THE EXPECTATIONAL FIELD, REVERSALS, AND OTHER ASPECTS OF DISINTEGRATED RELATEDNESS
A FORM OF CONSCIOUSNESS, to recapitulate, is not to be conceived as an isolated entity, standing alone, but as a part of a larger system that includes a relationship with the world, whether extrinsic or intrinsic. This connection with the world is what consciousness is for: Its purpose, in its most primitive form, is to enable the organism to respond adaptively to the environment. In lower forms of consciousness, the relationship is unidirectional, a response to stimulus, of which the fright–flight response is a complex example.
Seen in this way, a form of life that comprises the organism and its environment is, as French philosopher Henri Bergson put it in a letter to William James (as cited in Richardson, 2007, p. 430), a “phenomenon of attention.”
UNSTABLE RELATIONS: SELF AS
A PHENOMENON OF ATTENTION
A more evolved organism has an enhanced attentional capacity and is able to respond, not only to exogenous but also to increasingly complex endogenous stimuli. In the higher-order consciousness of the human primate, the endogenous stimuli to which attention has access include visualization of past events and, as importantly, of events that have never occurred. Such internally generated stimuli can serve as the origins of activity that is new and free of environmental stimuli. As Frederic Bartlett (1932) put it in his great book on Remembering, we have developed “constructive imagination and constructive thought wherein at length we find the most complete release from the narrowness of time and place” (p. 314).
As a consequence of our enhanced attentional capacity we are able to cope with an environment of greater complexity, created by the evolution of the social world. The relationship with the environment in this setting takes a new form. It becomes bidirectional, or more exactly, a continuing interplay, in which internally generated material can, as it were, be “traded” in ordinary converse (trading is an essentially human capacity, illustrated in the thesis of Marcel Mauss, 1969). Such a relationship is potentially “intimate,” this term being used in the quasi-technical sense of “inmost, most inward” (Oxford English Dictionary, 1971). This new form of relatedness is one of many patterns of relatedness we have available to us in our daily exchanges with those around us.
Our increased attentional capacity, which gives us the experience of self, allows us to respond appropriately to the expressions of those in our social environment, which are shifting from moment to moment. These circumstances demand a flexibility of response that is made possible by the nonlinear, associative, and constantly evolving background of subject consciousness—which might be seen, in a figurative way, as analogous to the current conceptions of consciousness arising from the ceaseless patterning and repatterning of neural networks. We are able to maintain coherence through changes in relatedness, each one manifested and giving rise to slightly different states of self–identity. The integrity of the self–identity complex is dependent upon an attentional system that allows each of us, in varying degrees, to achieve a stable but flexible standpoint in relation to others in our social world.
In those who suffer from BPD, attentional function is impaired. The coherence of the self–identity complex is deficient, leading to unstable relations in which forms of relatedness are distinct, shifting, and disconnected from each other. The situation resembles adolescence in which, for example, a boy keeps his relationships with his friends separate from his family because he relates to them in different ways and feels unable to be two different “selves” at the same time.
The forms of relatedness characteristic of those with BPD differ from the type of relationship dependent upon highly evolved awareness of inner events. A reduced capacity for such awareness leads to a state of mind in which, in subtle ways, the scope of imagination and memory is reduced. Relationships tend to be more reactive, more unidirectional, and somewhat inflexible. The sense of reciprocity is also impaired. Diminished attentional range seems to restrict the ability to create and tolerate models of reality that are not one’s own. Put another way, “perspective taking,” an aspect of theory of mind, is limited.
A cardinal feature of these forms of relatedness in people with BPD is an absence of intimacy, this term being used in the technical sense referred to previously. Intimacy is sometimes confused with attachment. The two terms, however, are not synonymous. Bowlby (1969, 1973) was quite clear in his description of attachment as a distinct form of relatedness. It has the apparent evolutionary purpose of protecting the animal from predators. It is first manifest, as is well known, in the separation anxiety shown by the child in the second half of the first year. An early analogue of it is displayed by a baby 3 months old, in a similar kind of distress when the mother is present but behaves as if she were absent (Milgrom-Friedman, Penman, & Meares, 1980).
