. F. & O’Neil, J. A., (eds.), Dissociation and the dissociative disorders: DSM-V and beyond. New York: Routledge.
Borderline personality may be best understood, and its etiology most accurately described, as a disorder of trauma, attachment, and dissociation. Dissociated self-states underlie the stable instability, i.e., the affect dysregulation, unstable identity and sudden changes in relationships, that characterizes BPD. The dissociative disorders literature describes highly conspicuous dissociative symptoms and florid manifestations of fully dissociated self-states, i.e., alter personalities. The dissociative symptoms of BPD may often be overshadowed by problematic behavior. More important, the alternating self-states in BPD are often partially, rather than fully dissociated, thus their dissociative nature is easily missed.