From Attachment to Collaboration:
Dissociation and Schizophrenia
1. Summary 1
2. Causes and Effects 2
3. What are the Issues? 4
4. Collaboration Technologies 5
5. The Global Network 6
6. A Brief History of Schizophrenia 6
7. Dysfunctional Collaboration in the Family 8
8. The Fallacy of the 50% Concordance Rate 9
9. Schizophrenia in Deprived Communities 10
10. The last 6 Million Years 11
11. Ritual Abuse and DID 12
12. Conclusions 13
13. References 14
14. CV 17
1. Summary 1
2. Causes and Effects 2
3. What are the Issues? 4
4. Collaboration Technologies 5
5. The Global Network 6
6. A Brief History of Schizophrenia 6
7. The Fallacy of the 50% Concordance Rate 8
8. Dysfunctional Collaboration in the Family 9
9. Schizophrenia in Deprived Communities 10
10. The last 6 Million Years 11
11. Ritual Abuse and DID 12
12. Conclusions 13
13. References, Incomplete 14
7733 8138 words
1. Summary
At first sight Dissociative Identity Disorder, DID, and schizophrenia seem as far apart as any two conditions could be. DID is almost entirely seen as an immediate consequence of severe early abuse (Fonargy, 1995) whereas schizophrenia is largely seen as a genetic predisposition that does not surface until late adolescence or adulthood. However this consensus view, this reality, falls apart when the surface is scratched. In particular the genetic predisposition is insignificantminimal, and largely irrelevant to prevention, treatment or healing.
Perhaps surprisingly, a diagnosis of DID is seen as controversial in spite of the consistency of diagnosis, yet the far less reliable diagnosis of schizophrenia is seen as science that is as hard and alien as the word itself. This misperception may be a consequence of the widely quoted 50% concordance rate for schizophrenia between identical twins (schizophrenia.com), (Frith, 2003). Were this to be true it might indicate that schizophrenia is primarily a genetic disease and might respond to drugs and brain operations. I like many others would assume this figure is meaningless unless it is confined to twins reared apart and I have been shocked at howjoined many professionals have beenin being surprised to find that there have been absolutely no experiments on identical twins reared apart from birth, let alone experiments that give this result (Leo, 2003).
Long-term studies yield the parsimonious but embarrassing conclusion that schizophrenia is primarily caused by the childhood social environment long before the adult breakdown. In the case of twins this includes the perhaps excessively social environment of the 9 months before birth. The risk of becoming schizophrenic can increase by an order of magnitude in particular types of deprived childhood environments (Pinto, 2008). Furthermore, this appears to have been consistently ignored over the last 40 years with the result that the social problems in many families of schizophrenics have been swept under the carpet of genetic determinism for all this time.
In the case of DID the situation could be better in that the abuse is often only too evident. However the attachment of dissociative victims to their perpetrators and other members of their family can make it very difficult to intervene to protect othersthem, let alone achieve criminal prosecutions (Sinason, 2002).
Up to about four the child builds Bowlby’s internal working model and acquires a sense of their own identity through strong one to one attachments to carers. They then start the far more complex task of learning how the local community operates, i.e. how the very human ability to collaborate constructively is achieved. Through to puberty the child is building the “internal social model” part of the internal working model. Although the environment from conception onwards and the overall genetic robustness of the child can have some effect, it is the primary hypothesis of this paper that the child’s social environment from when they acquire a theory of mind at around the age of three until about eight when their moral sense is articulated, that contributes most to a later vulnerability to schizophrenia.
Progress is being made. Already early parent-infant therapies are encouraging secure attachment between mother and child and may reduce the chance of later problems (Murray, 2005). A more psychological and less biological interpretation of schizophrenia may already be encouraging emotional literacy programmes in schools. These help young children learn the uniquely human art of language-mediated collaboration and thus reduce the chance of later breakdown. Sadly these activities will be far more useful in preventing such disorders in 20 years time than in helping with therapy today.
2. Causes and Effects
I have used DID and schizophrenia as my comparison for simplicity. Although there are a wide range of dissociative disorders, DID is the most extreme and most clearly linked to early abuse. I have compared it specifically with mainstream schizophrenia because it is more likely than other psychoses to be caused by the childhood environment rather than by genetic or physical brain damage, hormonal imbalance or recent events. The figures are striking but perhaps unfamiliar to relevant professionals. For example, i. In one study of 139 female outpatients, 78% of schizophrenic patients had suffered childhood abuse compared with only 26% for panic disorder, 30% for anxiety disorder and 42% for depressive disorder (Friedman 2002).
DID is almost invariably a result of extreme and ritualised abuse of the baby and infant by attachment figures. The baby is effectively placed in a double bind situation from which the easiest escape for a brain that has not yet connected up into an integrated whole is to split into two or more personalities separated by memory barriers. The PTSD like flashbacks of torture and pain are confined to Emotional Personalities, EPs, and do not disable the primary personality, the Apparently Normal Personality, ANP (Van der Hart, 2006).
The schizophrenia double bind (Bateson, 1956) can start with any environmental hiccup from conception onwards that is then amplified by the to and fro of “dysfunctional collaboration” amongst members of the immediate family. The primary components of this vicious circle have been given the technical terms Communication Deviance, High Expressed Emotion and Negative Affective Style, i.e. communicating at cross-purposes, excessively emotional communication, and constantly frustrating and contradicting the child’s emerging sense of how the rest of society works (Laing, 1960), (Leff, 2001). Because the problem grows slowly each member of the dynamic can see themselves as trying to help rather than making matters worse.