The behavior of attachment is maintained by anxiety. Intimacy depends upon no such fuel. Moreover, it can be gained in a meeting with a stranger, as exemplified by Bertrand Russell’s remarkable description of his first encounter with Joseph Conrad:
At our very first meeting, we talked with increasing intimacy. We seemed to sink through layer after layer of what was superficial, till gradually both reached the central fire. It was an experience unlike any other I have known. We looked into each other’s eyes, half appalled and half intoxicated to find ourselves together in such a region. (Russell, 1971, p. 203)
Whereas anxiety is a spur to attachment, an anxiety is an impediment to intimacy. There is fear that those experiences found in “the central fire” will, in some way, be devalued or harmed, inflicting damage on the individual equivalent to a physical hurt (Meares, 1976). In most cases, those who suffer from BPD have had such wounds inflicted upon them. As a consequence of such a past, many of those with BPD avoid intimacy. Rather than having frequently disrupted relationships, they live alone; a considerable number of our patients with BPD have had no intimate relationships. Although it can be argued that a failure to gain a sense of self deprives those with BPD of the opportunity for intimacy, it can equally be argued that harm inflicted on the proto-intimate expressions of the developing person stifled the emergence of self.
A third kind of relatedness is affiliation (Murray, 1938), which, like attachment, is akin to a drive, in this case toward companionship and toward belonging to a group, a tribe, a gang. It emerges before intimacy and after the onset of attachment. In maturity, the three forms of relatedness can be “compounded” into a single relationship, a marital one, for example. According to a neo-Jacksonian approach to the development of human relations, a failure to develop the most recently evolved form will result in an exaggerated expression of earlier forms. As a consequence, attachment needs are a salient aspect of the BPD picture, as reflected in DSM-IV’s first diagnostic criterion.
The disintegrated forms of relatedness seen in those with BPD are essentially traumatic. The nature of this kind of relationship, in which the higher-order systems controlling and modulating limbic activity may be hypofunctional, create a peculiar interpersonal effect that I call the expectational field (Meares, 2005, pp.114–125). This field is produced by what Bowlby (1973) would have called an internal working model (IWM). This term refers to the representation in memory of a particular relationship, which necessarily includes the attributes given to both partners in the relationship and their roles in relation to each other. When a particular IWM is triggered, the individual feels him- or herself to be in relation to the other in accordance with the “script” of the IWM (Meares, 1998). If, for example, the person has been the victim of relentless criticism and devaluation, he or she will expect, unconsciously, the other to behave in this way. With this expectation comes his or her assumption of the role of one devalued. This person is rarely aware of either the expectation or the role he or she plays in it.
The other person in the dyad, when this traumatic memory system is activated, tends to become influenced by the expectation of the subject. The other, without being aware of the influence of this expectation, comes to play out, or at least tends to play out, the role the subject has cast for him or her. The therapist, for example, may make remarks which are implicitly critical of the individual in a way which is uncharacteristic of him or her.
Although an effect of expectation upon the other partner is present, to some degree, in all relationships, one is not generally aware of it. In the traumatic relationship, however, there may be sensed a subtle coercion to behave, or not to behave, in a particular way, in accordance with the expectation. This feeling and tendency are the clinical bases of the conception of projection identification (Ogden, 1982), which Kernberg, in a series of publications (e.g., 1967, 1984), has described as a principal feature of BPD. Segal summarized Melanie Klein’s formulation of this concept as follows: “Parts of the self and internal objects . . . then become possessed by, controlled and identified with the projected parts” (Segal, 1973, p. 27). The theoretical assumptions underlying this definition are no longer generally agreed upon. A more empirically based term for this important clinical phenomenon is preferred.
