Journal of Personality and Social Psychology
1991. "WJI. 61, No. 2, 226-244Copyright 1991 by the American Psychological Association, Inc.
0022-3514/91/S3.00
Attachment Styles Among \bung Adults: A Test of a Four-Category Model
Kim Bartholomew
Simon Eraser University
Burnaby, British Columbia, CanadaLeonard M. Horowitz
Stanford University
A new 4-group model of attachment styles in adulthood is proposed. Four prototypic attachment
patterns are defined using combinations of a person's self-image (positive or negative) and image of
others (positive or negative). In Study 1, an interview was developed to yield continuous and categori-
cal ratings of the 4 attachment styles. Intercorrelations of the attachment ratings were consistent
with the proposed model. Attachment ratings were validated by self-report measures of self-con-
cept and interpersonal functioning. Each style was associated with a distinct profile of interper-
sonal problems, according to both self- and friend-reports. In Study 2, attachment styles within the
family of origin and with peers were assessed independently. Results of Study I were replicated. The
proposed model was shown to be applicable to representations of family relations; Ss' attachment
styles with peers were correlated with family attachment ratings.
This article describes a new model of attachment styles in
adulthood. Drawing on the theory of Bowlby (1973, 1980,
1982a), two types of internal working models are postulated—
an internal model of the self and an internal model of others.
Each internal model can be dichotomized as positive or nega-
tive to yield four theoretical attachment styles. This article sum-
marizes the relevant childhood attachment literature, reviews
recent work on adult attachment, describes the new model, and
then presents two empirical studies designed to validate the
proposed model.
Childhood Attachment and Internal Models
Attachment theory conceptualizes "the propensity of human
beings to make strong affectional bonds to particular others"
(Bowlby, 1977, p. 201). Bowlby hypothesizes that an attachment
system evolved to maintain proximity between infants and
their caretakers under conditions of danger or threat. More
recent formulations view the attachment system as functioning
continuously to provide children with a sense of "felt security"
which facilitates exploration by the child (Ainsworth, Blehar,
Waters, & Wall, 1978; Sroufe & Waters, 1977). The quality of
early attachment relationships is thus rooted in the degree to
which the infant has come to rely on the attachment figure as a
source of security (Ainsworth et al., 1978).
On the basis of infants' responses to separation from and
This article is based on Kim Bartholomew's doctoral dissertation at
Preparation of this article was supported by Social Sciences and
Humanities Research Council of Canada doctoral and postdoctoral
fellowships to Kim Bartholomew.
We thank James Fuendeling for helping to develop and conduct in-
terviews and Diana Doumas, Christine Duffy, Mike Emerzian, Gail
Halloway, Stephanie Kondik, and Suzanne Little for coding inter-
views.
Correspondence concerning this article should be addressed to Kim
Bartholomew, Department of Psychology, Simon Fraser University,
Burnaby, British Columbia, Canada V5A 1S6.reunion with caretakers in a structured laboratory procedure,
Ainsworth identified three distinct patterns of infant attach-
ment: secure, anxious-resistant, and avoidant. Children classi-
fied as securely attached welcome their caretaker's return after
a separation and, if distressed, seek proximity and are readily
comforted. Infants classified as anxious-resistant show ambiva-
lent behavior toward caregivers and an inability to be com-
forted on reunion. Infants classified as avoidant avoid proxim-
ity or interaction with the caretaker on reunion. Continuity in
infant attachment patterns seems to be mediated largely by
continuity in the quality of primary attachment relationships
(see Lamb, Thompson, Gardner, Charnov, & Estes, 1985).
According to Bowlby's theory, children, over time, internalize
experiences with caretakers in such a way that early attachment
relations come to form a prototype for later relationships out-
side the family. Bowlby (1973) identifies two key features of
these internal representations or working models of attachment:
"(a) whether or not the attachment figure is judged to be the sort
of person who in general responds to calls for support and
protection; [and] (b) whether or not the self is judged to be the
sort of person towards whom\anyone, and the attachment fig-
ure in particular, is likely to respond in a helpful way" (p. 204).
The first concerns the child's image of other people; the second
concerns the child's image of the self. Recent research has exam-
ined the nature of internal working models in relation to chil-
dren's earlier attachment styles. The data show, for example,

that children classified as ambivalent hold negative views of
themselves, but the data are not as consistent with respect to
children classified as avoidant (Cassidy, 1988; Kaplan & Main,
1985; Main, Kaplan, & Cassidy, 1985). A considerable body of
research also links the child's attachment style at 12 or 18
months to the child's social and emotional adjustment through
early childhood (see Bretherton, 1985).
Attachment in Adulthood
A basic principle of attachment theory is that attachment
relationships continue to be important throughout the life span
(Ainsworth, 1982,1989; Bowlby, 1977,1980,1982b). Although
226

ATTACHMENT STYLES 227
evidence exists documenting the continuity of attachment-re-
lated behaviors (see Belsky & Pensky, 1988; Bowlby, 1973,1980;
Ricks, 1985; Rutter, 1988), investigators have only recently ex-
amined the relationship between working models of attach-
ment and social and emotional adaptation in adults. Main has
developed an Adult Attachment Interview (George, Kaplan, &
Main, 1987; Main & Goldwyn, 1988) that explores adults* repre-
sentations of childhood attachment relations. On the basis of
these interviews, mothers have been classified into attachment
groups that parallel the three childhood attachment patterns
described above and are predictive of the quality of the mother's
interaction with her own child and the security of the child's
attachment (Crowell & Feldman, 1987; Grossmann, Fremmer-
Bombik, Rudolf, & Grossmann, 1988; Main et al, 1985). Ko-
bak and Sceery (1988) used this procedure to examine young
adults' self- and other-representations, providing some evidence
that secure subjects view themselves as relatively undistressed
and others as supportive, that dismissive (avoidant) subjects
view the self as undistressed and others as unsupportive, and
that preoccupied subjects (corresponding to anxious-resistant
children) view the self as distressed and others as supportive.
(They did not discuss a category of people who might exhibit a
negative view of both the self and others.)
Hazan and Shaver (1987) conceptualized romantic love as an
attachment process and developed a self-report procedure to
classify adults into three categories that correspond to the three
attachment styles of childhood. In contrast to Main's proce-
dure, these investigators relied on respondents' self-reports
rather than on inferences from a semi-structured interview.
Their results showed that compared with the secure group, the
two insecure groups reported more negative experiences and
beliefs about love, had a history of shorter romantic relation-
ships, and provided less favorable descriptions of their child-
hood relationships with parents (see also Collins & Read, 1990).
Subjects in the two insecure groups also reported more self-
doubt and less acceptability to others than did those endorsing
a secure self-description (see also Feeney & Noller, 1990).
These two approaches differed both in the particular attach-
ment relationships focused on (parent-child versus love rela-
tionships) and in the methodology used for classifying subjects
(interview versus self-report). Whereas the interview method
identified avoidant adults as people who denied experiencing
subjective distress and downplayed the importance of attach-
ment needs, the self-report method identified people who re-
ported feeling subjective distress and discomfort when they be-
come close to others. Thus, a single avoidant-detached category
may obscure conceptually separable patterns of avoidance in
adulthood. Moreover, although Bowlby (1973) suggested that
working models differ in terms of images of self and others, no
study has considered all four categories that are logically de-
rived by combining the two levels of self-image (positive vs.
negative) with the two levels of image of others (positive vs.
negative). The present research examined all four of these cate-
gories and assessed subjects through an interview as well as
through subjects' own self-reports.
A Model of Adult Attachment
The model of the self and the model of the other as conceptu-
alized by Bowlby can be combined to describe prototy pic formsof adult attachment (Bartholomew, 1990). If a person's abstract
image of the self is dichotomized as positive or negative (the self
as worthy of love and support or not) and if the person's ab-
stracted image of the other is also dichotomized as positive or
negative (other people are seen as trustworthy and available vs.
unreliable and rejecting), then four combinations can be con-
ceptualized. Figure 1 shows the four attachment patterns that
are derived from a combination of the two dimensions. Each
cell represents a theoretical ideal, or prototype (Cantor, Smith,
French, & Mezzich, 1980; Horowitz, Wright, Lowenstein, &
Parad, 1981; Rosen, 1978), that different people might approxi-
mate to different degrees.
Cell I indicates a sense of worthiness (lovability) plus an ex-
pectation that other people are generally accepting and respon-
sive. Because this cell corresponds conceptually to categories
that investigators call securely attached (e.g., Hazan & Shaver,
1987; Main et al, 1985), we labeled it secure. Cell II indicates a
sense of unworthiness (unlovability) combined with a positive
evaluation of others. This combination of characteristics would
lead the person to strive for self-acceptance by gaining the ac-
ceptance of valued others. This pattern corresponds concep-
tually to Hazan and Shaver's ambivalent group (Hazan &
Shaver, 1987) and to Main's enmeshed or preoccupied with at-

tachment pattern (Main et al., 1985) and is referred to as preoc-
cupied. Cell III indicates a sense of unworthiness (unlovability)
combined with an expectation that others will be negatively
disposed (untrustworthy and rejecting). By avoiding close in-
volvement with others, this style enables people to protect
themselves against anticipated rejection by others. Although
not explicitly discussed in previous work in adult attachment,
this style may correspond in part to the avoidant style described
by Hazan and Shaver (1987). We therefore labeled it fearful-
avoidant. Finally, Cell IV indicates a sense of love-worthiness
combined with a negative disposition toward other people.
Such people protect themselves against disappointment by
avoiding close relationships and maintaining a sense of inde-
pendence and invulnerability. This style corresponds concep-
tually to the detached or dismissing of attachment attitude de-
scribed by Main et al. (1985), so we labeled it dismissive-
avoidant.
The dimensions in Figure 1 can also be conceptualized in
MODEL OF SELF
(Dependence)
Positive
(Low)Negative
(High)
Positive
(Low)
MODELOF OTHER
(Avoidance)
Negative
(High)CELL I
SECURE
Comfortable with
intimacy and autonomy
CELL IV
DISMISSING
Dismissing of intimacy
Counter-dependentCELL II
PREOCCUPIED
Preoccupied with
relationships
CELL HI
FEARFUL
Fearful of intimacy
Socially avoidanl
Figure 1. Model of adult attachment.

228 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
terms of dependency on the horizontal axis and the avoidance
of intimacy on the vertical axis (see labels in parentheses). De-
pendency can vary from low (a positive self-regard is estab-
lished internally and does not require external validation) to
high (positive self-regard can only be maintained by others' on-
going acceptance). Avoidance of intimacy reflects the degree to
which people avoid close contact with others as a result of their
expectations of aversive consequences. The dismissing and
fearful styles are alike in that both reflect the avoidance of
intimacy; they differ, however, in the person's need for others'
acceptance to maintain a positive self-regard. Similarly, the
preoccupied and fearful groups are alike in that both exhibit
strong dependency on others to maintain a positive self-regard,
but they differ in their readiness to become involved in close
relationships. Whereas the preoccupied cell implies a reaching
out to others in an attempt to fulfill dependency needs, the
fearful cell implies an avoidance of closeness to minimize even-
tual disappointment. Therefore, cells in adjoining quadrants of
Figure 1 are more similar conceptually than those in opposite
quadrants.
Study 1
We administered a semi-structured interview asking subjects
to describe their friendship patterns; the subjects' responses
were used to assess the degree to which each person approxi-
mated each of the four styles in Figure 1. We also obtained
self-report and friends' ratings of each attachment style, so the
three sources of data could be compared. Additional question-
naires were administered to subjects and their friends to test
hypotheses implied by the model. In particular, self-reports of
self-concept, sociability, and interpersonal problems were ob-
tained, and self-reports of interpersonal problems were corrob-
orated by the judgments of close friends.
The study tested three specific hypotheses. First, multidi-
mensional scalings of each set of ratings (by raters, subjects, and
friends) were expected to reproduce the organization of Figure 1
across all three sources of data (interview, self-report, and
friend-report). Second, self-concept measures were expected to
differentiate groups with a positive model of the self (secure and
dismissing) from those with a negative model of the self (preoc-
cupied and fearful), whereas a sociability measure was expected
to differentiate groups with a positive model of others (secure
and preoccupied) from those with a negative model of others
(fearful and dismissing). Third, the groups were expected to
differ from each other in their interpersonal problems. The
groups with a negative image of self (preoccupied and fearful)
were expected to exhibit problems with passivity and unasserti-
veness, whereas those with a negative image of others (fearful
and dismissing) were expected to describe problems with socia-
lizing and intimacy Problems described by the secure group
were not expected to be distinctive in content,
Method
Subjects
Forty female and 37 male students from an introductory psychology
class constituted the target sample. They ranged in age from 18 to 22
(M = 19.6); 67% were White, 16% Asian, 5% Hispanic, 8% Black, and4% other. An equal number of same-sex friends constituted the friend
sample. The friends' age ranged from 18 to 23 (M = 19.8); 65% were
White, 13% Asian, 13% Hispanic, 4% Black, and 5% other.
Procedure
Equal numbers of men and women were randomly selected from the
subject pool and contacted by telephone. First-year undergraduate stu-
dents were excluded to ensure that subjects had been at college long
enough to make close friends. Potential subjects were invited to partici-
pate with a friend in "a study of friendship and how well people know
each other." Friends were required to be close, same-sex, nonromantic
friends whom subjects had known for at least 6 months. Subjects re-
ceived course credit for participation, and their accompanying friends
were paid $5.
Subjects were tested in groups of two to four friendship pairs. Sub-
jects and their friends completed two sets of questionnaires, one re-
questing demographic and personality information about themselves
and the other asking the same questions of their partner. Instructions
were given for participants to answer the second set of questions "ac-
cording to your perceptions and knowledge of your friend's character,
feelings or behavior, and not according to how you think your friend
may be likely to answer them." Then each subject and friend were
separated to complete the questionnaires. To avoid contrast effects,
target subjects completed the self-report questionnaires first, and their
friend completed the friend-report first. A second session was then
scheduled for subjects to receive the interview.
Measures
Attachment interview. The first author administered a semi-struc-
tured interview, which lasted approximately 60 min, to subjects in the

