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Introduction Peter Fonagy's paper "Attachment, the development of the self, and its pathology in personality disorders" opens up new clinical and research perspectives that deserve close attention and discussion. It is possible, for example, hypothesize that the nucleus of Borderline Personality Disorder, investigated from supposedly different viewpoints such as those of conflict theories (e.g., Kernberg) and deficit theories (e.g., Kohut and Linehan), could be seen, perhaps also etiologically, as the outcome of a disorganization of the attachment motivational system. Attachment disorganization implies both opposite Self-object representations and a deficit of metacognitive and emotional self-regulatory functions. Hence, the concept of attachment disorganization allows a unitary view, within important intersubjective experiences, of both conflict theories (lack of integration of Self-object representations, which are split from each other) and deficit theories (difficulties in impulse control and affective regulation) [for a discussion of the conflict-deficit dichothomy, see also the classic paper by Morris Eagle "Developmental defect versus dynamic conflict"]. This article is published here as a comment of Peter Fonagy's paper "Attachment, the development of the self, and its pathology in personality disorders". It tries to show the possibility, offered by attachment theory, of integrating the contributions of etiological theories of Borderline Personality Disorder that many authors believe to be irreconcileable. This paper was read at the XI Congress of the World Psychiatric Association, Hamburg, August 8, 1999. Instead of its Italian translation, a similar article, dealing with this subject according to the same lines, is published: it is titled "Il nucleo del Disturbo Borderline di Personalità: un'ipotesi integrativa" ["The nucleus of the Borderline personality Disorder: an integrative hypothesis"], and appeared in the Italian journal Psicoterapia (1999, 5, 16/17: 53-65), edited by Marco Casonato and published by Moretti & Vitali of Bergamo (Italy), whom we thank for the permission. Attachment and metacognition in borderline patients Giovanni Liotti, M.D. The mental functioning of patients suffering from the Borderline Personality Disorder (BPD) is characterised by two distinctive features: [1] unintegrated representations of self-with-other and [2] serious deficits in self-reflective, self-regulatory and metacognitive capacities. In order to discuss complex topics in a language as free as possible from metapsychological concepts of either psychoanalytic or other traditions, I’ll use the term "unintegrated" for both split and dissociated representations, that is, for the impossibility to hold a unitary representation of self and of a significant other, either this impossibility is the alleged outcome of an archaic defense named splitting or of dissociative processes (Marmer & Fink, 1994). For the same reason, I’ll use the term "metacognition" in a broad sense, to cover not only the capacity to think about one’s own thoughts (Flavell, 1979), but also mental abilities that have been variously labeled "mentalisation" (Fonagy, 1991), "reflective-self capacity" (Fonagy, Steele Steele, Leigh, et al., 1995), "theory of mind" (Wellman, 1990; Withen, 1991), and "emotional regulating system" (Linehan, 1993a, 1993b). Some theories have emphasized the theme of unintegrated representations of self-with-other in trying to identify the core disturbance of BPD. First and foremost among these is Kernberg’s theory. According to Kernberg (1975, 1984), the predominance of splitting, projection and projective identification in the organization of defenses leads to fragmented representations of self and important others -- each of these representations being strongly charged with either positive or negative affects. Other theories of borderline pathology emphasize metacognitive deficits, rather than split representations, as the source of the core disturbance in the patients. Notable among these are the psychoanalytic theory recently advanced by Fonagy and his collaborators (Fonagy, 1991; Fonagy et al., 1995), and, in a different vein, Linehan’s cognitive-behavioural theory (Linehan, 1993a, 1993b). Linehan addresses the idea that a deficit in the mental system regulating the experience and the expression of emotions lies at the base of borderline pathology. The mental system hypothesized by Linehan necessarily involves the metacognitive monitoring of emotional experience: A metacognitive deficit is implied in any inability to reflect on, and thereby regulate or modulate, impulses, affects, conations and cognitions. Thus, we can include Linehan’s theory among theories of BPD based on the idea of defective metacognitive abilities. As may be expected, different psychotherapeutic processes are set into motion when therapists see unintegrated representations rather than metacognitive deficits as the core disturbance of their borderline patients. The seeming paradox is that, according to a recent estimate, borderlines seem to benefit from both types of psychotherapy (Swenson & Sanderson, 1997). This observation invites to search for an integrated model of psychopathology and psychotherapy, that could take into account both metacognitive deficits and unintegrated self-representations (Maffei, 1997; Swenson & Sanderson, 1997). The main contention of my presentation is that attachment theory and research offers such an integrated model. The model of abnormal development that can reconcile the theory of unintegrated self representations with the theory of