Three studies from Lea Williams’s laboratory suggest how the expectational field is formed and how the force of this field is magnified when one enters a traumatic relationship, as compared with entering a nontraumatic relationship. The first study showed that the other, the therapist in this relationship, is likely to register signs in the voice, facial expression, and posture of the patient so small that he or she is not consciously aware of them. Williams’s observations depended upon a machine that charts with great accuracy the movements and gaze fixations as a subject looks at a face on a television screen. The usual scan path, evident when the face has a neutral expression, is triangular, moving from eye to eye, to the mouth, and then back again. In expressions conveying affect, the scanning becomes more complex and includes, in the case of a smile, fixations on the wrinkles at the corners of the eyes. These fixations are so fast that the subject would not have been aware that he or she was making such a check (Williams, Senior, et al., 2001). (See Figure 9.1.) Nevertheless, subliminally they create an impression. In the case of absent wrinkles in a smiling face, for example, one becomes wary without knowing why.
In another set of experiments, Williams and her group showed that these unconsciously registered signs are likely to be more potent than the same signs of which there is a conscious awareness. These experiments involved the study of brain responses to images of fearful and neutral faces that were exhibited for either a long duration (500 ms) or briefly (16.7 ms and masked). In the latter case the individual was not conscious of the visual perception (Williams, Liddell, et al., 2006). Although the fearful face was presented subliminally, the amygdala was activated: The face had evoked a flicker of fear in the subject. The imaging data were correlated with skin conductance recordings showing that subliminal fear perception evoked arousal. An earlier study (Liddell et al., 2005) suggested that the subliminal response may involve superior colliculus and pulvinar activity, regions believed to be associated with blindsight (Morris et al., 2001), which is the capacity of an individual blinded by damage to the occipital cortex to locate objects in space.
The brain response to conscious perception was different and seemed likely to involve a different neural pathway that included the medial prefrontal cortex. Activity in this region modified amygdaloid excitation. These findings supported those of an earlier study from the laboratory, showing enhanced amygdaloid responses to unconsciously perceived stimuli using ERPs as the measure of responses (Liddell et al., 2004).
These data suggest the workings of a strange dynamic in the intersubjective field during the conversation with a patient who has BPD, particularly during a period when an unconscious traumatic memory system has been triggered. Since it is unconscious, the modifying prefrontal effect upon it is lacking, and the subject is in the state of amygdaloid activation that is manifest in the body via the autonomic system. The small signs of this activation are picked up by the therapist, albeit unconsciously, so that their effect is magnified. A further study, described in an earlier chapter, showed that amygdaloid responses to unconsciously perceived stimuli in traumatized people are greater than in those who are not traumatized (Felmingham et al., 2008).
The studies coming from Lea Williams’s lab offer a means of understanding the faint sense of coercion to behave, or not to behave, in a particular way that the therapist might feel in a conversation with a patient with BPD, and which might lead to an uncharacteristic response on the part of the therapist. The studies do not, however, explain another phenomenon that may occur in the same conversation, which term a reversal (Meares, 1993a, pp. 87–100; 1993b; 2005, pp. 104–113).
In the case of a disintegrated self, in which there are multiple and shifting states of personal existing, each one correlates with a particular form of relatedness. These forms of relatedness both constitute and manifest a state of personal existing, a certain kind of mental state.
The change in the manifestations of these IWMs might be figuratively conceived as occurring, at any moment, in three dimensions. First there is a range of people, occurring in the present, who are good, bad, likeable, incompetent, and so on, and who, as it were, are confronting and linking to a range of experiences of the other. Who one is, here, occurs along a horizontal plane. A second category of experiences is vertical, fluctuating up and down a chronological axis. The individual’s states range between those of a young person and those of someone who is more nearly mature. The third dimension is also in the horizontal plane, orthogonal to the first. It involves a back-and-forth change in which the subject becomes the other. The poles of relatedness in a particular IWM are transposed. The subject takes on the role of the abuser as if inhabited by the original other.
