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Introduction by Paolo Migone Peter Fonagy, beside having given important contributions in various areas, is also a very well known researcher in one of the most interesting and promising fields, the research on attachment. Like Mary Main and other heirs of Bowlby, he continued to explore this line of research, and investigated the concept of "metacognition" (what he calls "reflective self function"), which attracts more and more the attention not only of psychoanalysts but also of researchers of the cognitive field. To this regard, we can say that maybe Fonagy, a leading figure in contemporary psychoanalysis, more than any other author contributed to the rich dialogue between analysts and cognitive therapists that we see today. This article we have chosen for publication in PSYCHOMEDIA is one of his clearest and most comprehensive papers, in which he shows an overview of the main issues of his research as well as its relevance for the understanding of personality disorders. The second part of this article (starting with paragraph 3.1) was published, with the slightly different title "Attaccamento sicuro e insicuro", in the Italian journal KOS, 1996, 129, June, pp. 26-32. An English version, written in 1997, will appear in: Maffei C., Derksen J. & Groen H. (editors), Treatment of Personality Disorders (New York: Plenum Press, in press). We thank the Italian journal KOS and Peter Fonagy for having given the texts and the publications permissions. Fonagy's paper is followed by a discussion by Giovanni Liotti, titled "Attachment and metacognition in borderline patients". Liotti is a leading figure of the Rome school of cognitivie therapy, and tries an integrative theorization on the etiology of Borderline Personality Disorder. After the publication of these documents, there has been a disussion on the concept of "metacognition" in the mailing list "Psychotherapy" of PSYCHOMEDIA. Attachment, the development of the self, and its pathology in personality disorders
1. Introduction Attachment theory concerns the nature of early experiences of children and the impact of these experiences on aspects of later functioning of particular relevance to personality disorder. The question we attempt to address here is how deprivation, in particular early trauma, comes to affect the individual’s propensity to personality disorder. As part of this question we are naturally also concerned to understand how such adverse consequences may be avoided. The key assumption made by the invoking of attachment theory is that individual social behaviour may be understood in terms of generic mental models of social relationships constructed by the individual. These models, although constantly evolving and subject to modification, are strongly influenced by the child’s experiences with the primary caregivers. Let us now turn to the details of the theory. 2. The nature of the attachment system Attachment theory, developed by John Bowlby (1969, 1973, 1980), postulates a universal human need to form close affectional bonds. It is a normative theory of how the ‘attachment system’ functions in all humans. Bowlby described attachment as a special type of social relationship, paradigmatically between infant and caregiver, involving an affective bond. More significantly, it may also be seen as the context within which the human infant learns to regulate emotion (Sroufe, 1990). The stability of early childhood attachment patterns is well demonstrated. Mary Ainsworth and her colleagues (Ainsworth, 1985; Ainsworth & Wittig, 1969; Ainsworth et al., 1978) developed a procedure commonly known as the Strange Situation, which classifies infants and toddlers into one of four attachment categories. Secure infants explore readily in the presence of the primary caregiver, are anxious in the presence of the stranger, are distressed by their caregivers departure and brief absence, rapidly seek contact with the caregiver following a brief period of separation, and are reassured by renewed contact. The recovery from an over-aroused disorganised state is smooth and carried to completion in the sense that the infant returns to exploration and play. Some infants, who are usually made less anxious by separation, do not automatically seek proximity with the caregiver on her return following separation and may show no preference for the caregiver over the stranger; these infants are designated ‘Anxious/Avoidant’. A third category, the ‘Anxious/Resistant’ infant manifest impoverished exploration and play, tend to be highly distressed by separation from the caregiver, but have great difficulty in settling after reunion showing struggling, stiffness, or continued crying, or fuss in a passive way. The caregiver’s presence or attempts at comforting fails to offer reassurance and their anxiety and anger appears to interfere with their attempts to derive comfort through proximity. Both these insecure groups appear to be coping with arousal and ambivalence through a precautious over-control of affect because they appear to be uncertain in their expectation that the caregiver will do his or her part to modulate their emotional arousal (Main & Weston, 1981; Sroufe, 1990). It is generally held that the patterning of attachment related behaviour is underpinned by different strategies adopted by children to regulate their emotional reactions. As affect regulation is acquired with the help of the child’s primary caregiver, the child’s strategy will be inevitably a reflection of the caregiver’s behaviour towards him/her. Secure infants’ behaviour is