Measures
target sample. Each interview was tape recorded. The interviewer
asked subjects to describe their friendships, romantic relationships,
and feelings about the importance of close relationships. If subjects had
not been involved in a romantic relationship, they were asked the rea-
sons. They were asked about loneliness, shyness, their degreeof trust of
others, their impressions of other people's evaluations of themselves,
and their hopes for any changes in their social lives.
On the basis of the interview audio recordings, three raters indepen-
dently rated each subject on four 9-point scales describing the subject's
degree of correspondence with each of the four prototypes. The raters
comprised two advanced female undergraduate psychology majors
and one female graduate student; they were blind to all other measures
in the study. A set of criteria (available from the first author) described
each prototype, and the rater was instructed to judge how well a sub-
ject's responses matched each of the prototypic descriptions. The four
prototypes can be briefly summarized as follows. The secure prototype
is characterized by a valuing of intimate friendships, the capacity to
maintain close relationships without losing personal autonomy, and a
coherence and thoughtfulness in discussing relationships and related
issues. The dismissing prototype is characterized by a downplaying of
the importance of close relationships, restricted emotionality, an em-
phasis on independence and self-reliance, and a lack of clarity or credi-
bility in discussing relationships. The preoccupiedprototype is charac-
terized by an overinvolvement in close relationships, a dependence on
other people's acceptance fora sense of personal well-being, a tendency
to idealize other people, and incoherence and exaggerated emotiona-
lity in discussing relationships. The fearful prototype is characterized
by an avoidance of close relationships because of a fear of rejection, a
sense of personal insecurity, and a distrust of others. Alpha coefficients
were computed to assess the reliability of the prototype ratings. The
reliabilities ranged from .87 to .95. The ratings were averaged, and the
highest of the four average ratings was considered to be the best-fitting

ATTACHMENT STYLES 229
category for that subject. From this procedure, 47% of the sample was
classified as secure, 18% as dismissing, 14% as preoccupied, and 21 % as
fearful. In addition, the raters were asked to rate each interview along
15 dimensions of relevance to adult attachment (see Appendix A for
definitions of the dimensions).
Self- and friend-reports. All subjects completed demographics and
friendship questionnaires, two self-concept measures, and a sociability
measure. In addition, the subjects completed the Relationship Ques-
tionnaire and the Inventory of Interpersonal Problems twice, once to
describe themselves and once to describe their friend. The friend's
version of these questionnaires was identical to the standard self-re-
port version, with the exception of wording: Instead of "I try to please
other people too much," for example, the friend's version read "F[your
friend ] tries to please other people too much." The following question-
naires were used:
1. The Demographics Questionnaire included family information
(e.g., marital status of parents, number of siblings) and personal activi-
ties (e.g., exercise, religious observance). Seven-point items assessed the
degree of experienced depression, anxiety, and happiness (with re-
versed scoring). These three items were combined into a composite
measure of subjective distress ifx = .68).
2. The Friendship Questionnaire contained equivalent demographic,
factual, and personal questions about the friend. One item assessed the
duration of the friendship, and five items assessed the nature of the
friendship (e.g., "Compared with close friendships you've had in the
past, how close is your friendship with FT*). The latter five items were
combined into a friendship closeness scale (target sample a = .80;
friend sample a = .86).
3. The Rosenberg Self-Esteem Inventory (Rosenberg, 1965) is a 10-
item scale that measures global self-esteem. A sample item is "I cer-
tainly feel useless at times" (reverse scored; coefficient a = .85).
4. The Fey Self-Acceptance Scale(Fey, 1955) is a 20-item measure of
self-acceptance. A representative item is "I'm pretty satisfied with the
way I am" (coefficient a = .86).
5. The Sociability Scale (Cheek & Buss, 1981) is a 5-item measure
that assesses the degree to which people like to socialize with others. A
sample item is "I like to be with people" (self-report coefficient a = .74;
friend-report coefficient = .78).
6. The Relationship Questionnaire is an adaptation of the attach-
ment measure developed by Hazan and Shaver (1987). This measure
consists of four short paragraphs describing the four attachment styles
(see Appendix B). Each respondent is asked to make ratings on a 7-
point scale of the degree to which they (or their friend) resemble each of
the four styles. These ratings are referred to as the self-report and
friend-report attachment ratings.
7. The Inventory of Interpersonal Problems (IIP; Horowitz, Rosen-
berg, Baer, Ureno, & Vitlasenor, 1988; Horowitz, Rosenberg, Ureno,
Kalehzan, & O'Halloran, 1989) is a 127-item inventory designed to
assess interpersonal difficulties in a broad cross-section of interper-
sonal domains. Subjects are asked to describe the amount of distress
that they have experienced from each interpersonal problem on a 5-
point scale ranging from not at all (0) to extremely (4). The IIP has
demonstrated acceptable reliability, validity, and sensitivity to changes
that occur during psychotherapy (Horowitz et al., 1988; 1989). Re-
sponses on this inventory were scored using a circumplex. procedure
that locates subjects' responses within a two-dimensional interper-
sonal space (defined by the dimensions of warmth and dominance) that
can be divided into eight octants (Kiesler, 1983; Wiggins, 1979). Sepa-
rate subscales describe distress in each of these octants (Alden, Wig-
gins, & Pincus, 1990). Starting with the region of greatest dominance
(neutral on warmth) and moving counterclockwise, the eight octants
are labeled overly autocratic (e.g., "I try to control other people too
much"), overly competitive (e.g., "I fight with other people too much"),
overly cold (e.g., "I keep other people at a distance too much"), overlyintroverted (e.g., "I feel embarrassed in front of other people too much"),
overly subassertive (e.g., "It is hard for me to be assertive with another
person"), overly exploitable (e.g., "I let other people take advantage of
me too much"), overly nurturant (e.g., "I put other people's needs before
my own too much"), and overly expressive (e.g., "I want to be noticed too
much"). (Self-report subscales coefficient a = .66 to .88; friend-report
subscales = .71 to .89.)
Results
Description of Attachment Groups
The 15 dimensions rated in the attachment interview were
used to identify a profile of correlates for each of the four at-
tachment prototypes. Because the prototype ratings were
based, in part, on subjects' dimension scores, these data should

be regarded as primarily descriptive. Table 1 shows mean rat-
ings on each of the 15 dimensions rated in the attachment inter-
view for subjects classified according to their highest prototype
rating, as well as the results of one-way analyses of variance and
Newman-Keuls comparisons for each dimension. Significant
group differences existed for each of the 15 dimensions. Corre-
lations between each dimension and each of the four continu-
ous prototype ratings were also calculated.
As shown in Table 1, the secure group obtained uniquely high
ratings on the coherence of their interviews and the degree of
intimacy of their friendships. They also received high ratings on
warmth, balance of control in friendships, and level of involve-
ment in romantic relationships. Correspondingly; the secure
prototype correlated highly with ratings of coherence, r(75) =
.78, p < .001, intimacy, r(75) = .77, p < .001, balance of control
in friendships, r(15) = .29, p < .01, level of involvement in
romantic relationships, r{15) = .40, p < .001, self-confidence,
r(75) = .41, p < .001, and warmth, r(75) = .59, p < .001.
The dismissing group scored uniquely high on self-confi-
dence and uniquely low on emotional expressiveness, frequency
of crying, and warmth. They scored lower than the secure and
preoccupied on all scales reflecting closeness in personal rela-
tionships: self-disclosure, intimacy, level of romantic involve-
ments, capacity to rely on others, and use of others as a secure
base. They were also rated as being low on elaboration and
caregiving and as being more in control than their social
partners in both friendships and romantic relationships. Con-
tinuous ratings of the dismissing prototype correspondingly
correlated positively with self-confidence, r(75) = .52, p < .001,
and negatively with elaboration, r{15) = -.43, p < .001, emo-
tional expressiveness, r{15) = -.69, p < .001, frequency of cry-
ing, r(75) = -.55, p < .001, warmth, r(75) = -.68, p < .001,
caregiving, r(75) = -.37, p < .001, and with all scales signifying
involvement in close relationships—self-disclosure, r{75) =
-.45, p < .001, intimacy, r(15) = -.33, p < .01, level of romantic
involvements, r{15) = -.35, p < .001, reliance on others, r(15) =
-.57, p < .001, and use of others as a secure base, r(75) = -.57,
p < .001. Consistent with the group results, the dismissing rat-
ing was also positively associated with the balance of control
scales, K75) = .40, p < .001, and r(75) = .39, p < .001 for friend-
ships and for romantic relationships, respectively.
The profile shown by the preoccupied group was opposite to
that of the dismissing in almost every respect; the means of
the two groups differed significantly on each of the 15 rating

230 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
Table 1
Mean Interview Ratings Across Attachment Groups
Model
Self
Other
n
General
Elaboration
Coherence
Friendships
Self-disclosure
Intimacy
Balance of control
Romantic relationships
Highest level involvement
Personal characteristics
Self-confidence
Emotional expressiveness
Crying frequency
Interpersonal characteristics
Warmth
Reliance on others
Others as secure base
Nonsocial vs social crying
CaregivingSecure
Positive
Positive
36
6.84,
6.08c
4.00b
5.09c
2.94C
3.6 le
3.29b
3.54C
3.76b
2.52b
3.13C
4.25b
3.34b
2.50b
4.25bDismissing
Positive
Negative
14
Measure
5.74,
5.45b
3.33,
4.10,
3.10e
2.60B
3.73C
3.93d
2.60.
1.45.
2.21,
3.268
2.43a
2.17,,
3.79,Preoccupied
Negative
Positive
11
7.95C
4.76,
5.12C
4.54b
2.62fl
3.61C
2.91a,b
2.86b
5.2Oc
3.32C
2.94^
5.I5C
4.I2C
3.70c
4.80cFearful
Negative
Negative
16
6.23^
5.00^b
3.05,
3-79,
2.608
2.60,
2.72a
2.24a
3.39b
2.17,,
2.70,,
3.46,
2.61.
l.75b
4.25^,I\% 76)
6.90*
16.54*
19.40*
23.12*
7.94*
6.06*
8.50*
27.77*
12.32*
5.75*
11.77*
14.65*
21.09*
7.60*
6.51*
Note, Means with different subscripts differ significantly at p < .05 according to Newman-Keuls pairwise
comparisons.
*p<.001.
scales. The preoccupied group scored uniquely high on ela-
boration, self-disclosure (showing a tendency to disclose inap-
propriately), emotional expressiveness, frequency of crying, reli-
ance on others, use of others as a secure base, crying in the
presence of others, and caregiving. They were also rated high on
level of romantic involvement and low on coherence and bal-
ance of control in friendships. Continuous ratings of the preoc-
cupied prototype correlated positively with the presence of elab-
oration, r(75) = .61, p < .001, emotional expressiveness, r(75) =
.78, p < .001, level of romantic involvements, r(75) = .34, p <
.01, disclosure, ii75) = .60, p < .001, the tendency to rely on
others, r(75) = .64, p < .001, use others as a secure base, r(15) -
.60, p < .001, and caregiving, r{75) = .38, /? < .001. The preoccu-
pied rating was also positively correlated with the tendency to
cry frequently, r{75) = .61, p < .001, and in the company of
others, r(75) = .45, p < .001, and negatively correlated with the
balance of control in friendships, r(75) = -.35, p < .01, coher-
ence, r(75) = -.39, p < .001, and self-confidence, r{75) = -.33,
p<.001.
Finally, the fearful group was rated significantly lower than
the secure and preoccupied on self-disclosure, intimacy, level of
romantic involvement, reliance on others, and use of others as a
secure base when upset. They were also rated as uniquely low in
self-confidence and as low on both balance-of-control scales.
Continuous ratings of the fearful prototype showed negative
correlations with self-confidence, r(75) - -.70, p < .001, andcoherence, r{75) ~ -.35, p < .01, and with all measures indicat-
ing closeness of relationships—including self-disclosure,
K75) = -.43, p < .001, intimacy, r(75) = -.52, p < .001, level of
involvement in romantic relationships, r(75) = —.36, p < .01,
capacity to rely on others, r(75) = -.30, p < .01, and use of
others as a secure base, r(75) = -.33, p < .01. The fearful rating
was also negatively correlated with the balance of control mea-
sures for both friends, r(75) = —.40, p < .001, and romantic
relationships, r(75) = —.32, p < .01, indicating a tendency to
assume a subservient role in close relationships.
A discriminant analysis was performed to assess the degree
to which the various interview ratings accounted for the overall
discrimination between the four attachment groups. The analy-
sis (using a stepwise method with minimization of Wilks's
lambda as the selection criterion) resulted in three significant
discriminant functions, which correctly classified 92% of the
sample—including 86% of the secure group, 94% of the fearful
group, and 100% of both the preoccupied and dismissing
groups. Twelve of the 15 interview rating scales independently
contributed significant variance to the final functions, con-
firming that the group distinctions are multiply determined.
Sex Differences in Attachment Ratings
Female subjects received significantly higher ratings than
male subjects on the interview-based preoccupied rating

