










































Graduate Student Journal of Psychology                     


Graduate Student Journal of Psychology                                       Copyright 2009 by the Department of Counseling & Clinical Psychology  
2009, Vol. 11                                                                                   Teachers College, Columbia University                          

 
 

Navigating the “Unhappy Constellation” of Dissociative Identity Disorder, Infant 
Trauma, and Type D Attachment 

 
Cameron Kiely-Froude 

The Catholic University of America 
 

Rebecca Fuller                                           
The Catholic University of America 

Patients with a current diagnosis of Dissociative Identity Disorder and a history of infant abuse may 
present for therapy with a constellation of neurobiological and socioemotional issues. During the 
initial stages of therapy, clinicians’ primary goal is to stabilize the patient and reduce acute 
symptoms. Understanding the most effective way to achieve this baseline goal requires the clinician 
to appreciate the chronic neurobiological effects of trauma for a patient abused during infancy. 
Through an attachment theory lens, this paper will discuss the effects of infant trauma on the brain, 
review traditional methods used to stabilize the patient, postulate complementary strategies discussed 
in the literature, and recommend directions for future research. 

 

Modern day psychologists define dissociation as a 
condition when thoughts, feelings, and experiences fail to 
integrate into the consciousness and become fragmented 
(Bernstein & Putnam, 1986; Spiegel & Cardena, 1991). 
Dissociative experiences exist on a continuum, ranging from 
common (i.e., daydreaming and déjà-vu) to pathological 
(i.e., failure to integrate thought, feelings, and emotions) 
(Mulder, Beautrais, Joyce, & Ferguson, 1998). Normal 
dissociative experiences are highly prevalent in the general 
population. Ross, Joshi, and Currie (1990) conducted one of 
the first studies on dissociation in a normal sample. From an 
initial population of 650,000 people, they selected 1055 
individuals using a stratified random sampling method. They 
reported that dissociative experiences were common in at 
least a quarter of the sample.  

The American Psychiatric Association (American 
Psychiatric Association, 2000b) categorizes four clinically 
significant dissociative disorders: Depersonalization 
Disorder (American Psychiatric Association, 2000a), 
Dissociative Amnesia (American Psychiatric Association, 
2000c), Dissociative Fugue (American Psychiatric 
Association, 2000d), and Dissociative Identity Disorder 
(American Psychiatric Association, 2000e). Specifically, 
Dissociative Identity Disorder (DID), previously referred to 
as Multiple Personality Disorder, is the alternation of two or 
more distinct personality states with impaired recall of 
important information (American Psychiatric Association, 
2000b). The prevalence of DID in the U.S. population is 
between 6% and 10% (Foote, Smolin, Kaplan, Legatt, & 
Lipschitz, 2006). However, since this disorder often goes 
unrecognized, it is difficult to accurately estimate the 
prevalence.1

                                                            

Correspondence: Cameron Kiely-Froude, kielycam@gmail.com  

This review will discuss a) the history and definition of 
dissociation, b) the criteria for diagnosis of dissociative 
disorders, c) the relationship of dissociation to infant trauma, 
d) the neurobiology of infant trauma and attachment, e) the 
various theories of infant attachment, and f) the phases of 
treatment for dissociative identity disorder. Lastly, with 
special attention to the first phase of treatment, a history of 
both infant trauma and Type D attachment, the authors 
propose complementary strategies to address stabilization 
and symptom reduction for adult patients with a history of 
infant trauma and a diagnosis of DID. 

       
Defining Dissociation and Dissociative Disorders 
 

The concept of dissociative disorders stems from Janet’s 
(1886) psychological experiments with his patient Lucie, 
who displayed spells of hypnosis where she neither 
remembered events nor felt physical pain. Eventually, Janet 
trained Lucie to enter a hypnotic state by asking her to 
concentrate on a conversation that he held with a third party. 
As she concentrated, Janet whispered questions to her and 
she wrote the answers on a sheet of paper. Lucie signed these 
pieces of paper as “Adriene.” Janet reported that Lucie’s 
consciousness had three states, which included Lucie 1, 
Lucie 2, and Lucie 3 (i.e., “Adriene”). Shortly after Janet 
hypnotized “Lucie 1,” this state was quickly interrupted by 
“Lucie 2.” “Lucie 2” retained memory for every episode for 
which she was present and also had the uncanny ability to 
remember events during which “Lucie 1” was present. 
“Lucie 3,” also known as “Adriene,” could remember every 
experience from “Luci 1” and “Luci 2” and she recalled 
events that occurred in early childhood. Janet argued that 
“Adriene” represented total consciousness as Lucie 
displayed conscious actions and felt physical pain when she 
became “Adriene” (van der Hart & Horst, 1989). Janet 
asserted that Lucie displayed dissociative phenomena as a 

59 



KIELY-FROUDE & FULLER 
 

 60 

result of a trauma that occurred when she was 7 years old 
(van der Hart & Horst, 1989). Research today challenges 
whether Lucie had a true case of DID or whether she is 
simply an illustration of a therapist’s influence over a patient 
(Piper & Merskey, 2004). 