based on the experience of well co-ordinated, positive interactions where the caregiver is rarely over-arousing and is able to restabilise the child’s spontaneously emerging disorganising emotional responses. Therefore, they remain relatively organised in stressful situations. Negative emotions are not seen as threatening in and of themselves but are regarded by the infant as serving a communicative function (Grossman et al., 1986; Sroufe, 1979, 1996). By contrast, Anxious/Avoidantly attached children are presumed to have experiences when their emotional arousal was not restabilised by the caregiver because of personal or social pressures on the caregiver and an associated mild neglect or even resentment of the child. The same expectations may arise in children who were over aroused through intrusive parenting, therefore they over-regulate their affect and steer away from situations that are likely to be emotionally arousing. Anxious/Resistantly attached children under-regulate, heightening their expression of distress possibly in an effort to elicit the expectable response of the caregiver. These children have low thresholds for threat and may become preoccupied with having contact with the caregiver, but show signs of frustration regarding this contact even when it is available (Sroufe, 1996). A fourth group of infants appear to exhibit a range of seemingly undirected behavioural responses giving the impression of disorganisation and disorientation (Main & Solomon, 1990). Infants who manifest freezing, handclapping, headbanging, the wish to escape from the situation even in the presence of the caregiver, are referred to as ‘Disorganised/ Disoriented’. It is generally held that for such infants the caregiver has served both as a source of fear and as a source of reassurance, thus the arousal of the attachment behavioural system produces strong conflicting motivations. Not surprisingly, a history of severe neglect or physical or sexual abuse is often associated with the manifestation of this pattern (Cicchetti & Beeghly, 1987; Main & Hesse 1990). 2.1 Determinants of attachment security It is beyond the scope of this paper to consider in detail the rich literature on determinants of infant security. There are many excellent reviews available, notably by Belsky (Belsky et al., 1995). Clearly genetic transmission may account for some component of the prediction from parental attachment status to the child’s security of attachment (van Ijzendoorn, 1992). The influence of temperament on attachment security is controversial, but the balance of the evidence is now against the appropriateness of a temperamental account (Kagan, 1982; Lamb et al., 1984). There is little evidence that distress-prone infants become anxious-resistant babies (van den Boom, 1990). Temperament changes in the first year of life (Belsky et al., 1991) and the attachment pattern of a child to his two parents is often inconsistent (Fox et al., 1991) and appears to be dependent on the internal working model of each parent (Steele et al., 1996). The quality of maternal care has been repeatedly shown to predict infant security. The sensitive responsiveness of the parent is traditionally regarded as the most important determinant of attachment security in the infant (Isabella, 1993; Isabella & Belsky, 1991). The parameters assessed include: ratings of maternal sensitivity (e.g. Cox et al., 1992; Isabella, 1993), prompt responsiveness to distress (Del Carmen et al., 1993), moderate stimulation (Belsky et al., 1984), non-intrusiveness (Malatesta et al., 1986), interactional synchrony (Isabella et al., 1989), warmth, involvement and responsiveness (O'Connor et al., 1992). These associations have been strengthened by findings from experimental studies, where the enhancement of maternal sensitivity has been shown to increase the proportion of secure infants in high-risk populations (van den Boom, 1995). Similar parameters have been predictive for fathers (Cox et al., 1992) and for professional caregivers (Goosens & van Ijzendoorn, 1990). Negative parental personality traits are associated with insecurity in many studies, although by no means all (Zeanah et al., 1993). This has been shown for anxiety (Del Carmen et al., 1993), aggression (Maslin & Bates, 1983) and suspicion (Egeland and Farber, 1984). Parental psychopathology is also found to be a risk factor in some studies (Campbell et al., 1993). Of the contextual factors, support from the partner (Goldberg and Easterbrooks, 1984) and from others in the mother's environment (Crnic et al., 1983) appear important. The strength of these associations is reinforced by experimental studies where social support was systematically manipulated (Lyons-Ruth et al., 1990; Jacobson & Frye, 1991; Lieberman et al., 1991). These predictors of infant security are correlated to one another and are all likely to be unequally distributed across socio-economic groups. It is known that socio-economic status and other indicators of social deprivation are linked to both infant and adult classifications (e.g. Ward & Carlson, 1995; van Ijzendoorn & Kroonenberg, 1988; Crittenden et al., 1991; Zeanah et al., 1993). Poor parenting skills and the maltreatment of children are more common in families suffering economic hardship (Gabarino, 1992). Insecure classification is more common in deprived groups. Maltreatment of children, strongly associated with economic deprivation (Belsky, 1993) is most likely to be associated with the disorganised/disoriented pattern of infant attachment. 