Although originally remarked upon by Freud (1915c), this oscillation between the poles of a traumatic IWM has been the subject of very little discussion since that time. The rapid switching between poles that Freud (1924) characterized as active–passive and sadistic–masochistic is a disconcerting feature of the relationship with those suffering from BPD. Peter Hobson and his colleagues (1998) give an account of the rapid switches in attitude those with BPD exhibit in their exchanges with others. They might shift, for example, from seductive to contemptuous. These investigators suggested that such shifts reflect the malign experiences those with BPD have had with others.
The appearance of a reversal often signals a sharp deterioration in the frail connectedness established between patient and therapist. It can be understood as a reflection of an increased state of fragmentation.
The behavior of reversal and the experience of the expectational field are the bases of the psychoanalytic concept of projective identification (Meares, 2000b), as previously remarked. In my view they should be considered as separate but related phenomena, not to be understood as having a defensive purpose.
Fragmentation of self–other representations can be conceived as a reflection of a failure of maturation. Seen in this way, the “splitting” between the manifestations of IWMs, characteristic of BPD, is not primarily defensive, although in certain circumstances it may become so.
That integration comes with maturation is supported by child developmental studies. Perhaps the best known studies come from Tom Bower (1971). One of his experiments involved a clever system of mirrors in which an image of the same person could appear simultaneously in two or three cubicles at the same time. Infants were presented with two situations. In the first, the mother was in one cubicle while strange women occupied the others. In the second, the mother seemed to be in each cubicle. Infants younger than 20 weeks responded to the first situation by smiling at mother and in various ways interacting with her while ignoring the other women. In the multiple-mother situation created by the mirrors, the baby happily cooed and waved to each mother in turn. Older infants responded to the first situation similarly, but when confronted by multiple images of the mother, they showed distress as if their concept of mother as a single person had been upset.
Numerous other studies, beyond the scope of this chapter, support the notion that the perceptual and conceptual world of the child is as if in pieces relative to the adult. Although integration of small fragments of personal reality into larger wholes comes with maturation, it is not inevitable, at least in terms of higher-order functions and systems. This integration depends upon suitable responses from the social environment. Such was the thesis of Vygotsky & Luria (1994) whose concept of sociogenesis was influenced by the ideas of Janet: “Janet was arguing that all higher, typically human conducts have a social origin. They exist first between people, as social acts, and only afterward as intraindividual, private acts. These private acts, however, retain their social character” (van der Veer & Valsiner, 1988, p. 58). Janet had speculated that the process he called “personal synthesis” involves a coherence in the responses of the caregivers that fosters unification. He wrote: “The child creates his individuality because one always mentions him in the same way and because one’s behaviour towards him has a certain unity” (Janet, 1929, p. 268). Failure of sociogenesis not only results in disturbance of the coherence of “individuality” but also of that individual’s stability in the way of relating to others.
The basis of fragmentation of IWMs has been conceived in terms of attachment. Bowlby (1973) suggested that unsatisfactory relationships between the developing child and the primary caregivers may lead to a disturbance of attachment in which, instead of a relatively unified system of IWMs, representations of particular forms of relatedness develop that are multiple and disconnected. This idea has gained support through the work of Mary Main and her colleagues. These studies led to the description of a disorganized form of attachment (Main & Solomon, 1990), a fourth category added to the trio identified by Ainsworth and her collaborators (1978; i.e. secure, insecure-avoidant, insecure-resistant). Disorganized attachment was found to be related to unresolved traumata in the lives of the caregivers. Main and Hesse (1990) suggested that traumatized caregivers may behave in a way that is frightening to the child and, worse, offers no resolution to the fright. These data led Main (1991) to argue that disorganized attachment results in multiple, incoherent, disaggregated representations of self and other.