The current diagnostic criteria in the DSM-IV for 
Dissociative Disorders are as follows (American Psychiatric 
Association, 2000b):  

1. The presence of two or more distinct identity or 
personality states, each with its own relatively enduring pattern of 
perceiving, relating to, and thinking about the environment and self.  

2. At least two of these identities or personality states 
recurrently take control of the person's behavior.  

3. Inability to recall important personal information that is 
too extensive to be explained by ordinary forgetfulness.  

4. The disturbance is not due to the direct physiological 
effects of a substance (e.g., blackouts or chaotic behavior during 
alcohol intoxication) or a general medical condition (e.g., complex 
partial seizures). 

5. In children, the symptoms are not attributable to 
imaginary playmates or other fantasy play. A patient’s history, x-
rays, blood tests, and other procedures can be used to eliminate the 
possibility that symptoms are due to traumatic brain injury, 
medication, sleep deprivation, or intoxicants, all of which can 
mimic symptoms of DID.   

Before diagnosing a client with DID, differential 
medical and psychological diagnoses should be carefully 
considered. For example, therapists must clarify whether a 
patient’s symptoms are not a physiological response to 
substance abuse or a general medical condition (e.g., 
complex partial seizures). A client’s medical history, blood 
tests, and x-rays will rule out symptoms from substance 
abuse, sleep deprivation, and other issues that produce 
symptoms which mimic those of DID. Differential 
psychological diagnoses for DID include, but are not limited 
to, Psychotic Disorders, Anxiety Disorders, Somatization 
Disorders, and Personality Disorders. Clinicians may utilize 
the Dissociative Disorders Interview Schedule to 
discriminate between various DSM-IV diagnoses (American 
Psychiatric Association, 2000b; Ross & Ellason, 2005). 
After the therapist addresses the differential diagnoses, the 
therapist may use The Structured Clinical Interview for 
DSM-IV Dissociative disorders to diagnose dissociative 
disorders. The next step is to create a plan to treat the patient 
in light of the DID diagnosis. Often categorized as a 
population with limited social capacity, poor boundaries, and 
manipulative character traits, patients with DID certainly 
pose a significant challenge to therapists (ISSD, 2005; 
McAllister et al., 2001). 

 
Dissociation and Infant Trauma 

 
Studies speculate a link between dissociation and the 

experience of trauma (Ferguson & Dacey, 1997; Mulder et 
al., 1998; Sanders & Moore, 1999), especially when trauma 
occurred in childhood (Zlotnick et al., 1996). Children, 

namely infants, may resort to dissociation to cope with 
trauma because of their limited range of coping strategies 
(Schore, 2001). There is a growing recognition that 
consequences of infant victimization include: (a) 
psychological maladjustment (Yehuda, Halligan, & 
Grossman, 2001), (b) altered brain development (Keverne, 
2004; Schore, 2001, 2002), and (c) delayed socioemotional 
growth (Main & Hesse, 1990).  

Relationships are also seen between dissociation and 
Posttraumatic Stress Disorder-like symptoms (Farley & 
Keaney, 1997), bulimic symptoms (Reto, Dalenberg, & Coe, 
1993), and self-mutilation (Briere & Gil, 1998). While 
dissociation protects the infant psyche from trauma, it 
ultimately becomes a maladaptive coping strategy in 
adulthood (Schore, 2001).  

While research continues to point to an association 
between trauma and dissociation, Frankel (1996) and Piper 
and Merskey (2004) warn against claiming causation 
between two variables when research points only to 
association. Nevertheless, dissociation presents in many 
survivors of childhood abuse who may seek assistance from 
a trained psychologist. Therefore, therapists must be 
prepared to treat patients with a diagnosis of DID who report 
a history of childhood abuse. Moreover, due to the tenuous 
causal relationship between childhood abuse and DID, 
therapists should not assume that the patient’s history of 
childhood abuse caused DID in adulthood (Piper & Merskey, 
2004).   

 
Infant Attachment 

 
Infant attachment is assessed through a standardized 

laboratory procedure when the infant is between 12 and 18 
months old (Ainsworth, 1982). Clinicians observe the infant 
during two brief episodes of separation and reunion with the 
primary caregiver. The infants’ response in the scenario is 
meant to reflect the relationship that the infant and caregiver 
maintain in the home (Ainsworth, Blehar, Waters, & Wall, 
1978). Initially, there were three classes of attachment: 
secure (type B: infant cries at separation and is easily 
comforted at reunion), insecure-avoidant (type A: infant 
cries at separation and avoids caregiver at reunion), and 
insecure-ambivalent (type C: infant cries at separation and is 
not easily comforted at reunion). Several years later, Main 
and Solomon (1986) created a disorganized (type D) 
attachment type for children whose behaviors did not reflect 
a coherent pattern. The creation of this fourth category 
emerged when researchers reported that a portion of infants 
demonstrated an absence of an organized emotional 
regulation strategy during stressful periods (Carlson, 
Cicchetti, Barnett, & Braunwald, 1989; Main & Solomon, 
1990). Behaviors fell on a continuum, ranging from abstract 
(observer’s expectation of infant patterns) to obvious 
(freezing of movement and dazed expression for 30 seconds 
or longer).  