2.2 The continuity of patterns of attachment Bowlby proposed that the quality of childhood relationships with the caregivers results in internal representations or working models of the self and others that provide prototypes for later social relations. Internal working models are mental schemata, where expectations about the behaviour of a particular individual toward the self are aggregated. The expectations are themselves abstractions based on repeated interactions of specific types with that individual. If the child’s physical injury is quickly dealt with, sources of unhappiness are rapidly addressed, the child will develop the legitimate expectation that, with that person at least, his distress is likely to be met by reassurance and comforting. The internal working model is the result of a natural process of abstraction of the invariant features from diverse social situations with a particular individual (Stern, 1985, 1994). Such internal models of attachment remain relatively stable across the lifespan (Collins & Read, 1994). Secure children, with the benefit of well-regulated caregiver-infant relationships behind them, are expected to evolve positive expectations concerning their exploratory competence, to achieve a reliable capacity for modulation of arousal, a good capacity for communication within relationships and, above all, confidence in the ongoing availability of the caregiver. Early experiences of flexible access to feelings is regarded as formative by attachment theorists, enabling secure children both to maximise the opportunities presented to them by the environment and draw on socially supportive relationships. The autonomous sense of self emerges fully from secure parent-infant relationships (Emde & Buchsbaum, 1990; Lieberman and Pawl, 1990; Fonagy et al., 1995). The increased control of the secure child permits it to move towards the ownership of inner experience and come to recognise the self as competent in eliciting regulatory assistance, to develop metacognitive control and to achieve an understanding of self and others as intentional agents whose behaviour is organised by mental states, thoughts, feelings, beliefs and desires (Sroufe, 1990; Fonagy et al., 1995). 2.3 Prediction from adult attachment measures The stability of these attachment assessments are dramatically illustrated by longitudinal studies of infants assessed with the Strange Situation and followed up in adolescence or young adulthood with the Adult Attachment Interview (AAI) (George et al., 1985). The AAI asks subjects about childhood attachment relationships and the meaning which an individual currently gives to attachment experiences. The instrument is rated according to the scoring system developed by Main & Goldwyn (1994) which classifies individuals into Secure/Autonomous, Insecure/Dismissing or Avoidant, Insecure/Preoccupied or Resistant or Unresolved/Disorganised with respect to loss or trauma, categories according to the structural qualities of their narratives of early experiences. (While autonomous individuals clearly value attachment relationships and regard these as formative, insecure individuals are poor at integrating memories of experience with their assessment of the meaning of that experience. Those dismissing of attachment deny or devalue early relationships. Preoccupied individuals tend to be confused, and angry or passive in their current relationships with their parents and others). Two studies (Hamilton, 1994; Waters, et al., 1995) have shown a 68-75% correspondence between attachment classifications in infancy and classifications in adulthood. This work speaks to the remarkable stability of attachment classifications across the lifespan. Similar findings are beginning to emerge using other measures of attachment in adults (Hazan & Zeifman, 1994). 3. The transgenerational transmission of attachment patterns There is further important evidence that attachment relationships may play a key role in the transgenerational transmission of hardship and deprivation. Individuals categorised as secure are 3 or 4 times more likely to have children who are securely attached to them (van Ijzendoorn, 1995). This turns out to be true even in prospective studies where parental attachment is assessed before the birth of the child (Benoit & Parker, 1994; Fonagy et al., 1991; Radojevic, 1992; Steele et al., 1996; Ward & Carlson,1995). These findings also emphasise the importance of quality of parenting in determining the child’s attachment classification. The findings from our lab suggest that parental attachment patterns predict variance in addition to temperament measures or contextual factors, such as experience, social support, marital relationship, psychopathology and personality (Steele, Steele & Fonagy, in preparation). If attachment is linked to personality disorder we may anticipate a substantial overlap between determinants of infant security and long-term predictors of criminality. 