metacognitive deficit as the core disturbance in BPD, stems from a careful consideration of attachment disorganization. In the Strange Situation (the experimental procedure for the assessment of attachment behaviour during the first two years of life: Ainsworth et al., 1978), disorganised attachment shows up as incompatible responses emitted simultaneously or in quick sequence, or else as lack of orientation during attachment interactions (Main & Solomon, 1990). Disorganization of attachment in infancy yields multiple, dramatic, unintegrated representations (Internal Working Model) of self and the attachment figure (Liotti, 1992, 1995, 1999a; Main, 1991). It also brings over hindrances to metacognitive development, like other types of insecure attachment (Fonagy et al., 1995; Meins, 1997). Thus, we now know well a developmental process that is able to reflect itself both in the development of unintegrated representations of self-with-other and in metacognitive deficits (Liotti,1999b). The retrospective assessment of the Internal Working Model of early attachments in adult populations is an extremely difficult task. Early Internal Working Models and patterns of attachment, moreover, may change in the context of new relationships. These difficulties nothwithstanding, there are accumulating empirical evidence and theoretical-clinical reflections supporting the hypothesis that disorganized attachment is a risk factor in the development of BPD. I’ll first review briefly thess evidence and reflections, and then I’ll dwell on some consequences of a model of BPD based on attachment disorganization in the psychotherapy of this disorder. Disorganisation of attachment and psychopathology During the second year of life, most infants in low-risk families are able to organise their attachment behaviour according to three patterns: secure, avoidant and ambivalent (Ainsworth, Blehar, Waters & Wall, 1978; Main, 1995). Even in these low-risk samples, however, a substantial minority of infants -- about 20% according to recent estimates (Carlson , Cicchetti, Barnett & Braunwald, 1989; Main & Morgan,1996) -- are unable to give organisation and orientation to attachment behaviour (Main, 1995; Main & Solomon, 1990; Solomon & George, 1999). In samples at high risk for emotional disorders (e.g., mother-child dyads where the mother suffers from depression, mother-child dyads living in chaotic or maltreating families, or mother-child dyads characterised by prenatal alcohol abuse) disorganisation of infant attachment is the rule: from 50% to 80% of the children in high-risk samples proved unable to organise attachment behaviour along any identifiable pattern (Carlson et al., 1989; Lyons-Ruth, Repacholi, McLeod & Silva, 1991; O’Connor, Sigman & Brill, 1987; Radke-Yarrow, McCann, De Mulder & Belmont, 1995). The finding that disorganized attachment is the rule in high-risk families encourages careful inquiries on the ways in which the two variables, attachment disorganization and psychopathology, may be linked. Recent research on early attachment has identified a particular relational configuration leading to disorganization of attachment behaviour in the infant (Main & Solomon, 1990; Main & Hesse, 1990; Solomon & George, 1999). The essence of this relational configuration has been captured by the hypothesis of a style of caregiving that is frightened and/or frightening to the infant, and is linked to unresolved traumas or losses in the attachment figure (Main & Hesse, 1990; Schuengel, Bakermans, vanIjzendoorn & Blom, 1999). To suffer from unresolved traumatic memories means that fragments of past painful events emerge unpredictably in the stream of consciousness, and that these fragments cannot be integrated in any organised process of thought (Horowitz, 1986; Main & Morgan, 1996). Parents who were abused children, or who suffered the loss of an attachment figure or of another child, may tend to remember these events while taking care of their infants. When people experience an intrusion of unresolved traumatic memories in their stream of consciousness, they will unwittingly, and often unconsciously, express fear. Main and Hesse (1990) originally formulated the hypothesis that infants whose caregivers are suffering from unresolved traumatic memories will quite often witness, in the caregiver’s face, an expression of fear. To the infant, the expression of fear in an adult’s face is in itself frightening, i.e., it is interpreted as a signal of danger and it activates the inborn tendency to fight or flight (Fields & Fox, 1985; Main & Hesse, 1990). The activation of fight-flight reactions by the same source of signals that modulate attachment creates the paradoxical situation underlying disorganized attachment. The caregiver, who is the source of the infant’s safety, appears at the same time to be a source of danger. Infants tend to attack defensively the frightened/frightening caregivers, or to withdraw from them. Withdrawing from the caregiver, however, means loneliness, and any threat of loneliness forces infants to approach the caregivers because of the inborn structure of the attachment system (Bowlby, 1969/1982, 1988). Caught in this unsolvable dilemma, infants display a disorganised admixture of approach and avoidance behaviour toward the caregiver, or else freeze or display defensive aggressiveness in the middle of a friendly approach: this is the essence of attchment disorganization. The information available to infants disorganised in their attachment behaviour is such as to disrupt the construction of a unitary Internal Working Model of self and the attachment figure: the Internal Working Model of disorganized attachment is multiple, fragmented and incoherent (Main, 1991). It conveys representations of the self and of the attachment figure so contradictory or incompatible that they cannot be reciprocally integrated: they tend to remain dissociated at least in the first steps of personality development, and may stay so even in adult life (Carlson,1997; Liotti, 1992, 1995, 1999a, 1999b; Main & Morgan, 1996). The type of dramatic, fragmented Internal Working Model stemming from attachment disorganization may be captured by the idea that the child oscillates between construing self and the attachment figure as persecutor, rescuer and victim of each other. 