Abuser alters present a dilemma in the treatment of adults with dissociative identity disorder, because they often undermine the therapy as well as re-abuse the patient. They are paradoxical because they were created to help the child survive abuse, but continue to do so by abusing the self. They were often modelled after an abusive primary caregiver to whom the child was attached. Object-relations and attachment theories clarify how creation of the abuser personality serves to preserve the attachment to the abusing caregiver. By understanding how abuser alters function to maintain attachment, contain overwhelming memories, and protect against abuse, therapists can better engage abuser alters in a therapeutic alliance. Empathy, cognitive reframing, and gentle paradoxical techniques can help host and abuser personalities become more empathic toward one another, develop common purpose, and begin integrating. By working through the transference, attachment to the internalised abusive caregiver is replaced by healthy attachment to the therapist in the therapeutic alliance.