ATTACHMENT STYLES 231
(women's M= 3.10, men's M = 2.00), z(75) = 2.88, p < .01; male
subjects received significantly higher ratings than female sub-
jects on the interview-based dismissing rating (women's M =
3.10, men's M= 4.01), t(15) = 2.70, p < .01. To control for these
sex differences, sex of subject was included as a covariate in all
correlational and group analyses.
Depth of Friendships
On average, the pairs of friends reported reasonably close
friendships of 1 to 2 years' duration. The four groups did not
differ significantly in the length of the friendships according to
either subjects, F(3, 72) = 1.22, ns, or their accompanying
friend, F(3, 72) = 0.75, ns. In addition, there were no group
differences in the composite measure of closeness of friend-
ships according to either subjects, F(3,72) = 1.82, ns, or friends,
F(3, 72) = 0.37, ns. Therefore, the group differences reported
below cannot be explained by a difference in either the length
or the closeness of the friendships.
Intercorrelations of Attachment Styles
The pattern of correlations among the four attachment rat-
ings for each method was hypothesized to be consistent with
the model presented in Figure 1. Interview attachment ratings
in opposing positions were negatively correlated: Between the
secure and fearful ratings, r(75) = — .55, p< .001; between the
preoccupied and dismissing ratings, r(15) = -.50, p < .001. The
correlations between styles in adjacent positions showed non-
significant or low negative correlations with one another
(range = —.26 to —.14). Similar patterns were found for the
self-report and friend-report attachment ratings (on the Rela-
tionship Questionnaire): The secure and fearful ratings were
negatively correlated (respective rs = -.65 and -.69, ps < .001),
and the preoccupied and dismissing ratings were negatively
correlated (respective rs = -.37 and —.41, ps < .001). For both
self- and friend-reports, the styles in adjacent positions showed
nonsignificant or negative correlations with one another with
one exception: Friend ratings of the fearful and dismissing
styles were positively correlated, r(J5) = .27, p < .05.
Multidimensional scalings were performed to determine if
the dimensional structure underlying the intercorrelations of
the attachment ratings were consistent with the proposed
model. Intercorrelations among the four continuous attach-
ment ratings were used as measures of proximity. A separate
correlation matrix was prepared for each set of attachment rat-
ings—interview ratings, the subjects' own ratings of their
match to each attachment style (on the Relationship Question-
naire), and the friends' ratings of subjects on each attachment
style (on the friend version of the Relationship Questionnaire).
Each matrix was then subjected to a nonmetric multidimen-
sional analysis using the program KYST (Kruskal, Young, &
Seery, 1973). The one-dimensional solutions yielded stress val-
ues from .38 to .50 (Stress Formula 2; Kruskal & Wish, 1978),
whereas the two-dimensional solutions yielded a stress value of
.00 in each case. To facilitate comparisons with the theoretical
model, the axes were rotated so that the secure placement was in
the upper left quadrant at 45° from each axis. As indicated inFigure 2, each set of data yielded a configuration roughly corre-
sponding to the structure proposed in Figure 1.
In addition, a factor analysis was performed to examine the
convergence of interview ratings, the subjects* self-ratings, and
the friends' ratings. Figure 3 shows the results of a principal-
components analysis with varimax rotation of the intercorrela-
tions of the three sets of attachment ratings (with axes rotated to
facilitate interpretation). The two factors accounted for 47% of
the variance.1
Self-Concept Measures
Subjects in the two groups that were theoretically expected to
reflect a negative self-image were hypothesized to exhibit lower
scores on measures of self-concept than subjects in the two
groups that were theoretically expected to reflect a positive self-
image. Using subject classifications derived from the interview-
based attachment ratings, a 2 (positive vs. negative self-image) X
2 (positive vs. negative other-image) multivariate analysis of co-
variance (MANCOVA; using sex as a covariate) was therefore
performed on the three self-concept measures: self-esteem, self-
acceptance, and subjective distress. The results showed a signifi-
cant main effect for the self factor only, as hypothesized, FQ,
70) = 7.11, p < .001. Follow-up univariate analyses showed
significant effects for the self factor for each of the three mea-
sures (all ps < .001; see Table 2 for group means). No other main
effect or interaction was significant.
Correlational analyses confirmed this pattern of results. Rat-
ings of the degree to which subjects matched the secure and
dismissing prototypes were positively correlated with measures
of self-concept (partial correlations, controlling for sex, ranged

from .20 to .41, all ps < .05), whereas ratings of the degree to
which subjects matched the fearful and preoccupied prototypes
were negatively correlated with measures of self-concept (par-
tial correlations ranged from —.18 to -.49, all ps < .06).
Sociability Measure
On the other hand, the model implies that subjects in the two
groups that were expected to reflect a positive image of others
would exhibit higher scores on the measure of sociability than
subjects in the two groups expected to reflect a negative image
of others. Therefore, a 2 (positive vs. negative self-image) X 2
(positive vs. negative other-image) analysis of covariance (AN-
COVA) was performed on the sociability measure (with sex as a
covariate). The results showed a significant main effect for the
other factor only, as hypothesized, F(l, 72)= 19.96,p<.001 (see
Table 2 for group means). Correspondingly, sociability was posi-
tively correlated (controlling for sex) with the secure and preoc-
cupied prototype ratings, r(14) = .36, p < .001, and r{74) = .24,
p < .05, and negatively correlated with the fearful and dismiss-
ing prototype ratings, r{lA) = -.41, p < .001, and r(74) = -.20,
p < .05.
1 Although the different sources of attachment ratings tended to con-
verge, the correlations between specific attachment ratings across
methods were not high. The average correlation between correspond-
ing ratings across interview and self-reports was. 34; the average corre-
lation across interview and friend-reports was .25.

232 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
Interview
\X>*
0.3-
.1.0 •
Self-report Friend-report
1.0-
0J-
•OS-
•
•in-secure
A
A
DismissingPreoccupied
A
A
Fearful1.0-
0.3-
0 -
-0.3-
-1.0 •Secure
A
A
Dismissing
L-~ i 1 1 1Preoccupied
A
A
Fearful
' " 1 "-' 1 -T"' 1 "
• iJO -OS 0 0.3 14 '* -0-3 0
Figure 2. Multidimensional scalings of interview, self-report, and friend-report attachment ratings.0.5 1.0

ATTACHMENT STYLES 233
Secure ^rIs
\ 1 1
-0.8
Dismissing.-—"
-0.4
/ a /-0.4
-0.80.8
0.4
1
>
L/
0.4
>Preoccupied
^ aj
i i ii i i
0.8
y/
Fearful
O Interview ratings
A Self-report ratings
• Friend-report ratings
Figure 3. Factor analysis of interv iew, self-report,
and friend-report attachment ratings.
Self-report ratings of sociability were corroborated by friend-
reports. The main effect for positivity of other models was repli-
cated, F(\, 72) = 7.08, p < .001, but there was also a significant
effect for the self model factor, F{\, 72) = 3.12, p < .05. Inspec-
tion of means (see Table 2) indicated that friends tended to see
the dismissing group as especially low on sociability: Follow-up
Newman-Keuls comparisons indicated that the mean of the
dismissing group was significantly lower than that of each of the
other attachment groups.
Interpersonal Problems
Finally, we examined the location within the two-dimen-
sional interpersonal space of subjects' interpersonal problems,
as reported on the UP. First, each subject's mean response
across all problems was examined. A two-way ANCOVA re-
vealed a significant main effect for the self factor only, F(l, 72) =
11.82, p < .001. The two groups with a negative self-image re-
ported higher levels of interpersonal problems overall than the
groups with a positive self-image. Parallel analyses with friends'
reports revealed a trend for groups with negative self models to
be judged to experience higher mean levels of interpersonal
problems, F(l, 71) = 2.93, p < .10. Therefore, in the following
analyses, each subject's score on each of the eight subscales (for
both self- and friend-reports) was converted to an "ipsative
score." That is, each subject's subscale scores were expressed as adeviation from that subject's overall mean, thereby reflecting
the extent to which that group of problems was more or less
problematic for that particular person.2 Each subscale score
was then expressed as a z score using the mean and standard
deviation of that subscale for the entire sample.
Each of the eight subscale scores was correlated with each
prototype rating, and the mean of each subscale was also com-
puted for each prototype group. Group means on the circum-
plex subscales, for self- and friend-reports, are shown graphi-
cally in Figure 4. Significant group differences were found on
six of the eight subscales for both self-reports and friend-re-
ports. Correlational analyses for self-reports and friend-reports
are contained in Table 3. All of the self-report and friend-report
problem subscales were significantly correlated with at least
one of the attachment ratings.
As shown in Figure 4, the secure group's profile of means was
elevated on the warm side of the interpersonal space according
to both self- and friend-reports. However, no one subscale score
was extreme: The largest standardized mean scores were on the
order of 0.25. Correlations between secure ratings and the self-
report circumplex subscales revealed significant, although mod-
est, positive correlations with the overly expressive and autocra-
tic scales, as well as negative correlations with the cold and
introverted scales. The friends' reports showed positive correla-
tions with the exploitable and nurturant scales and negative
correlations with the cold and introverted scales.
The dismissing group showed a self-reported profile centered
on the hostile side of the interpersonal space. Correlational
analyses indicated that the cold subscale is most highly corre-
lated with this attachment style. The friends generally con-
firmed this pattern, although friends1 reports tended to show
the dismissing style as more strongly associated with introver-
sion than self-reports did. Also, the dismissing rating was nega-
tively correlated with both self- and friend-ratings of the nurtur-
ant and expressive scales and with self-ratings of the subasser-
tive and exploitable scales.
The self-report profile of the preoccupied group showed an
elevation on the overly expressive scale, with the correlational
analyses confirming this location of interpersonal problems.
Friends' reports also described these subjects as highest on the
2 When a personality inventory has many subscales, it is sometimes
necessary to ipsatize subjects' subscale scores. This procedure has been
shown to be particularly important for the IIP because a principal-
components analysis of the IIP items typically yields a large general
first factor that reflects differences among people in their readiness to
endorse complaints (Horowitz, Rosenberg, Baer, Ureno, & Villasenor,
1988). That factor may be considered a complaint factor, an acquies-
cence factor, or an intensity factor, and as shown by Wiggins, Steiger,
and Gaelick (1981, p. 283), it reflects individual differences in the use
of the response format, rather than differences in important aspects of
interpersonal functioning. Therefore, the person's average response

level must be treated separately from the circumplex components per
se. The preferred way to control for individual differences in people's
average response level is to ipsatize the subscale scores by expressing
each score as a deviation from the subject's own mean across all sub-
scales (Cronbach, 1949; Horowitz et al., 1988; Strack, 1987; Wiggins &
Pincus, 1989). The ipsatizing procedure has been shown to improve
the circumplex properties of interpersonal measures (Paddock & No-
wicki, 1986; Rinn, 1965; Wiggins et al., 1981).

234 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
Table 2
Means of Self-Report Self-Concept Measures and Self and Friend-Report
Sociability Across Attachment Groups
Model
Self
Other
n
Self-concept
Distress
Self-esteem
Self-acceptance
Sociability
Self-report
Friend-reportSecure
Positive
Positive
36
3.34
35.28
3.75
3.62
3.48Dismissing
Positive
Negative
14
Measure
3.00
36.50
3.87
3.07
2.63Preoccupied
Negative
Positive
11
4.30
32.21
3.39
3.87
3.71Fearful
Negative
Negative
16
4.19
30.69
3.19
2.91
3.31
Note. Higher numbers reflect higher distress, self-esteem, self-acceptance, and sociability.
overly expressive scale, but the friends' means were also ele-
vated in other octants reflecting dominance (i.e.; the autocratic
and competitive scales). Correspondingly, the preoccupied rat-
ing was positively associated with friend-ratings of the expres-
sive, autocratic, and competitive subscales. That is, the friends'
descriptions of the subjects' problems revealed less overall
warmth and more overall dominance than the subjects1 self-re-
ports revealed. Preoccupied ratings were also negatively corre-
lated with self-ratings on the cold scale and friend-ratings on the
introverted and exploitable scales.
Finally, the fearful group reported relatively more problems
reflecting a lack of assertiveness and social inhibition (introver-
sion). The corresponding friends' reports confirmed this gen-
eral pattern of results, as did the correlational analyses for both
sets of data. Also, the fearful rating was negatively correlated
with both self- and friend-ratings of the autocratic scale and
with self-ratings of the competitive and expressive scales.
Conclusions
This study demonstrated that a semi-structured interview
can be used to assess the degree to which subjects approximate
each of the four hypothesized attachment styles. An additional
15 interview rating scales demonstrated the distinctiveness of
each of the four styles. The internal structures of the interview
ratings, the self-report ratings, and the friend-report ratings of
the four attachment styles were consistent with the proposed
model. Thus, a two-dimensional structure spatially reproduced
the hypothesized relationships among the four styles, and the
three sets of ratings independently produced similar results.
The data also supported the hypothesis that the two groups
theoretically described as having a positive self-model would
differ on measures of self-concept from the two groups theoreti-
cally described as having a negative self-model. Also as hypoth-
esized, the two groups theoretically described as having a posi-
tive model of others differed on a measure of sociability from
the two groups described as having a negative model of others.Taken together, the results supported the implication of
Bowlby's theory that four different attachment styles can be
identified.
The circumplex analyses confirmed the hypothesis that each
style is associated with a distinct pattern of interpersonal prob-
lems. Fearful subjects were most likely to report interpersonal
problems in the overly passive region of the interpersonal space
(the lower quadrants), whereas dismissing subjects were more
likely to report problems related to a lack of warmth in social
interactions. The one group whose problems did not conform
to the original hypothesis was the preoccupied group. Whereas
their negative self-image and positive other-image were ex-
pected to reflect problems in being overly warm and passive
(the lower right quadrant), their problems reflected a greater
degree of warmth-dominance (the upper right quadrant). Ex-
amples of items falling in this region of the interpersonal space
are "I want to be noticed too much" and "it is hard for me to stay
out of other people's business." These findings suggest that al-
though preoccupied people are highly dependent on others to
maintain positive self-regard, they attempt to achieve this aim
though a controlling (overly dominating) interpersonal style.
Finally, the data also showed that self- and friend-reports of
interpersonal problems were generally consistent across the
four attachment styles.
Study 2
Study 1 examined ratings of the attachment styles that were
based on the subjects' descriptions of their close friendships
and romantic relationships, and these assessments were shown
to predict important aspects of subjects' personalities and inter-
personal functioning. Study 2 was designed (a) to replicate the
circumplex analyses of Study I, (b) to extend the proposed
model of attachment to representations of relationships within
the family of origin, and (c) to investigate the relationships be-
tween family and peer attachment representations. To examine
these questions, the subjects of Study 2 were interviewed about

ATTACHMENT STYLES 235
Autocratic Autocratic
Competitive
Introverted
SubassertiveExpressive
ExploitableCompetitive
Cold
IntrovertedExpressive
Nurturant
Exploitable
Subassertive
IntrovertedDISMISSING
Autocratic
Expressive
Nurturant
IntrovertedFEARFUL
Nurturant
Subassertive Subassertive
Friend-report
Figure 4. Self-report and friend-report profiles of interpersonal problems across attachment groups.
both family relationships and peer relationships, and each in-
terview was used independently to rate the person according to
their approximation to each of the four attachment prototypes.
It was expected that both sets of attachment ratings would
reproduce spatially, the structure hypothesized by the model.
Attachment theory suggests that people's representations of fa-milial relationships predispose them toward particular styles of
relating to friends; therefore, independent assessments across
the two domains were expected to be positively correlated. De-
spite this correlation, however, family and peer attachment as-
sessments may contribute in different ways to a person's current
interpersonal difficulties, so this study also examined the rela-

