Attachment Disorganization and the Controlling

Strategies: An Illustration of the Contributions of

Attachment Theory to Developmental
Psychopathology and to Psychotherapy
Integration
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Giovanni Liotti
APC School of Psychotherapy, Rome, Italy

Attachment theory may be instrumental in providing a framework for

psychotherapy integration, but to cope with the complexities of clinical
realities it should be considered within an overall evolutionary approach to
the basis of human interpersonal behavior and also in the perspective of
developmental psychopathology. To illustrate these premises with materials
that can be of immediate interest to practicing psychotherapists, this article
focuses on the example of the clinical applications of research findings on
attachment disorganization and its developmental sequels. The controlling
strategies that usually follow in the preschool years infant disorganized
attachment illustrate the relevance of considering the dialectics and the
dynamic tensions between attachment motives and other evolved motives
such as caregiving and dominance–submission. The role played by the
disorganized-controlling strategies in psychopathological developments and
in the relational dilemmas that often characterize the psychotherapy of
difficult patients is discussed and exemplified through two clinical vignettes.
It is argued that the model based on attachment disorganization and con-
trolling strategies relies on concepts that are understandable and potentially
acceptable to psychotherapists of different orientations.
Keywords: disorganized attachment, controlling strategies, psychotherapy

Attachment disorganization in infancy and childhood is likely to play

a role in the development of a range of Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition (DSM-IV) disorders, especially but not

Giovanni Liotti, Director of Training, APC School of Psychotherapy, Roma, Italy.

Correspondence concerning this article should be addressed to Giovanni Liotti, Director
of Training, APC School of Psychotherapy, Viale Castro Pretorio 116-I 00185 Roma, Italy.
E-mail: gio.liotti@fastwebnet.it

232
Journal of Psychotherapy Integration © 2011 American Psychological Association
2011, Vol. 21, No. 3, 232–252 1053-0479/11/$12.00 DOI: 10.1037/a0025422
 Special Issue: Disorganized-Controlling Strategies 233

exclusively in those disorders that involve deficits in the integrative func-

tions of consciousness and in mentalizing capacities (Bateman & Fonagy,
2004; Dozier, Stovall-McClough & Albus, 2008; Levy, 2005; Liotti, 1992,
1999, 2004, 2006; Liotti & Gumley, 2008; Lyons-Ruth, 2003; Rutter, Krep-
pner & Sonuga-Barke, 2009; Schore, 2009). Even if more research data are
needed before we can satisfactorily understand the intersubjective pro-
cesses that link infant attachment disorganization to the genesis of inter-
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personal difficulties and psychopathological experiences throughout per-

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sonality development, the knowledge of this dimension of attachment

already provides valuable support to clinical practice (Levy, 2005; Liotti,
2007; Rutter et al., 2009). To make optimal use of their knowledge of
attachment disorganization in clinical practice, psychotherapists of any
orientation should cast it in a developmental psychopathology framework.
In such a framework, a key research finding concerns the development of
controlling interpersonal strategies by children aged 3– 6 who had been
infants disorganized in their attachments (Lyons-Ruth & Jacobvitz, 2008;
Main & Cassidy, 1988; Teti, 1999; Van IJzendoorn, Schuengel, & Baker-
mans-Kranenburg, 1999).
This article aims at illustrating, through the example of attachment
disorganization, the integrative potential of attachment theory and re-
search in psychotherapy. In pursuing this aim, after a summary of research
findings and theoretical reflections concerning infant attachment disorga-
nization, I’ll dwell on the defensive meaning of the disorganized-
controlling strategies and on the importance of understanding it when
dealing with the relational dilemmas and the stalemates in the psychother-
apy that often stem from a disorganized attachment style.

INFANT ATTACHMENT DISORGANIZATION: A SUMMARY

In 1985, Main and collaborators published a preliminary report of a

new, disorganized category of infant attachment, to be added to the already
well-known organized categories: secure, insecure-avoidant, and insecure-
resistant (Main, Kaplan & Cassidy, 1985).
Disorganized attachment (DA) in the Strange Situation Procedure
(SSP: Ainsworth, Blehar, Waters & Wall, 1978) is coded when the child
demonstrates lack of orientation during attachment interactions and/or
incompatible responses— emitted either simultaneously or in quick succes-
sion—to episodes of separation–reunion with the caregiver (Main & Sol-
omon, 1990). DA is characterized by simultaneous approach and avoidance
of the caregiver, resulting in a lack of organization and orientation in the
infant’s overall attachment behavior and in the pattern of attention paid to
 234 Liotti

the caregiver. In comparison, secure, avoidant, and resistant patterns of

attachment involve a precise behavioral and attentional strategy.
It is noteworthy that the percentage of infant DA classifications rises
sharply from 15% in nonclinical low-risk samples to more than 70% in
high-risk samples (e.g., samples at risk for emotional disorders, clinical
samples, and family violence samples: Lyons-Ruth & Jacobvitz, 2008),
suggesting that DA may play an important role in psychopathological
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developments.
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DA is statistically linked to unresolved traumas and losses in the life of

