Journal of Trauma & Dissociation, 12:495–509, 2011

Copyright © 2011 Crown copyright

ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299732.2011.593259

Understanding Maltreating Mothers:

A Synthesis of Relational Trauma, Attachment
Disorganization, Structural Dissociation
of the Personality, and Experiential Avoidance

JACKIE AMOS, FRANZCP

Southern Adelaide Health Service, Child and Adolescent Mental Health Service, Adelaide,
South Australia, Australia

GARETH FURBER, PhD and LEONIE SEGAL, PhD

Health Economics and Policy Group, University of South Australia, Adelaide,
South Australia, Australia

Treatment options are limited for families in which the child has
severe and intractable disturbances of emotion and behavior, in
which there is suspected or confirmed maltreatment by the mother,
and in which the mother has her own history of childhood neglect
and abuse. This paper proposes a model for understanding mal-
treatment in mother–child dyads, drawing upon the developmental
psychopathology, behavior, and trauma literatures. At the core of
this model is the hypothesis that a mother’s maltreating behav-
ior arises from unconscious attempts to experientially avoid the
reemergence of an attachment-related dissociative part of the per-
sonality that contains the distress arising from her own early
experiences of attachment relationships. The implications of this
model for therapy are considered.

KEYWORDS relational trauma, attachment disorganiza-

tion, experiential avoidance, exposure, response prevention,
interpersonal trauma, structural dissociation

Received 6 April 2010; accepted 8 October 2010.

The authors would like to thank Mrs. Heather Chambers and Mrs. Ann Kasprzak for their
inspirational clinical work that drives them to learn more about this population and the three
anonymous reviewers for their generous and insightful comments.
Address correspondence to Jackie Amos, FRANZCP, Onkaparinga Regional Team of
SAHS—CAMHS, Unit 3/209 Main South Road, Morphett Vale, 5162, South Australia, Australia.
E-mail: Jackie.amos@health.sa.gov.au

495
496 J. Amos et al.

INTRODUCTION

Over the past 7 years, an increasing number of complex mother–child dyads

have been presenting to Child and Adolescent Mental Health Services in
Adelaide, South Australia, for help. Typically, the child, aged 3–12 years, has
entrenched behavioral and emotional problems. Symptoms include opposi-
tional behavior (e.g., lying, stealing, refusing to follow directions, swearing,
and name calling); explosive outbursts of aggression toward property, other
children, pets, and primary caregivers; poor sleep; hyperactivity; severe
anxiety; somatic concerns; and unsoothable distress. At school, they fail
to progress academically, disrupt the classroom, and struggle with peer
relationships. They attract multiple diagnoses, including separation anxiety
disorder, overanxious disorder of childhood, depression, oppositional defi-
ant disorder, attention-deficit/hyperactivity disorder, conduct disorder, and
learning disorders.
The mothers who present the child for treatment are similarly complex.
They report elevated stress, anxiety, and depression; histories of neglect,
abuse, and trauma; conflicted relationships with their families of origin;
and adult relationships marred by hostility, dissatisfaction, and domestic
violence. The mothers either are parenting alone or remain in unsupport-
ive partnerships. Many, through their involvement with adult mental health
services, have received diagnoses such as borderline personality disorder,
complex posttraumatic stress disorder, bipolar disorder, depression, anxiety,
and dissociative disorders.
In our experience, these dyads have been largely unresponsive to stan-
dard models of care such as parent effectiveness training, family therapy,
cognitive behavior therapy, and pharmacotherapy. This clinical observation
has some support from the research; for example, non-completers of par-
enting programs closely resemble our families in that the parent is highly
distressed and punitive (Werba, Eyberg, Boggs, & Algina, 2006).
In response to these difficulties we have been experimenting with an
intensive relationship-focused dyadic psychotherapy called parallel parent
child narrative/parent and child therapy (PPCN/PACT; Amos, Beal, & Furber,
2007; Chambers, Amos, Allison, & Roeger, 2006). We have found that chil-
dren who failed to improve with other interventions respond well to this
relational approach. For example, an 8-year-old girl with severe separa-
tion anxiety and school refusal had received 2 years of cognitive behavior
therapy, school interventions, and medication without improvement before
responding positively to PPCN/PACT. A similarly aged boy with externaliz-
ing symptoms had received individual counseling, medication, and school
support but did not improve until receiving PPCN/PACT. Both were able to
be discharged permanently from the clinic and have been well at follow-up
more than 12 months after completing the process.
 Journal of Trauma & Dissociation, 12:495–509, 2011 497