Liotti has reviewed this background to his own work as a prologue to putting forward a model of dissociation and BPD that depends upon the implicit view that dissociation as a state of mind cannot be separated from dissociation as a form of relatedness. In a series of papers, Liotti (1992, 1994, 1995, 1999) proposed that disorganized attachment is the first step in a developmental pathway that might culminate in the clinical expression of dissociation in adult life. The caregiver who relates to the child in a way that is associated with the development of disorganized attachment in the child, behaves in a manner that is not only frightening at times but also unpredictable and contradictory. The mother might, for example, be frightened of the child. The child is now placed in a situation in which simultaneous but incompatible perceptions of the caregiver are received. The child’s need to respond appropriately is overwhelming, since the bond to the caregiver is felt as necessary to existence. The discordant and incongruent signals, however, do not indicate how to behave. The child might be immobilized, as if stunned, or in an apparent trance state analogous to the adult state of dissociation.
Liotti (1992) suggested that disorganized attachment has three possible main outcomes: (1) satisfactory adaption, in response to the integration of disaggregated IWMs though later secure attachments; (2) the development of a propensity for dissociation in later life; or (3) dissociative disorders due to later traumata amplifying the earlier vulnerability associated with disorganized attachment. In later papers Liotti (1995, 1999, 2000, 2004) proposed that the disorders that are the outcome of the third pathway include BPD and complex posttraumatic stress disorder.
In essence, Liotti’s work suggests that a relationship dominated by an individual whose behavior is determined by multiple and disconnected IWMs creates in the partner a state of mind that mirrors the relatedness; that is, it produces a disaggregated form of consciousness. In circumstances where the maturational process of integration in psychic life is facilitated by a suitable interplay with the caregiving environment, the original difficulty may be overcome. If not, dissociative pathology may emerge in more florid forms.
Liotti’s theories are given evidential support not only by his own studies (Liotti & Pasquini, 2000; Pasquini et al., 2002) but also by the observations of other groups. The Minnesota Longitudinal Study (Carlson, 1998; Ogawa et al., 1997) reported the outcome of 168 young adults whose attachment patterns had been observed in their second year of life. Those who had displayed disorganized attachment in childhood had higher dissociation scores in adult life than those with other forms of attachment. In addition, those who had suffered subsequent traumata had higher scores than those who had not (Ogawa et al., 1997). Three subjects in the study had developed clinically diagnosable dissociative disorders. All had exhibited disorganized attachments as infants (Carlson, 1998).
A later study from Dutra and Lyons-Ruth (2005) confirmed and extended the findings of Ogawa and colleagues. They followed 56 infants at social risk from birth to the age of 19. At the age of 19, they found that five measures of infant, childhood, and adolescent maltreatment failed to predict dissociation at age 19. In contrast, infant disorganization, maternal lack of involvement with the infant at home at 12 months, and disrupted maternal affective communication in the laboratory at 18 months contributed to the prediction of dissociative symptoms at 19. In addition, concurrent dissociative symptoms in the mother, but not PTSD, depression, or anxiety, were related to those of the adolescents’ dissociation scores.
The findings of this study suggested that the measures of maternal care are better predictors of a dissociative outcome than infant disorganization itself. They found, surprisingly, that hostile, frightening, and intrusive behaviours on the part of the mother were weak predictors. Less salient behaviors were more pathogenic: for example, “withdrawing from emotional contact, being unresponsive to the child’s overtures, displaying contradictory, role-reversal, or disoriented responses when the infant’s attachment needs are heightened” (Dutra & Lyons-Ruth, 2005, p. 69).
REVERSAL IN THE CHILD’S BEHAVIOUR
Reversals, as noted previously, characterize the relatedness of those with BPD. This kind of behavior was strikingly evident in schoolchildren who had shown disorganized attachment during infancy as they seemingly mirrored the contradictory, role-reversed behavior of their mothers. Lyons-Ruth and Jacobvitz (1999) reviewed two longitudinal studies of infants who had exhibited disorganized attachment. At this stage in development they were hesitant and apprehensive in their behaviors. Their school-age behavior was typically discontinuous with such demeanors. Over 80% of the children displayed either punitive-dominant or caregiving behavior toward the attachment figure. Both those behaviors can be conceived as “controlling.”