the caregivers (Main & Solomon, 1990), a finding that has been replicated
in a large number of controlled studies (for a review, see Lyons-Ruth &
Jacobvitz, 2008). When unresolved traumas and losses are not found in
parents of children with DA, it has been suggested that these parents’ state
of mind during caregiving is characterized by hostility, helplessness, and
dissociative mental processes. Studies of the parent’s mental state related
to attachment and caregiving, based on the Adult Attachment Interview,
provide support to this suggestion (Lyons-Ruth, Yellin, Melnick, & At-
wood, 2005). Although the infant genotype may moderate sensitivity to
parental behavior causing infant disorganization (Gervai et al., 2007), any
theoretical explanation of the statistical link between infant DA and the
caregiver’s state of mind characterized by unresolved losses/traumas
should be based on a careful reflection on the parent–infant communicative
style.

Theoretical Explanations of Attachment Disorganization

The key concept advanced to explain the link between infant DA and
caregiver’s unresolved states of mind is that these states of mind create the
base for a caregiving attitude that is frightening to the child (Main & Hesse,
1990). The unwitting rehearsal of a traumatic memory during caregiving
interactions may appear as an expression of fear in the caregiver face or
general attitude, in contexts that are devoid of danger. Another possibility
is that the unresolved trauma makes the caregiver more prone to become
aggressive toward the infant. The two possibilities are captured by the
phrase “frightened/frightening (FR) caregiving behavior” (Main & Hesse,
1990). FR caregiving behavior causes “fright without solution” in the
infant, because “the caregiver becomes at the same time the source and the
solution of the infant’s alarm” (Main & Hesse, 1990, p. 163). Fear comes to
coexist paradoxically, in the infant’s experience, with the soothing provided
by proximity to the caregiver. A study by Schuengel et al. (1999) provides
empirical support to the hypothesis that FR behavior is the main mediating
factor between the caregiver’s state of mind and the infant’s DA.
 Special Issue: Disorganized-Controlling Strategies 235

The origins of DA within the relationship with a FR caregiver may be

further theoretically explained in terms of conflict between two different
inborn control systems, the attachment system and the fight-flight-freezing
system (i.e., the evolved defense system that is set into action whenever any
mammal, including man, faces a threat of damage or death). The attach-
ment and the defense systems normally operate in harmony: infant mam-
mals flight from the source of threat to find refuge in proximity to the
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attachment figure. The two systems, however, clash in any type of infant–
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caregiver interaction where the caregiver becomes at the same time the
source and the solution of the infant’s fear (Liotti, 2004). Being exposed to
frequent interactions with a FR caregiver, infants are caught in a relational
trap: their defense system motivates them to flee from the caregiver, while
at the same time their attachment system motivates them, under the
commanding influence of separation fear, to strive for achieving comforting
proximity to her or him.

The Internal Working Model of Disorganized Attachment

The experience of fright without solution, according to attachment

theory, is memorized (as any other recurring experience with the caregiver)
within a structure of memory and expectation called Internal Working
Model (IWM: Bowlby, 1969/1982). The IWM of early attachment is a
structure of implicit memory (Amini et al., 1996): that is, it is hardly
accessible to consciousness. It determines expectancies about what is likely
to happen in later attachment interactions and thus influences the expres-
sion of the inborn disposition to search for help and the comfort of
protective proximity to an attachment figure whenever one is distressed.
Life events that activate the attachment motivational system also activate
the IWM of attachment.
The IWM of disorganized attachment is likely to convey multiple
and incoherent representations of aspects of reality (the self and a single
caregiver) that are represented as singular and coherent in babies with
organized attachment patterns (Main, 1991). In other words it could be
thought, on theoretical grounds, that the disorganized IWM involves a
dissociative (compartmentalized) mental process (Liotti, 1992, 1999,
2004; Main & Morgan, 1996). Empirical support for this hypothesis is
provided by sparse but convergent research data (for reviews, see
Hesse, Main, Abrams & Rifkin, 2003; Liotti, 2004, 2006; Lyons-Ruth &
Jacobvitz, 2008).
To provide the clinician with an easy to grasp concept of the type of
multiple information conveyed by the IWM of disorganized attachment,
 236 Liotti

Liotti (1995, 2004) suggested to use the idea of drama triangle originally
coined by Karpman (1968) in a different clinical–theoretical context. In the
drama triangle, representations of self and others shift from the prototype
of the rescuer to those of the persecutor and the victim. In the disorganized
IWM, the attachment figure is represented negatively, as the cause of the
ever-growing fear experienced by the self (self as victim of a persecutor),
but also positively, as a rescuer: the parent, although frightened by unre-
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solved traumatic memories, is nevertheless usually willing to offer comfort