Three themes characterize our experience of this therapy. First, once

a strong therapeutic relationship is established, mothers, without excep-
tion, disclose episodes of abuse/neglect toward their child. Examples have
included hitting the child to stop outbursts of anger, locking the child out
of the house, pinning the child to the bed and screaming in his or her
face, “forgetting” the child is walking with them, beating the child and then
gently nursing an infant sibling in front of him or her, and not feeding the
child all day and leaving him or her to cry for hours without attempting
to soothe him or her. In most cases the extent of the abuse/neglect does
not meet thresholds for statutory intervention by child protection agencies
but helps explain the poor trajectories of these families through commu-
nity mental health services, as children with histories of maltreatment have
been found to exit treatment sooner without sustained improvements in their
presentations (Lau & Weisz, 2003).
Second, both mother and child show significant shifts in their presen-
tation within and between sessions. For example, one mother’s affect and
memory was severely constricted during history taking, however she became
enraged and threatening whenever her child became distressed. Another
mother who was generally overbright became terrified and child-like when
her son was distressed or hurt and overtly hostile when he became bois-
terous. Similar shifts are evident in the children. One girl who presented
in session as silent, frozen, and timid was reported as highly controlling at
home, insisting that she sleep in her mother’s bed, refusing to go to bed
unless her mother accompanied her, and violently attacking her mother if
she refused to comply. She would fall to the ground screaming if threatened
with separation from her mother. Another child (a boy) would alternately
chase his family around the house with knives, rock back and forth with
a dazed expression on his face, and become clingy and anxious under
conditions of perceived separation.
Third, both mother and child engage in a variety of avoidance behavior
when their attention is focused toward each other or their shared history.
For example, when detailed histories of the mother–child relationship are
taken during PPCN/PACT sessions, children frequently attempt to disrupt
the storytelling process. One child piled toys on the therapist’s lap until she
could no longer see the mother, whereas others repeatedly left the room or
interrupted with noisy play. When mothers are invited to silently observe
their child in the playroom through a one-way screen, they fidget and sigh,
glaze over, face away from the window, attempt to engage their therapist in
dialogue, use their mobile phone, or eat.
The theoretical model presented in this paper was developed in an
attempt to explain these three observations, namely ongoing maltreatment,
shifts in presentation, and avoidance of the relationship. The aim was to
coherently link these observed phenomena in a way that was consistent
498 J. Amos et al.

with concepts and findings from the attachment, trauma, and behavioral
psychology literatures, ultimately informing the development and refinement
of therapies to help this group.

A MODEL OF MATERNAL MALTREATMENT OF CHILDREN

AGED 3–12

The model is presented in three parts. First, a motivational systems per-

spective of personality development, which underpins much of the model,
is outlined. Second, we explore the concepts of relational trauma, a
motivational systems explanation of the ensuing attachment disorganiza-
tion, structural dissociation of the personality, and experiential avoidance.
Finally, we use this formulation to provide an explanation of maternal
maltreatment.

A Motivational Systems Perspective of Personality

From an ethological perspective (Bowlby, 1969/1982; Cortina & Liotti, 2005;
Van der Hart, Nijenhuis, & Steele, 2006), the basic building blocks of per-
sonality are inborn psychobiological systems that mediate behavior from
early in life, maturing in response to internal factors such as increasing cog-
nitive and emotional capacity and hormonal changes and in response to
external experiences. Found widely in mammals, these systems are differ-
entially activated by stimuli both internal and external to the individual, and
once triggered they guide behavior toward achieving specific goals. Once
the desired outcome is obtained the system’s influence on behavior is ter-
minated. Different authors have used different names for these systems. For
example, Bowlby (1969/1982) talked about control systems or operating sys-
tems, Nijenhuis and colleagues (Van der Hart et al., 2006) referred to them
as action systems, whereas Liotti used the term motivational systems (Liotti,
2008), which is the term this paper adopts.
A number of motivational systems thought to govern interpersonal
behavior have been identified. Of particular importance to our model are the
attachment system, which governs careseeking behavior in times of fear and
distress; the defense system, which governs threat management; the caregiv-
ing system, which governs the care and protection of youngsters; and the
social rank system, which governs one’s place in the social hierarchy based
on dominance and ritualized aggression (Cortina & Liotti, 2005). During nor-
mal development these systems form integrated internal guides for managing
the demands of adult life (Van der Hart et al., 2006). Motivational systems
become available to the individual at various points during development;
for example, the attachment and defense systems are operational from birth,
 Journal of Trauma & Dissociation, 12:495–509, 2011 499