236 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
Table 3
Correlations of Continuous Attachment Ratings and Self- and
Friend-Report Interpersonal Problem Scales
Scale
Cold
Nurturant
ExpressiveSecure
Self
.22*
.05
-.27**
-.37***
-.11
.12
.19
.20*Friend
.03
-.04
-.29**
-.23*
-.01
.23*
.22*
.12Dismissing
Self
.03
.16
.58***
.10
-.20*
-.22*
-.24*
-.20*Friend
-.02
.00
.46***
.32**
-.09
-.18
-.27**
-.24*Preoccupied
Self
.15
.14
-.35***
-.15
-.12
-.11
.04
.41***Friend
.33**
.24*
-.16
-.32**
-.18
-.21*
.04
.32**Fearful
Self
-.35***
-.22*
.03
.45***
.38***
.16
-.06
-.43***Friend
-.27**
-.14
.04
.25*
.20**
.06
-.08
-.14
Note. N = 77. Correlations are partial (controlling for sex) and are based on ipsative scorings of circum-
plex scales.
* p < .05. ** p < .01. ***p< .001.
tive power of the two sets of ratings to predict people's interper-
sonal problems.
Method
Subjects
Subjects were 33 female and 36 male students in introductory psy-
chology classes who agreed to participate in an "interview about social
relations" for course credit. They ranged in age from 17 to 24 (M =
19.5), and their ethnic composition was 79% White, 9% Hispanic, 6%
Asian, 3% Black, and 3% other.
Procedure
Subjects were tested in sessions that were 1 to 2 weeks apart; each
session lasted approximately 1 hr. In the first session, subjects were
randomly assigned to either a male interviewer (an advanced under-
graduate psychology major) or a female interviewer (the first author)
and were interviewed about their relationships with family and then
with friends. In the second session, subjects completed a self-report
packet of questionnaires.
Attachment interview. The first half of the interview focused on the
subject's representations of family relationships. Subjects were asked
about their family backgrounds, the quality of their relationships with
each parent from their earliest memories to the present, their reactions
to being separated from parents, their feelings of being rejected by
parents, and parental reactions to their emotional upsets as a child.
Subjects were also asked to make general evaluations of their child-
hood experiences in the family and to describe how these experiences
had influenced them. The second half of the interview was an abbre-
viated version of the interview described in Study 1. Each interview
was tape-recorded.
Attachment ratings were based on prototypes of each of the four
attachment styles. The peer attachment prototypes were identical to
those used in Study 1. Comparable descriptions were prepared for
styles of relating to family members (available from the first author).
Four independent raters (two for the family section and two for the peer
section) rated each interview. The raters were advanced undergraduate
psychology majors or graduate students, three were female and one was
male, and all were blind to other measures in the study. Raters listened
to the relevant section of the tape-recorded interview and rated each
subject on 7-point scales describing the degree to which that subjectmatched each of the four attachment prototypes. The final ratings of a
subject consisted of the mean of the two ratings for each style. Each
subject thus received two sets of final ratings, one for the family attach-
ment interview (hereafter called the family ratings) and one for the peer
attachment interview (hereafter called the peer ratings). The reliabil-
ities of the family ratings ranged from .75 to .86, and those of the peer
ratings ranged from .74 to .88. As in Study 1, the highest of the four peer
ratings was used to assign subjects to one of the four adult attachment
patterns. This procedure resulted in the following distribution of sub-
jects across the attachment groups: 57% secure (n= 39), 18% dismissing
{n = 12), 10% preoccupied in = 7), and 15% fearful (n = 10).
Self-report measures. During the second session, each subject com-
pleted the UP as well as a battery of other measures (e.g., parenting
scales, self-description tasks) that are not relevant to this report. Coeffi-
cient alphas for the subscales of the IIP ranged from .72 to .85.
Results
There was a significant sex difference on the preoccupied
rating across both segments of the interview. For the family
interview, the mean preoccupied'rating was 3.09 for women and
1.96 for men, t(61) = 3.10, p < .01; for the peer attachment
interview, the mean preoccupied rating was 2.76 for women and
1.69 for men, t{61) = 2.72, p < .01. No sex differences occurred
on any of the other ratings. Sex was entered as a covariate in all
subsequent group and correlational analyses.
Intercorrelations of Attachment Ratings
For each set of correlations, the pattern was consistent with
the proposed model. In both cases, attachment ratings that are
diagonally opposed in the model showed significant negative
correlations. For the family ratings, the correlation between the

secure and fearful ratings was -.65 (p < .001 )T and that between
the preoccupied and dismissing ratings was -.54 (p < .001). For
the peer ratings, the correlation between the secure and fearful
ratings was -.39 (p < .01), and that between the preoccupied
and dismissing ratings was -.47 (p < .001). In both cases, rat-
ings in adjacent positions showed uniformly low or 0 correla-
tions, with rs ranging from -.32 to .06.

ATTACHMENT STYLES
A multidimensional scaling was performed on each set of
intercorrelations among the continuous attachment ratings. For
both the family and peer ratings, a two-dimensional solution
with a stress value of zero was obtained (Stress Formula 2; one-
dimensional solutions had stress values of .55 and .50, respec-
tively). In each case, the resulting configuration was consistent
with the proposed model (see Figure 5).
Family and Peer Attachment Ratings
As expected, corresponding family ratings and peer ratings
were significantly correlated with one another. For the secure
ratings, r(61) = .39, p < .001; for the fearful ratings, r(67) = .29,
p < .01; for the preoccupied ratings, r(67) = .66, p < .001; and for
the dismissing ratings, r(67) = .41, p < .001. In contrast, all
correlations between noncorresponding ratings were nonsigni-
ficant or negative (with a range from -.40 to .01).
A two-way ANCOVA (positive vs. negative self-image X posi-
tive vs. negative other-image, controlling for sex) again revealed
a significant self-model effect only for mean endorsement of
interpersonal problems, F{\, 63) = 8.28, p< .01. The preoccu-
pied and fearful groups expressed higher mean levels of inter-
personal distress than the other two groups. Therefore, each
circumplex subscale score was ipsatized by expressing it as a
deviation from the subject's overall mean level of interpersonal
problems. Each subscale score was then standardized across
the entire sample. Figure 6 presents the circumplex profiles for
each attachment group. Significant group differences were ob-
tained in a two-way ANCOVA on seven of the eight subscales.
In addition, each insecure prototype rating was significantly
correlated with five or six of the circumplex scales (see Table 4).
The secure attachment rating was not strongly related to the
circumplex ratings: The secure group's standardized subscale
means were consistently close to zero. Moreover, the secure rat-
ing only showed low correlations with two scales (positive with
the expressive scale and negative with the introverted scale).
The dismissing group showed its highest means on subscales
reflecting excessive coldness, with the correlational analyses
showing positive correlations with the cold and competitive
subscales and negative correlations with the exploitable, nurtur-
ant, and expressive scales. The preoccupied group showed ele-
vated means on the subscales in the warm-dominant quadrant,
and the continuous preoccupied rating was most strongly asso-
ciated with the overly expressive subscale. The preoccupied tax-
ing was also positively correlated with the nurturant and auto-
cratic scales and negatively correlated with the cold, intro-
verted, and subassertive scales. Finally, the fearful group
showed elevated means on those subscales located in the pas-
sive octants; the introverted subscale showed the highest mean.
Correlational analyses also indicated that the fearful style was
positively associated with problems of introversion, subasserti-
veness, and the tendency to be exploited and negatively corre-
lated with problems related to being overly nurturant, expres-
sive, autocratic, and competitive.1.0-
0.5-
Peer
1.0-
0.5-
-1.0 -Secure
A
-
A
A
A
Fearful
-1.0 -0.5 0.5 1.0
Figure 5. Multidimensional scalings of family and
peer interview attachment ratings.
Comparison of Study 1 and Study 2 Circumplex Analyses
To facilitate comparisons between the circumplex results of
Studies 1 and 2, each subject's eight subscale scores were used to

238 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
SECURE PREOCCUPIED
Nurturant
urturant
Subassertlve Sub assertive
Nurturant
Nurturant
Subassertlve Subassertlve
Figure 6. Self-report profiles of interpersonal problems across attachment groups.

ATTACHMENT STYLES 239
Table 4
Correlations of Continuous Peer Attachment Ratings and Self-
Report Interpersonal Problem Scales
Scale
Cold
Nurturant
,05
-.18
-.07
-.28*
-.04
-.07
.14
.23*Dismissing
.11
.29**
.43***
.12
-.04
-.25*
-.24*
-.33**Preoccupied
.36**
.18
-.32**
-.32**
-.33**
.02
.26*
.42***Fearful
-.51***
-.29"
.02
.49***
.34**
.21*
-.32**
-.33**
Note. N = 69. Correlations are partial (controlling for sex) and are
based on ipsative scorings of circumplex scales.
*p<.05. **/><.0i. •••/>< .001.
calculate a mean rating along the nurturance and dominance
dimensions in accordance with the procedure described by
Wiggins, Phillips, and Trapnell (1989). Significant group differ-
ences were obtained on the dimensional scores across both
methods and studies according to one-way ANCOVAs (with sex
as a covariate). Results for warmth and dominance scores, re-
spectively, were Study 1 self-reports, F(3, 71) = 6.72, p < .001,
and F(3, 71) = 5.45, p < .01; Study 1 friend-reports, F(3, 71) =
5.23, p < .01, and FQ, 71) = 2.71, p = .05; Study 2 self-reports,
F(3, 63) = 4.52, p < .01, and F(3, 63) = 6.02, p < .001. The
placement of the group centroids in the interpersonal space
(that is, the mean warmth and dominance coordinates) from
the self-reports and friend-reports of Study 1 and the self-re-
ports of Study 2 are shown in Figure 7.
The three corresponding centroids for the secure group were
in relatively close proximity to one another; in all three sets of
data, the secure interpersonal style was associated with a less
extreme interpersonal profile (that is, a mean placement closer
to the origin) than the other three styles. The three centroids of
the dismissing group were also close to one another, in all cases
reflecting the salience of the overly cold subscale. The centroids
of the preoccupied group showed the greatest diversity across
the three sets (perhaps partly because of this group's small size),
but in all cases the centroid fell in the warm-dominant quad-
rant, reflecting the salience of problems with overexpressive-
ness in all three data sets. Finally, the angular locations of the
centroids of the fearful group were also similar across the three
assessments. In all three cases, the centroids showed the influ-
ence of the introverted and subassertive scales.
Family and Peer Attachment Ratings as Predictors
of Interpersonal Problems
The variables of warmth and dominance were used as sum-
mary measures of the subject's interpersonal problems, and a
regression analysis was performed to predict these measures
from the family ratings and from the peer ratings. In order to
compare the predictive power of the family and peer ratings, a
hierarchical regression analysis was performed twice. In bothanalyses, sex was entered first in the equation. Then, in one
case, the family ratings were entered as a block followed by the
peer ratings; in the other case, the peer ratings were entered
first.
First consider the prediction of the dominance aspect of in-
terpersonal problems. When entered as the first variable in the
equation (after sex), the family ratings accounted for 18% of the
variance, F(4, 62) = 3.31, p < .05, and the peer ratings ac-
counted for an additional 27%, F(4, 58) = 7.30, p < .001; but
when the peer ratings were entered first, they accounted for
41% of the variance, F(4,62) = 10.71, p < .001, and the family
ratings did not add significantly, F(4,58) = 1.15, ns. A different
pattern was obtained in predicting the warmth aspect of inter-
personal problems. In that case, when family ratings were en-
tered first, they accounted for 31% of the variance, F(4, 62) =
7.50, p < .001, and the peer ratings added an additional 10%,
F(4, 58) = 2.59, p < .05; when the order of entry was reversed,
the peer ratings accounted for 28% of the variance, F(4, 62) =
6.53, p < .001, and the family ratings added an additional 13%,
F(4, 59) = 3.34, p< .05. Thus, only peer ratings independently
accounted for variation among people in the dominance aspect
of interpersonal problems, whereas both sets of ratings contrib-
uted independently to variation among people in the affiliative
aspect of their problems.
Conclusion
The intercorrelations among the family ratings were consis-
tent with the proposed model. In addition, family attachment
D Study 1 - Self-report
O Study 1 - Friend-report
A Study 2 - Self-report
Figure 7. Attachment group centroids of interpersonal problems for
Study 1 self-reports and friend-reports and Study 2 self-reports.

240 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
ratings were moderately correlated with corresponding peer at-
tachment ratings, suggesting that the four adult attachment
styles are meaningfully related to, although by no means reduci-
ble to, representations of childhood experiences. Thus, the pro-
posed model of adult attachment is also applicable to represen-
tations of family relations. In addition, the circumplex analyses
largely replicated the findings of Study 1.
Finally, the results demonstrated that both the family and
peer attachment ratings contributed to the prediction of the
warmth and dominance dimensions underlying interpersonal
problems. The peer ratings were strongly related to both di-
mensions of interpersonal problems. In contrast, the family
ratings only independently contributed to the prediction of
problems along the warmth dimension.
According to the circumplex model of interpersonal behav-
ior, behaviors on the affiliation dimension tend to invite corre-
sponding responses (e.g^ warmth invites warmth) and, there-
fore, tend to be self-perpetuating. Thus, in a longitudinal study
of child rearing, Schaefer and Bayley (1963) found considerably
higher consistency over time for the warmth dimension of ma-
ternal behavior than for the dominance (control) dimension.
The degree of warmth experienced and expressed within the
family of origin may therefore be particularly salient in family
attachment representations, which may in turn mediate the af-
filiation dimensions of peer relations, at least up to late adoles-
cence.
In contrast, determinants of dominance may be more com-
plex and subject to greater variation over time and across rela-
tionships. Schaefer and Bayley (1963) suggest that because chil-
dren's needs for control and autonomy change radically over the
course of development, parents may tend to shift to more or less
age-appropriate behaviors on this dimension over time. Thus,
to the extent that dominance imbalances exist in child-parent
relationships, they may be less stable, hence a less salient char-
acteristic of family attachment representations, than the affec-
tive tone of the relationships. Furthermore, in relationships of
dominance, two sides of the relationship may be learned: A
person who is typically dominated learns both to submit and to
dominate. For instance, Troy and Sroufe (1987) present evi-
dence that avoidant preschoolers have internalized both the
victim and victimizing aspects of their relationship with par-
ents and may be capable of assuming either role depending on
their social partner. Therefore, problems with dominance may
be best understood in terms of the person's history with peers.
General Discussion
This article examined a model of individual differences in
adult attachment in which two underlying dimensions, the per-
son's internal model of the self (positive or negative) and the
person's internal model of others (positive or negative), were
used to define four attachment patterns. A prototypic descrip-
tion of each style was generated, and each subject's degree of
correspondence to each prototype was assessed through a semi-
structured interview concerning the person's current relation-
ships with peers and early relationships within the family. Multi-
dimensional scalings confirmed the hypothesized underlying
structure. Across family ratings and peer ratings, and across
interview, self-reports, and friend-reports, configurations of at-tachment ratings conformed to the theoretical model. The data
also showed a convergence between family and peer ratings and
between ratings from the interview, self-reports, and friend's
reports. Self-concept measures differentiated the attachment
styles with respect to the model of self only, and measures of
sociability differentiated the styles with respect to the model of
other only. Differences in interpersonal problems were also ex-
amined, and circumplex analyses indicated that each attach-
ment style was associated with a distinct profile of interper-
sonal problems. The findings were, for the most part, consis-
tent for self-reports and friend-reports and for self-reports
across the two studies.
The results of this research confirm that the valence of both
self-models and models of others are separate, important di-
mensions of an adult's orientation to close relationships and
that the two dimensions can vary independently. The present
findings thus underscore one limitation of conceptualizing dif-
ficulties with intimacy as simply either overdependency or
avoidance of intimacy. In the present studies, the two groups
with a negative model of the self (the preoccupied and fearful)
showed similar responses to measures of personal insecurity,
but they differed on measures indicating readiness to become
intimate with and rely on other people. The two groups also
showed diametrically opposite patterns of interpersonal prob-
lems: Whereas the problems of the preoccupied subjects were