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to the child, and the child may feel such comforting availability in conjunc-
tion with the fear. Together with these two opposed representations of the
attachment figure (persecutor and rescuer) meeting a vulnerable and help-
less (victim) self, the disorganized IWM also conveys a negative represen-
tation of a powerful, evil self meeting a fragile or even devitalized attach-
ment figure (persecutor self, held responsible for the fear expressed by the
attachment figure). Moreover, there is the possibility, for the child, of
representing both the self and the attachment figure as the helpless victims
of a mysterious, invisible source of danger. Finally, because the frightened
attachment figure may be comforted by the tender feelings evoked by
contact with the child, the implicit memories of disorganized attachment
may also convey the possibility of construing the self as the powerful
rescuer of a fragile attachment figure (i.e., the little child perceives the self
as able to comfort a frightened adult).
Indirect empirical support to the above conceptualization of the dis-
organized IWM is provided by two types of research data. School-age
children who had been disorganized infants assume either caregiving (res-
cuer) or punitive (persecutor) attitudes toward their caregivers (Hesse et
al., 2003; Lyons-Ruth & Jacobvitz, 2008; Main & Cassidy, 1988). In another
series of research studies (Lyons-Ruth, Yellin, Melnick, & Atwood, 2005),
adults who reported histories of traumatic attachments and whose children
developed disorganized attachments toward them typically show multiple,
nonintegrated dramatic representations of self and attachment figures,
shifting from hostility (persecutor) to helplessness (victim) and to compul-
sive caregiving (rescuer).

DEVELOPMENTAL PROCESSES STEMMING FROM INFANT

ATTACHMENT DISORGANIZATION

The disorganized IWM is likely to yield multiple, dramatic, fragmented

representations of self and others whenever it becomes active throughout
development—that is, whenever during a child’s growth the attachment
system is activated by loneliness, fear, or pain. This assumption, it should
 Special Issue: Disorganized-Controlling Strategies 237

be emphasized, does not imply that children who have been disorganized
infants constantly show, during their development, disassociated, utterly
incoherent, and dysregulated mental states in their interactions with other
people. On the contrary, before they reach school age, almost all children
who have been disorganized in their infant attachments develop an orga-
nized behavioral and attentional strategy toward their caregivers. Research
data suggest that a majority of DA children achieve such an organization
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by exerting active control on the parent’s attention and behavior either

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through caregiving or through domineering-punitive strategies (Hesse et

al., 2003; Lyons-Ruth & Jacobvitz, 2008; Main & Cassidy, 1988). Control-
ling– caregiving strategies in children (also known as inverted attachment)
are identified by solicitous, overbright caring behavior directed toward the
caregiver. Controlling–punitive strategies are identified by attempts to
punish or embarrass the caregiver through harsh criticism.
The emergence of the controlling strategies in children who have been
disorganized in their infant attachments may be explained as a case of
reciprocal inhibition between different motivational/behavioral systems.
The argument runs as follows.
The attachment system is one among a number of different motiva-
tional/behavioral systems that regulate social interactions in all mammals.
These systems are the result of evolutionary processes and can be concep-
tualized as universal, inborn dispositions aimed at pursuing each a specific
biosocial goal (Gilbert, 1989, 2005; for a multimotivational perspective on
human behavior cf. also Lichtenberg, 1989). A list of such systems should
comprehend, besides the attachment system (whose goal is care-seeking),
also a caregiving system, a ranking system aimed at achieving dominance
through competitive behavior, a sexual mating system, and a cooperative
system (Gilbert, 1989, 2005). Although there are dynamic tensions between
these different systems that may allow for simultaneous activation of two
or more of them, the prevailing system that is active in a social exchange
tends to inhibit the activities of the other systems. Thus, a relative inhibi-
tion of the attachment system may be achieved through coopting another
motivational system during the daily interactions with the caregiver. When
a disorganized IWM dominates them since infancy, there is a good reason
to inhibit the activities of the attachment system as often as possible
throughout development: a defensive inhibition of the attachment system
protects both the child and his or her relationship with parents from the
unbearably chaotic experience of disorganization. The activation of the
caregiving system (Solomon & George, 1996) in the service of a defensive
inhibition of the attachment system yields controlling caregiving strategies
in the child. The activation of the dominance-submission inborn strategies
(competitive or ranking system: Gilbert, 1989, 2005) lies at the base of
controlling punitive strategies. It could be hypothesized that the controlling
 238 Liotti

caregiving strategy grows out of one of the prototypical self-representa-

tions of the drama triangle, namely, the rescuer. The controlling punitive
strategy may be based on the representation of self as persecutor.
While controlling punitive and controlling caregiving strategies have
been well documented in developmental studies of the sequels of early
attachment disorganization, one could hypothesize, on clinical and theo-
retical grounds, that other strategies could be devised by some children to
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cope with the shattered states brought on by the activation of the disorga-
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nized IWM. Other inborn, evolved, social dispositions— besides caregiving