whereas the social rank and caregiving systems become active at around the
age of 3 years (Cortina & Liotti, 2005).
In infancy, motivational systems are relatively simple. For example,
when an infant experiences a stimulus that arouses fear/distress (e.g.,
hunger, novel environment), the attachment system is activated and gives
rise to a behavioral response (crying). The infant’s goal is to secure the prox-
imity and attention of the primary caregiver via activation of the attachment
figure’s caregiving motivational system. Early learning, which arises from the
infant’s experiences at the hands of the caregiver, is encoded out of aware-
ness in implicit or procedural memory at a somatic–emotional level “that
does not require language or consciousness” (Amini et al., 1996; Liotti, 2006,
p. 59, 2008; Liotti & Gumley, 2008). Over time, attachment–caregiving inter-
actions are elaborated into an internal working model (IWM) that provides
the infant/child/adult with prescriptions for effective action in distressing sit-
uations. The IWM is based on both the actual care received and the infant’s
perception of the same and contains information about the self, how oth-
ers are likely to respond to requests for help, and how to elicit the needed
attention (Bowlby, 1969/1982).
Similar IWMs evolve both for the other motivational systems (and their
subsystems) and for groups of motivational systems (Van der Hart et al.,
2006). Personality, in this model, is a result of the unique elaboration and
integration of motivational systems with experience.

Relational Trauma and Disrupted Affective Communication

As previously described, in times of distress, an infant’s attachment system
is activated, supporting the infant’s goal of seeking care from an available,
affectively attuned caregiver (Figure 1, Box 1). Lyons-Ruth (2008), in her
research into high-risk samples of mothers and infants, has identified five
ways in which this attuned affective communication becomes disturbed.
These “affective communication errors” (which are coded in her AMBIENCE
coding system) include

where the mother both invites the infant to approach her and blocks
that approach; role confusion where the mother draws attention to
herself when the infant is in need; disorientation where the mother
appears frightened, hesitant or confused with incongruent affect; neg-
ative intrusive behavior where the mother mocks or teases the infant
and; withdrawing behavior where the mother fails to initiate interaction.
(Lyons-Ruth, 2008, pp. 207)

These communication errors have been identified as a discrete form of

trauma (Schore, 2003; Schuder & Lyons-Ruth, 2004) that has been referred
to as relational trauma (Figure 1, Box 2). Relational trauma arises when
500 J. Amos et al.

FIGURE 1 Structural dissociation of the personality and experiential avoidance as an outcome

of abuse and neglect. IWM = internal working model.

affective communication errors in the mother–infant relationship lead to the

infant experiencing overwhelming fear that is not mitigated but rather exac-
erbated by the presence of the attachment figure. These errors in affective
communication between mother and infant become traumatizing events to
the infant because the infant relies on this external figure to regulate his or
her internal distress, fear, and arousal. Failure to modulate the fear response
is at the core of all forms of trauma; as Tarabulsy et al. (2008, p. 325)
stated, “These daily relationship disturbances of a continuous nature (rela-
tional trauma) have a cumulative negative impact on the child that rivals
discrete episodes of neglect and abuse.”