It is not until the child’s emerging theory of mind reaches the “false belief” level, usually in the fourth year, theory of mind is developing , usually in the fourth year, that the dysfunctional collaboration in the household becomes a major challenge to the child. One survival strategy, for a child too young to leave home, is to cut off from the contradictory behaviours. But the brain is still growing and desperately needs raw material to build its internal social model. The descent into schizophrenia is faster if abuse is part of the dynamic, which it often is (Read, 2005). Without an external environment that makes sense, all the child is left with are the imaginary friends, dolls and toys that other children are putting away. This imaginary community starts to take on adult features, for instance the Wizard of Oz is replaced by the CIA. (Sometimes the community is real. The CIA has conformed that they have tried to train DID children as agents (Sinason, 2008), (, Ross, 2006)).
An extreme form of disorganized attachment in which the baby senses it should not exist and fears it will be murdered has been named Infanticidal Attachment by Brett Kahr (Kahr, 2007). Adah Sachs (Sachs, 2008) has divided this extreme into an abstract version in which the carer only threatens death and a concrete one in which the child sees or thinks it sees murder of animals, children or, most traumatising, the child’s sibling or twin. Brett Kahr argues that the symbolic version is so common in dysfunctional families that it may well be a major early contributor to adult schizophrenia, perhaps via the vicious circle described here. Adah Sachs shows how the concrete experience is often an integral part of ritual abuse and can lead to DID.
Unfortunately, attachment is for life, not just for infancy, and the carer’s treatment is actually internalized as a lifelong feeling of worthlessness and a tendency towards suicide. This suicidal response may clarify the differing responses to abuse and neglect in infancy and middle childhood. Early abuse and neglect can lead to dissociation and social hypervigilance whereas abuse and neglect after the personality has integrated are experienced as dysfunctional collaboration and lead in the opposite direction, to isolation, failure to build an adequate internal social model and vulnerability to decades laterto schizophrenia from late adolescence onwards.
When the adolescent spurt in brain growth cuts in, all that is now learnt as a teenager is interpreted in terms of the internal social model acquired before puberty. . It is too late to resolve contradictions with the real world. They are handled by cutting off from social interaction, just as some keep away from computers and others are repelled by money. Those parts of the brain that link what goes on inside the head with what goes on in society, primarily the executive functions, sensory cortex and hippocampus, mark time or measurably shrink. (This shrinkage has usually been observed just before breakdown and often assumed to be genetic. However, a more coherent explanation is lack of use, the differences in shrinkage between schizophrenia and DID correspond to the different parts of the brain that are being underused or bypassed in earlier life. The hypervigilance of DID ensures that the executive functions and sensory cortex do not shrink (Perry, 2001). ).
With shrinking cognitive resources, keeping up appearances gets harder and harder but not impossible. Often the strain shows as poor academic performance. Adolescents quickly learn to keep their mouths shut. They have learnt that it is not polite to talk about their sexual fantasies or mutually incompatible religious beliefs and may assume that everyone else has equally bizarre internal social models that are also not talked about. In the case of children who have been sexually abused it is not the dolls but hallucinations of the abusers voice that often fill the gap left by lack of contact with the outside world (Romme, 2009).
The new adult is well aware that life is safe within the immediate physical world of, say, railway timetables, well-defined jobs and social roles. It is not usually until there is some form of social trauma in adulthood that the individual is taken way outside their comfort zone. The schizophrenic breakdown can occur weeks to a yearor years later. As they get older people become more capable and the chance of breakdown drops, and there must be many who are never stretched beyond their own breaking point.
In an ideal world the cure is obvious: perhaps drugs to relieve unbearable stress and allow basic functions to be regained, then long term therapy that allows enough time to build a revised internal social model that is more in step with local consensus reality. Alas, in the real world, it can be impossible to find drugs that calm without disabling and the therapy could take longer than a lifetime even if it were affordable. Just as learning a second language takes far longer than when starting from scratch as a baby, so learning the grammar of consensus reality takes longer when an adult.
3. What are the Issues?
In the recent past the social contribution to schizophrenia has largely been ignored and the genetic contribution exaggerated. There appears to be a need to fit a disease/cure model, possibly due to fear of parents being blamed or concerns about the pharmaceutical industry. A knock-on reason may be that relevant professionals are not adequately trained in trauma and dissociation. It may not be possible to address these impediments until there is an integrated and credible model of child development that takes Bowlby’s attachment theory further and clarifies how the child’s belief system and concept of community develop. Such a model would build on what is now known about brain development, social networks and the evolution from instinctive ape to encultured human. It is perhaps “collaboration theory”.
In the short term it may be easier for trainee psychiatrists to accept the importance of early social factors if they learn about early attachment patterns, including the extreme disorganized attachment that contributes to DID, before they learn about schizophrenia and related psychoses.?
In the previous decade, before I joined the Clinic for Dissociative Studies, I had been exploring how future communications technologies could improve collaboration between people across different social groups, different cultures and different countries (Leevers, 2001). I was inspired by the results of earlier communications technologies. For instance, there has never been a war between two countries that both had more than 3 telephones per 100 populations. If only the inoculation against adult schizophrenia was as simple as a mobile telephone for every child! In fact we were constantly concerned about the lack of theory to support what we could do with the emerging technologies of social networking. Part of the problem was the difficulty of expanding our thinking from the 9 to 5 world of work to the 24 hour day and 80 year life of real human beings. There was little concern about how new media would influence the construction of the child’s internal social model, even amongst the sociologists.