Liotti (2006) points out, using the evidence of Hesse et al. (2003), that these reversals may be conceived as defenses that are helpful to the child in maintaining some kind of integration. When, however, anxiety is activated, the defensive strategy collapses and the original disorganized IWM again becomes manifest. In the Hesse study, 6-year-old controlling children were shown pictures from a separation anxiety test. These children, who initially presented as well oriented and organized in their thinking, gave incoherent, unrealistic, and catastrophic narrative responses to the pictures. Such observations may have significant implications for our understanding of reversals in the behavior of those with BPD.
MENTALIZATION, THEORY OF MIND,
AND TRAUMATIC ATTACHMENT
The foregoing observations have focused on “relational traumata” (Schore, 2003a & 2003b) in those with BPD that impede a particular aspect of the maturation of self, namely, its coherence. Fonagy and his colleagues (2003 report on deficiencies in BPD of another cardinal aspect of self. They suggest that traumatic early attachment experiences hinder the emergence of “mentalization.” Mentalization is a term coined by Uta Frith and her colleagues (1991) to refer to the ability that underlies the mental accomplishments in having a “theory of mind” (Premack & Woodruff, 1978). Fonagy and Bateman (2008) define mentalization as “the capacity to make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes” (p. 5). They further note: “It is not the fact of maltreatment but more the family environment that discourages coherent discourse concerning mental states and it is this that is likely to predispose the child to BPD” (p. 13).
Fonagy and his colleagues (2003) used measures of reflective function and theory of mind to evaluate the two main features of mentalization in BPD. Recent evidence, however, does not support the supposition that those with BPD perform poorly on theory of mind tests (Fertuck et al., 2009; Arntz et al., 2009). In the Fertuck study, those with BDP showed an enhanced ability to judge mental state as indicated by the “reading the mind in the eyes” test (Baron-Cohen et al., 2001). This is consistent with clinical observations that many of those with BPD are acutely aware of facial expression and have the capacity to make very sensitive discernments, enabling them to respond in a way that they believe is expected or necessary.
The study of Arntz and colleagues (2009) depended upon a more advanced theory of mind capacity devised to test those with subtle deficiencies (Happé, 1994). The subject is asked questions about double bluff, mistakes, persuasion, and white lies. It is not surprising that those with BPD did not perform poorly on these tests, since strategies involving deception are familiar to those with BPD. The capacity for pretense develops at 2–3 years, earlier in human life than the conception of self. Moreover, sympathy may be well developed, enabling the patient with BPD to have, at times, startlingly accurate intuitions about the mental life of others that are based on their own experience. Sympathy, however, is not empathy. These same patients may make assumptions about the other that are grossly inaccurate since they derive from an understanding of their own desires, beliefs, and so forth, rather than from the capacity to imagine a personal reality that differs from their own.
Theory of mind may not adequately identify the specific deficit in attributing mental states to others that those with BPD often display. Those with BPD, it should be remembered, include politicians and highly successful entrepreneurs whose success has depended, in part, on very efficient “mind reading.” On the other hand, they can be remarkably obtuse in dealing with others. Their specific deficit is in the capacity for what may be called empathy, which, contrary to the assertion of Arntz and colleagues (2009), is not exemplified by appropriate responses to someone bereaved, a behavior dependent upon sympathy. In my view, the capacity to empathize with others is related to, and arises from, the development of self, identified by a reflective awareness of mental states sensed as one’s own. The realization that one has a unique and personal world that differs from others gives rise to another realization: that others also have their own unique, personal and private worlds.
Episodic memory, involving the recall of events from one’s life, is a cardinal indicator of self. Theory of mind tests, however, can be performed normally by a person without episodic memory, as demonstrated in two rare cases of people who, through injury to the brain, were unable to recollect personal happenings in their own lives (Rosenbaum et al., 2007). Thus, although episodic memory and theory of mind performance depend upon similar areas of brain function (Buckner & Carroll, 2007) they appear to be independent. On the other hand, linguistic analyses of a patient who was studied early in treatment and again 6 months later suggested that the emergence of reflectiveness on inner events, evident in the second analysis, was related to a capacity for empathy (Meares, Butt, et al., 2005).