and dominance—may intervene instead of the attachment system to reg-
ulate the interactions between child and parent, so that behavior and
intersubjective experience can achieve at least a degree of organization For
instance, one could hypothesize that some disorganized children resort, at
times, to activation of the sexual system to defensively deal with attach-
ment motivations and the activation of a disorganized IWM. Indeed,
abnormally sexualized parent– child interactions has been convincingly
attributed, through evolutionary and anthropological analyses, to dysfunc-
tion of the attachment motivational system (Erikson, 2000). Thus, at least
one other controlling strategy may be hypothesized to develop in some
children with an history of infant DA, namely, a controlling sexualized
strategy somehow remindful of the Oedipal complex.
The defensive activation of another motivational system in response to
a disorganized IWM of attachment should not be construed as a purely
intrapsychic process, or be related exclusively to the child’s temperamental
variables. Rather, the choice of the motivational system that defensively
substitutes for the attachment system or the inhibition of relational needs
is likely influenced by the caregivers’ attitudes. Evidence supporting this
hypothesis begins to emerge in the literature. For instance, parents who
show frightened/frightening behaviors toward their children are also more
likely than other parents to display unusual arrays of submissive, care-
seeking, violently domineering, and sometimes sexualized behaviors to-
gether with caregiving (Hesse et al., 2003).
It is noteworthy that the controlling strategies stemming from infant
DA may collapse under the influence of environmental or organismic
conditions able to strongly and durably activate the attachment system. For
instance, 6-year-old controlling children appear well oriented and orga-
nized in their thinking, behavioral, and attentional strategies until they are
shown the pictures of a version of the Separation Anxiety Test (Main,
Kaplan & Cassidy, 1985). These pictures portray situations that are able to
powerfully activate a child’s attachment system (e.g., parents leaving a
child alone). Once the system is thus activated, the formerly organized
strategies of thought and behavior collapse in the controlling children: the
underlying disorganization of their mental operations is suddenly revealed
 Special Issue: Disorganized-Controlling Strategies 239

by the unrealistic, catastrophic, and utterly incoherent narratives produced

in response to the pictures (an illustration of these narratives may be found
in Hesse et al., 2003). It is arguable that the collapse of the controlling
strategies in the face of traumatic experiences that activate the attachment
system strongly and durably mediates the appearance of posttraumatic
dissociation (Liotti, 2004, 2006; Liotti & Prunetti, 2010).
Besides the development of controlling strategies, other sequels of
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infant DA have been identified by longitudinal research studies or postu-

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lated by theoretical reflections based on contemporary developmental

neuroscience. Solid data from a longitudinal research show that dissocia-
tive mental processes are to be expected to be significantly more pro-
nounced in children and adolescents who have been disorganized in their
infant attachments (Carlson, 1998; Ogawa, Sroufe, Weinfield, & Carlson,
1997). Metacognitive (mentalizing) capacities are hindered during devel-
opment of children with DA (Fonagy, Target, Gergely, Allen, & Bateman,
2003). The development of the stress coping system in the growing child’s
right brain may take a deviant form as the consequence of severe disorga-
nized infant attachments (Schore, 2009). Such an abnormal development of
the stress coping system in the brain may support another expected con-
sequence of DA, namely defective emotion regulation (Conklin, Bradley &
Westen, 2006; DeOliveira, Neufeld-Bailey, Moran & Pederson, 2004;
Hesse et al., 2003).

DISORGANIZED ATTACHMENT AND PSYCHOPATHOLOGY

Since the publication of Main’s (1991) seminal paper stating the pos-
sibility of multiple and incoherent IWM of a single attachment figure, a
number of theoretical and clinical studies advanced the hypothesis that
infant DA may be the first step in developmental pathways characterized
by less than optimal or even frankly defective capacity for mental integra-
tion of emotional-interpersonal information (Fonagy, 1999; Fonagy et al.,
1995; Liotti, 1992, 1993, 1995, 1999; Main & Morgan, 1995). These studies
argued that DA attachment is a risk factor in the development of disorders
implying dissociative processes and/or borderline features. A few research
studies lent support to the hypothesis (Carlson, 1998; Liotti, Pasquini &
The Italian Group for the Study of Dissociation, 2000; Ogawa et al., 1997;
Pasquini, Liotti, & The Italian Group for the Study of Dissociation, 2002;
West, Adam, Spreng & Rose, 2001). However, later empirical studies and
critical reviews on the role of DA in developmental psychopathology
suggest that its influence may be widespread and extended to developmen-
tal itineraries leading to different syndromes besides those showing explicit
 240 Liotti

dissociative symptoms or borderline features (Dozier et al., 2008; Hesse et

al., 2003; Levy, 2005; Lyons-Ruth & Jacobvitz, 2008).
Theories stating that dissociative processes are quite pervasive in psy-
chopathological developments even if they do not appear necessarily as
explicit classical dissociative symptoms (e.g., Bromberg, 2003; Bucci, 2003;
Howell, 2005) easily reconcile the hypothesis that DA is a risk factor in
disorders involving dissociative symptoms with observations pointing to a
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role of DA in a vast array of DSM disorders. The role of controlling