centered in the warm-dominant quadrant, those of the fearful
subjects were centered in the cold-passive quadrant.
Similarly, the two groups defined as avoidant of close rela-
tionships (the fearful and dismissing) both showed difficulties
in becoming close to and relying on others, but they differed
significantly on measures reflecting an internalized sense of
self-worth. Only the fearful style was consistently associated
with social insecurity and lack of assertiveness. Thus, the com-
mon assumption that people who maintain interpersonal dis-
tance are driven by a fear of intimacy would seem to be an
oversimplification. In both cases, however, the person's avoid-
ance of intimacy preempts the possibility of establishing close
relationships that might otherwise help the person update work-
ing models of other people.
This project raises a number of important theoretical issues.
For one, research has consistently demonstrated a positive rela-
tion between self-acceptance and acceptance of others (e.g., Fey,
1955; Phillips, 1951). In attachment terms, models of the self
and models of other people are postulated to have a common
origin in early interpersonal interactions and are therefore gen-
erally expected to be "complementary and mutually confirm-
ing" (Bowlby, 1973, p. 204). In fact, the majority of subjects in
these studies were judged to display attachment styles with con-
gruent self- and other-models. However, two of the four attach-
ment styles, the preoccupied and dismissing styles, were defined
in terms of differing valences of self- and other-models. The
present research has thus identified interpersonal patterns with
discrepant valences between self- and other-acceptance (cf. Ep-
stein & Feist, 1988). These two groups demonstrate two strate-
gies that people may use at times to cope with unwelcome social
information. In the preoccupied'style, people blame themselves
for perceived rejections by others and are thereby able to main-
tain a positive view of others. In the dismissing style, people
downplay the importance of others whom they have experi-

ATTACHMENT STYLES 241
enced as rejecting and are thereby able to maintain high self-es-
teem. Thus, models of the self and of others can complement
and mutually confirm one another without being congruent.
None of the subjects in this project uniquely fit any one at-
tachment prototype. Instead, most subjects reported a mix of
tendencies across time and within and across relationships:
Many subjects were rated as showing elements of two, three, and
occasionally all four of the attachment styles. Therefore, a great
deal of individual variability was lost when the four continuous
ratings were collapsed into a simple, four-category classifica-
tion. Nonetheless, the two approaches produced almost identi-
cal patterns of results across dependent measures. That is, the
conclusions were very similar whether a correlational analysis
was used (involving four continuous ratings) or whether a be-
tween-groups comparison of four groups was used. Thus, the
present studies did not provide any convincing evidence for the
advantage of continuous attachment ratings over a group classi-
fication. However, the continuous ratings may have advantages
that will emerge in future research. For one, continuous ratings
allow an investigator to more precisely assess individual differ-
ences. For example, two persons classified the same way may
differ in the intensity of their highest ratings or in the pattern-
ing of their secondary ratings, and those differences may be
significant (e.g., in understanding clinical phenomena). Corre-
lational analyses may also be particularly useful for samples
that are not sufficiently large for group analyses or in which one
or more attachment groups is underrepresented. Therefore, ad-
ditional studies of diverse populations need to compare results
obtained with each method before we can be clear about their
relative advantages. Future work should consider also the rela-
tive merits of measuring attachment patterns in terms of two
dimensions rather than four prototypes. In fact, both of these
issues are currently being explored with the aid of structural
equation modeling (Griffin & Bartholomew, 1991).
The individual differences explored in this project fall within
the normal range of attachment patterns for a student popula-
tion. Although a few subjects reported that their social difficul-
ties were a source of serious depression or anxiety, most subjects
in these studies were reasonably well functioning. For instance,
all of the subjects in Study 1 had a friend who agreed to accom-
pany them in the study. Also, although some subjects described
difficult family backgrounds, the majority came from intact
upper-middle-class families. The fact that significant group dif-
ferences emerged despite such a restricted range reflects the
robustness of the reported relationships. Nonetheless, it is im-
portant for future research to extend the procedure to other age
groups and other populations. One important direction would
be to examine clinical populations and determine whether the
attachment styles are distinctively related to specific forms of
psychopathology and whether certain attachment styles make a
person more or less amenable to specific forms of treatment.
People with a dismissing attachment style, for example, might
be so much less invested in other people that they would be less
amenable to forms of treatment that required an exploration of
interpersonal interactions.
The model proposed in this article is the first to provide a
theoretical rationale as to why four, rather than three, distinct
attachment patterns are expected and the first to specify the
expected relations among attachment styles. It is also the firstwork to assess attachment representations of both familial and
peer relationships and to use multiple assessment methods (in-
terviews, self-reports, and friend-reports). However, several
studies have reported results consistent with the proposed
model. Collins and Read (1990) have reported that one possible
solution to a cluster analysis of three continuous measures of
adult attachment was four clusters in which two anxious styles
were differentiated. Brennan, Shaver, and Tobey (in press) have
recently compared the four-category model (as measured by the
self-report Relationship Questionnaire) and the traditional
three-category model (using the 1987 Hazan and Shaver mea-
sure). They found that fearful subjects tended to endorse both
the avoidant and ambivalent options on the Hazan measure and
that a two-dimensional structure underlay the attachment rat-
ings as hypothesized by the four-category model. In the child-
hood attachment literature, a fourth style characterized by a
mix of ambivalence and avoidance and associated with parental
abuse and neglect has recently been reported by Main and Solo-
mon (1990; the disorganized or D pattern) and by Crittenden
(1988; the avoidant/ambivalent or A/C pattern). Moreover, the

possibility of a relation between the fearful style and the D or
A/C types is suggested by Latty-Manris finding that adult chil-
dren of problem drinkers tended to endorse both the ambiva-
lent and avoidant options on the Hazan measure (Latty-Mann
& Davis, 1988) and Brennan's finding that adult children of
problem drinkers were overrepresented among those reporting
a fearful style (Brennan et al., in press). However, future studies
are clearly required to determine the precise relations between
the proposed four-category model and previous conceptualiza-
tions of individual differences in attachment.
Another important next step is to identify the mechanisms
by which an attachment style is maintained. In processing so-
cial information, people seem to produce behaviors that evoke
specific reactions from other people, and this social feedback is
interpreted in ways that confirm the person's internal models of
the self and others (see Caspi & Elder, 1988; Swann, 1983,1987).
In fact, it is precisely "because persons select and create later
social environments that early relationships are viewed as hav-
ing special importance" (Sroufe & Fleeson, 1986, p. 68). For
instance, selective affiliation in the form of the seeking or avoid-
ance of social contacts and the selection of social partners who
are likely to confirm internal models is expected to be central in
maintaining adult patterns of attachment (see Collins & Read,
1990; Davis & Kirkpatrick, 1991). A related process, which
Caspi and Elder (1988) call "interactional continuity" (p. 232),
involves structuring social interactions so as to induce social
partners to engage in self-confirming interaction patterns. Al-
though the circumplex placements of the various attachment
groups are suggestive of their characteristic interaction strate-
gies, naturalistic observation is still needed to describe their
actual social behavior and the reactions that that behavior tends
to evoke in social partners. Finally, a whole array of informa-
tion-processing biases are available to guide the processing of
social feedback so as to confirm internal models (see Green-
wald, 1982; Swann, 1983). Internal models are expected to di-
rect attention, organize and filter new information, and deter-
mine the accessibility of past experiences. Thereby, ambiguous
stimuli (which may form the bulk of all social stimuli) tend to be
assimilated to existing models.

242 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
Given the multiple pathways through which representations
of attachment relations may perpetuate self-confirming social
experiences, perhaps the more difficult question is how such
representations come to be modified. Epstein (1980) argues
that compelling emotional experiences that are inconsistent
with existing models are required to change them. Such experi-
ences are likely to arise within emotionally significant relation-
ships, such as those with a spouse or therapist. Research has
documented the potential therapeutic value of supportive spou-
sal relationships in moderating the effects of difficult early at-
tachment relationships (e.g., Brown & Harris, 1978; Crocken-
berg, 1987; Quinton, Rutter, & Liddle, 1984). Major life transi-
tions involving the adoption of new social roles (such as leaving
for college, getting married, having children, or retiring) may
also be opportune times for evaluating and potentially reorgan-
izing attachment representations (cf. Caspi & Elder, 1988;
Ricks, 1985). It has also been suggested that by coming to un-
derstand and forgive parents for their parenting weaknesses or
by achieving an autonomous stance in relation to parents, peo-
ple can overcome the influence of early models (Main et al.,
1985; Ricks, 1985). Thus, a challenge for future research is to
explore empirically how attachment patterns are externalized,
maintained, and revised in interaction with the social environ-
ment.
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(Appendixes follow on next page)

244 KIM BARTHOLOMEW AND LEONARD M. HOROWITZ
Appendix A
Study 1 Interview Rating Scales
1. Elaboration (9-point scale, a = .88) refers to how forthcoming
subjects were in the interviews, including the degree to which specific
memories were recounted to support generalizations, depth versus su-
perficiality of self- and other-descriptions, and emotional content.
2. Coherence (9-point scale, a = .68) refers to the degree to which
subjects presented a coherent, integrated, and internally consistent
portrayal of their experiences and feelings in close relationships.
3. Self-disclosure in friendships (7-point bipolar scale, a = .87). A
score of 1 indicates a complete avoidance of self-disclosure, 4 indicates
open disclosure with discretion, and 7 indicates indiscriminate and
excessive self-disclosure.
4. Intimacy of friendships (7-point scale, « = .79) rates the degree of
intimacy evident in platonic friendships.
5. Balance of control in friendships (5-point bipolar scale, a = .55). A
1 indicates that the subjects were much more involved, more compro-
mising, and less in control of the course of their relationships than
social partners, a 3 indicates ideal mutuality, and a 5 indicates that the
subjects were more in control than social partners.
6. Highest level previous involvement in romantic relationships (5-
point scale, a = .96). The scale ranged from no previous involvements (I)
to some dating (2) to one or more short-term, nonserious relationships (3)
to at least one long-term, serious relationship (4) to a serious relationship
involving a long-term commitment (5).
7. Balance of control in romantic relationships (5-point bipolar scale,
a = .79). See (5) above.
8. Self-confidence (5-point scale, a = .84) rates social self-confidence.
9. Emotional expressiveness (7-point bipolar scale, a =.82). Al indi-
cates an extremely rigid overcontrolled emotional style, a 4 indicatesthe capacity for open emotional expression coupled with the ability to
control emotions when appropriate, and a 7 indicates an undercon-
trolled histrionic style.
10. Crying frequency (5-point scale, a = .93). The scale ranges from
almost never, less than once per year (1) through average frequency,
sometimes (3) to constant, almost daily (5).
11. Warmth (5-point scale, a = .72). A 1 indicates extreme interper-
sonal coldness, a 3 indicates an average level of warmth, and a 5 indi-
cates an exceptional degree of warmth.
12. Reliance on others (7-point bipolar scale, a = .81). This scale
ranges from compulsive self-reliance (1) to excessive emotional depen-
dence on others (7). The midpoint of 4 indicates the ability to rely
comfortably on others when appropriate, coupled with the capacity to
be self-reliant.
13. Use of others as a secure base when upset (5-point scale, a = .83).
Scores range from never goes to others when upset (1) through sometimes
goes to others, but also uses other coping mechanisms (3) to always goes
to others, principal response to any upset (5).
14. Nonsocial versus social crying (5-point bipolar scale, a = .95). A1
indicates crying only when alone, a 3 indicates an equal likelihood of
crying alone or with others, and a 5 indicates crying almost exclusively
in the presence of others.
15. Caregiving (7-point bipolar scale, a = .62). This scale assesses
the tendency to look after others in personal relationships. A 1 indi-
cates extreme antipathy to looking after others or having others rely on
one, a 4 indicates comfort with caregiving in appropriate situations
without any tendency to seek out others to look after, and a 7 indicates
an excessive need to look after others to the point of martyrdom.
Appendix B
Self-Report Attachment Style Prototypes
Secure. It is relatively easy for me to become emotionally close to
others. I am comfortable depending on others and having others de-
pend on me. I don't worry about being alone or having others not
accept me.
Dismissing. I am comfortable without close emotional relation-
ships. It is very important to me to feel independent and self-sufficient,
and I prefer not to depend on others or have others depend on me.
Preoccupied. I want to be completely emotionally intimate with
others, but I often find that others are reluctant to get as close as I would
like. I am uncomfortable being without close relationships, but I some-
times worry that others don't value me as much as I value them.Fearful. I am somewhat uncomfortable getting close to others. I
want emotionally close relationships, but I find it difficult to trust
others completely, or to depend on them. I sometimes worry that I will
be hurt if I allow myself to become too close to others.
Note. In subsequent revisions, the word relatively has been deleted
from the secure prototype and the words somewhat and sometimes
have been deleted from the fearful prototype.
Received July 24,1990
Revision received March 8,1991
Accepted March 22,1991 •

C:\Works\Data\projects\Python\Diagnosis Project\chat_app\knowledge\documents\A Model of Attachment-System.pdf