Relational Trauma and Attachment Disorganization

In an extension of Ainsworth’s work on the use of the Strange Situation to
define and measure attachment styles in mother–infant dyads, Hesse and
Main (2000) identified a pattern of attachment behavior they called attach-
ment disorganization. This form of attachment relationship is predicted by
high levels of affective communication errors using the AMBIENCE coding
process (Lyons-Ruth, 2008), and research has found that more than 80% of
infants experiencing maltreatment have disorganized styles of attachment
when measured on the Strange Situation (Lyons-Ruth & Jacobitz, 1999).
In explaining attachment disorganization, Liotti (in press) and Van der
Hart et al. (2006) proposed that relating to a withdrawing, confusing, and
hostile parent (as described by Lyons-Ruth, 2008) leads to the simultaneous
activation of two conflicting motivational systems: the attachment system
and the defense system (Figure 1, Box 3). Normally both systems work
cooperatively to ensure proximity to the caregiver in times of danger and
distress. However, when the emotional relationship with the caregiver is
 Journal of Trauma & Dissociation, 12:495–509, 2011 501

both the source of and the solution to the distress, the attachment system
“pulls” the infant toward the caregiver, whereas the defense system “pulls”
him or her away, leaving the infant with an insoluble experience of fear.
Because of this built-in internal confusion, disorganized infants fail to
elaborate a coherent IWM of careseeking (Liotti, 2006, 2008). Instead, they
develop multiple, contradictory IWMs of the same parent comprising models
of successful comfort seeking derived from moments of effective caregiving,
models of inverted care when the parent is soothed by the presence of
the infant, and IWMs derived from the defense system and its various sub-
systems (freeze, fight, flight, and total submission). These IWMs “contain”
intense affects (with the corresponding bodily sensations) such as fear and
rage (Liotti, 1999). The simultaneous or rapid sequential activation of these
multiple internal representations accounts for the behavior described in dis-
organized infants in the Strange Situation, including incomplete approaches
to the parent, slowing and stilling, trance-like states, aggression, and other
contradictory approach/avoidance movements (Main & Hesse, 2000). Thus,
not only do these infants/toddlers need to manage the distress that originally
triggered their attachment system (i.e., episodes of abuse/neglect, relational
trauma), but they also need to manage the associated internal confusion.
This confusion arises from the simultaneous and incompatible activation of
the attachment and defense system–derived IWMs, full of unmanaged affect
and contradictory and changing prescriptions for action.

Experiential Avoidance and Structural Dissociation

Observational research into toddlers and children with histories of dis-
organized relationships with their primary caregivers reveals interesting
adaptations. First, toddlers show early signs of behavioral avoidance, turn-
ing away from the mother toward other preferred individuals with whom
their relationships are less confusing (Lyons-Ruth, 2008). Second, as these
toddlers become children (3–6 years), they start to exhibit new behavior
toward their caregiver referred to as controlling behavior, two categories
of which have been identified: controlling hostile punitive and controlling
caregiving (Lyons-Ruth & Jacobitz, 1999). Liotti (2006, 2008) has developed a
theoretical model postulating that this represents the defensive deactivation
of the attachment system and the activation of other motivational systems
(ordinarily activated in response to other personal/social needs) in its place.
He has suggested that activation of the social rank system explains the
hostile/punitive behavior, and activation of the caregiving system explains
the caregiving behavior. This substitution allows the infant/child to avoid
the internal distress and confusion associated with the activation of the
attachment system with its multiple contradictory IWMs by providing alter-
native responses to the conditions that originally activated the attachment
system.
502 J. Amos et al.

These ideas of the defensive deactivation of the attachment system and

the substitution of behaviors mediated by alternative motivational systems
have parallels in other models of psychopathology. For example, discussing
structural dissociation of the personality in response to potentially trauma-
tizing events, Van der Hart et al. (2006) suggested that when an individual
lacks the capacity to integrate an overwhelming experience the personality
becomes divided into dissociative parts. They referred to “apparently nor-
mal parts of the personality” and “emotional parts of the personality.” The
division(s) in the personality is (are) then maintained by the phobia of inner
experiences related to the trauma.
Hayes, Wilson, Gifford, Follete, and Strosahl (1996) used the term
experiential avoidance to describe something similar

that occurs when a person is unwilling to remain in contact with par-

ticular private experiences (e.g. bodily sensations, emotions, thoughts,
memories, behavioral predispositions) and takes steps to alter the form or
frequency of these events and the contexts that occasion them. (p. 1154)