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strategies stemming from infant DA may further explain how disorders not
explicitly involving dissociative symptoms may be based on the dissociative
processes characterizing the IWM of DA. As far as the IWM is kept at
brake by a controlling punitive strategy, for instance, developmental path-
ways stemming from a latent tendency toward dissociation may involve
abnormal aggressive dominance in interpersonal relations (that may be-
come a risk factor for antisocial personality disorder) rather than frankly
dissociative symptoms. On theoretical grounds, therefore, different itiner-
aries of personality development may be started by early DA (Liotti, 1992).
1. Infant DA is not followed by pathological developmental pathways,
because of socially rewarding controlling strategies (e.g., controlling care-
giving strategies) or later corrective relational experiences that bring the
formerly disorganized IWM toward attachment security. This is likely to be
a frequent occurrence in the life of people who had been disorganized in
their infant attachments, as suggested both by epidemiological consider-
ations (DA is a frequent occurrence in samples from low-risk families) and
by research findings suggesting that infant DA is not significantly predictive
of psychopathology in preschool years (e.g., it does not seem to predict
externalizing disorders in preschool children: Keller, Spieker & Gilchrist,
2005). As long as the defensive controlling strategies are in place, and the
attachment system is not activated in any strong an prolonged way, there
is no theoretical reason to expect that the disorganized IWM manifests its
dissociative features and its link with memories of fright without solution.
2. Controlling strategies and persistent inhibition of the attachment
system may pave the way to developmental processes leading to adolescent
or adult personality disorders that do not involve dissociative experiences.
This is particularly likely to happen if no adverse life event (e.g., traumas,
separations and losses) causes the collapse of the controlling strategies
during personality development, but the type of controlling strategies is not
socially acceptable (e.g., controlling punitive). The personality disorders
stemming from these developmental pathways may be occasionally com-
plicated by dissociative and/or anxiety symptoms when patients are con-
fronted with stressors that activate the attachment system. It is noteworthy
that these symptoms may subside quickly if the patient is able to resort to
the controlling defenses (i.e., with aggressive-punitive interpersonal behav-
 Special Issue: Disorganized-Controlling Strategies 241

ior or with a compulsory caregiving attitude), but they tend to recur every
time a distressing life event activates the attachment system again.
3. Traumatic events may repeatedly impinge on a disorganized
attachment system during development, causing the collapse of the
controlling strategies, the reactivation of the disorganized IWM, and the
dissociative experiences contingent upon such a reactivation. It is argu-
able that this line of development plagues the mental growth of children
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living in maltreating families and constitutes a major risk factor for the
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development of disorders involving clear-cut and severe dissociative

symptoms (i.e., the dissociative disorders and the subtypes of borderline
and schizophrenic disorders emerging from traumatic family environ-
ments: Liotti, 1992, 1999, 2004, 2006; Liotti & Gumley, 2008; Liotti et
al., 2000; Ogawa et al., 1997; Pasquini et al., 2002; Dutra, Bianchi, Siegel
& Lyons-Ruth, 2009; Howell & Blizard, 2009).

IMPLICATIONS FOR PSYCHOTHERAPY

The knowledge of attachment disorganization and controlling strate-

gies is particularly helpful to psychotherapists of any orientation when they
happen to face, in their daily practice, three problems:
1. Making sense of the appearance of anxiety and dissociative phe-
nomena in seemingly favorable relational contexts (including the thera-
peutic relationship),
2. Dealing with the relational dilemmas that are typically encountered
during the treatment of patients coming from traumatic family environ-
ments, and
3. Understanding the resistance to change of attitudes that patients
came, thanks to the clinical dialogue, to acknowledge as maladaptive and
irrational.

The Relational Context of Dissociative Symptoms

It is a common occurrence that patients report sudden anxiety or panic

attacks that arose in interpersonal contexts where no obvious threat or
conflict was consciously detectable. Anxiety may arise in patients during
clinical dialogues that seem safe and even rewarding to both patient and
therapist. To the traditional interpretation of these events in terms of
unconscious processes (either psychoanalytic or cognitive unconscious:
Eagle, 1987), a model based on attachment theory and research adds the
possibility that the cause of anxiety is a collapse of the disorganized–
 242 Liotti

controlling strategies. This hypothesis is particularly powerful in explaining

cases in which an exploration of the patients’ experience during and after
the mounting anxiety hints to dissociative phenomena (e.g., it involves
depersonalization, derealization or hypnoid states of mind). The following
clinical vignette illustrates how the clinical hypothesis works.
Ugo, aged 27, had asked for psychotherapy after having been diag-
nosed with a serious heart and lung disease (Pulmonary Hypertension). His
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mental ailments could be diagnosed Borderline Personality Disorder

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(BPD). Ugo came soon to idealize his empathic psychotherapist (T).