3.1 Attachment and mentalising A compelling model for the transmission of secure attachment, which has moved the field beyond a simple view of caregiver sensitivity, was suggested by Mary Main (1991) in her seminal chapter on metacognitive monitoring and singular versus multiple models of attachment. Main (1991) showed that the absence of metacognitive capacity, the inability to "understand the merely representational nature of their own (and others') thinking" (p. 128), makes infants and toddlers vulnerable to the inconsistency of the caregiver's behaviour. They are unable to step beyond the immediate reality of experience and grasp the distinction between immediate experience and the mental state which might underpin it. Main drew our attention to the development in the child of the mental state that Dennett (1987) called "the intentional stance". Dennett stressed that human beings are perhaps unique in trying to understand each other in terms of mental states: thoughts, feelings, desires, beliefs, in order to make sense of and, even more important, to anticipate each other’s actions. It is self-evident that by attributing an emotional or cognitive state to others we make their behaviour explicable to ourselves. If the child is able to attribute a withdrawing, non-responsive mother's apparently rejecting behaviour to her emotional state of depression, rather than to himself as bad and unstimulating, the child is protected from, perhaps permanent, narcissistic injury. Perhaps even more central is the child’s capacity to develop representations of the mental states, emotional and cognitive, which organise his/her behaviour toward the caregiver. We attempted to operationalise individual differences in adults' metacognitive capacities which we believe might help to fill the 'transmission gap'. We were curious to know if the extent of self-reflective observations about the mental states of self and others in Adult Attachment Interview (AAI) narratives could predict infant security. We chose the term "reflective self-scale" (as opposed to "self-reflection scale") to underscore that we were concerned about the clarity of the individual's representation of the mental states of others as well as the representation of their own mental state. Consistent with our expectation, reflective-self ratings were reliable (intraclass r = .8 and above) and provided a good pre-natal prediction of the Strange Situation behaviour of the child. Both fathers and mothers who were rated to be high in this capacity were three or four times more likely to have secure children than parents whose reflective capacity was poor (Fonagy et al., 1991). The capacity for metacognitive control may be particularly important when the child is exposed to unfavourable interaction patterns, in the extreme, abuse or trauma. For example, in the absence of the capacity to represent ideas as ideas, the child is forced to accept the implication of parental rejection, and adopt a negative view of himself. A child who has the capacity to conceive of the mental state of the other can also conceive of the possibility that the parent's rejection of him or her may be based on false beliefs, and therefore is able to moderate the impact of negative experience. We examined this issue by administering a brief structured interview to parents in our sample, 18 months after they had completed the Adult Attachment Interview, concerning a number of simple indicators of family stress and deprivation which had been reported in past studies to increase dramatically the probability of adverse outcome, including, in a recent study, the likelihood of insecure infant attachment. These indicators included: single parent families residing separately, overcrowding, paternal unemployment, etc. We divided our sample into those who had reported significant experience of deprivation (more than 2 items) and those who had not. Our prediction was that mothers in the deprived group would be far more likely to have children securely attached to them if their reflective-self rating (metacognitive capacity) was high. 10 out of 10 of the mothers in the deprived group with high reflective-self ratings had children who were secure with them, whereas only 1 out of 17 of deprived mothers with low ratings did so. Reflective-self function seemed to be a far less important predictor for the non-deprived group. Our findings imply that the intergenerational replication of early negative experiences may be aborted, the cycle of disadvantage interrupted, if the caregiver acquires a capacity to fully represent and reflect on mental experience (Fonagy et al., 1994). 3.2 Metacognitive monitoring and the development of the self Metacognitive monitoring completes one aspect of the intergenerational cycle. Not only are parents high in reflective capacity more likely to promote secure attachment in the child, particularly if their own childhood experiences were adverse, but also secure attachment may be a key precursor of robust reflective capacity (Fonagy et al., 1995). In London, we have collected cross-sectional data from 3-5 year olds which appears to indicate a strong correlation between security on a projective measure of attachment (the SAT) and the early development of a theory of mind, using the belief-desire reasoning task. We found the children who were rated Secure on the Separation/Anxiety test were more likely to pass the theory of mind tasks (Fonagy et al., 1997). In a longitudinal study, we found that of 92 children, the 59 who had passed the task at 5 years, 66% were secure at one year with their mother. Of the 29 who failed, only 31% had been secure. Attachment security to father was less significantly associated with greater competence at this task. There was clear indication that the reflective self function of mother was associated with the child’s success. 