27CHAPTER 2
A Model of Attachment-System 
Functioning and Dynamics
in Adulthood
After Bowlby and Ainsworth’s attachment theory was applied to adolescents and 
adults, it became influential in both developmental and social/personality psychology, and thousands of studies were conducted to explore its implications. The resulting very large literature needs to be summarized, organized, and coherently conceptualized so that future studies and clinical interventions can build systematically on what is already known. We produced the first edition of this book in 2007, based on the many studies done up to that time, and since then there have been hundreds more publications. To organize our own research, which focuses on the dynamics of the attachment behavioral system in adulthood and its relation to other behavioral systems such as exploration, caregiving, and sex, we created a model of attachment-system dynamics and their intra-psychic and interpersonal implications (e.g., Mikulincer & Shaver, 2003, 2009, 2013; Shaver & Mikulincer, 2002a, 2002b, 2009b, 2011). In the present chapter we describe the model and show how it relates to other theoretical approaches to personality and social behavior. We focus particularly on how attachment-related aspects of personality develop and influence adult emotions, emotion regulation, and social relationships.
This chapter is a conceptual foundation for what follows in subsequent chapters, 
so we include at the end of the chapter a brief outline of the rest of the book, showing how subsequent chapters expand on the implications of our model for such issues as self-esteem, emotion regulation, the accomplishment of major life tasks (e.g., identity formation, career choice, work performance, and health maintenance), personal adjust-ment, couple relationship functioning, mental health, organizational behavior, and psy-chotherapy.
THE MODEL
To characterize the activation and operation of the attachment system in adulthood, we (Mikulincer & Shaver, 2003; Shaver & Mikulincer, 2002a) proposed a control-system model that integrates the large research literature with the theoretical writings of Bowlby  the dynamics of the attachment behavioral
system in adulthood

28 THE ATTACHMENT BEHAVIORAL SYSTEM
(1969/1982, 1973, 1980), Ainsworth (1991), Cassidy and Kobak (1988), and Main 
(1995). The model is an extension and refinement of previous control-system models of attachment dynamics proposed by Shaver et al. (1988) and Fraley and Shaver (2000). It deals with three issues (indicated by three gray blocks, or modules, in Figure 2.1): (1) proximity seeking following attachment-system activation (the attachment system’s pri-mary strategy), (2) beneficial consequences of using this strategy effectively to attain the support of a security-providing attachment figure, and (3) secondary strategies (called anxious hyperactivation and avoidant deactivation) pursued in response to attachment figure unavailability or unresponsiveness. The model also includes the goals of the pri-mary and secondary attachment strategies, associated beliefs and expectations about self and others, and associated rules for managing distress and close relations. In addition, the model explains what happens when secondary strategies fail to accomplish their aims.
The first component of the model (the upper gray area in the figure) includes moni-
toring and appraisal of threatening events—the process responsible for activating the attachment system. The second component (the central gray area in the figure) deals with monitoring and appraising attachment figure availability, which is related to individual differences in felt security and the psychological correlates and consequences of secure attachment. The third component (the lower gray area in the figure) involves monitoring and appraising the viability of proximity seeking as a way of dealing with attachment insecurity. This component represents the “choice” to use either a hyperactivating or a deactivating strategy to deal with insecurity, the former strategy being associated with an anxious attachment style and the latter with an avoidant attachment style. The word “choice” appears in quotation marks, because the process is likely to be largely uncon-scious and influenced by previous life experiences, beginning in infancy, that the person did not, and probably still does not, understand. We call it a “choice” in order to empha-size that there are different possible responses to attachment figure unavailability.
The model also postulates hypothetical excitatory and inhibitory “neural circuits” 
(shown as upwardly directed arrows on the left side of the figure), resulting from recur-rent use of secondary strategies. These hypothetical circuits affect the monitoring and appraisal of threats and of attachment figure availability. We assume that all compo-nents and circuits in the model, not only the “choice” among secondary strategies for dealing with attachment figure unresponsiveness, can operate in the adult mind either consciously or unconsciously, and either deliberately or automatically. Moreover, these components and circuits can operate either in parallel, synchronously, or in conflicting ways at conscious and unconscious levels.
Although we conceptualize hyperactivation and deactivation of the attachment 
system (associated with anxious and avoidant attachment, respectively) as independent strategies, we acknowledge the existence of “disorganized” or “fearfully avoidant” strat-egies that involve being high in both anxiety and avoidance (Bartholomew & Horowitz, 1991; Main & Solomon, 1990). Moreover, because we view attachment security as a state caused by the absence of a need (except on rare occasions) to use either a hyperacti-vating or a deactivating strategy, we conceptualize a secure person as one who scores low on the use of both strategies.
The model is sensitive to both context and personal dispositions (situations and traits, 
as these constructs are characterized in social/personality psychology). Every component of the model can be affected by context (e.g., dangers or threats, current information about attachment figure availability or unavailability, and current information about the viability of seeking proximity to and protection from an attachment figure in a particular situation), which initiates “bottom-up” influences on the operation of the attachment a security-providing attachment figure,beneficial consequences 
anxious hyperactivation and avoidant deactivation) pursued in response to attachment 
figure unavailability or unresponsiveness.
 expectations about self 
and others,
“choice” 
conscious and unconscious levels.dealing with attachment figure unresponsiveness,
hyperactivation and deactivation of the attachment
system anxious and avoidant 
f “disorganized” or “fearfully avoidant” 
high in both anxiety and avoidance

A Model of Attachment-System Functioning and Dynamics 29
system. For example, reminding a person of supportive behavior on the part of a past or 
present attachment figure can cause even a chronically insecure person to feel momentarily more secure and to behave accordingly. Each component of the model is also affected by a person’s prevailing working models of self and other, which bias appraisals of threats, attachment figure availability, and proximity-seeking viability. These biases are part of a “top-down” process by which a person’s chronic attachment style (i.e., dominant attachment-related schemas and associated mental and behavioral strategies) shapes the functioning of the attachment system. For example, a chronically anxious person tends to exaggerate threats and remain vigilant for even minor indications of attachment figure unresponsiveness, which in turn keeps the attachment system hyperactivated.
FIGURE 2.1. A model of attachment-system activation and functioning in adulthood.
reminding a person of supportive behavior on the part of a past or
present attachment figure c
a chronically anxious person tends
to exa ggerate t hreats an d remain vi gilant for even minor in dications o f attac hment figure
unresponsiveness, which in turn keeps the attachment system hyperactivated.

30 THE ATTACHMENT BEHAVIORAL SYSTEM
Overall, the model emphasizes both reality—the current context in which the attach-
ment system is activated—and fantasies, defenses, and cognitive biases associated with particular attachment schemas, strategies, and styles. We intend for this model to capture what was correct about both psychoanalytic theory’s emphasis on internal biases and Bowlby’s (1969/1982) claim, which we quoted in Chapter 1, that attachment working models are “tolerably accurate reflections of what actually happened.”
Activation of the Attachment System
Following Bowlby’s (1969/1982) lead, we assume that the continuous monitoring of inter-nal and external events (ranging from momentarily recalled past experiences to noticing during a conversation with a relationship partner that he or she seems no longer interested in one’s troubles or sexual desires) can result in threat-related activation of the attach-ment system. These triggering events include both physical and psychological threats, such as receiving a frightening medical diagnosis, hearing a radio news flash about a rapidly approaching tornado, or noticing that one’s spouse seems strongly attracted to a new office mate. The threats can be either attachment-unrelated (e.g., the medical diag-nosis) or attachment-related (e.g., the appearance of a new rival for a spouse’s affection), just as in childhood a person can be threatened by a bleeding scratch or by the impending departure of his or her attachment figure (e.g., noticing that mother is walking out the door to get in her car and leave for work).
We assume that every event perceived as threatening by a person of any age tends 
to activate the attachment system. Such activation automatically heightens access to attachment-related thoughts, feelings, and action tendencies (e.g., images and thoughts of one’s attachment figure and strategies for contacting or gaining proximity to him or her), which in turn increases the likelihood of seeking contact with an attachment figure. Although this part of the model deals with the normative (i.e., normal, general) operation of the attachment system, which occurs regardless of individual differences in attachment history or attachment style, it is also affected by the excitatory and inhibitory circuits associated with hyperactivating and deactivating attachment strategies (shown along the left-hand side of Figure 2.1).
The Subjective Nature of Attachment-System Activation
According to the model, attachment-system activation depends on the subjective appraisal
of threats (which may be conscious or unconscious), not simply on the actual occur-rence of threats. Although the presence of genuine threats is obviously important, a per-son’s perception of internal or external stimuli or events as threatening is the trigger for attachment-system activation. This idea fits with most contemporary models of emotion regulation (see Gross’s [2014] edited volume for updated reviews of these models), which emphasize the role of appraisal in distress management. We view threat appraisal as a result of both the actual presence of a threat and a person’s expectation that unfolding events may have negative consequences for his or her well-being, safety, security, adjust-ment, or survival. Although these expectations can be based on a rational, conscious risk analysis of unfolding events, excitatory and inhibitory circuits resulting from second-ary strategies may bias them. Moreover, as mentioned above, the appraisal process is not always conscious, and the appraising mind may not be aware of its monitoring and appraising activities. (As we show throughout this volume, it is possible to alter a person’s sense of threat or safety by presenting subliminal stimuli via a computer screen.)
Another important feature of our model is that inner  sources of threat (e.g., troubling Such activation automatically heightens access to
attachment-related thoughts, feelings, and action tendencies 
 increases the likelihood of seeking contact with an attachment figure.

A Model of Attachment-System Functioning and Dynamics 31
thoughts, images, or dreams) can activate the attachment system. For example, thinking 
even briefly about one’s own mortality can be extremely threatening (Pyszczynski, Sul-livan, & Greenberg, 2015) and can activate the attachment system (Shaver & Mikulincer, 2012a). In such cases, a person does not have to face a literal, immediate, external threat; merely being reminded of the general possibility of death is enough to activate the system. And again, these thoughts need not be conscious; they can be activated by a stimulus as minimal as the word “death” presented subliminally (e.g., Mikulincer, Birnbaum, Wod-dis, & Nachmias, 2000).
Understanding these two processes—subjective appraisal of threats and activation of 
the attachment system by threat-related thoughts—is crucial for understanding how sec-ondary attachment strategies (hyperactivation and deactivation) bias attachment-system activation. Hyperactivating strategies include vigilance with respect to possible threats, exaggerated appraisals of threats (catastrophizing), and rumination about previous and merely possible threatening experiences that reactivate proximity-seeking efforts and emphasize the urgency of gaining a partner’s attention, care, and support. This often causes attachment-anxious individuals to activate their attachment system even in the absence of objective threats. Deactivating (“avoidant”) strategies, in contrast, include diversion of attention away from threats and inhibition or suppression of threat-related thoughts that might activate the attachment system and cause a person to desire social comfort or support. Because of these strategic maneuvers, avoidant individuals often dis-tance themselves from threats and keep themselves from thinking about either their need for comfort or protection or the relief they might experience in the presence of a loving and protective relationship partner.
The Two-Stage Process of Attachment-System Activation
Once a threat is appraised, a two-stage process of attachment-system activation is initi-ated. In the first stage, the appraisal causes preconscious activation of the system and automatic heightening of access to attachment-related thoughts and action tendencies. In the second stage, this preconscious activation arouses conscious thoughts of proximity seeking and, in many cases, initiates efforts to seek proximity and protection. In young children, the first stage typically gives way quickly to the second, because the thought of an action tends to trigger the action unless there is restraint or inhibition. In adults, there may be many steps between the first and second stages, and the second stage may take place only intrapsychically rather than behaviorally.
Preconscious activation of the attachment system consists of heightened availability 
of attachment-related mental representations, such as representations of security-enhanc-ing attachment figures (including their appearance, comforting words, affectionate behaviors, and personal qualities, including their name); episodic memories of comforting interactions with these figures; memories of the feelings one experienced when comforted by attachment figures; thoughts related to proximity, love, and support; and mental acti-vation of proximity-seeking goals. These preconsciously aroused representations are then available for use in subsequent information processing and action, which means they can shape a person’s state of mind and influence his or her behavioral plans even before he or she notices or acknowledges them in the stream of consciousness. This line of theoretical reasoning fits with recent findings from social-cognitive research showing that accessible ideas, words, and images can automatically alter a person’s goals and behaviors without conscious planning (e.g., Bargh & Morsella, 2010).
In infancy and early childhood, most children probably have a limited repertoire 
of mental representations of attachment figures and a similarly small repertoire of —subjective appraisal of threats 
diversion of attention awa y from threats and inhibition or su ppression of threat-related
thoughts that mi ght activate the attachment s ystem and cause a person to desire social 
comfort or support. 
s preconscious activation of the system 
to seek proximity and protection.
appearance, comforting words, affectionate
behaviors, and personal qualities, including their name)
 memories of the feelings one experienced when comforted
by attachment figures;  proximity, love, and support;

32 THE ATTACHMENT BEHAVIORAL SYSTEM
proximity- and comfort-seeking behaviors. Most young children probably also have a 
limited number of available attachment figures (although this obviously differs as a func-tion of family size, culture, and other factors), and they are largely limited to the figures provided by the local environment (e.g., the family home, a close adult relative’s home, a day care center). In adolescence and adulthood, however, a person may have a wider range of potential comforters and attachment figures, as well as the ability to call on such people or locate a new potential attachment figure. As explained in greater detail in Chapter 3, much of adolescents’ and young adults’ time and energy is devoted to explor-ing the trustworthiness of potential attachment figures (e.g., friendly peers; one or more romantic partners; a devoted coach, teacher, or professional mentor). During these years, at least in modern industrialized societies, a person may be lonely at times, which attach-ment researchers view as an emotion caused by separation anxiety or activation of the attachment system without a specific target (Mikulincer & Shaver, 2014a). Loneliness is especially common in adolescence and early adulthood, when many people are not yet confident about their attachment relationships outside the family home.
As mentioned earlier, another difference between infancy and adolescence or adult-
hood is that, in the later age periods, preconscious activation of the attachment system does not necessarily lead to observable proximity-seeking behavior. Age and experience generally yield an increased ability to gain security from mental representations of secu-rity-enhancing attachment figures without actually having to seek immediate physical proximity to them. In fact, activation of these mental representations can create a sense of safety and security, which helps a person deal independently with threats. In other words, activation of the adult attachment system can occur intrapsychically, with or without awareness.
In some cases, a reduction in attachment anxiety can occur simply as a result of reen-
acting or imagining supportive interactions with attachment figures. That is, satisfaction of attachment needs can be accomplished partly in one’s imagination; for example, when a person imagines being loved by a movie star, a character in a book, or an acquaintance who seems kind and lovable but with whom one does not actually have a close relation-ship. This is the way we interpret many people’s ability to gain genuine solace from imag-ined interactions with God, Jesus, the Buddha, deceased loved ones, and media heroes and heroines.
Like Bowlby (1969/1982), however, we assume that no one at any age is completely 
free of dependence on actual flesh-and-blood attachment figures. There are conditions, such as physical and psychological traumas, serious illnesses, important school or job failures, and losses of loved ones, in which symbolic proximity to an internalized or imagined attachment figure may not be sufficient to provide adequate comfort and relief, and under such conditions attachment-system activation can trigger proximity-seeking behavior regardless of a person’s age. There are also developmental periods, such as old 
age, in which people’s physical and psychological resources may be taxed to the point where it becomes necessary to seek proximity to and support from “stronger and wiser” (if usually younger) others. In such cases, attachment-system activation is manifested in conscious thoughts, behavioral intentions, and actual proximity- and support-seeking behavior.
Attachment-System Activation and Self-Representations
In 2004, we added another path to the model of attachment-system activation (Miku-lincer & Shaver, 2004). In addition to the search for real, external attachment figures or a person may have a wider
range of potential comforters and attachment figures, as well as the ability to call on 
such people or locate a new potential attachment figure.
time and energy is devoted to explor -
ing the trustworthiness of potential attachment figures (e.g., friendly peers; one or more
romantic partners; a devoted coach, teacher, or professional mentor). 
Age and experience
generall y yield an increased abilit y to gain securit y from mental re presentations of sec u-
rity-enhancing attachment figures without actually having to seek immediate physical 
proximity to them.