Although Ugo expressed great appreciation for the atmosphere and the
contents of the clinical dialogues, and his countenance and speech during
the therapeutic exchange did not betray anxiety, at the end of each session
his hands were regularly cold and moist (it is customary in Italy to shake
hands at the beginning and at the end of each meeting). T wondered
whether this could be a sign of underlying anxiety during the sessions, or of
Ugo’s cardiovascular disease, but was unable to decide in favor of one or the
other hypothesis until a series of sessions characterized by the patient’s stern
criticism of the therapist’s attitudes. At the end of each session where Ugo
expressed critical remarks about T’s attitudes in the dialogue, his hands were
warm and dry (for a detailed discussion of the clinical case, see Liotti, in press).
According to the hypothesis based on attachment theory, Ugo’s at-
tachment system had been disorganized since childhood (his family history
was in keeping with this possibility) and has become active within the
therapeutic relationship because of T’s accepting and supporting attitude
and because of the pain and fear consequent to his severe physical illness.
This meant that Ugo was experiencing, at a preconscious level of his mental
processes, the fright without solution and the dissociative tendencies that
characterize the activation of the disorganized IWM, while at the same
time he was consciously very appreciative of T’s empathic understanding.
Hence the anxiety betrayed by the cold moist hand while at the conscious
level Ugo seemed calm and appreciative of the clinical exchange. As soon
as T, noticing that Ugo begun to report new dissociative experiences that
were not present in the first phase of the therapy and that hindered his
compliance with his cardiologist’s prescriptions, decided to set limits to his
patient’s maladaptive way of coping with the physical illness, Ugo reacted
by resorting to the controlling-punitive strategy he had defensively used
since childhood to cope with the disorganization of attachment processes.
Anxiety quickly subsided thanks to the powerful inhibition of attachment
needs contingent on the controlling strategy. The logical consequence of
this hypothesis was for T to search for a cooperative attitude in the clinical
dialogues rather than going on with the supportive, empathic attitude he
had in the first phase of the treatment that seemed to foster unproductively
the activation of Ugo’s attachment system.
 Special Issue: Disorganized-Controlling Strategies 243

Preliminary data from a research study by Prunetti et al. (2008) sup-

port the hypothesis that BPD patients at the beginning of treatment tend
to react to therapist’s empathic attitudes with anxiety and disorganization
of their mental processes, as predicted by the model of attachment disor-
ganization in this disorder.
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Relational Dilemmas

Attachment disorganization has been held to be the source of difficult

to solve relational dilemmas. Steele, Van der Hart, and Nijenhuis (2001)
conceptualize these dilemmas as they tend to show up in the psychother-
apeutic relationship by stating that the patient oscillates between “phobia
of attachment” and abnormally clinging dependency on the therapist.
Blizard (2001) and Holmes (2004) remark that the therapist, when facing
these dilemmas, usually feels that every clinical choice leads to a blind
alley. Searching for meaning in the clinical dialogue may be the only way
of increasing the clinging patients’ sense of security and autonomy, but at
the same time the very words used in such a quest for meaning may arouse
memories of attachment trauma and lead to withdrawal. According to
Bateman and Fonagy’s (2004) theory of a deficit in the mentalizing (or
metacognitive) capacity as the main consequence of attachment trauma
and attachment disorganization, still another formulation of the relational
dilemmas stems from DA may be advanced. While the patients’ traumatic
memories and disorganized IWM distort the construing of the therapeutic
dialogue, the mentalization deficit hampers the fruition of psychodynamic
interpretations. A further conceptualization, illustrated in the above para-
graph by Ugo’s case, focuses on the predictable failure both of an empathic
approach and of a more detached interpretative approach. The therapists’
empathic attitudes could foster the activation of the disorganized IWM,
while more emotionally detached interpretations of the meaning of trans-
ferential– countertransferential responses could be perceived as repetition
of the indifference or even neglect by former attachment figures.
Because these dilemmas are linked to the dynamics between disorga-
nized attachment and defensive, controlling strategies involving the care-
giving, the ranking, and the sexual systems, therapists are advised to face
them by resorting to relational attitudes that foster cooperative exchanges.
The cooperative one is the only motivational system with an evolved
base that is not negatively influenced by early attachment disorganization
and the controlling strategies that are its main developmental sequels
(Liotti, Cortina & Farina, 2008). Therapists should strive, therefore, for a
dialectical balance between sympathetic emotional closeness and a more
 244 Liotti

egalitarian cooperative attitude of exploration and coconstruction of new

meaning structures. The knowledge of attachment disorganization is in-
strumental in achieving this balance. Only when the exercise of cooperative
interactions has yielded sufficient corrective relational experiences and
related insights can the IWM of disorganized attachment be consciously
revised within the therapeutic dialogue.
Knowledge of DA and the controlling strategies makes sense also of
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the widely diffused notion that having two therapists operating in two
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parallel settings is useful in the treatment of BPD (American Psychiatric

Association, 2001). The coordination of two therapists operating in parallel
settings may prove superior to any single setting in coping successfully with
the relational dilemmas stemming from a disorganized IWM. This may
hold true whatever types of treatment are simultaneously provided: indi-
vidual psychotherapy and pharmacotherapy, individual psychotherapy and
family therapy, or individual and group psychotherapy as in Linehan’s and
in Bateman and Fonagy’s models (Bateman & Fonagy, 2004; Linehan,
1993). The consideration of the dynamics of DA explains the usefulness of
two-therapists models (Liotti, Cortina, & Farina, 2008).
At the simplest level of explanation, the contingent security offered by
the presence of a second source of potential help may reduce the emotional
strain that would otherwise impinge on the first therapeutic relationship by
separation anxiety and the consequent activation of the disorganized IWM
(for instance, as the therapist’s holidays are foreseen). At a more sophis-
ticated level of explanation, the dynamics of DA explain the usefulness of
parallel integrated treatments in BPD through the consideration of men-
talization deficits.
Attachment-related traumatic experiences and their rehearsal within
the therapeutic relationship seriously impede the capacity to reflect on
one’s own and the other’s state of mind (Bateman & Fonagy, 2004). This
happens because of automatic construing the mind of the other as contain-
ing destructive intentions against one’s own mind, a deeply negative inter-
personal schema that is rather easily activated by a disorganized IWM.
While the relational strain within the primary therapeutic relationship
hinders the patient’s mentalization, the second therapist may assist the
patient in construing alternative hypotheses about the primary therapist’s
beliefs and intentions. The less threatening interpersonal context the pa-
tient may perceive within the second therapeutic setting facilitates a better
understanding of mental states. This widened capacity for considering
alternative hypotheses on the first therapist’s mental state may protect the
primary therapeutic relationship from premature interruption and thera-
peutic stalemates.
Another therapeutic effect of parallel integrated treatments on the
patient’s mentalizing capacity is linked to the possibility of presenting to
 Special Issue: Disorganized-Controlling Strategies 245