HOSTILE-HELPLESS, ANACLITIC, AND OTHER FORMS OF IWM IN BPD
That those suffering from BPD relate to others according to a disintegrated system of IWMs is implicit in the DSM catalogue of criteria for BPD. The interpersonal style is “unstable,” vacillating, for example, between polar extremes of idealization and devaluation. Attempts to categorize these IWMs follow the early studies from which emerged the notion of disorganized attachment. Two kinds of Adult Attachment Interview (AAI) transcripts related to disorganized attachment have been designated “unresolved” (U) and “cannot classify” (CC; Hesse, 1996). The unresolved classification can be made only if there is a history of trauma or loss. This raises a methodological difficulty since a transcript characteristic of the U code cannot be given that code in the absence of trauma. U transcripts reveal a lack of coherence in the discussions of trauma and suggest deficient integration of the trauma event into conscious life. The integration may be impaired by contradictory maternal behaviors, particularly of being frightening to and frightened of the infant.
The CC classification is co-called because the transcript suggests different and shifting forms of attachment, reflecting a disintegration of IWMs. In the first part of the interview the subject displays a “dismissing” attitude to attachment and then shifts, without apparent awareness of the contradiction, to a “preoccupied” state in which is given a jumbled, confusing, often angry, and prolonged account of early childhood. Fonagy and his colleagues (1996) found that those with BPD are particularly likely to be associated with “unresolved” and “preoccupied” types of attachment. Choi-Kain and her colleagues (2009) report that preoccupied and fearful attachment styles differentiated individuals with BPD from depressed people and from another comparison group of nonborderline subjects. Furthermore, being rated as having both styles of attachment confers a greater risk for being diagnosed with BPD than either style alone.
In his review of this subject, Liotti (2006) points out that U and CC attachment classifications are particularly common in dissociative and borderline groups. This observation is consistent with the main thesis of this chapter, that dissociation and a particular form of interpersonal style are interrelated.
In more recent studies Lyons-Ruth and her colleagues (2005) have developed a new coding that develops the U category but is not contingent upon a history of trauma or loss. They call this coding hostile/helpless (H), and it is given when the subject, now an adult, gives contradictory and unintegrated emotional descriptions of the main original caregiver. Lyons-Ruth has stressed how H/H relations between a mother and infant predispose to the formation of disorganized attachment. H/H coding is particularly common in patients with BPD (Lyons-Ruth, Menick, et al., 2007).
Another main category of IWM in BPD is related to the fear of abandonment and of being alone, a prominent feature of the disorder noted by pioneers of the syndrome (Stern, 1938; Adler & Buie, 1979; Gunderson, 1996). Bornstein and colleagues have thoroughly reviewed the evidence concerning “dependency” and BPD (Bornstein et al., 2010). Levy et al. (2007) suggest that dependency in BPD is of a particular kind. They used Blatt’s methods in their investigation. Using Rorschach methods, Blatt and Auerbach (1988) described two kinds of BPD pathology associated with depression, which they called anaclitic/dependent and self-critical introjective. Following this, Blatt and his coworkers (1976) developed a 66-item scale covering a wide range of depressive feelings, beliefs, forms of relating, and so forth. Factor analysis revealed three factors composing the scale, entitled the Depressive Experiences Questionnaire (DEQ). The factors were Dependency, Self-Criticism, and Efficacy. The Dependency factor was subjected to a further analysis, from which emerged two scales: Anaclitic Neediness and Interpersonal Depression (Blatt et al., 1995). The former covers separation fears and the latter, loneliness and loss. This investigation was conducted with attachment theory in mind, suggesting that it is not inappropriate to call these factors and subfactors IWMs. Levy and colleagues (2007) conclude that Anaclitic Neediness and Self-Criticism are characteristic of BPD pathology. On the other hand, the over-arching Dependency factor did not distinguish BPD and non-BPD groups.