A Model of Attachment-System Functioning and Dynamics  33
relying on internal, mental representations of past or imagined attachment figures, there 
is also the possibility of attaining comfort, relief, and increased “felt security” by relying on what we call security-based self-representations —that is, components or subroutines 
of the self that originated in interactions with available attachment figures but are now experienced as aspects of oneself. According to this new path, activation of the attach-ment system during times of need can evoke (1) mental representations of oneself (includ-ing traits and feelings) derived from interactions with previously available and responsive attachment figures ( self-in-relation-with-a-security-enhancing-attachment-figure ) and 
(2) mental representations of oneself derived from identifying with, or introjecting (to use the psychoanalytic term), features and traits of one or more caring, supportive attach-ment figures ( self-caregiving representations ). If these representations are available in 
memory, they can serve a soothing function and increase a person’s sense of security. We devised a way to test these theoretical ideas in the laboratory and found empirical support for them (see Chapter 6).
Mental representations of self-in-relation-with-a-security-enhancing-attachment-
figure are organized around self-aspects (e.g., roles, traits, feelings, behaviors, expecta-tions) that were previously experienced and recorded in memory during interactions with attachment figures. During such interactions, a person may have construed him- or her-self as sturdy, active, and capable based on having coped effectively with whatever threat or danger activated the attachment system. He or she may also feel calm, soothed, and loved because of the attachment figure’s availability and kindness. The beliefs and feel-ings are stored in semantic memory and are strongly associated with representations of available attachment figures and the positive feelings one has experienced in interactions with them. Moreover, these representations become more available under conditions of threat that activate the attachment system. They then down-regulate or alleviate distress and help a person cope effectively with the challenging situation.
The second category of security-based self-representations—those concerned with 
self-caregiving (which psychologists whose ideas are influenced by Buddhism call “self-compassion”; Neff, 2012)—includes self-representations based on identifying with and incorporating into oneself a supportive attachment figure’s soothing qualities. To the extent that an attachment figure has demonstrated compassion, empathy, kindness, and encouragement when a person was distressed, these qualities can be modeled internally and assigned to oneself, which aids emotion regulation. This means that a person often treats him- or herself in ways he or she was treated by key attachment figures. A person whose figures have generally been sensitive, caring, and forgiving will adopt a similar approach to him- or herself, and will use the skills and personal qualities “borrowed” from attachment figures to comfort the self. When a threat arises, the person automati-cally activates self-caregiving routines that help him or her cope with distress.
Attachment Style and Attachment-System Activation
The entire process of attachment-system activation described in preceding sections can be affected by a person’s chronic or dispositional attachment style. We will consider these effects in three separate points. First, dispositional attachment patterns can alter the content of the mental representations activated by threat appraisals. For people high in attachment security, threat appraisals increase the mental accessibility of thoughts of positive interactions with attachment figures—thoughts about proximity, safety, sup-port, love, and relief. For people who are insecurely attached, however, threat appraisals often increase access to negative thoughts and memories (e.g., thoughts about separations,

34 THE ATTACHMENT BEHAVIORAL SYSTEM 
rejections, and losses). Such people’s painful experiences with attachment figures have 
established a strong associative link in their minds between activation of the attachment system and worries about separation or rejection (and in the worst case, abuse), increasing the accessibility of these worries whenever proximity-seeking tendencies are activated.
Second, dispositional attachment patterns can affect proximity- and support-seek-
ing behavior. Secure peoples’ histories of interactions with responsive attachment figures increase their confidence in proximity seeking as an emotion regulation strategy and reinforce reliance on this strategy under stressful conditions. In contrast, insecure people have a history of painful interactions with less responsive (or less consistently responsive) attachment figures, which leads to the worry or conviction that proximity seeking may fail to accomplish its goal, which in turn forces insecure people to deal with unresolved distress through hyperactivating or deactivating attachment strategies.
Third, attachment patterns can alter the activation of security-based self-representa-
tions under distressing conditions. Calling upon this source of personal security should be most common among people high in attachment security, because they, compared with their insecure counterparts, have experienced more security-boosting interactions with attachment figures. This means that secure people can mobilize caring qualities 
within themselves—qualities modeled on those of their attachment figures—as well as representations of being loved and valued. These representations can provide genuine comfort, allowing secure people to feel worthy and relatively unperturbed even under stress. In contrast, insecure people are less likely to be able to call upon mental residues of past positive experiences. In fact, they may find that attachment-system activation reminds them, consciously or unconsciously, of the many times when their attachment figures were unavailable or unresponsive when needed.
Attachment Figure Availability and Security-Based Strategies
Once the attachment system is activated, an affirmative answer to the question posed in the first component of our model (Figure 2.1, upper gray box)—“Is an attachment figure available?”—results in a sense of felt security. Attachment figure availability also fosters what we, following Fredrickson (2001), call a “broaden-and-build” cycle of attachment security, which augments a person’s resources for maintaining emotional stability in times of stress and expands the person’s perspectives and capacities. (According to Fred-rickson, this is the general function of positive emotions.) This broaden-and-build cycle also encourages the formation of intimate and deeply interdependent bonds with others and maximizes personal adjustment without a need for reality-distorting defenses, such as narcissistic self-inflation (an avoidant defense) or attempts to merge symbiotically with others (an anxious defense).
In the long run, repeated experiences of attachment figure availability have an endur-
ing effect on intrapsychic organization and interpersonal behavior. At the intrapsychic level, such experiences act as a resilience resource, sustaining emotional well-being, men-tal health, and personal adjustment, and they cause secure working models of self and others to be a person’s most accessible social schemas. At the interpersonal level, repeated experiences of attachment figure availability create secure attachment, with many ben-efits in close relationships (e.g., trust, clear and open communication, ability and will-ingness to care for others). The broaden-and-build cycle of attachment security can be viewed as the core advantage of being a secure person.
As in the system-activation component of our model (the upper gray box), the answer 
to the second question (the middle gray box), concerning attachment figure availability,

A Model of Attachment-System Functioning and Dynamics 35
depends on subjective appraisals and can therefore be biased by attachment history and 
strategies. Anxious individuals’ hyperactivating strategies intensify the vigilant monitor-ing of attachment figures’ behavior and tilt perceptions in the direction of noticing or imagining insufficient interest, availability, or responsiveness. As a result, the likelihood of detecting real or imagined signs of disinterest, distance, rejection, or unavailability is increased, because an attachment figure can’t always be immediately available and totally at a needy partner’s disposal. Avoidant individuals’ deactivating strategies interfere with monitoring the availability or unavailability of an attachment figure, increasing the like-lihood that genuine signals of attachment figure availability will be missed or misper-ceived. In contrast, secure working models facilitate positive appraisals of attachment figure availability, building on and confirming a positive view of relationship partners as available and supportive. This stance encourages a secure person to overlook or down-play inevitable instances of temporary unresponsiveness or unavailability.
These cognitive biases are amplified when attachment-related mental representations 
are preconsciously activated. At a preconscious level, expectations concerning attachment figure availability depend entirely on the kind of internalized figure, available or unavail-able, one tends to recall. Insecurely attached people tend to give a negative answer to the question of attachment figure availability because they have overly ready mental access to cognitive representations of unavailable figures. People who are higher in attachment security, in contrast, tend to answer this question positively because they have available many mental representations of supportive attachment figures.
Despite these cognitive biases, however, reality is still of great consequence in the 
appraisal of attachment figure availability. The actual presence of a responsive attach-ment figure or contextual factors that activate representations of an available figure (fac-tors such as being instructed to think about such a person; see Mikulincer & Shaver, 2007a, for a review) can yield an affirmative answer to the availability question. These contexts, mainly when they are clear-cut, personally meaningful, and repeated over time and situations, can counteract even insecure people’s tendencies to doubt the availability of attachment figures, and can therefore trigger a broaden-and-build cycle of attachment security. In other words, an insecure person can be helped to function more securely, both temporarily (as in some of the experiments we describe in Chapter 3) and chroni-cally (as in successful psychotherapy or other kinds of transformative relationships we describe in Chapters 10, 14, and 15).
The Broaden-and-Build Cycle of Attachment Security
In our model the broaden-and-build cycle of attachment security, which results from appraising attachment figures as available and responsive, is viewed as a cascade of men-tal and behavioral processes. This cascade enhances emotional stability, personal and social adjustment, satisfying close relationships, and autonomous personal growth. The most immediate psychological benefit of attachment figure availability is effective man-agement of distress and restoration of emotional equanimity. According to our model, interactions with responsive attachment figures impart a sense of safety, relieve distress, and arouse positive emotions (relief, satisfaction, gratitude). Secure people can there-fore remain relatively unperturbed under stress and experience longer periods of positive affectivity, which in turn contribute to sustained emotional well-being and mental health. (The importance of sustained positive emotion has been demonstrated convincingly in recent neuropsychological studies; Davidson, 2015.)
Experiences of attachment figure availability contribute to a reservoir of positive detecting real or imagined signs of disinterest, distance, rejection, or unavailability is
increased, because an attachment figure can’t always be immediately available and totally 
at a needy partner’s disposal.Anxious individuals’ hyperactivating strategies intensify the vigilant monitor -
ing of attachment figures’ behavior and tilt perceptions in the direction of noticing or
imagining insufficient interest, availability, or responsiveness. 
secure working models facilitate positive appraisals of attachment 
figure availabilit y, buildin g on and confirmin g a positive view of relationshi p partners as
available and supportive. 
 available or unavail -
able,

36 THE ATTACHMENT BEHAVIORAL SYSTEM 
beliefs about distress management and positive mental representations of self and others. 
Interactions with responsive attachment figures sustain a background sense of hope and optimism, making it easy for a person to believe and feel that most of life’s problems are solvable and most distress is manageable. These interactions also create positive beliefs about other people and heighten confidence in most relationship partners’ sensitivity, responsiveness, and good will. In addition, secure individuals learn to perceive them-selves as strong and competent, valuable, lovable, and special—thanks to being valued, loved, and viewed as special by caring attachment figures.
Appraising attachment figures as available, responsive, and supportive also creates a 
reservoir of useful procedural knowledge concerning emotion regulation and coping with stress. This knowledge is organized around the “secure-base script” discussed in Chapter 1 and includes three regulatory tendencies: acknowledging and appropriately communi-cating distress; seeking proximity, intimacy, and support; and engaging in instrumental problem solving. During interactions with supportive attachment figures, secure people learn that they can confidently and openly express their vulnerability and neediness and rely on another’s support, and that these tendencies yield positive outcomes. They also learn that they can often solve important problems themselves, and that turning to oth-ers is an effective way to bolster their own considerable coping capacity. The “emotion-focused coping” components of this script (Lazarus & Folkman, 1984)—acknowledging and expressing feelings and seeking emotional support—work in the service of alleviating distress so that “problem-focused coping” efforts, such as seeking instrumental support and solving a problem, can proceed successfully.
Besides boosting positive core beliefs and constructive regulatory strategies, experi-
ences of attachment figure availability can have beneficial effects on prorelational cogni-tions (beliefs that closeness is rewarding and that intimate relationships are beneficial) and assuage worries about being rejected, criticized, or disapproved when one expresses feelings and needs. These beliefs make it easier for a person to get psychologically close to a relationship partner, express needs, desires, and hopes, and ask for support when needed. They also predispose a person to feel comfortable with intimacy and interdepen-dence; emphasize the benefits of being together; and offer generous interpretations of a partner’s ambiguous or disappointing behavior. That is, security-enhancing interactions leave in their wake a network of prorelational emotions, behaviors, and beliefs, thereby heightening secure people’s chances of establishing and maintaining intimate and deeply interdependent relationships.
Possessing these rich resources for dealing with stress makes it less necessary to rely 
on psychological defenses that distort perception and generate interpersonal conflict. According to our model, people who possess security-enhancing mental representations of attachment experiences generally feel safe and protected without having to deploy other defensive strategies. They can devote mental resources that otherwise would be employed in preventive, defensive maneuvers to other behavioral systems (e.g., caregiving) and to more growth-oriented activities (e.g., exploration, affiliation). Moreover, being confident that support is available when needed, secure people can take calculated risks and accept important challenges that contribute to the broadening of their perspectives and facilitate the pursuit of individuation and self-actualization.
Proximity-Seeking Viability and Secondary Attachment Strategies
Attachment figure unavailability results in attachment insecurity, compounds the distress aroused by actual dangers and threats, and triggers a cascade of mental and behavioral