the patient, within different relationships, coherent representations of self

and others. Psychoanalytic oriented therapists suggest that the possibility
of two therapists offering to the patient a coherent view of self-with-other
may have a corrective effect on the splitting defense mechanism, quite
typical of BPD: the partial, split representation that may appear in each of
the two settings may become more easily integrated when the comments or
interpretations of the two therapist converge toward the same view of what
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is happening (Bateman & Fonagy, 2004).

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The knowledge of attachment dynamics suggest a further, particularly

promising way of dealing with situations where the patient idealizes one
therapist— construed as the “rescuer” according to one aspect of a disor-
ganized IWM—and devalues or fears the other one, construed as a help-
lessly vulnerable (“victim”) or as threatening (“persecutor”) according to
the other basic aspects of the same IWM. The idealized therapist, rather
than commenting on the patient’s devaluation of the other therapist, strives
to cooperate on equal grounds with the patient toward the very same
goal that is now hindered in the relationship with the second therapist. To
pursue this goal, it is mandatory that the idealized therapist not only avoids
taking sides, however subtly, with the patient against the second therapist,
but also limits classic psychoanalytic interpretations on the reported prob-
lems in the other therapeutic relationship. The reason for this is that
interpretations may be understood by the patient as evidence that the
idealized therapist knows better that the other one, which would disrupt
the goal of preserving cooperation on equal grounds as a main goal of all
the persons involved in the parallel settings. The activation of cooperative
social mentalities (Gilbert, 1989, 2005)—rather than attachment, caregiving
or competitive/ranking mentalities—preserves the therapeutic relationship
both for the enactment of the disorganized IWM and from the controlling
strategies with which it is usually defensively dealt with.
Finally, another important positive effect of parallel integrated treatments
is the increased sense of security of the therapist. BDP patients, especially
those with aggressive impulsive behaviors, quite often evoke negative feelings
in their therapists. Fear, anger, a sense of deep impotence, and a wish to
interrupt the therapy are therapists’ responses not uncommonly experienced
during the treatment of severe BDP (Bradley & Westen, 2005). If these
countertransferential reactions are expressed (however subtly), they retrau-
matize the patent by reproducing at least one aspect of the interpersonal
situation that originally yielded disorganization of attachment: a fragile, frag-
mented self meeting a vulnerable, frightened attachment figure. The involve-
ment of a second, cooperating clinician in the therapy of these severely
disturbed patients can reduce the emotional strain on the first therapist insofar
as it allows for the sharing of difficulties, worries, and responsibilities.
 246 Liotti

The two-therapists model, it should be emphasized, is a double-edged

weapon because it may easily become “a recipe for dangerous splitting with
one professional being idealized and the other denigrated” (Bateman &
Fonagy, 2004, p. 146). If parallel integrated treatments are to achieve correc-
tive relational experiences rather that instigate dangerous splitting, the two (or
more) therapists operating in the parallel settings must share theoretical
agreement, must be able to cooperate on equal grounds, and must regularly
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exchange information about the outcomes of their interventions (Liotti, Cor-

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tina, & Farina, 2008). Only when they are organized as “one-team interven-
tions” (Bateman & Fonagy, 2004) can parallel integrated treatments offer
precious opportunities for corrective relational experiences that do not require
in advance the use of mentalization capacities but can foster these capacities.

Resistance to Change

Patients sometimes state that, although they understood, thanks to psy-

chotherapy dialogues, that a given attitude of belief is irrational and patho-
genic they are unable to get rid of it. If the patients’ personal history (or their
present behavior in the face of adversities that are likely to activate the
attachment system) suggests that the system is disorganized, psychotherapists
may find it useful to explore whether such a resistance to change is linked to
the dynamics of a controlling strategy. Patients may have been protecting
themselves, since early childhood, from the dissociative experiences contin-
gent upon the activation of a disorganized IWM through a controlling strategy.
The controlling strategy involves irrational beliefs that are now consciously
acknowledged as irrational and pathogenic, but patients are not aware that the
strategy is aimed at protecting from shattering experiences of fragmentation of
the sense of self, and that to act in deviance from those beliefs implies a feeling
of a nameless impending danger whose roots are in the implicit knowledge of
past attachment interactions and may have never become fully explicit (i.e.,
fully conscious). The following clinical vignette, where the patient became
surprisingly insightful in the middle of a very tense clinical dialogue, illustrates
this possibility.
Maria (M), after 11 months of a cognitive– behavioral psychotherapy that
had momentarily afforded an increased ability to regulate her aggressive
impulses, experienced a serious relapse: she attacked vehemently her partner
at work screaming and insulting her. In the session after the event she com-
plained, in an aggressive tone of voice, that the therapy was a total failure:
M. This therapy of yours is a waste of time and money. You are unable
to cure me. I think I’ll stop here.
T. Would you say something about what happened in the days before
this episode at your office . . . .
 Special Issue: Disorganized-Controlling Strategies 247