80% of children whose mothers were above the median in reflective self function passed, whereas only 56% of those whose mothers were below did so. These results suggest that the parents' capacity to observe the child's mind facilitates the child's general understanding of minds mediated by secure attachment. The availability of a reflective caregiver increases the likelihood of the child's secure attachment which, in turn, facilitates the development of theory of mind. Throughout these studies we assume that a secure attachment relationship provides a congenial context for the child to explore the mind of the caregiver, and, as the philosopher Hegel (1807) taught us, it is only through getting to know the mind of the other that the child develops full appreciation of the nature of mental states. The process is intersubjective: the child gets to know the caregiver's mind as the caregiver endeavours to understand and contain the mental state of the child. The child perceives in the caregiver's behaviour not only her stance of reflectiveness which he infers in order to account for her behaviour, but also he perceives in the caregiver's stance an image of himself as mentalizing, desiring and believing. He sees that the caregiver represents him as an intentional being. It is this representation which is internalised to form the self. "I think therefore I am" will not do as a psychodynamic model of the birth of the self; "She thinks of me as thinking and therefore I exist as a thinker" comes perhaps closer to the truth. If the caregiver's reflective capacity enabled her accurately to picture the infant's intentional stance, the infant will have the opportunity to "find itself in the other" as a mentalizing individual. If the caregiver's capacity is lacking in this regard, the version of itself that the infant will encounter will be an individual conceived of as thinking in terms of physical reality rather than mental states. 4. Some speculations about pathological development based on the dialectic model The fundamental need of every infant is to find his mind, his intentional state, in the mind of the object . For the infant, internalisation of this image performs the function of "containment", which Winnicott has written of as "giving back to the baby the baby's own self" (Winnicott, 1967, p. 33) . Failure of this function leads to a desperate search for alternative ways of containing thoughts and the intense feelings they engender. The search for alternative ways of mental containment may, we suggest, give rise to many pathological solutions, including taking the mind of the other, with its distorted, absent or malign picture of the child, as part of the child's own sense of identity. Winnicott (1967) wrote: "What does the baby see when he or she looks at the mother's face? ...ordinarily, the mother is looking at the baby and what she looks like is related to what she sees there... [but what of] the baby whose mother reflects her own mood or, worse still, the rigidity of her own defences... They look and they do not see themselves... what is seen is the mother's face" (p. 27). This picture then becomes the germ of a potentially persecutory object which is lodged in the self, but is alien and unassimilable. There will be a desperate wish for separation in the hope of establishing an autonomous identity or existence. However, tragically, this identity is centred around a mental state which cannot reflect the changing emotional and cognitive states of the individual, because it is based on an archaic representation of the other, rather than the thinking and feeling self as seen by the other. Paradoxically, where the child's search for mirroring or containment has failed, the later striving for separation will only produce a movement towards fusion. The more the person attempts to become himself, the closer he moves towards becoming his object, because the latter is part of the self-structure. This in our view accounts for the familiar oscillation of borderline patients, between the struggle for independence and the terrifying wish for extreme closeness and fantasised union. Developmentally, a crisis arises when the external demand for separateness becomes irresistible, in late adolescence and early adulthood. At this time, self-destructive and (in the extreme) suicidal behaviour is perceived as the only feasible solution to an insoluble dilemma: the freeing of the self from the other through the destruction of the other within the self. In some individuals, for whom separateness is a chronic problem, we assume that the experience of self-hood can only be achieved through finding a physical other onto whom the other within the self can be projected. Naturally, this increases the individual’s need for the physical presence of the object. Thus, many such individuals experience considerable difficulty in leaving home and if they finally achieve physical separation, they can only do so by finding an alternative and comparable figure onto whom the other within the self may be projected. If the other dies, or abandons the individual, a pathological mourning process may be initiated whereby the person feels compelled to maintain a live picture of the other, in order to retain the integrity of the self. Another possible outcome of poor development of the psychological self, with consequent conflicts over separation, is that the body may be used to contain and enact mental states. In these cases the child's own body comes to serve the function of metarepresentation of feelings, ideas and wishes. Violence towards the body of the self (e.g. self cutting) or that of the other (apparently unprovoked aggression or ‘mindless violence’ may be a ways of ‘controlling’ mental states which are invested in bodily states (e.g. the mother seen as part of ones own body) or destroying ‘ideas’ experienced as within the body of the other. In other young children the search for the psychological self in the other may lead to the physical image of the object being internalised as part of the child's identity. In extreme