INFANT TRAUMA AND DID 

 61 

Infants categorized as having a Type D attachments 
display one of the following: disordering of expected 
temporal sequences, simultaneous display of contradictory 
behavior patterns, incomplete or undirected movements and 
expressions, direct indices of confusion and apprehension, 
and behavioral stilling (Main & Solomon, 1990). Research 
on the disorganized attachment bond report four findings that 
distinguish D attachments from the others: (1) attachment 
status is independent across caregivers (Main & Solomon, 
1986), (2) caregivers reported unresolved attachment-related 
trauma issues (Main, 1983; Main & Cassidy, 1988; Main, 
Kaplan, & Cassidy, 1985), (3) a majority of infants with 
abusive parents display type D attachment as compared with 
a minority of control infants (Egeland & Stroufe, 1981; Main 
& Hesse, 1990), and (4) 5 years later a majority of children 
displayed controlling and parental behaviors toward their 
parents (Main & Cassidy, 1988). At a 5-year follow-up, 
researchers found that when children displayed a type D 
attachment with one caregiver and a different classification 
with another caregiver during infancy, attachment status 
remained the same with the former caregiver and changed to 
either type B or C with the other caregiver (Main & Hesse, 
1990). When interviewers asked mothers about their 
children’s separation, mothers’ responses remained fearful 
and disorganized (Main & Hesse, 1990). Research also 
points to the relationship between disorganized attachment 
behavior and dissociation, which will be discussed in greater 
depths in this paper (Hesse & Main, 2000).  
 
Neurobiology of Attachment and Trauma 

 
Animal models provide researchers with a solid 

foundation on which to understand the long-term 
neurological consequences of child abuse (Gutman & 
Nemeroff, 2002). Stemming from classical articles that 
report the effects of maternal separation on the squirrel 
monkey (Coe, Lulbach, & Schneider, 2002), current research 
demonstrates the long-term neurobiological changes in 
animals that are subjected to prenatal and post-natal stressors 
(Nemeroff, 2004). Generally, studies show that periods of 
maternal separation may cause neurobiological issues that 
resemble mood and anxiety disorders (Nemeroff, 2004).   

Research on non-human primate models also supports 
the notion of a sensitive period of neurobiological 
development and attachment with the mother. Hubel and 
Wiesel (1979) sought to test the importance of sensitive 
periods of development in cats by blocking the visual input 
to one eye of a cat during a sensitive period. Results showed 
that the cat suffered permanent impairment in that eye. When 
researchers tested this theory on children (Taylor & Taylor, 
1979), they found that children have irreversible reduction in 
visual acuity if they have cataracts or squint beyond the age 
of 8 to 10 years old. These findings suggest that external 
influences during sensitive periods have major consequences 
on healthy development. Is it safe to extend these findings to 
other areas of the human brain where stunted development 

may not display as readily as it may in certain human brain 
regions or in animal brains? 

The literature has only recently begun to explore the 
qualities of trauma at the infant stage of development (Perry, 
Pollard, Blakley, Baker, & Vigilante, 1995). Beginning in 
pregnancy and continuing through age 2 years old, the infant 
brain is the most plastic and requires an immense amount of 
energy to develop (Perry et al., 1995). Reflective of the 
animal studies described earlier, infants also have sensitive 
periods of development (Perry et al., 1995) when their brains 
are receptive to novel information but also highly susceptible 
to the effects of abuse (Schore, 2001). Although the 
sequence of brain development is not influenced by the 
infant's environment, the quality of brain development relies 
upon the external stimuli provided by the caregiver (Schore, 
1994). 

The infant brain expects certain experiences to occur 
during infancy. For example, the infant expects for the 
mother to regulate her emotional states (Schore, 1994), 
minimizing the negative and maximizing the positive 
(Schore, 1997). The infant expects this type of warmth from 
the mother since she is the only person that the infant knows, 
and it depends upon the mother to care for its basic survival 
needs. This includes all executive functioning tasks, 
arguably one of the most important of which is the infant's 
reliance on the mother to modulate its emotional and 
physical response to external stimuli (Streeck-Fisher & van 
der Kolk, 2000). The immature infant brain lacks the 
sophistication to cope with trauma in the ways used by 
healthy adults (Perry et al., 1995; Schore, 2001). When the 
mother fails to regulate the infant's response to stimuli by 
soothing and calming the baby, the infant must rely on its 
primitive coping mechanisms. Primarily, the infant brain 
responds to trauma in two ways: hyperarousal and 
dissociation (Perry et al., 1995).  

When an infant feels distressed, its autonomic nervous 
system is activated and it screams and cries (Schore, 2001). 
When the primary caretaker fails to comfort the child, it 
becomes increasingly agitated and its sympathetic nervous 
system (SNS) becomes hyperaroused (Perry et al., 1995), a 
phenomenon that Gellhorn (1967) labeled egotropic arousal. 
During egotropic arousal, high levels of corticopin releasing 
factor (CRF) and noradrenaline are released into the 
bloodstream (Brown et al., 1982). When CRF and 
noradrenaline are secreted, a rush of adrenaline surges 
through the body. This chemical reaction causes the brain to 
enter a hypermetabolic state (Schore, 2001).    