Although Hayes et al. referred to “willingness” and “taking steps,” which

imply a conscious response, we believe that experiential avoidance (a pho-
bia of inner experience) can and often does occur largely outside of
conscious awareness (Amini et al., 1996; Liotti, 2006, 2008; Liotti & Gumley,
2008).
Drawing on the ideas of Liotti (2006, 2008), Van der Hart et al. (2006),
and Hayes et al. (1996), we hypothesize that the experience of relational
trauma and subsequent attachment disorganization (and associated IWMs)
cannot be integrated by the infant/toddler/child by virtue of his or her
age and stage of development (Figure 1, Box 4). Instead, the multiple
IWMs become divided from the rest of the developing personality, forming
what we are calling an attachment-related dissociative part of the personal-
ity (ARDP; Figure 1, Box 5). The division in the personality is maintained
by the child’s need to avoid the confusion and distress associated with the
activation of the ARDP (experiential avoidance/phobia of inner experience;
Figure 1, Box 6). However, this leaves the growing child with a dilemma.
He or she continues to experience distress and the need for help and res-
cue, which is usually achieved by seeking proximity to an attuned caregiver
(or substitute caregiver[s]). Following Liotti (2008), we suggest that as alter-
native motivational systems that are usually activated by other needs and
forms of social relatedness (social rank/caregiving) become available to the
child, they are activated in place of the attachment system. This is how inner
experiences associated with the activation of the attachment system come
to be avoided long term (Figure 1, Box 6). There are two possible reasons
for this. First, the IWMs and ensuing actions derived from the activation
of these systems are less aversive and do not need to be so strenuously
 Journal of Trauma & Dissociation, 12:495–509, 2011 503

FIGURE 2 Maternal maltreatment arising from structural dissociation and experiential

avoidance. ARDP = attachment-related dissociative part of the personality.

avoided. Second (as we discuss later in this paper), the mother may well
be relating to her child from an immature social rank or caregiving position
(Figure 2, Box 8 ), making it likely that the relational context will activate
complementary systems within the child. These substitutions are negatively
reinforced (operant conditioning), a process that is likely to prevent these
systems from maturing appropriately as they are activated in the service of
interpersonal needs inconsistent with their usual purpose.

Maintenance of Attachment-Related Structural Dissociation

into Adulthood
We hypothesize that this pattern of structural dissociation and experiential
avoidance persists into adulthood (Figure 2, Box 7). Some of the best evi-
dence for this comes from studies using the Adult Attachment Interview
to understand the state of mind with regard to the attachment (ARDP in
our model) of mothers whose infants are classified as disorganized. This
research points to significant dissociation or compartmentalization of inner
experiences related to careseeking in attachment relationships. Two coding
systems in particular, unresolved (U) and cannot classify (CC; Hesse, 1996;
Hesse & Main, 2006), capture mothers who experience significant intrusions
of past fear when discussing trauma or loss (U) or whose general narrative
around early relationships is contradictory and/or incomplete (CC). Of par-
ticular interest for us is an additional coding system, the Hostile/Helpless
coding system (Lyons-Ruth, Yellin, Melnick, & Atwood, 2005), which was
originally designed to capture the states of mind of mothers who had expe-
rienced relational trauma. In this system, these states of mind are viewed
504 J. Amos et al.

as outgrowths of the hostile punitive and caregiving controlling stances of

childhood; however, we theorize that they represent chronic activation of
the substitute motivational systems hypothesized by Liotti (2008) into adult-
hood. Because the Adult Attachment Interview is designed to access states
of mind related to early attachment caregiving experiences, we conclude
that these Hostile/Helpless states of mind also represent dissociative parts
of the personality, which we refer to as the hostile/helpless dissociative parts
of the personality (HHDP; Figure 2, Box 7).