M. I’m not going to tell you anything anymore. What is the purpose
when I am worse than ever?
T. Then I’ll advance an hypothesis. In the last session you said you
were considering divorce. Maybe this is not an easy decision to take.
Maybe the prospect of separating and living on your own caused anxiety.
In the past, we noticed that when you are afraid of something, particularly
afraid of loneliness, you tend to become somehow aggressive toward
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people in general.
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M. (silence, 30 seconds). Funny thing, an event of my childhood came

to my mind just now. I awoke in the middle of the night and cried. My
mother came. As soon as I saw her, I screamed and screamed and yelled at
her to hide beside the wardrobe.
T. Why?
M. I don’t know. I was afraid at looking at her. It was like a nightmare,
but I was awake.1
This clinical tip, although it does not constitute evidence of it, is in keeping
with the hypothesis that Maria had been disorganized in the early attachment
to her mother, and that she resorted to a controlling-punitive strategy to cope
with disorganization. Very likely, her tendency to become unduly aggressive in
interpersonal relationships stemmed from this strategy and involved irrational
beliefs according to which everybody who misbehaved, even slightly, in her
presence deserved hard explicit criticism. Maria had acknowledged, thanks to
her cognitive psychotherapy, that such a belief was both irrational and patho-
genic and become thereupon more able to regulate her aggressiveness. How-
ever, the activation of her attachment system (resulting from her considering
seriously the possibility of divorcing her husband) evoked the implicit basis of
her controlling punitive strategy, which was established much before the
explicit belief concerning the “need” to criticize severely any type of misbe-
havior.

CONCLUDING REMARKS

The example of DA illustrates a typical quality of the clinical applica-

tions of attachment theory: its basic concepts can be integrated within
different types of psychotherapy. The focus on family processes to make
sense of the patient’s symptoms is in keeping with the basic assumptions of

1
This episode has been reported to me by my Colleague, Dr. Fabio Monticelli, from the
transcript of a psychotherapy session. I gratefully acknowledge his help in my search for a
concise example of the integrative power of attachment theory while exploring resistance to
change in psychotherapy. Data concerning the patient have been disguised so as to make it
impossible to identify her.
 248 Liotti

family therapists. The consideration of the patients’ personal history since

infancy and the defensive dynamics that follow throughout development
early insecure attachments (in particular DA, where they appear as con-
trolling strategies) may appeal to psychoanalytically oriented psychother-
apists, as does the similarity between the psychoanalytic concept of trans-
ference and the basic assumption of attachment theory that any new
attachment relationship tends to be construed according to a preexistent
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IWM. The theory that complex interpersonal strategies should be explored

This document is copyrighted by the American Psychological Association or one of its allied publishers.

as the consequence of learning processes in response to real-life events

rather than as the outcome of fantasy-driven unconscious mental processes
is compatible with the theoretical framework of cognitive– behavioral psy-
chotherapies. As a consequence, attachment theory may provide an inter-
esting conceptual framework for those who are aiming at an integration
between different types of psychotherapy.
It should be remarked, however, that attachment theory was con-
ceived by John Bowlby (1969/1982) as a first attempt at organizing
preexisting psychological knowledge and at exploring present problems
in psychology on the basis of evolutionary thinking. In this respect,
attachment theory is concerned with only one among a number of
evolved dispositions to pursue biosocial goals and survival goals. Some
passages in this article hint at the need to consider other psychological
(or behavioral) systems, besides the attachment system, to understand
developmental processes stemming from early attachment experiences
(e.g., the caregiving system and the ranking system involved in the
controlling strategies, or the defense, fight-flight-freezing system in-
volved in responses to traumas). Thus, according to Bowlby attachment
theory should be studied in the general framework of evolutionary
psychology and evolutionary anthropology rather than regarded as a
self-concluded, overall theory of human interpersonal behavior. From
these premises it follows that to profit from attachment theory in
psychotherapy integration we should begin by exerting evolutionary
thinking in psychopathology and psychotherapy more often that it
seems to be usually the case. This has been the main reason why I
decided to focus on the example of the controlling strategies stemming
from infant DA when I had been asked to submit a paper to this issue
of the Journal of Psychotherapy Integration: the more interesting exam-
ples of the integrative potentiality of attachment studies in psychopa-
thology and psychotherapy show up only when we consider other
human motives together with attachment during our exploration of
human abnormal development and difficult psychotherapy relation-
ships. The knowledge of attachment processes is necessary in psycho-
therapy integration, but it is not sufficient to achieve our aim.
 Special Issue: Disorganized-Controlling Strategies 249

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