At this stage in the stress response, the processes that are 
essential to the infant’s survival become hyperaroused and 
secondary processes are inhibited (Perry et al., 1995). The 
infant’s heart rate increases, eyes dilate, and breathing 
quickens (Schore, 2001). The baby is fully alert and 
hypersensitive to its dangerous environment. To preserve 
energy for survival needs, the infant’s digestion and 
reproductive urges are inhibited (Schore, 2001). Although 
infant and adult reactions to stress hold some similarities, 



KIELY-FROUDE & FULLER 
 

 62 

there is one critical difference that places infants at a higher 
risk for developing maladaptive coping strategies in later 
years; infants cannot choose how they react to stress in the 
same manner as adults. Cannon (1929) called his stress 
response theory “fight or flight” because the person who 
experiences the stress prepares to either fight the danger or to 
flee from it. Infants do not have the luxury to decide whether 
to fight or flight (Perry et al., 1995). They can do neither.   

The irony for infants with abusive parents is that the 
person to whom they literally cry for help is the one who 
harms them. After many failed attempts at crying for its 
mother's attention, the infant will abandon this help-seeking 
behavior (Perry, 1995). At this point, the infant has moved 
through the "fight or flight" continuum and enters the 
dissociative continuum (Schore, 2001). Instead of seeking 
help and attention from the mother in the form of crying, 
infants who dissociate retreat inward and cease to interact 
with their external or internal environments (Schore et al., 
1994). When infants experience a helpless and desperate 
situation, their parasympathetic regulatory system begins 
inhibiting certain brain processes in order to protect them 
from the dangerous situation. Instead of expending energy 
on processes to prepare for a fight mentality (i.e., quick heart 
rate, dilated pupils), the body enters a state of conservation 
withdrawal (Kaufman & Rosenblum, 1967). Unlike the 
overarousal experienced in the primary stages of trauma, 
dissociation involves numbing, avoidance, compliance, and 
restricted affect (Putnam & Loewenstein, 1993). The infant 
brain responds to stress in this manner to numb the physical 
pain of abuse and to remain virtually invisible as a strategy 
for protecting itself against further harm (Perry et al., 1995; 
Schore, 1994). Instead of utilizing complex systems in the 
cortical-limbic region to modulate stress, the infant who 
dissociates relies on primitive autoregulatory systems found 
in subcortical-limbic brain regions (Schore, 2001).    

In an effort to maintain homeostasis during egotrophic 
hyperarousal, parasympathetic trophotropic arousal 
(Gellhorn, 1967) occurs for the infant. Simultaneous 
activation of the sympathetic-adrenal-medullary and 
hypothalamic-pituitary-adrenal (HPA) axes typically occurs 
during acute stress, but eventually they operate 
independently (Schore, 2001). When an infant experiences 
chronic trauma, both the sympathetic energy-expending and 
parasympathetic energy-conserving components of the 
infant’s developing autonomic nervous system are 
hyperactivated (Perry et al., 1995). Despite the rush of 
adrenaline surging throughout the infant’s body during the 
acute response to stress (SNS activation), the infant’s brain 
begins secreting opioids, which decrease blood pressure and 
heart rate and inhibit processes like crying (PNS activation). 
Schore (2001) describes this paradox as the infant's body and 
brain "riding the brake and the gas at the same time" (p. 
231). The simultaneous arousal of these two systems 
(Putnam, 1997) may explain why infants classified as having 
a type D attachment rapidly shift into primitive sympathetic 

states. Among other criteria, Main and Solomon (1990) 
characterized Type D infants as displaying undirected 
expressions and contradictory behavior. A chronically 
abused infant who rapidly shifts between sympathetic 
hyperarousal and hyperparasympathetic dissociation will 
meet these criteria. The infant may display distress in the 
form of crying and shrieking (sympathetic hyperarousal) 
followed immediately by emotional withdrawal and blunted 
affect (hyperparasympathetic dissociation). 

Since abused infants’ brains are in a perpetual state of 
survival mode, they lack the limbic formation and 
organization displayed by infants reared in healthier 
households (Schore, 1994). An infant with an 
underdeveloped limbic system may display difficulty 
adapting to changing environments and organizing novel 
information (Mesulam, 1998). An infant’s stress response 
sets the pattern for later stress responses (van Ijzendoorn, 
Schuengel, & Bakermans-Kranenburg, 1999). Therefore, an 
infant who chronically hyperarouses and dissociates in 
response to a traumatic situation will likely classify as 
having a type D attachment and may utilize dissociative 
behaviors later in life (Van Ijzendoorn, et al., 1999). 
Individuals prone to entering dissociative states may utilize 
this primitive defense not only during acute stress but also 
moderate and mild stress (Schore, 2001). When dissociation 
becomes an instinctual reaction to trauma, the infant's 
emotional intelligence is stunted (Schore, 2001). 