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 (a parent frightened by unresolved traumatic memories may be willing to offer comfort to the child, and may be unaware of the facial expression and of its effect on the infant; the child may feel such comforting availability together with the fear). Together with these two opposed representations of the attachment figure (Persecutor and Rescuer) meeting a vulnerable and helpless (Victim) self, the Internal Working Model conveys also a negative representation of a powerful, evil self meeting a fragile or even devitalised attachment figure (Persecutor self, held responsible for the fear expressed by the attachment figure). Moreover, there is the possibility, for the child, to represent both the self and the attachment figure as the helpless victims of a mysterious, invisible source of danger. And finally, since the frightened attachment figure may be comforted by the tender feelings evoked by contact with the infant, the implicit memories of disorganized attachemnt may also convey the possibility of construing the self as the powerful Rescuer of a fragile attachment figure (the little child perceives the self as able to comfort a frightened adult) [see Table I]. Table I: Representations of the Self representations of the attachment figure (a.f.)
The child shifts between these non-integrated representations of self-with-other; both the self and the attachment figure’s representations shift from one to the other of the three basic positions of the "drama triangle": RESCUER <--> PERSECUTOR <--> VICTIM Descriptions of the shifts of a patient’s self-representations between the poles of the Victim, the Persecutor and even the Rescuer (while the therapists is represented, in sometimes very quick succession, as Rescuer, Persecutor and Victim) may be found in the literature on the psychotherapy of borderline and dissociative patients (Davies & Frowley, 1994; Liotti, 1995 [see Table II]). This is a further hint at the possibility that disorganized attachment is a risk factor in the development of these disorders. These disorders are also marked by deficits in the integrative functions of consciousness and memory, that is, by metacognitive deficits. Let us now dwell on studies that assessed metacognitive deficits in children and adolescents that have been disorganized in their early attachments. Table II: Disorganized attachment: research findings
Pre-school children who had been infants disorganised in their attachments rank very low, particularly if compared with formerly securely attached children, in the false-belief tests used for the assessment of the child’s theory of mind (Fonagy, Redfern & Charman, 1997; Meins, 1997). In a longitudinal study, children whose attachment behaviour in infancy had been disorganised, were judged by their teachers as significantly more confused and "absent minded" than their peers with a different attachment history (Carlson, 1997). Children 5- 8 year old, judged disorganised in their response to the Children Attachment Interview (Green, Stanley, Smith & Goldwyn, in press), show marked impairment of metacognitive and mentalising capacities in comparison to securely attached peers. Adolescents who had been fearful/disorganised children showed marked difficulties in tests of formal reasoning, when compared with peers who had different attachment experiences (Jacobsen, Edelstein & Hofmann, 1994). Metacognitive deficits during development bring over concurrent difficulties in understanding, naming, discriminating and therefore controlling mental states in general and emotions in particular (Fonagy et al., 1995; Maffei, 1998). A number of studies provide evidence that disorganised infants tend to grow into children with difficulties in the control of anxiety (Hesse & Main, 1999) and aggression (Lyons-Ruth, 1996; Van Ijzendoorn, 1997). Finally, a metacognitive deficit implies a poor capacity to reflect on one’s own mental representations. This capacity yields the possibility of integrating contradictory features in cohesive wholes. It is therefore not surprising that children who have been infants disorganised in their attachments show negative and disorganised self-representations more often than controls (Cassidy, 1988; Hesse & Main, 1999; Main, 1995; Solomon, George & DeJong, 1995). Another finding that allows for the hypothesis that disorganized attachment plays a role in the development of BPD comes from a study by Anderson and Alexander (1996). Dissociative experiences in a sample of adult survivors of childhood sexual abuse, most of them likely to suffer from borderline disturbances, were related to actual (not necessarily early) disorganized attachment. Disorganized, fearful adult attachments in these patients was able to predict dissociation, while abuse variables such as age of onset, coercion, nature of the abuse and even the centrality of the relationship between the perpetrator and the victim did not predict dissociation (Anderson & Alexander, 1996). Finally, in support