cases, this may result in gender identity disorder (Fonagy & Target, 1995). If the child finds no alternative interpersonal context where he is conceived of as mentalizing his potential in this regard will not be fulfilled. In cases of abusive, hostile or simply totally vacuous relationship with the caregiver, the infant may deliberately turn away from the mentalizing object because the contemplation of the object's mind is overwhelming as it harbours frankly hostile intentions toward the infant's self. This may lead to a widespread avoidance of mental states which further reduces the chance of identifying and establishing intimate links with an understanding object. As studies of resilient children suggest, even a single secure/understanding relationship may be sufficient for the development of reflective processes and may 'save' the child. Metacognitive monitoring is biologically prepared and will spontaneously emerge unless it's development is inhibited by the dual disadvantage of the absence of a safe relationship and the experience of maltreatment in the context of an intimate relationship. We do not anticipate that trauma outside of the context of an attachment bond would have pervasive inhibitory effects on mentalizing. It is because the theory of mind or, more broadly, and reflective self function evolve in the context of intense interpersonal relationships, that the fear of the mind of another can have such devastating consequences on the emergence of social understanding. To illustrate the clinical relevance of this model, it may be helpful to consider borderline personality disorder from the point of view of attachment theory. 4.1 A transgenerational model of borderline personality disorder Although accurate figures are hard to come by and vary across studies, considerable evidence has accumulated to support the contention that child abuse is transmitted across generations. Oliver (1993), in his recent review of 60 studies, mainly from the United States and the UK, concluded that approximately one third of child victims of abuse grow up to continue a pattern of seriously inept, neglectful or abusive child-rearing as parents. Research has documented that a specific link exists between the history of childhood maltreatment and borderline personality disorder and sexual abuse is especially implicated. In brief, as infants and children, borderline individuals frequently have caretakers who are themselves within the so called 'borderline spectrum' of severely personality disordered individuals. The social inheritance aspect of BPD may be an important clue in our understanding of the disorder. George Moran, Mary Target and I (Fonagy et al., 1993) have put forward an attachment theory formulation of severe narcissistic and borderline states based on epidemiological findings of the association of severe personality disorder and a history of childhood maltreatment and sexual abuse. We proposed that borderline individuals are those victims of childhood (sexual) abuse who coped by refusing to conceive of the contents of their caregiver's mind and thus successfully avoided having to think about their caregiver's wish to harm them. They go on to defensively disrupt their capacity to depict feelings and thoughts in themselves and in others. This leaves them to operate upon inaccurate and schematic impressions of thoughts and feelings and they are thus immensely vulnerable in all intimate relationships. Many of the symptoms of BPD individuals may be understood in terms of a defensive strategy of disabling mentalizing or metacognitive capacity: 1. Their failure to take into consideration the listener's current mental state makes their associations hard to follow. 2. The absence of concern for the other which may manifest as extreme violence and cruelty, arises because of the lack of a compelling representation of suffering in the mind of the other. A key moderator of aggression is therefore absent. The lack of reflective capacity in conjunction with a hostile world view may predispose individuals to child maltreatment but such inhibition may be a necessary component of all violence against persons. Military training has the apparent and explicit aim of fashioning men into machines and the enemy into an inanimate or sub-human object. Seeing the other as imbued with thought and feeling is very likely imposes a break. 3. Their fragile sense of self (identity diffusion to use Kernberg's term), may be a consequence of their failure to represent their own feelings, beliefs and desires with sufficient clarity to provide them with a core sense of themselves as a functioning mental entity. This leaves them with overwhelming fears of mental disintegration and a desperately fragile sense of self. 4. Such patient's mental image of object remains at the immediate context dependent level of primary representations - he/she will need the object as they are and will experience substantial difficulties when confronted with change. 5. Absence of prominence 'as if' in the transference requires meta representations, the capacity to entertain a belief whilst at the same time knowing it to be false. Psychotherapy requires such pretence and it's absence manifests as so called 'acting out' of the transference. 