Research suggests that chronic childhood abuse may 
severely impact the orbitofrontal cortex (Balbernie, 2001; 
Schore, 1994, 2001, 2002), an area of the limbic system 
involved in cognitive processes like emotional regulation 
and positive affect (Anderson, Bechara, Damasio, Tranel, & 
Damasio, 1990). Development of this part of the brain 
depends on interpersonal relationships during infancy, which 
include but are not limited to attachment bonds with the 
mother (Balbernie, 2001; Schore, 2000). The orbitofrontal 
cortex assesses the infant's internal state and regulates its 
emotional reactivity (Balbernie, 2001). Well-adjusted 
children react appropriately to aversive stimuli in their 
environments, whereas maladjusted children may overreact 
to external stimuli or dissociate entirely (Schore, 1994). An 
underdeveloped orbitofrontal cortex may result in a lack of 
flexibility to cope with aversive stimuli and a limited array 
of cognitive coping strategies like self-soothing (Morgan, 
Romanski, & LeDoux, 1993).  

Patients with a history of infant trauma and a current 
DID diagnosis likely suffer from many of the 
neurobiological issues discussed above. Intense 
psychotherapy may affect not only the socioemotional well-
being of the patient, but also the patient’s neurobiological 
reactions to stress. A landmark study by Paquette et al., 
(2003) found that cognitive and behavioral changes achieved 
during psychotherapy lead to regional brain alterations in 
patients diagnosed with major depression or Obsessive 
Compulsive Disorder. Researchers chose subjects suffering 
from spider phobia (n = 12) and measured their regional 



INFANT TRAUMA AND DID 

 63 

brain activity before and after cognitive behavioral therapy 
(CBT) using fMRI. Before completion of CBT, fMRI scans 
taken during fear states showed a significant activation of the 
right dorsolateral prefrontal cortex, the parahippocampal 
gyrus, and the associative cortical areas, bilaterally. After 
completion of CBT, significant activation was not shown in 
the dorsolateral prefrontal cortex or the parahippocampal 
gyrus. This study, the first to measure the effects of therapy 
on brain states, shows that therapy has the potential to 
change patients’ reaction to stressful stimuli. As noted 
earlier, an underdeveloped limbic system greatly impedes the 
patient’s ability to cope with stressful situations beyond 
primitive responses. Therapists may work with patients to 
change their maladaptive responses to stress, which were 
systematically created during infancy. Working with the 
patient to develop more sophisticated responses to stressful 
situations can be addressed during phase one of treatment. 
This is a vital step that will provide the patient with the 
necessary tools to combat intense issues in later treatment 
phases (i.e., traumatic memories and “alter” reintegration).  
 
Treating Dissociative Identity Disorder 
 

The International Society for Study of Dissociation 
(ISSD) recognized the complexities in treating patients with 
DID and created a set of guidelines for therapists to follow 
(ISSD, 2005). The ISSD recognizes that patients with a 
complicated trauma related disorder, such as DID, are most 
appropriately treated with a phase or stage oriented 
approach. Typically, treatment includes three stages: (a) 
Enacting safety, stabilization, and symptom reduction, (b) 
working directly and in depth with traumatic memories, and 
(c) utilizing identity integration and rehabilitation (ISSD, 
2005).  

Each phase of treatment is important to the patient’s 
mental health and physical safety (ISSD, 2005). Yet, the 
literature is imbalanced in the amount of research dedicated 
to each phase. The number of studies that discuss traumatic 
memories and identity integration outweigh those that 
address safety, stabilization, and symptom reduction. Aside 
from the growing body of research studying the efficacy of 
using pharmacological modalities to stabilize patients with 
DID (ISSD, 2005; Putnam & Loewenstein, 1993), the 
stabilization phase of treatment for DID has only recently 
begun to receive attention. Considering phase one is the 
groundwork upon which the therapeutic relationship is built, 
it is surprising that more research is not dedicated to 
studying the initial stages of the patient-therapist 
relationship. To fill the gap in the literature on the first phase 
of treatment, this paper will focus solely on safety, 
stabilization, and symptom reduction. 

Many patients with DID focus primarily on establishing 
a trusting relationship with the service provider, often for a 
substantial amount of their time in treatment (McAllister et 
al., 2001; ISSD, 2005). This finding may illustrate the 
difficulty for patients to reduce symptoms and remain stable. 
Patients with a long abuse history, reaching as far back as 

infancy, may demand a longer and more in depth focus on 
the safety and trust issues that are discussed in phase one 
(ISSD, 2005) to ensure a healthy dependency on the therapist 
(Steele, van der Hart, & Nijenhuis, 2001). When patient and 
therapist explore how to increase the patient’s feelings of 
internal and external safety and learn strategies that reduce 
her symptoms, the patient may become more functional in 
therapy and in her daily activities (ISSD, 2005). While this is 
an ideal scenario, it is not easily achieved. 

 
The Early Phase of Treatment: Setting Biopsychosocially 
Competent Boundaries 

 
A healthy therapeutic relationship is a delicate balance 

among sympathetic listening skills, re-parenting tactics, and 
boundary setting (Peternelj-Taylor, 2002). While 
maintaining appropriate boundaries with every patient is 
important to the therapeutic relationship (Atkins & Stein, 
1993), it is especially important when working with 
childhood abuse survivors (Briere & Elliot, 1994). The 
power dynamic presented in therapy mimics the relationship 
that survivors had with their caregiver(s): the patient (or, 
child) seeks help and nurturance from the therapist (or, 
caregiver) (Peternelj-Taylor, 2002). The therapist and 
caregiver hold the power in the relationship, while the 
patient and child are the vulnerable counterparts seeking 
guidance.  