of an etiologic relationship between early disorganized attachment and adult borderline pathology is the recent finding of a wide epidemiological survey of patients consecutively admitted to the Italian Mental Health services. The mothers of borderline patients suffered significantly more often than the mothers of other psychiatric patients, with the exception of dissociative patients, of unresolved losses during the two years following the patients’ birth (Pasquini, personal communication: this epidemiological survey is still to be completed). Since unresolved losses in the mothers are related to disorganized attachment in the children, this finding support the etiologic role of early disorganized attachment in the development of BPD. A model of BPD based on disorganized attachment not only acknowledges the importance both of unintegrated self-representations and of metacognitive deficits: it also explains how the affective instability, the dramatically mutable relational style, the self-damaging behaviour and the identity disturbance are related to the frantic efforts of avoiding real or imagined abandonment. All these features of the borderline states are explained by the model as the consequence of the recurrent activation of the attachment motivational system . When active, the attachment system of these patients causes fear of abandonment and frantic efforts to avoid it, while the multiple, shifting representations of the Internal Working Model are responsible for the uncertain sense of self, the dramatically changing attitudes toward significant others, and the self-damaging behaviour (Self as Persecutor, deserving punishment). Transient paranoid ideation (where the Self is construed as Victim, and others as Persecutors), may be related to the episodic activation of the attachment system within unfavourable interpersonal relationships. The dissociative experiences may be explained as the outcome of the activation of the attachment system in interpersonal contexts that are particularly confusing: these experiences would then reflect the disordered state of a consciousness that is forced to deal with multiple and incompatible simultaneous self-representations. Thus, the model of borderline pathology based on attachment disorganization invites the psychotherapist to pay special heed to the activation of the patient’s attachment system within the therapeutic relationship. Disorganised attachment in the psychotherapy of borderline states Many psychotherapists strive to shape the therapeutic relationship, since the very first session, according to the ideal of therapeutic alliance or of collaborative empiricism (Beck & Emery, 1985). This is performed through the active search of an explicit agreement on goals and rules of the therapeutic work (a particularly convincing example of how this mutual agreement is constructed at the beginning of the treatment of borderline patients may be found in Linehan, 1993a, 1993b). If the joint formulation of a shared goal for the treatment has been successful, the inborn motivational system mediating co-operative behaviour is likely to become active both in the therapist and in the patient at the beginning of the treatment. Patients, however, do suffer. Since the beginning of psychotherapy, they are gradually disclosing their troubles to benevolent persons (the therapists) that they come to perceive as emotionally available and as "stronger and/or wiser" than themselves (Bowlby, 1979, p.129). Disclosing one’s suffering to an available person who is perceived as stronger and wiser than the self is the typical situation in which, "from the cradle to the grave" (Bowlby, 1979, p. 129), the inborn attachment system is activated. Therefore, in the course of psychotherapy, the co-operative system will give way to the attachment system. In most borderline patients, the activation of the attachment system is accompanied, since early childhood, by unpleasant states of mind related to the dramatic and multiple Internal Working Model of disorganized attachment (disorientation, altered states of consciousness, a loop of increasing fear whether one approaches or avoids the attachment figure, dramatic shifts between the representation of self and the attachment figure as a Rescuer, a Persecutor and a Victim). It is therefore likely that these patients have learned to inhibit, as far as possible, the activation of the attachment system in order to avoid the unpleasant experiences that accompany it. One way to inhibit the activation of the attachment system is to shift to another inborn motivational system, whose operations manifest themselves with emotions and behaviour alike to those of attachment. For instance, anger may appear as an operation of the attachment system whose goal is to energetically ask for the attachment figure’s attention (e.g., the secure child protests during the separation from the mother in Ainworth’s Strange Situation: Ainsworth et al., 1978). Anger, however, may also appear as an operation of the competition system (e.g., ritualised aggression aimed at defining the social rank: Gilbert, 1989, 1992). It is therefore possible that, in their relationships, borderline patients quickly transform attachment anger into competitive anger, thereby facilitating the activation of the agonistic rather than the care-giving system in the other person. In this way, an interpersonal cycle is facilitated that cuts off the activation of attachment in the borderline patients and of care-giving in their partners, thereby protecting the patients from dissociative and other unpleasant experiences linked to their attachment system. Of course, such a "protection" is