Maternal Maltreatment Arising from Experiential Avoidance

and Structural Dissociation
Our view of how maltreatment emerges in the context of structural disso-
ciation and experiential avoidance is based on models of trauma derived
from learning theory (Van der Hart et al., 2006). These models involve a
potentially traumatizing event, reexperiencing phenomena (intense distress,
memories, thoughts, and sensations), triggers, and avoidance processes that
seek to ameliorate reexperiencing phenomena. For traumatized individuals,
external (e.g., places, objects) or internal (e.g., emotions, sensations, mem-
ories, or cognitions) events bearing some resemblance to aspects of the
original trauma can trigger reexperiencing. If this occurs in the presence
of neutral objects/events, these can become classically conditioned triggers
that are then experienced as aversive in their own right; strategies that sup-
port the avoidance of this distress become negatively reinforced (operant
conditioning) and strengthen over time.
How motherhood can disrupt experiential avoidance. Central to under-
standing maltreatment is recognizing how becoming a mother can interrupt
the well-established pattern of ARDP avoidance and HHDP substitution.
Liotti (2008) stated that a defensively deactivated (experientially avoided)
attachment system (ARDP in our model) can be reactivated by intense mental
pain, interpersonal losses or separations, commencement of an attachment-
like relationship, or situations in which the controlling strategies no longer
work. In our clinical experience, based on mothers’ narratives, aspects of
motherhood can both overwhelm the capacity of the relatively immature
HHDP and act as potent and reliable triggers for reactivating the ARDP in
some or all of these ways (Figure 2, Box 8).
First, mothers who lose the support of work, social networks, or part-
ners can find themselves isolated and facing an emotionally overwhelming
task. Second, the presence of the infant places the mother back into an
attachment relationship, albeit this time as the primary caregiver. Seeing
her infant’s distress, neediness, helplessness, and dependency can awaken
unintegrated memories of having been in this position and of not having
had her own needs met (Fraiberg, Adelson, & Shapiro, 1975). The mother
 Journal of Trauma & Dissociation, 12:495–509, 2011 505

experiences her infant’s emotional demands as terrifying, given that affec-

tive communication was the source of fear in her infancy and childhood
(Figure 2, Box 9). Third, ordinary attributes of the infant can be specific
trauma reminders for the mother depending on her idiosyncratic history.
For example, the infant boy who helps himself to his mother’s breast can be
experienced as violating and intrusive to the woman with a history of sex-
ual abuse. An infant or growing child may resemble a violent partner, and
normal toddler rage can fill the mother with fear as she sees the ex-partner
rather than her own little child.
Reexperiencing and maltreatment as experiential avoidance. The
repeated and potent activation of the ARDP in the presence of the infant is
a highly unsettling experience for the mother. Because this part of her per-
sonality has (a) been encoded in implicit memory and (b) been structurally
avoided since an early age, she reexperiences it in the form of sensations and
emotions rather than a well-formed narrative. The mother fails to recognize
that what has been activated has its origins in her own infancy/childhood
and that it is the context, not the infant, that is the trigger (known as source
attribution error; Briere & Scott, 2006). Thus, the infant (and usual infant
behavior) becomes a classically conditioned stimulus for the distress that
arises (Figure 2, Box 10).
We hypothesize that maltreatment arises out of processes that deacti-
vate or avoid the ARDP (Figure 2, Box 11). The first of these involves the
activation of the mother’s defense system (e.g., freeze, fight, flight, total
submission), which directs the mother’s behavior toward neutralizing the
perceived threat (i.e., the child). In this situation, the infant is approached
violently (i.e., fight) or avoided (freeze, flight, submission), leading to the
more traditional types of maltreatment (physical abuse, neglect; Figure 2,
Box 12). The second process to deactivate the ARDP involves the reinstate-
ment of the HHDP to manage the attachment/caregiving requirements of the
parent–child relationship (Figure 2, Box 13). In this situation, the reinstate-
ment of these systems gives rise to chronic hostile and helpless responses to
the growing child. In these two ways, the relationship becomes dominated
by the affective communication errors described previously plus or minus
discrete episodes of neglect and abuse (i.e., relational trauma; Figure 2,
Box 14).
It is important to note that in this model the mother’s response to her
infant or child’s expression of need centers on the reduction/avoidance of
her own distress. Parallel to her experience of being a child and attempting
to manage the distress associated with relational trauma, she now attempts
to manage the distress elicited by the attachment needs of her infant/child.
Thus, the success of her response is measured by her ability not to accu-
rately respond to the child’s needs but rather to deactivate or avoid the
ARDP. In fact, the two processes described become negatively reinforced
by the successful deactivation of the ARDP (Figure 2, Box 11). We believe
506 J. Amos et al.

this process is similar to the self-destructive behavior (e.g., substance abuse,

non-accidental self-injury) seen in other populations who attempt to mod-
ulate powerful internal experiences using seemingly destructive behavior
(Chapman, Gratz, & Brown, 2006; Chawla & Ostafin, 2007). It may also
explain why maltreatment can be highly resistant to change, even when
external consequences (e.g., child protection involvement) are severe.