One of the goals in therapy is to guide and nurture the 
patient without re-traumatizing or abusing her (McAllister et 
al., 2001). When a therapist treats a patient without violating 
her boundaries, the patient’s inherent belief that caretakers 
will compromise ethics and morals for their own personal 
gain is challenged (Boyrs, 1994). When the creation of 
boundaries stems from the therapists deep understanding of 
the patient’s issues surrounding trust and intimacy, they are a 
healthy and essential part of the therapeutic process. 

Therapists who blindly and defensively follow rules 
solely to protect themselves from malpractice claims are 
usually inefficient and negligent to the unique needs of their 
patients (Boyrs, 1994; Lazarus, 1994). Lazarus illustrates 
this point with an example when he disregarded traditional 
boundaries with a “difficult” patient by inviting the patient to 
share a meal with him. Ultimately, the boundary violation 
was a “turning point” in therapy and served to dramatically 
reduce the patient’s hostility.  

While many therapists may take offense to this example, 
it is used to illustrate why boundaries exist in therapy, when 
clinicians may appropriately disregard certain boundaries, 
and how boundary negotiation occurs between therapist and 
client. For instance, Lazarus reports that a traditional 
boundary violation resulted in improved patient functioning. 
While many therapists may assert that sharing a meal with a 
patient is unethical, Lazarus’s unconventional relationship 
with the patient serves to remind us that patients are human 
beings that thrive on warmth and compassion.  

Does this mean that therapists who set boundaries with 
patients are treating them in a detached manner? Boyrs 



KIELY-FROUDE & FULLER 
 

 64 

(1994) asserts that adherence to boundaries does not equate 
to depersonalized and cold therapy. Rather, strict boundaries 
during therapy may serve to model for the patient how she 
can create boundaries within herself to reduce the sense of 
fragmentation experienced by many patients with DID. The 
opposing viewpoints in the literature on boundaries serve to 
create a continuum for which therapists can personally 
decide the end on which they will practice. Although Boyrs 
(1994) and Lazarus (1994) disagree on a number of tenets 
regarding clinical boundaries, they both agree on at least one 
overarching concept: therapists who engage in "rote, 
mindless rule following" are performing a disservice to their 
clients (Boyrs, 1994, p. 273).  
 
Trauma-induced Neurobiological Changes and their 
Influence on Treatment 
 
Challenging “mindless rule following” may not always 
include walking the fine line of boundary infraction with the 
patient. It may include assessing parts of the patient’s 
internal systems that are not traditionally part of 
psychotherapy. Analyzing and discussing the patient’s 
neurobiology is a way that therapists can understand the 
patient in a fresh and innovative light that defies tradition. 
Neurobiological changes in brain structure may have 
significant effects on the therapeutic process.  

Studies report that parahippocampal gyrus, 
hippocampus, and amygdala volumes were smaller in 
participants with DID than healthy control groups (Ehling, 
Nijenhuis, & Krikke, 2008).  As described earlier, Schore 
(2001) reports that corticolimbic areas of the abused infant 
brain do not develop appropriately, which results in 
compromised intra- and interpersonal interactions. Although 
psychologists are still in the preliminary stages of 
understanding exactly how certain neuroanatomical brain 
changes affect daily functioning, researchers have a sound 
grasp on the functions of certain parts of the brain.  

Immature functioning in certain brain regions may 
impact the fluidity of the therapeutic process. Research 
demonstrates that the hippocampus is an integral component 
to learning and memory (Vargha-Khadem et al., 1997) and is 
particularly sensitive to stress (Sapolsky, 1996). Specifically, 
the hippocampus is responsible for placing a memory in the 
appropriate time, place, and context, as well as integrating 
memories as they occur (Holscher, 2003). Patients with a 
history of infant abuse will likely have a hippocampus that is 
dramatically reduced in volume in comparison to patients 
who have not experienced severe trauma (Stein, Koverola, 
Hanna, Torchia, & McClarty, 1997). 

Although the literature has yet to directly address how 
brain abnormalities affect the therapeutic process, studies 
have analyzed this phenomenon in other contexts. For 
example, Saigh, Mroueh, and Bremner (1997) studied 
academic performance in traumatized adolescents in Beirut. 
Compared with a non-traumatized group and a traumatized 
group without PTSD, the participants with past trauma and 

confounding PTSD had greater deficits in academic 
performance. Since therapy is a place where patients learn 
about themselves and their diagnoses, similar issues may 
extend to the therapy office.  

When setting boundaries with a traumatized population, 
the therapist may present information using a number of 
different modalities throughout treatment. This may include 
verbal, physical, and pictorial representations presented 
consistently during therapy. Since a primary function of the 
corticolimbic system is to regulate appropriate interactions 
with others and moderate emotional reaction, patients may 
have difficulty accepting the boundaries and verbally 
communicating why they are resistant.  

In this case, the therapist may include non-verbal 
activities like art (Chapman, Morabito, Ladakakos, Schreier, 
& Knudson, 2001), dance (Gray, 2001), and sandplay 
(Daniels & McGuire, 1998) into the session. Research on 
these types of alternative therapy is scarce and needs further 
investigation to support their efficacy as independent 
modalities. The limited literature on these therapy models 
indicate their effectiveness in reducing PTSD symptoms in 
children (Chapman et al., 2001), rebuilding adults’ sense of 
self after torture (Gray, 2001), and communicating recurrent 
nightmares in adult war survivors (Daniels & McGuire, 
1998). 