earned at a cost: the patient will appear to suffer from the affective instability and the inappropriate, intense anger that are listed among the diagnostic criteria for BPD (American Psychiatric Association, 1994). Another way of inhibiting the activation of the attachment system implies a shift of the meaning attributed to the wish for bodily contact with another human being. Since both the attachment system (whose goal is protective proximity and comforting hug) and the sexual system imply a wish for physical closeness, borderline patients may misinterpret as sexual, both in themselves and in other people, wishes that are instead related to attachment needs. It is because of the confusion between sexual and attachment wishes that borderline patients may appear improperly seductive within the therapeutic relationship, and may get trapped into promiscuous or dangerous sexual affairs within other social relationships. Thus, a model of borderline pathology based on attachment theory allows for many specific therapeutic interventions when the patient displays aggressive or seductive behaviour in the therapeutic relationship. When the patients attachment needs become prominent within the therapeutic relationship, strong oscillation of attitudes toward self and the therapist are common in the borderline patients: in a short span of time, even within a single session, borderline patients may dramatically ask for help, look distant and indifferent, state their wish to quit therapy because of the fear of being damaged, express the fear of being dangerous to beloved persons, make the therapist feel important and loved but also threatened or oppressed. These multiple transferences, linked to the activity of the patients’ attachment system, are usually not amenable to transference interpretations, because of their complexity and because of the patient’s poor metacognitive capacity. They are a common antecedent of premature interruption of therapy. Thus, multiple simultaneous transferences are better prevented than dealt with after they appear. Linehan’s treatment manual (Linehan, 1993a, 1993b), suggests an interesting way of preventing the problems created by a too intense activation of the attachment system in the psychotherapy of borderline states. Linehan’s model uses, since the beginning of treatment, two independent even if correlated therapeutic settings (individual and group). Provided that there is theoretical and technical agreement between the individual and the group therapists, the co-ordination of two simultaneous therapeutic settings is demonstrably superior to any of the single settings in reducing both drop-outs and self-destructive behaviour (Linehan, 1993a, 1993b). The positive effect of two simultaneous settings in the treatment of borderline states may be explained on the basis of attachment dynamics. The simultaneous existence of another caregiving relationship (with the group therapist) protects the relationship with the individual therapist from the consequences of an intense activation of the patient’s attachment system. If the activation of the patient’s attachment system within an individual psychotherapy brings over an increased propensity to painful dissociative experiences, and to dramatic shifts in the way of construing self and therapist, both patient and therapist are likely to find the therapeutic relationship too difficult to be either tolerated (on the patient’s side) or dealt with successfully (on the therapist’s side). What happens in these circumstances, according to attachment theory, is a repetition of the situation leading to DA: to relinquish a relationship that alone appears capable of affording comfort from unbearable emotional pain is frightening, but to approach the attachment figure is equally frightening. Each pole of this dilemma increases the intensity of the painful emotions implied by the other. One of the likely consequences of this state of affairs is the patient’s dropping out from treatment; another is a therapeutic stalemate (both are unfortunately common occurrences in the treatment of borderline patients: Gunderson & Sabo, 1993b). If, however, a second therapist is engaged in the therapeutic program (e.g., the group therapist in Linehan’s model), the patient may feel that there is another source of help available, and this may reduce the emotional strain on the first therapeutic relationship. If one reason for the usefulness of two simultaneous settings in the treatment of borderline patients is the distribution of the patients’ attachment needs on more than a single therapist, then such usefulness should appear also with combined interventions other than individual and group. Combined individual psychotherapy and family therapy, or even individual psychotherapy and pharmacological therapy (if the drugs are prescribed by a psychiatrist who is well grounded in psychological treatments), could protect the individual psychotherapy from drop-outs as well as individual and group interventions do. Summary According to Kernberg’s psychoanalytic model of borderline disorders, split representations of self and others constitute the key feature to be dealt with in psychotherapy. According to Linehan’s cognitive-behavioural model of borderline disorders, the dysregulation of the emotional control system, which is related to defective metacognitive abilities, is the key feature to be corrected in psychotherapy. Disorganised attachment provides us with a model of borderline pathology that combines both Kernberg’s emphasis on split representations and Linehan’s emphasis on defective metacognition. 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