Simone Hoermann, Ph.D., is a Psychologist in private practice in New York City. She specializes in providing psychotherapy for Personality Disorders, Anxiety, and Depression
On several occasions, I have written about the difficulties in self-regulation that are commonly experienced by people with Personality Disorders. Related to that, people with Personality Disorders also tend to have difficulties in interpersonal relationships. Take, for example, someone with Avoidant Personality Disorder who only has very few relationships, or someone with Borderline Personality Disorder who is extremely afraid of abandonment. Many experts believe that these difficulties are in some way related to experiences in early childhood relationships. While we don’t know how exactly Personality Disorders develop and what causes them, there is some indication that it is probably a combination of biological makeup and disposition in interaction with life experiences and the environment that are at the root of these difficulties.
One lens through which to look at this is Attachment Theory, first postulated by John Bowlby in the late 1960s. Bowlby suggested that we all are born with a biologically determined need to form close relationships. According to Bowlby, the human infant has the inborn need to seek proximity to a caregiver in moments of fear and distress. In other words, when the child feels that there is some form of threat or distress, its attachment behaviors get activated. You are probably familiar with some of these behaviors: Clinging, crying, smiling, or proximity seeking. In turn, the caregiver tends to respond through soothing and protective behaviors.
Bowlby’s colleague Mary Ainsworth found that the caregiver’s response and sensitivity to the child greatly influence the development of the attachment system. Ainsworth thought that, if the caregiver understands the child’s signals responds appropriately, thereby helping to soothe and regulate the child, then the infant develops a secure attachment style. The idea is that, over time, the child develops a model of how relationships work, based on their relationship experience with their early caregiver. This model is referred to as “internal working model” and is thought to influence all later relationships of importance.
Ainsworth developed a laboratory based procedure that would help observe and identify a child’s attachment style. This test is called the Strange Situation test and is based on observing how the child interacts with a stranger while the caregiver leaves the room, and how the child responds to the caregiver when they reunite. Ainsworth was able to distinguish four different attachment patterns in children: Secure, anxious/avoidant, anxious/resistant, and disorganized.
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As Klaus Grawe in his book Neuropsychotherapy notes, there is some evidence that insecure attachment is common in people with personality disorders, as it is in general in people with mental illness, although studies trying to identify a relation between diagnosis and attachment patterns have generated inconsistent results. There is some evidence from research that children with secure attachment styles are more resilient, more self-confident, and more empathic. Interestingly, attachment styles appear to be transmitted across generations: Mother with secure attachment styles seem to be more likely to have children who are securely attached as well. Not too surprisingly, Arietta Slade and her team found that mothers who were better able to reflect on their own behavior were more likely to have securely attached children.
Peter Fonagy and his team took attachment theory a step further: Fonagy emphasized the importance of the caregivers ability to understand the child, to “keep the child’s mind in mind”. This parental ability to reflect – or mentalize- helps the child develop self-understanding and an understanding of other people, which is crucial for the development of self-soothing and emotion regulation skills.
Attachment patterns are thought to be fairly stable over time, although I do believe that, as we grow older, we can still change and develop- we can have relationship experiences that can have a positive effect on our “internal working models”. We can develop supportive romantic relationships and friendships, and we can work on modifying problematic relationship patterns. Self-soothing and relationship skills are something that can be learned: DBT focuses on teaching emotion regulation and crisis survival skills, and MBT focuses on developing the capacity to metalize, while TFP attempts at changing deeply engrained internal representations of self in relation to others.
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