Reduced hippocampal volume and immature 
corticolimbic system in traumatized populations are only two 
examples of the several brain structures affected by chronic 
abuse and stress. Therapists can manage patient care by 
understanding the neuropsychological literature and 
modifying treatment plans to account for the unique neural 
functioning of each patient. Patients who consistently violate 
boundaries may have difficulty accepting those limitations 
into their neural networks and respecting them in therapy.  

Patients with a history of abuse starting in infancy have 
learned to dissociate in order to protect themselves from a 
caretaker chronically violating physical, emotion, and mental 
boundaries. Therefore, the transition into therapy will likely 
reflect that history. Literally, trauma has reshaped patients’ 
brains. Since the patient experienced abuse at the hands of a 
caretaker during infancy, the therapist should consider 
assessing the patients’ psychopathology and neurobiology 
under an attachment lens.  
 
Traditional Strategies for Treating Dissociative Identity 
Disorder 
 

Talk therapy and alternative interventions. Talking is a 
major part of most therapy sessions. When treating survivors 
of trauma who dissociate, a multidisciplinary approach to 
treatment may prove effective since the patient may not have 
the words to express her emotions verbally. Schore (2001) 
offers persuasive evidence that right brain development is 
severely impeded in chronically abused children. The areas 
that respond to the traumatic event are those located 
primarily in the right hemisphere, for example the right 



INFANT TRAUMA AND DID 

 65 

amygdala. Given the underdevelopment of those areas 
during infancy, neural networks connecting experiences with 
emotions in certain brain centers may not have formed. 
Perhaps this is a reason why infants store memories of abuse 
in their limbic system, which is considered a major network 
for emotions (Schore, 2001). What effect does this abnormal 
storing of events have in later years? Van der Hart, Bolt, and 
van der Kolk (2005) explain that when a person remembers a 
traumatic event the primary language and speech areas shut 
down. Therefore, when patients arrive at therapy years after 
the abuse occurred, they may present with overwhelming 
emotions and limited verbal capacity. Clinicians may use 
alternative ways of understanding the patient’s physical and 
emotional state aside from verbal communication, like 
utilizing grounding and containment strategies as a means to 
assist clients in achieving stability during and after therapy 
(ISSD, 2005). These strategies may be used during phase 
one of treatment to teach the patient a series of healthy 
coping mechanisms that she may employ throughout the 
therapeutic process.  

The following section includes a brief outline on the 
traditional therapeutic techniques of grounding and 
containment as well as a review of the sparse literature on 
complementary forms of treatment such as exercise and 
meditation. These techniques will be reviewed in light of the 
attachment issues and neurobiological functioning in adults 
abused as infants. Self-soothing techniques like grounding 
and containment may be especially useful for adults with an 
infant abuse history since they do not require that the patient 
express herself verbally. Instead, they ask the patient to 
connect her mind and body in novel ways. These are likely 
invaluable additions to therapy sessions with trauma 
survivors since they are tools that the patient may adopt as 
coping techniques in her everyday life. These techniques 
empower the patient to regulate her own emotional responses 
to stress, which she may lack as a result of an 
underdeveloped corticolimbic system.  

Grounding and containment. When a patient enters a 
dissociative state during therapy, clinicians may use that 
moment as an opportunity to work with the client on 
grounding and containment techniques. Getler (2005) 
describes grounding techniques as “tools to help the patient 
stay in the here and now” (p. 69). Therapists can remind the 
patient where she is, the date and month, and other facts that 
will help her remain in reality. Therapist may encourage 
patient to feel her own body and touch physical objects in 
the room (Getler, 2005). The therapist may use grounding 
techniques at various points during the session to meter the 
patient’s disclosure, as well as to help her remain 
emotionally and physically present.  

Diaphramatic breathing is another strategy that provides 
patients with a means to center the self and modulate 
overwhelming feelings. Aside from providing the patient 
with a technique to collect her thoughts and feelings, deep 
breathing also grounds the patient in the moment and 
reminds her that she is physically present. Therapists may 
also discuss ways to temper an oncoming dissociative state 

by identifying behaviors that occur just before the patient 
dissociates. Brown, Russell, Thorton, and Dunn (1999) 
report that discussing patients’ visual responses to 
dissociation like field constriction, fogginess, and difficulty 
concentrating on stimuli, are effective for connecting mind 
and body for patients who have eating disorders. Therapist 
may consider teaching these techniques during initial 
sessions of treatment to provide the patient with healthy 
coping mechanisms that she may use during more intense 
parts of treatment.  

To date, research in the area of grounding and 
containment needs randomized controlled studies that assess 
the efficacy of these techniques for trauma survivors. 
Research endeavors may include an analysis of how 
therapists teach these techniques and the manner in which 
patients receive the instruction. Understanding the effects of 
these techniques on patients during therapy and in their daily 
lives will allow for a more standardized approach to treating 
patients with a history of infant trauma and a DID diagnosis.  
 
