5

ATTACHMENT, THE DEVELOPMENT OF THE

SELF, AND ITS PATHOLOGY IN
PERSONALITY DISORDERS

Peter Fonagy

Freud Memorial Professor of Psychoanalysis

Director, Sub-Department of Clinical Health Psychology
University College London
Director of Research, Anna Freud Centre
Co-ordinating Director, Child and Family Centre and
Centre for Outcomes Research and Effectiveness
Menninger Foundation
Topeka, Kansas

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 dis-
order. 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 invok-
ing 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.

Address for correspondence: Sub-Department of Clinical Health Psychology, University College of London,
Gower Street, London WCIE 6BT, Tel: +44 171 391 1791, Fax: +44 171 916 8502, e-mail: pJonagy@ucl.ac.uk.

Treatment of Personality Disorders, edited by Derksen et al.

Kluwer Academic / Plenum Publishers, New York, 1999. 53
54 P.Fonagy

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 and Wittig, 1969; Ainsworth
et aI., 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 reas-
sured 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 automat-
ically 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 im-
poverished 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 and Weston, 1981;
Sroufe, 1990).
It is generally held that the patterning of attachment related behaviour is under-
pinned by different strategies adopted by children to regulate their emotional reac-
tions. 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, pos-
itive 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 aI., 1986; Sroufe, 1979, 1996).
By contrast, Anxious/Avoidantly attached children are presumed to have experi-
ences 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
Attachment and Its Pathology in Personality Disorders ss

thresholds for threat and may become preoccupied with having contact with the care-
giver, 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 behav-
ioural responses giving the impression of disorganisation and disorientation (Main and
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 "Disor-
ganised/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 and Beeghly, 1987; Main and 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.1 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 secu-
rity is controversial, but the balance of the evidence is now against the appropriateness
of a temperamental account (Kagan, 1982; Lamb et aI., 1984).2
The quality of maternal care has been repeatedly shown to predict infant secu-
rity. The sensitive responsiveness of the parent is traditionally regarded as the most
important determinant of attachment security in the infant (Isabella, 1993; Isabella and
Belsky, 1991). The parameters assessed include: ratings of maternal sensitivity (e.g. Cox
et aI., 1992; Isabella, 1993), prompt responsiveness to distress (Del Carmen et aI., 1993),
moderate stimulation (Belsky et aI., 1984), non-intrusiveness (Malatesta et aI., 1986),
interactional synchrony (Isabella et aI., 1989), warmth, involvement, and responsive-
ness (O'Connor et aI., 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 aI., 1992) and
for professional caregivers (Goosens and van Ijzendoorn, 1990).
Negative parental personality traits are associated with insecurity in many studies,
although by no means all (Zeanah et aI., 1993). This has been shown for anxiety (Del
Carmen et aI., 1993), aggression (Maslin and Bates, 1983) and suspicion (Egeland and
Farber, 1984). Parental psychopathology is also found to be a risk factor in some studies
(Campbell et aI., 1993). Of the contextual factors, support from the partner (Goldberg
and Easterbrooks, 1984) and from others in the mother's environment (Crnic et aI.,
1983) appear important. The strength of these associations is reinforced by experi-
mental studies where social support was systematically manipulated (Lyons-Ruth et aI.,
1990; Jacobson and Frye, 1991; Lieberman et aI., 1991).

IThere are many excellent reviews available, notably by Belsky (Belsky et aI., 1995).
2There 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 aI., 1991) and the attachment pattern of a child to
his two parents is often inconsistent (Fox et aI., 1991) and appears to be dependent on the internal working
model of each parent (Steele et aI., 1996).
56 P.Fonagy

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 and Carlson, 1995; van Ijzendoorn and
Kroonenberg, 1988; Crittenden et aI., 1991; Zeanah et aI., 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 interac-
tions 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 legiti-
mate expectation that, with that person at least, his distress is likely to be met by reas-
surance 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, 1994).
Such internal models of attachment remain relatively stable across the lifespan
(Collins and Read, 1994). Secure children, with the benefit of well-regulated caregiver-
infant relationships behind them, are expected to evolve positive expectations con-
cerning their exploratory competence, to achieve a reliable capacity for modulation of
arousal, a good capacity for communication within relationships and, above all, confi-
dence 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 and Buchsbaum, 1990; Lieberman and Pawl,
1990; Fonagy et aI., 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 com-
petent 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 aI., 1995).

2.3. Prediction from Adult Attachment Measures

The stability of these attachment assessments are dramatically illustrated by lon-
gitudinal studies of infants assessed with the Strange Situation and followed up in ado-
lescence or young adulthood with the Adult Attachment Interview (AAI) (George
et aI., 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 and Goldwyn (1994) which
classifies individuals into Secure/Autonomous, Insecure/Dismissing or Avoidant,
Attachment and Its Pathology in Personality Disorders 57

Insecure/Preoccupied or Resistant, or Unresolved/Disorganised with respect to loss or

trauma, categories according to the structural qualities of their narratives of early ex-
periences. (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 aI., 1995) have shown a 68-75% cor-
respondence between attachment classifications in infancy and classifications in adult-
hood. 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 and Zeifman, 1994).