TRANSGENERATIONAL TRANSMISSION OF BPD
The evidence presented so far regarding the developmental background of individuals with BPD gives support to ideas that were put forward a century earlier. William James, building on the observations of Pierre Janet, wrote: “Children are not born with a sense of unified identity—it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have been blended into a relatively unified identity remain separate” (1983, p. 264). It might be expected that those who have been “overwhelmed” by inappropriate responsiveness of the caregiving environment and who develop BPD in later life will be likely to create a similar caregiving environment for their children. Their disconnected and unpredictable interpersonal style, derived from “enmeshed,” “unresolved” (Patrick, 1994; Crandell et al., 2003), and other attachment patterns, might result in the transgenerational transmission of BPD.
This possibility is being investigated by Peter Hobson and his group at the Developmental Psychopathology Unit at the Tavistock Clinic, London. In a study of mothers with BPD and their 2-month-old babies, Crandell et al. (2003) videotaped the dyad at play; during a period when the mother maintained a still face; and during the recovery period from the unresponsive still maternal face. During the baseline period the mother with BPD and her baby were indistinguishable from the control dyads. The differences in the still face period were not marked, but babies of mothers with BPD showed increasing looking away and dazed expressions. The dazed expressions continued in the recovery period when the mother’s behavior seemed relatively ineffective in facilitating the baby’s regrouping. These mothers were judged “intrusively insensitive” compared with controls. It seems important that evidence of disturbance in the mother–child relationship did not properly emerge until stress was introduced.
A second study concerned ten 12-month-old babies and their mothers who suffered BPD (Hobson et al., 2005). The investigation involved three different situations: (1) A still-faced stranger subsequently attempted to engage the infants in a game; (2) the babies were confronted by the Strange Situation of Ainsworth and Wittig; and (3) the mothers were asked to teach their infants to play with a toy train and miniature figures. Compared with 22 controls, (1) the infants of mothers with BPD were less organized and allowed less opportunity for positive engagement; (2) a higher proportion (8 out of 10) rated as showing disorganized attachment; and (3) the mothers were more “intrusively insensitive.”
In a second study of mothers with BPD and their year-old infants, the dyads were compared with dyads in which the mothers were depressed mother and in dyads with mothers who had no psychiatric disorder (Hobson et al., 2009). As expected, a higher proportion (85%) of women with BPD showed disrupted communication with their infants. They also displayed frightened/disoriented behavior.
These data provide compelling evidence that children of mothers diagnosed with BPD are at risk. Treatment of mothers with BPD might therefore confer a double benefit, not only helping the mothers but also, hopefully, diminishing the chances that their children will suffer the same disorder. The phenomenon of reversal repeatedly displayed by the parent might be particularly pathogenic. Our own studies have shown that treatment of patients with BPD is associated with beneficial changes in their family relationships (Gerull, Meares, Stevenson, Korner, & Newman, 2008).
This chapter has concerned the disintegration of representations in memory of traumatic forms of relatedness. These different “scripts” record the role of the subject and his or her relatedness with the other in the traumatic scene. The disintegration causes the individual to shift, typically quite sharply, from one way of relating to another. Each shift is associated with a different expectation of the other. The expectation is that the other will behave as the original traumatizing other. Certain neurophysiological data are presented in order to show how this expectation is heightened where traumatic memory is activated and has a subliminal effect upon the other which is perceived unconsciously. Another aspect of the disintegrated form of relatedness arises when the poles of the traumatic “script” become as if reversed, and the subject takes on the role of the traumatizer.
Developmental aspects of the disintegration are discussed. These data suggest that the disintegration may arise in early life through the child living in a parental atmosphere, which leads to disorganized attachment. The disorganized behavior of the child mirrors the later disintegration of psychic life, which is referred to as dissociation.