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Mental Disorders

Attachment Theory of Personality Disorder

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.

Another influential way of thinking about personality disorders stems from attachment theory. This theory is credited to John Bowlby and Mary Ainsworth.  Like object relations theory, attachment theory proposes that people develop internal representations of relationships through their interactions with early caregivers. These internal representations, or working models of relationships, then go on to influence: 1) personality development, 2) social interaction tendencies, 3) expectations of the world and of other people and, 4) strategies for regulating emotions. 

baby holding adult handThe theory separates these working models of relationships into two main categories, secure attachment and insecure attachment, according to the degree of safety and security present within the relationships represented by the models. The category of insecure attachment is further subdivided based on how children react to others as a result of their working models: ambivalent, avoidant, or disorganized.

  • Secure attachment
  • Insecure attachment
    1. Ambivalent attachment: clinging to caregiver, proximity seeking
    2. Avoidant attachment: rejecting caregiver
    3. Disorganized attachment: alternating between clinging, then rejecting caregiver

Characteristic of these insecure attachment styles are behaviors that are overly clingy or proximity seeking (ambivalent attachment), or behaviors that are rejecting of the caregiver (avoidant attachment). Some insecurely attached children develop a disorganized attachment style, which is characterized by alternating back and forth between clingy behavior, then rejecting behaviors, coupled with a fear of the caregiver.

Attachment theory proposes that children's early relationships with caregivers should ideally give rise to a secure attachment. Secure attachment is formed by the provision of a secure base from which children can safely explore the world.  Trusted caregivers become a sort of "home base" or safe harbor from which children can safely venture out into their surrounding environment.  When feeling anxious, unsafe, and in need of comfort they can return to their "home base" as needed.

When children are upset, they are biologically programmed to seek protection and comfort from caregivers.  Caregivers who meet children's needs for protection and comfort do so by providing effective and appropriate soothing responses.  When caregivers model these effective soothing responses, this enables children to learn how to calm and soothe themselves.  Children's positive experiences of safety and comfort shape the formation of mental representations of themselves and others. These healthy representations are characterized by a basic sense of self-worth and of trust in other people (i.e., secure attachment).  Over time, through the trusted caregivers' consistent behavior, children learn to regulate their own affect. They learn to internalize a self-soothing, comforting coping strategy that previously took place in the space between caregiver and child.  

In contrast, when caregivers are rejecting, cold, and inconsistent in response to children's needs, children do not experience caregivers as soothing and safe. They subsequently develop mental representations of relationships as unsafe and insecure (i.e., insecure attachment).  Little or no modeling of soothing behavior is offered within these insecure attachments. Whatever is offered cannot be trusted because it is inconsistently provided. So, children do not effectively learn how to regulate their own emotion or to soothe themselves.

Early maltreatment culminating in the formation of an insecure attachment style may cause children to become confused in their approach to relationships with caregivers and other authority figures.  They anticipate abuse or neglect. Thus, they are motivated to be cautious or avoidant, while simultaneously needing support and protection from the same people they wish to avoid.  This need motivates their approach for support or comfort. Unfortunately, this need is not met. Such an incompatible and confusing mixture of interpersonal motivations may account for a behavioral pattern called approach-avoidance.  This style has been described in persons with Borderline Personality Disorders as, "Come close, No! Go away!"  An insecure attachment style does not constitute disorders in-and-of themselves. However, when combined with other biological and environmental risk factors such as abuse, they may contribute to the development of a personality disorder.

Dialectical Behavior Therapy and Schema Therapy incorporate certain elements of attachment theory. Mentalization-Based Therapy (MBT) rests heavily upon attachment theory. The theoretical foundation of MBT follows in the next section.