3. THE TRANS GENERATIONAL TRANSMISSION OF

ATTACHMENT PATTERNS
There is further important evidence that attachment relationships may playa key
role in the transgenerational transmission of hardship and deprivation. Individuals cat-
egorised 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 and
Parker, 1994; Fonagy et aI., 1991; Radojevic, 1992; Steele et aI., 1996; Ward and Carlson,
1995). These findings also emphasise the importance of quality of parenting in deter-
mining 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, psy-
chopathology, and personality (Steele, Steele, and Fonagy, in preparation). If attach-
ment 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 Mentalizing

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 multi-
ple 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 incon-
sistency 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 explic-
able 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,
58 P.Fonagy

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 under-
score 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 = 0.8 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 aI., 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 sig-
nificant 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 pre-
dictor for the non-deprived group. Our findings imply that the intergenerational repli-
cation 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 aI., 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 mQre likely to promote secure attach-
ment 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 aI., 1995).
Attachment and Its Pathology in Personality Disorders 59

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 Separa-
tion/Anxiety test were more likely to pass the theory of mind tasks (Fonagy et aI., 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 facil-
itates 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 attach-
ment 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 devel-
ops 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 reflec-
tiveness 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 psycho-
dynamic 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 desper-
ate 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
60 P.Fonagy

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 chang-
ing 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 indepen-
dence and the terrifying wish for extreme closeness and fantasised union. Develop-
mentally, 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 individ-
ual's need for the physical presence of the object. Thus, many such individuals experi-
ence 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" experi-
enced as within the body of the other. In other young children the search for the psy-
chological 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 and 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.
Attachment and Its Pathology in Personality Disorders 61

As studies of resilient children suggest, even a single secure/understanding rela-

tionship 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 devas-
tating consequences on the emergence of social understanding. To illustrate the clini-
cal 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, consider-
able evidence has accumulated to support the contention that child abuse is transmit-
ted 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 spec-
trum" 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 aI., 1993) have put forward an
attachment theory formulation of severe narcissistic and borderline states based on epi-
demiological 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 vio-
lence 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 there-
fore 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 train-
ing 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.
62 P.Fonagy

3. Their fragile sense of self (identity diffusion to use Kemberg'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 representa-
tions, 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 aI., 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 experi-
ence of severe maltreatment in childhood who respond to this experience by an inhibi-
tion of reflective self junction are less likely to resolve this abuse, and are more likely
to manifest borderline psychopathology.
Childhood maltreatment mayor may not have long term sequelae and the deter-
minants of the outcome are only partially understood. Here we propose that if chil-
dren 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 reflec-
tive 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.
Attachment and Its Pathology in Personality Disorders 63

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 like-
lihood of a satisfactory resolution of the disturbing experience through the use of reflec-
tive 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 person-
ality 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 men-
talising function rapidly fails them, they regress to the intersubjective state of the devel-
opment 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 ,:"icious 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 mal-
treatment 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 care giving 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 and 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 psychi-
atric inpatient control group matched for diagnoses (Axis 1111) 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
64 P.Fonagy

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 psychi-
atric 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 attach-
ment figures was dominant in psychiatric patients but relatively more among prison-
ers. (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 (pos-
session, 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 MENTALIZING

Clinical psychoanalysis inevitably deals with individuals whose past experience

has left them vulnerable to current stress and the repetition of adverse early experi-
ences. 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 con-
stant adjustments facilitate the development of an internal world where the behaviour
of others may be experienced as understandable, meaningful, predictable, and charac-
teristically human. This reduces the need for splitting of frightening and incoherent
Attachment and Its Pathology in Personality Disorders 65

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 hislher strategy to forego mentalizing, thus further distort-
ing the normal development of a reflective function. Caught in a vicious cycle of para-
noid 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 partic-
ular, 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 func-
tion 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

The paper puts forward an attachment theory model of severe personality dis-
turbance. It is suggested that (1) secure attachment is the basis of the acquisition of
metacognitive or mentalizing capacity; (2) the caregiver's capacity to mentalize may
foster the child's bonding with the parent; (3) maltreatment may undermine the acqui-
sition of a mentalizing capacity; (4) symptoms of borderline personality disorder may
arise as a consequence of inhibited mentalizing; (5) violent crime and anti-social per-
sonality disorder may be possible because the capacity to reflect upon the mental
states of the victim is compromised; (6) psychotherapeutic work may facilitate the
reactivation of this inhibited capacity.

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AUTOBIOGRAPHICAL NOTE

Peter Fonagy, PhD (London), Dip. Clin. Psy. (London), Freud Memorial Profes-
sor of Psychoanalysis, Director, Sub-department of Clinical Health Psychology, Depart-
ment of Psychology, University College London; Research Director, The Anna Freud
Centre, London; Director, Child and Family Center, Menninger Foundation, Topeka,
Kansas, Training, and Supervising Analyst, British Psycho-Analytical Society.