Complementary Treatment Strategies 
 

 Exercise. Since Morgan and Goldston’s (1987) 
observation that psychiatric patients who were unfit were 
more depressed than their physically fit counterparts, 
researchers continue to study the relationship between 
physical fitness and mental health. A review paper by Byrne 
and Byrne (1993) tentatively reports that exercise programs 
decrease depression and anxiety while enhancing positive 
mood. Similarly, Steptoe and Butler (1996) showed that 
rigorous exercise was related to a decrease in emotional 
distress. In a very recent study, Moor, Stubbe, Boomsma, 
and Geus (2006) collected data on a sample (N = 19,288) of 
twins who exercised a minimum of 60 minutes weekly at 4 
METs (Metabolic Energy Expenditure Index). Exercisers 
were less anxious (-.18 SD), depressed (-.29 SD), and 
neurotic (-.14) than non-exercisers. Exercisers were also 
more extraverted (+ .32 SD) and achieved higher scores in 
areas of sensation seeking (+.25 SD, - + .47 SD) than non-
exercisers.  

While studies have shown that exercise is effective in 
reducing mild to moderate anxiety symptoms, research does 
not adequately identify the specific components of exercise 
that may alleviate anxiety symptoms (Jorm et al., 2004). 
Further research is needed to understand how exercise 
affects psychopathology in patients that report infant trauma.  

Meditation. Four out of five randomized controlled 
studies that examined the effects of meditation on anxiety 
report that meditation produced equivalent effects to other 
forms of relaxation (i.e., muscular relaxation, biofeedback) 
(Jorm et al., 2004). A recent study (Simpson et al., 2007) 
evaluated whether a 10-day Vipassana meditation course 
offered in a minimum security prison was associated with 
participants (N = 302) substance use and psychological 
distress outcomes at 3-months. Results indicate that there 
was no significant difference in PTSD symptom severity 
between patients who completed the meditation and those 



KIELY-FROUDE & FULLER 
 

 66 

who did not. The meditation course was associated with 
improvements in drug use and drinking outcomes for those 
with and without PTSD symptoms.   

In his descriptions of Kundalini Yoga Meditation 
Techniques, Shannahoff-Khalsa (2004) discusses how 
mentally ill patients, specifically those with depression and 
sleep disorders, may use these techniques to battle their 
condition(s). “Tuning in,” a technique used before the 
practice of any Kundalini practice, gives the experience of 
“being in a womb of healing energy” (p. 93). The practice 
leads the patient into a meditative trance through a 
combination of chanting and deep breathing exercises. 
Further research is needed to understand how specific 
meditation techniques affect individual symptomatology in 
patients with DID.  

 
Conclusion 

 
Bridging the research gap between the fields of 

neurology and psychology is the next logical step in the 
study of infant trauma and DID. The authors assert that the 
overall goal is to develop a holistic view of the 
neurobiological and psychological effects of infant abuse on 
the adult survivor and to effectively treat them. Future 
research endeavors should focus on reporting the 
relationship between neurobiology and psychology in 
patients with DID and a history of infant abuse. Academic 
neurological literature clearly outlines the devastating effects 
of chronic emotional and physical trauma to the anatomy and 
physiology of the developing infant brain. Academic 
psychological literature illustrates the attachment and 
boundary issues that manifest in therapy with adults 
survivors of childhood abuse. First, the authors encourage 
researchers to build on these studies in addition to the work 
of Schore (1994, 1996, 2001) and Perry et al. (1995) to 
develop a comprehensive understanding of how infant 
trauma impacts and disrupts child and adult socioemotional 
adjustment.  

Secondly, more longitudinal studies are needed to 
understand how the brain changes along the developmental 
continuum, and which specific types of infant abuse (i.e., 
Shaken Baby Syndrome, sexual abuse) produce effects that 
alter development. Understanding the interaction between a 
patient’s neurobiological systems and their development can 
greatly improve clinical care and guide treatment. In recent 
years, infant research on relational trauma has been growing 
steadily. As this knowledge base develops, new clinical tools 
will provide therapists with better assessment measures for 
evaluating trauma survivors and their families presenting for 
treatment.  

Lastly, future research endeavors should also study how 
infants removed from abusive households and placed in 
protective care may or may not develop secure attachments 
to other caregivers (i.e., foster parents). Clinically, this will 
provide therapists with information regarding the creation of 
attachment bonds with foster parents. With this information 

therapists may develop attachment techniques to teach 
protective caretakers as they learn how to develop secure 
attachment bonds with their infant. This may have great 
public health implications since healthy development of 
cortical regions is associated with appropriate intra- and 
interpersonal communication and emotional regulation in 
adulthood.  

In closing, understanding physicians’ and therapists’ 
experiences working with abusive families and treating 
neglected infants is an essential component to the existing 
literature on infant abuse. When neurologists and 
psychologists collaborate on understanding how abuse 
affects the patients across the lifespan, the literature may 
move closer to identifying a causal relationship between 
childhood abuse and dissociation. Identifying the 
relationship among infant attachment to caregiver, 
neurobiological changes after infant trauma, and adult 
psychopathology will allow for comprehensive, multi-
disciplinary treatment of patients with DID and a history of 
infant abuse.  

 
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