4.2 The association of attachment status and borderline states In an ongoing study (Fonagy et al., 1996) we administered AAI's to a sample of 85 consecutively admitted non-psychotic inpatients at the Cassell Hospital in London, which is run along the principles of a psychoanalytic therapeutic community. About 40% of the patients met diagnostic criteria for borderline personality disorder (BPD) on the basis of a structured interview (SCID-II). The distribution of AAI classifications arrived at totally independently of the diagnostic process, did not distinguish well Borderline Personality Disorder (BPD) from other personality disorder diagnoses but the number of entangled (particularly E3) classifications were well above the number which would be expected by chance (75%). Borderline patients' interviews were, however, differentiated by a combination of 3 characteristics: (1) higher prevalence of sexual abuse reported in the AAI narratives, (2) significantly lower ratings on the reflective self-function scale, (3) a significantly higher rating on the lack of resolution of abuse, but not loss scale of the AAI. Further, there was a significant interaction between abuse and RSF: individuals with experience of abuse who had low RSF were very likely to have a diagnosis of BPD. These findings are consistent with our assumption that individuals with experience of severe maltreatment in childhood who respond to this experience by an inhibition of reflective self function are less likely to resolve this abuse, and are more likely to manifest borderline psychopathology. Childhood maltreatment may or may not have long term sequelae and the determinants of the outcome are only partially understood. Here we propose that if children are maltreated but they have access to a meaningful attachment relationship which provides the intersubjective bases for the development of mentalising capacity, they will be able to resolve (work through) their experience and the outcome of the abuse will not be one of severe personality disorder. We do not expect that their reflective processes will protect them from episodic psychiatric disorder, such as depression, and epidemiological data suggests that victims of childhood maltreatment are at an elevated risk for many forms of [Axis-I] disorder. However, if the maltreated child has no social support of sufficient strength and intensity for an attachment bond to develop which could provide the context for the acquisition of a reliable capacity to envisage the psychological state of the other in intense interpersonal relationships, then the experience of abuse will not be reflected on or resolved. Naturally, the unresolved experience of abuse diminishes the likelihood of meaningful relationships which, in a self-perpetuating way, further reduces the likelihood of a satisfactory resolution of the disturbing experience through the use of reflective processes. In fact a pattern may be established whereby suspicion and distrust generalises and leads to a turning away from the mental state of most significant objects and an apparent 'decoupling' of the 'mentalizing module' leaving the person bereft of human contact. This may account for the 'neediness' of borderline personality disordered individuals; yet no sooner do they become involved with another then the malfunctioning of their inhibited mentalising capacity leads them into terrifying interpersonal confusion and chaos. Within intense relationships their inadequate mentalising function rapidly fails them, they regress to the intersubjective state of the development of mental representation and they are no longer able to differentiate their own mental representations from those of others and both of these from actuality. These processes combine and they become terrorised by their own thoughts about the other experienced (via projection) in the other, particularly their aggressive impulses and fantasies ; these become crippling and most commonly they reject or arrange to be rejected by their object. Psychoanalysis or psychotherapy can break the vicious cycle by reinforcing reflective capacity. 5. Crime, violence and attachment As with borderline patients, a history of maltreatment is present in 80-90% of juvenile offenders and approximately a quarter of those with histories of severe maltreatment are likely to have criminal convictions (e.g. Taylor, 1986). We have suggested that attachment to individuals as well as social institutions may be critical in reducing the risk of delinquency and adjustment processes are severely disrupted by childhood maltreatment. More specifically, if attachment to the primary caregiver is intimately linked to the acquisition of reflective capacity (see section on moral development, above), the latter may be a key mediator in predisposing an individual to criminality, particularly to violent offences. We may suppose that those individuals, who were never exposed to interpersonal relationships where the acquisition of a reflective capacity would have been facilitated, or who were exposed to caregiving environments where their only route to adaptation was the inhibition of mentalizing, are most likely to develop insecure attachments and manifest low reflective capacities, thus removing essential inhibitions on criminal activities. The capacity to envision the mental state of the potential victim may be essential in preventing us from deliberately harming other members of our social group (or species). To put these ideas to a test, Levinson & Fonagy (in preparation) collected AAI’s from 22 prisoners (convicted or on remand with diagnosable psychiatric disorder) and matched them with 2 control groups on age, gender, social class and IQ: 1) a psychiatric inpatient control group matched for diagnoses (Axis I/II) and 2) a normal control group recruited from a medical outpatient department. The findings may be summarised as follows: (1) There was significantly more secure attachments