The aim of this paper is to discuss the possible link between attachment and Borderline Personality disorder and the management of clinical settings with these patients.

It is known that Borderline Personality Disorder has a severe impact on the patient’s daily life and it also has high social costs, because of the high percentage of suicides, the high comorbidity with other pathologies and the extensive use of psychological and pharmacological treatments. Although this pathology has always received great attention by clinicians, little is known about his etiology, even if the scientific community agrees that its onset may be explained by the interaction between biological factors (such as dysfunction in front-limbic area, known as responsible for the emotional regulation) and psychosocial factors (insecure attachment, being victim of abuse during childhood, traumas).

Moreover, although it has not been found yet a specific relationship between specific attachment styles and Borderline Personality Disorder (probably because of methodological issues, many instruments are nowadays available to assess attachment style), attachment disorders seem to represent a high risk factor for Borderline Personality Disorder onset.

This paper would offer, after a brief introduction on Borderline Personality disorder, the presentation of attachment theory, the different instruments nowadays known to assess attachment styles (instruments suitable both for children and for adults) and different data supporting the relationship between attachment disorders and Borderline Personality Disorder.

Attachment

In regards to the caregiver, he/she may provide insecure attachment if she is not able to be responsible for child’s needs in an appropriate way, or rather she is not able to ensure his needs, to provide protection, to be a secure basis for the environment exploration. When this happens, the child may conceive his caregiver as unstable: as consequence of this, the child can’t use his internal working model (an implicit model that he will use to deal with interpersonal relationships) neither to ensure himself in difficult situations nor to regulate emotional reactions. Gunderson argued about similarities between the behavioral patterns of Borderline Personality Disorder, such as being scared of dependence’s needs, being scared of abandonment, monitoring the distance from the caregiver and some of the behaviors acted by insecure (attachment) children.

Mentalization

In regards to mentalization, Fonagy et al. believe that this ability emerges in early childhood. The caregiver’s ability in understanding, reflecting and answering in an appropriate way to children’s mental states would promote child’s ability to understand his own and others mental states. As a consequence of the development of this ability, the child would use it to face the world, to represent mental states in symbolic terms, to manage emotional states in an appropriate way.

On these basis it’s understandable why little stressful situations, emotional or relational, trigger severe anger or frustrations in patients affected by Borderline Personality Disorder as they can’t refer to a protective attachment figure: stressful stimuli are perceived from the patients as dangerous and activate attachment system, in order to ensure themselves that a reassuring person may manage the situation. The emergency to feel a protective person interfere both with the ability to deal with the situation and with the mentalization process: as consequence of that, the stressful situations will become less understandable and the patient responds with a chaotic, disorganized and disruptive behavior (impulsive behavior, self-arm, dissociations). Patients affected by Borderline Personality Disorder mentalize now and then: the inactivation of this process is triggered by stressful relational situations.

A psychotherapy session, may present a potentially stressful situation in relational terms, it could happen that the inability to mentalize is put in action through the “pretend mode”: the patient seems to produce a good speech, he seems to be aware of his own troubles, but the contents produced are not related to his internal world and don’t have emotional value. A proof of the patient’s mentalization activity impairment consists in giving a meaning to the actions carried out by other people on the basis of the consequences that these actions produce on himself (for example, one person told me accidentaly something that hurts me – this person hates me and his real intention was to hurt me).

Attachment theorists suggest to therapists to act as a sensible caregiver in order to help the patient to manage his mentalization deficit and to promote self-efficacy. The clinicians should help the patients to explore their own feelings and to understand the reason of their reactions; moreover therapists should use the interpretation in the right moment, when the patient is not struggling, when he would be more able to understand it and thus to receive a benefit from it. It is prudent being aware that interpretations focused on past experience are less helpful than interpretations on present events, as this could increase negative feelings promoting pseudo-insights.

This perspective would help the clinician and the patient to conceive behavioral or emotional symptoms as consequence of the therapeutic alliance.

In order to face the inhibited mentalization process, it may be also helpful to give the patient insight of his behavior, to relate it to the emotions, to connect the behavior to its reasons (“did you start to insult her as you realized she was criticizing you because of your delay?”), to encourage the patient to remember other situations in which he felt the same kind of feelings (“did it happen other time you felt rejected from him?”), to recognize the existence of mixed and complex feelings and to encourage the patient to evoke which aspects of the situation might have brought a different outcome (“looking back to the past, would you have acted in a different way”?)

Marta Bezzone

You might also be interested in:

Attachment

Cloninger approach to personality

Find a therapist:

Find a therapist

References

Adult Attachment in the Clinical Management of Borderline” Fossati A., Journal of Psychiatric Practice Vol. 18, No. 3 May 2012

– Leichsenring F, Leibing E, Kruse J, et al. Borderline personalità disorder. Lancet 2011;377:74–84.

– Paris J. The nature of borderline personality disorder: Multiple dimensions, multiple symptoms, but one category. J Pers Disord 2007;21:457–73

– Bowlby J. Attachment and loss. Vol. II: Separation:Anxiety and anger. New York: Basic Books; 1973.

– Fonagy P. Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. Int J Psychoanal 1991;72:1–18.

– Bateman AW, Fonagy P. Psychotherapy for borderline personality disorder: Mentalization based treatment. Oxford: Oxford University Press; 2004.

– Fonagy P, Bateman A. Progress in the treatment of borderline personality disorder. Br J Psychiatry 2006;188:1–3.

– Bateman AW, Fonagy P. Mentalization based treatment for borderline personality disorder: A practical guide. Oxford: Oxford University Press; 2006