On Attachment Woes

Are You or Your Clinicians Attached to Certain Presumptions that Might Effect Family Members Negatively and Impede Recovery?

Clinicians often talk about a poor sense of attachment as the root cause of BPD. Those who make this claim presume that the sufferers’ early caregivers were unable to provide a secure and stable emotional environment. This led the sufferers to feel rejected and develop an overwhelming sense of abandonment, mistrust, avoidant behavior, difficulty understanding themselves and others, emotional instability and, ultimately, BPD. Even more dramatically, this learned lack of empathy and the inability to correctly understand and validate the self and others is passed on from the child to its children—unless it learns how to empathize, mentalize, and validate through an extensive therapeutic process—so BPD will be passed on from mother to child ad infinitum.

For parents, this line of reasoning oftentimes sounds like an accusation: “It is all the parents fault” or, even more specifically, “It is all the mother’s fault.” After all, isn’t the mother responsible for all early attachment woes?

Even if this presumption were unequivocally true, I would argue that clinicians ought to be far more sensitive about how they present it to parents, especially since these selfsame family members are oftentimes crucial to a BPD sufferer’s recovery. Driving them away emotionally, is a lose-lose proposition. Furthermore, taking this hypothesis as gospel can only lead clinicians to look down upon BPD sufferer’s parents, which again harms treatment outcomes (unless a parent was openly abusive, in which case, there is a legitimate reason to thoroughly consider the probity of a parent’s role in recovery).

If we are unsure of the parents’ culpability than adopting such an assumption is even more problematic.  While secure attachment is doubtless important, even if the correlation between poor attachment and BPD indicates that poor attachment is a root cause of some of the symptoms as Peter Fonagy has shown in his work on mentalization (Journal of the American Psychoanalytic Association 48(4):1129-46), jumping to the conclusion that poor attachment is, therefore, caused exclusively by the caregiver and is the caregiver’s fault is a good example of faulty reasoning. While this narrative is compelling, it is also somewhat tautological (how can the lack of poor attachment conclusively prove that poor attachment is the root cause of poor attachment), and we must make the category distinction between poor attachment as responsible for the disorder and the caregiver as responsible for the disorder.

As we all know different children have different temperaments and different levels of resilience, so, first of all, one caregiver’s poor attachment skills might be good enough for one child and not for another. Blaming a parent whose parenting seems good enough, in general, or who has successfully raised other children for failing with this particular one is illogical. Why would they or should they question their early rearing of a particularly temperamental or sensitive child?

Furthermore, as we all know some individuals come through traumas (in this case, poor attachment) relatively unscathed and others do not. Additionally, some children attach easily and others do not. So, ironically, even a faultless caregiver faced with a child born with a low level of resilience or with difficulty attaching properly may unfortunately fail to provide for their needs. In effect, such a child sabotages its own attachment process because only an exceedingly rare parent would guess at its special needs. The consequences may be dire, but again they are not the caregiver’s fault. Attachment may, indeed, be responsible for the disorder, but the parent is not.

Finally, even a securely attached child may undergo a particularly violent trauma that undoes their secure attachment.

So even if there is a correlation between poor attachment and BPD, making the leap of logic from that to generalizing and blaming all caregivers—in particular the mothers—for all the sufferer’s ills is highly illogical and is a terribly insensitive claim to make. It hurts the parents—who are already suffering terribly—and only serves to distance them further from their difficult child, thus undermining the help and support they could provide in the recovery process.

Addendum: At a recent lecture on the treatment of eating disorders, Professor Daniel Stein of Israel’s Sheba Medical Center argued that the unfortunate perception of parents as blameworthy was a result of the question asked by early eating disorder researchers: What is the cause of this disorder? Since the sufferers’ primary influences were their families, it made sense to begin by focusing on the families as the possible source of the disorder. Over time, this unfortunately turned from an objective, scientific investigation to discover the cause of eating disorders into what felt, at least to the parents, like a blame game. By its very nature, this research question led clinicians to perceive carers as the source of the problem [MG] and, therefore, undermined a fruitful relationship between the two P’s, professionals and parents.

Stein concluded by saying that as clinicians realized that the cause of the disorder was very complex and difficult to pin down, they began to investigate why certain patients responded well to treatment and others did not. This change of focus led to a more natural alliance between clinicians and carers, as parents are an important part of the positive equation when it comes to recovery.

Curiously, three days later at a seminar on dealing with the comorbidity between mental illness (Axis I Disorders) and addiction, Eitan Turkel, MSW, Co-ordinator of the Comorbidity Program at Kfar Shaul-Eitanim Medical Center in Jerusalem, detailed the three issues targeted in treatment: boundaries, cognitive distortions, and the system. Commenting on the latter, he said: today “the families are involved when at one point in history, it would only be a bit of an exaggeration to say that the families were perceived to prevent recovery.” In dealing with addiction, as well, the families have gone from the position of “enemy” to valued ally in the recovery process.