in the normal control group but the two clinical groups did not differ in terms of overall level of security. (2) 36% of the prison group vs. 14% of the psychiatric group were classified as ‘Dismissing’ with normal controls in between (23%). (3) 45% of the prisoners vs. 64% of psychiatric controls were classified as ‘Preoccupied’ with only 14% of non-criminal controls receiving this classification. (4) 82% of psychiatric patients but only 36% of prisoners and 0% of non-clinical controls received ‘Unresolved’ classifications. (5) 82% of prisoners and only 36% of psychiatric patients were rated as having been abused with only 4% of normal controls. (2/3 of abuse was physical, 1/3 sexual in both clinical groups). (6) Neglect was more prevalent in the prison group but rejection was more frequently reported by psychiatric patients. (7) Current anger with attachment figures was dominant in psychiatric patients but relatively more among prisoners. (8) Prisoners had significantly lower ratings on the reflective function scale (RSF) than either psychiatric patients or those from the non-clinical group, but RSF ratings of normals was still significantly higher than those of psychiatric patients. (9) When the prison group was split into those with violent index offences (murder, malicious wounding, GBH, armed robbery, indecent assault to child), vs. non violent ones (possession, importation, obtaining property by deception, theft, handling stolen goods) the rating on reflectiveness of the former group was found to be significantly lower than the latter. This pattern of results is consistent with our assumption that criminality arises in the context of weak bonding with individuals and social institutions and the relatively ready dismissal of attachment objects. Criminal behaviour may be seen as a socially maladaptive form of resolving trauma and abuse (which was almost ubiquitous in our small sample). Violent acts are committed in place of experienced anger concerning neglect, rejection and maltreatment. Committing antisocial acts is facilitated by a non-reflective stance of the victim which may be of particular significance in cases where the victim is clearly identifiable as in violent acts against another person. This is only a pilot investigation, but the results are promising to the extent that they link attachment related narratives to the nature of the offence committed. Naturally, an important alternative account to the one proposed here may be that it was these crimes which caused the disorganisation of the attachment system and it was the psychological impact of crime which permeated the interviews of the violent group. The less serious offences may have made less impact on the representation of relationships. 6. Psychotherapy and mentalising Clinical psychoanalysis inevitably deals with individuals whose past experience has left them vulnerable to current stress and the repetition of adverse early experiences. The treatment imposes a non-pragmatic elaborative, mentalistic stance. This enhances the development of reflective self function and may in the long run enhance the psychic resilience of individuals in a generic way, providing them with improved control over their system of representation of relationships. It equips them with a kind of self-righting capacity where through being able to operate on their representational models, the latter can become an object of review and change. Such gradual and constant adjustments facilitate the development of an internal world where the behaviour of others may be experienced as understandable, meaningful, predictable and characteristically human. This reduces the need for splitting of frightening and incoherent mental representations of mental states, and new experiences of other minds can more readily be integrated into the framework of past relationship representations. The abused child, evading the mental world, never acquires adequate meta-control over the representational world of internal working models. Unhelpful models of relationship patterns emerge frequently and the internal world of the child and adult comes to be dominated by negative affect. The individual's enhanced suspiciousness of human motives reinforces his/her strategy to forego mentalizing, thus further distorting the normal development of a reflective function. Caught in a vicious cycle of paranoid anxiety and exaggerated defensive manoeuvres, the individual becomes inextricably entangled into an internal world dominated by dangerous, evil and above all mindless objects. He has abnegated the very process which could extract him from his predicament, the capacity to reflect on mental states. Psychotherapeutic treatment in general, and psychoanalytic treatment in particular, compels the patient's mind to focus on the mental state of a benevolent other, that of the therapist. The frequent and consistent interpretation of the mental state of both analyst and patient (i.e. the interpretation of the transference in the broadest sense) is then desirable, if not essential, if the inhibition on this aspect of mental function is to be lifted. Over a prolonged time period, diverse interpretations concerning the patient's perception of the analytic relationship would enable him to attempt to create a mental representation both of himself and of his analyst, as thinking and feeling. This could then form the core of a sense of himself with a capacity to represent ideas and meanings, and create the basis for the bond that ultimately permits independent existence. 7. Summary
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