DISCUSSION

To summarize, maltreatment in this model is the result of complex psy-

chological processes that facilitate the avoidance of a dissociative part of
the personality (ARDP) in which all of the confusion, distress, memories,
images, feelings, and sensations of early relational trauma are stored. The
infant/child, who is mistakenly identified as the source of the mother’s dis-
tress, is targeted directly, leading to the destructive approach and avoidance
behavior that defines maltreatment. The dynamics of the parent–child rela-
tionship (dominated by shifts in presentation and relationship avoidance)
are understood as having their origins in the activation of the dissociative
parts of the personality (ARDP, HHDP) in response to the affective demands
of the relationship. This fits well with our clinical observations.
In our view, the dominant implication of this model is that successful
detoxification and integration of the ARDP will remove the target of expe-
riential avoidance and weaken the dominance of the HHDP, allowing the
maturation of the caregiving motivational system and the development of
more attuned and effective emotional communication between parent and
child. The theoretical model predicts that activation of, exposure to, and
counter-conditioning of the ARDP is crucial to the success of any therapy
for this population. This is akin to other models of trauma therapy for bor-
derline personality disorder (Briere & Scott, 2006) and dissociative disorders
(Van der Hart et al., 2006) in which exposure to content related to early
attachment distress and interpersonal trauma is a key element of treatment
(Fonagy, Gergely, Jurist, & Target, 2005; Liotti, 2006, 2008).
The fundamental challenge is to develop an exposure task that can suc-
cessfully elicit and counter-condition a part of the personality that is held in
implicit memory and has been structurally avoided for a long time. Our the-
oretical model suggests that the child will be the most potent activator of the
ARDP in the mother. We note that in PPCN/PACT, when we use a one-way
screen to provide mothers (and their therapist) with the opportunity to watch
their child interact with another therapist, mothers frequently become visibly
agitated, aggressive, frozen or vague, and overwhelmed, and we believe this
to represent the activation of the ARDP. When these reactions are discussed
in the context of a rich description of the mothers’ early relational history, it
helps the mothers put together the pieces of the puzzle, linking their early
 Journal of Trauma & Dissociation, 12:495–509, 2011 507

relational trauma with their reactions to their child (integrating the ARDP).
This weakens the source attribution error and allows the mothers to expe-
rience their previously unintegrated distress in the presence of a supportive
empathic other, linked to its original context.
It is interesting that a number of parent–child relationship therapies
include possible relational exposure components. Parent–child interaction
therapy (Herschell, Calzada, Eyberg, & McNeil, 2002) incorporates live
parent–child interactions as a key component, and Circle of Security (Marvin,
Cooper, Hoffman, & Powell, 2002) uses videotaped sessions of parent–child
interactions; both of these may also represent child-safe ways of exposing
the mother to her ARDP.
We go as far as to suggest that relational exposure underlies the benefi-
cial effects of a number of existing parent–child treatments whose theoretical
targets vary from dysfunctional social learning interactions (e.g., parent–child
interaction therapy), beliefs, cognitions (Abuse-Focused Cognitive Behaviour
Therapy; Kolko, 1996), and maternal sensitivity (e.g., Watch, Wait and
Wonder; Cohen et al., 1999).

CONCLUSION

The strength of this model lies in its dedicated application of the scientific
method, of using observations from clinical practice and the published lit-
erature to develop initial hypotheses and combine these hypotheses into a
logic-driven model. We believe this model provides an excellent template
upon which to refine and develop models of intervention in this popula-
tion. Furthermore, it is a good starting point for exploring concepts such
as structural dissociation and experiential avoidance and how they might
apply to other related populations such as fathers and children, perpetra-
tors of domestic violence, mother–child dyads with histories of insecure
but organized attachment relationships, and foster care relationships. We
are convinced that the regular discussion of theory and its relation to clin-
ical practice will provide the best basis for refining clinical treatments and
matching them to the right populations.

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