A Model of Attachment-System Functioning and Dynamics 37
processes that can jeopardize emotional well-being, personal adjustment, and relation-
ship satisfaction and stability. This painful series of experiences forces a person to adopt a secondary attachment strategy—hyperactivation, deactivation, or a combination of the two (see the third gray box in the bottom section of Figure 2.1). The “choice” between possible strategies (which, as we have already said, can be unconscious and automatic rather than deliberate, and hence not be a “choice” in the usual sense) depends on subjec-tive appraisal of the expected success or failure of heightened proximity-seeking efforts and on the likely value of proximity if it is pursued.
According to Mikulincer, Shaver, and Pereg (2003), attachment figure unavailability 
can result in two kinds of psychological pain: (1) the distress caused by failing to achieve or maintain proximity to an attachment figure and (2) the sense of helplessness caused by ineffective co-regulation of distress and the appraisal of oneself as alone and vulnerable. Although these two kinds of painful feelings are related, their relative strength may vary across situations, relationships, and individuals. Moreover, each kind of feeling predis-poses a person to adopt a particular coping strategy.
One state of mind is based on the failure of attachment behaviors to achieve a positive 
result (connection, closeness, love, or protection) and on being punished (with inatten-tion, rejection, or hostility) for enacting these behaviors. In such a state, seeking greater proximity to the attachment figure is likely to be viewed as futile if not downright dan-gerous. A person in this predicament is more or less forced to adopt a deactivating strat-egy. A very different state of mind emerges from emphasizing the failure to co-regulate distress and worrying that one does not have the capacity to deal with threats alone. This state of mind encourages a person to work harder to gain attention, cooperation, and protection from an attachment figure—that is, to hyperactivate the attachment system. Under such conditions, distance from an attachment figure is perceived as dangerous, and one becomes afraid of what will happen if one attempts to regulate distress alone.
An array of contextual (external) and internal factors contribute to the relative 
strength of these two different states of mind. The factors that encourage deactivation include, for example, (1) consistent inattention, coolness, rejection, or angry responses from an attachment figure; (2) threats of punishment for proximity-seeking signals and behaviors; (3) violent or abusive behavior on the part of an attachment figure; and (4) explicit or implicit demands for greater self-reliance and inhibition or suppression of expressions of need and vulnerability. The factors that encourage hyperactivation include (1) unpredictable or unreliable caregiving experienced as out of sync with one’s needs and requests for help; (2) intrusive caregiving that interferes with the acquisition of self-regulation skills and punishes a person for trying to cope autonomously; (3) explicit or implicit messages from an attachment figure that one is stupid, helpless, incompetent, or weak; and (4) traumatic or abusive experiences that occur while one is separated from attachment figures. These factors create an ambivalent state in which approaching the attachment figure is sometimes punishing and sometimes rewarding, but avoidance of this figure seems dangerous. Of course, this state of mind may be exacerbated by temper-amental deficits in self-regulation and problems in controlling attention and cognition.
Hyperactivating Strategies
The main goal of hyperactivating strategies is to get an attachment figure, perceived as unreliable or insufficiently responsive, to pay more attention and provide protection or support. These strategies are exaggerations of the primary attachment strategy—intense monitoring of a relationship partner and strong efforts to maintain proximity—and to work harder to gain attention, cooperation, and 
protection from an attachment figure— hyperactivate 
The factors that encourage deactivation
include, for examp le, (1) consistent inattention, coo lness, rejection, or angry responses
from an attachment fi gure; (2) threats of punishment for proximit y-seekin g signals and 
behaviors; (3) violent or abusive behavior on the part of an attachment figure; and (4) 
explicit or implicit demands for greater self-reliance and inhibition or suppression of 
expressions of need and vulnerability. The factors that encourage hyperactivation include
(1) unpredictable or unreliable caregiving experienced as out of sync with one’s needs
and requests for help; (2) intrusive care giving that inter feres wit h the acquisition o f self-
regulation skills and punishes a person for tr ying to co pe autonomousl y; (3) ex plicit or

implicit messages from an attachment figure that one is stupid, helpless, incompetent, or
weak; and (4) traumatic or a busive ex periences t hat occur w hile one is se parate d from
attachment figures. T
The main goal of hyperactivatin g strate gies is to get an attac hment figure, perceive d as 
unreliable or insufficientl y responsive, to pay more attention and provide protection or
support. 
strong efforts to maintain proximity—

38 THE ATTACHMENT BEHAVIORAL SYSTEM
are the key distinguishing features of an anxious attachment pattern. They consist of 
overdependence on a relationship partner for comfort; excessive demands for atten-tion and care; strong desire for enmeshment or merger; attempts to minimize cognitive, emotional, and physical distance from a partner; and clinging or controlling behavior designed to guarantee a partner’s attention and support. These responses are based on what an attachment-anxious person interprets to be past rewards for energetic, even stri-dent, applications of the primary attachment strategy, because such applications seem, at least at times, to succeed (or to have succeeded in the past). Unfortunately, while sometimes successful with at least some interaction partners, these strategies can eas-ily encourage intrusive, coercive, and aggressive behavior toward a relationship partner that promote relationship dysfunction, partner dissatisfaction, and eventual rejection or abandonment—ironically and tragically the very outcomes most dreaded by attachment-anxious people.
To gain a partner’s attention, care, and support, such people also tend to exagger-
ate the seriousness of psychological and physical threats and problems, exaggerate their inability to cope autonomously with life demands, intensify the experience and expression of distress, protest any hint of an attachment figure’s unavailability or lack of responsive-ness, and present themselves in degrading, childish, or excessively needy ways. According to Cassidy (1994), attachment-anxious people often deliberately emphasize their vulner-abilities, helplessness, and dependence while desperately hoping that this exaggeration will capture an attachment figure’s attention and love. Moreover, because they still hope to gain a partner’s attention and protection, attachment-anxious people often take some of the blame for a partner’s unreliable care, which unfortunately reinforces their negative self-images and doubts about their lovability.
These hyperactivating strategies, although originally intended to garner affec-
tion and alleviate distress, can increase the accessibility and intensity of threat-related thoughts and emotions, making it all too likely that the new, self-manufactured sources of distress will mingle and become confounded with old ones. As a result, attachment-anxious people have difficulty controlling the spread of activation from one affectively negative thought to another, and their mind can easily become overwhelmed by a torrent of negative thoughts and feelings. (For this reason, people who produce an uncontrolled stream of negative memories, thoughts, and feelings during the Adult Attachment Inter-view are classified as “enmeshed and preoccupied with attachment”; see Hesse, 2008, and Chapter 4 of this book.) The anxious pattern of information processing gives primary attention to the affective tone of information and favors the organization of memory in terms of simple, undifferentiated features, such as the extent to which the information is threatening or implies rejection. As a result, hyperactivating strategies create a volatile, undifferentiated memory network pervaded by negative thoughts and feelings.
Hyperactivating strategies and associated mental processes have negative effects on 
social perception; they damage an anxious person’s self-image by emphasizing helpless-ness and vulnerability to rejection and encourage negative appraisals of others (who are seen as untrustworthy, unfaithful, or frustrating). Chronic reliance on hyperactivating strategies places anxious individuals at risk for emotional and adjustment problems. It impairs their ability to regulate negative emotions, thereby perpetuating distress, which tends to continue even after objective threats subside. Hyperactivating strategies also have a negative impact on relationship satisfaction and stability, and they interfere with other behavioral systems by impeding their activation and diverting them to serve the goals of the attachment system (e.g., helping someone in order to be thanked, having sex with someone in order to deter or postpone rejection or abandonment). These maneuvers overdependence on a relationship partner for comfort; excessive demands for atten -
tion and care; strong desire for enmeshment or merger; attempts to minimize cognitive,
emotional, and physical distance from a partner; clinging or controlling behavior
designed to guarantee a partner’s attention and support.
To gain a partner’s attention, care, and su pport, such people also tend to exa gger-
ate the seriousness of psycholo gical and physical threats and problems, exa ggerate their
inability to cope autonomously with life demands, intensify the experience and expression 
of distress, protest any hint of an attac hment figure’s unavai lability or lack of responsiv e-
ness, and present themselves in degrading, childish, or excessively needy ways. A
hoping that this exaggeration

will capture an attachment figure’s attention and love.

A Model of Attachment-System Functioning and Dynamics 39
make it unlikely that an anxious person will attain the kind of security and equanimity 
necessary for good health, a clear mind, autonomous creativity, and self-development.
Deactivating Strategies
When proximity seeking is perceived as dangerous or disallowed, a person tends to adopt deactivating strategies, which include denial of attachment needs and “compulsive self-reliance” (Bowlby’s, 1969/1982, term). They also include the dismissal of threats and of the need for attachment figure availability, because thinking about threats or attachment figures may reactivate a defensively deactivated attachment system. At the interpersonal level, deactivating strategies involve inhibition of the primary attachment strategy (prox-imity seeking). People who rely on deactivating strategies have two main goals in rela-tionships: (1) gaining whatever they need while maintaining distance, control, and self-reliance; and (2) ignoring or denying neediness and avoiding negative emotional states that might trigger attachment-system activation. The first goal is manifested in observ-a b l e  a t t e m p t s  t o  c o n t r o l  a n d  m a x i m i z e  p s y c h o l o g i c a l  d i s t a n c e  f r o m  a  p a r t n e r ;  a v o i d  interactions that require emotional involvement, intimacy, self-disclosure, or interdepen-dence; and deny or suppress attachment-related thoughts and feelings that might imply or encourage closeness, cohesion, or consensus. The second goal is reflected in reluctance to think about or confront personal weaknesses and relational tensions and conflicts; unwillingness to deal with a partner’s distress or desire for intimacy and security; and suppression of thoughts and fears related to rejection, separation, abandonment, or loss.
Deactivating strategies also affect mental organization. Avoidant people try to 
inhibit, suppress, or exclude from awareness thoughts or feelings that imply vulnerability, neediness, or dependence, which results in ignoring important information about psycho-logical or physical threats, personal weaknesses, and attachment figure responses. This in turns lowers the accessibility in memory of threatening attachment-related thoughts and inhibits the spread of activation from one such memory to another. It can also create difficulties in the encoding of information that is congruent with defensively excluded cognitions and emotions. Attention is diverted from threatening and attachment-related information, so such information is processed only shallowly because it has few if any strong excitatory neural connections with accessible, central nodes in the memory net-work. As a result, the information is not fully integrated with other parts of the network and is encapsulated in segregated mental structures, which Bowlby (1980) and George and West (2001) called “segregated systems.” The resulting barriers in memory and dis-rupted action systems contribute to avoidant individuals’ failure to deal effectively with many negative experiences.
Deactivating strategies and their associated mental processes have a distorting effect 
on self-perception and destructive effects on the perception of others. Avoidant people defensively inflate their self-conceptions, presumably to feel less vulnerable and less inter-ested in relying on deficient relationship partners. They tend to denigrate partners, dis-miss or downplay their needs, and distrust them. Deactivating strategies also impair a person’s ability to regulate negative emotions, causing avoidant individuals to keep anger and resentment alive internally while attempting not to express them externally. They are also prone to withhold commitment to even close relationship partners, because this might make them dependent or vulnerable to rejection. And they tend to view their rela-tionships as unsatisfying, giving themselves an excuse to flee if a relationship becomes too intimate or demanding. An avoidant person’s pervasive downregulation of feelings and reluctance to express or experience enthusiasm interferes with other behavioral systems When proximity seeking is perceived as dangerous or disallowed, a person tends to adopt 
deactivating strategies, which include denial of attachment needs and “compulsive self-
reliance” 
At the interpersonal
level, deactivatin g strate gies involve inhibition of the primar y attachment strate gy (prox-
imity seeking). 
(1) gaining whatever they need while maintaining distance, control, and self-
reliance; (2) ignoring or denying neediness and avoiding negative emotional states
that might trigger attachment-system activation. 
to control and maximize psychological distance from a partner; avoid 
interactions t hat require emotiona l invo lvement, intimacy, se lf-disclosure, or inter depen-
dence; deny or suppress attachment-related thoughts and feelings 
to think about or confront personal weaknesses

to think about or confront personal weaknesses 
inhibit, suppress, or exc lude from awareness t houghts or feelings t hat imp ly vulnerability,
neediness, or dependence, w
Deactivating strategies also impair a
person’s a bility to re gulate ne gative emotions, causin g avoidant in dividuals to keep anger
and resentment alive internally while attempting not to express them externally.

40 THE ATTACHMENT BEHAVIORAL SYSTEM
by making sure they (e.g., the caregiving system or the sexual system) do not result in 
increased intimacy or emotional involvement.
Attachment Disorganization: The Case of Fearful Avoidance
In some cases, intensely insecure people are unable to provide a simple answer to the question “Is proximity-seeking a viable option?” Hence, they have trouble “choosing” decisively between deactivating and hyperactivating strategies. Simpson and Rholes (2002b) reasoned that such people, whom Bartholomew and Horowitz (1991) called fear-ful avoidant, “may enact both strategies in a haphazard, confused, and chaotic manner .. . their behavior under stress may be an incoherent blend of contradictory, abortive approach/avoidance behaviors or perhaps paralyzed inaction or withdrawal” (p. 225). Like dismissingly avoidant individuals, fearfully avoidant people often cope by with-drawing and distancing themselves from relationship partners. Unlike their dismissing counterparts, however, who deny being afraid or needing anyone’s support, “fearful avoidant” individuals continue to experience anxiety, ambivalence, and a desire for their relationship partners’ love and support. They are avoidant because they consciously fear the possible negative consequences of reliance on others, but they regret feeling this way.
This mixed attachment strategy, identified by high scores on both the anxiety and 
the avoidance dimensions of attachment style (see Chapter 4), resembles the “disorga-nized” attachment pattern sometimes observed in Ainsworth’s Strange Situation (Main & Hesse, 1990). Disorganized infants are characterized by simultaneous or rapidly vacil-lating displays of approach and avoidance behavior toward an attachment figure and by aimless, disoriented, or confused actions in response to attachment figure unavailability. Fearful avoidance in adolescence or adulthood probably has to be extreme before it par-allels disorganization in infancy (which is usually found primarily in abusive or dysfunc-tional families), but when a person scores quite high on both the anxiety and avoidance scales of a measure of adult attachment, he or she may qualify as disorganized and may well have come from an abusive or neglectful family (see Chapter 5).
Theoretically, fearful avoidance derives from a failure to achieve any of the goals 
of the major attachment strategies: safety and security following proximity seeking (the p rimary ,  s ecur e  s tr a t e gy ) ,  d e f e n s i v e  d e a cti v a ti o n  o f  th e  a tta c hm e n t  s y s t e m  ( th e  a v o i d -ant strategy), or intense and chronic activation of the attachment system until security-enhancing proximity is attained (the anxious strategy). One important example is the abused child, who cannot achieve security but also cannot simply give up on an abusive parent. Another example is the child of a confused, drug-addicted, or grieving parent whose behavior cannot be predicted and who cannot be relied upon to provide com-fort. In such cases, the attachment system is reactivated despite deactivating strategies, attachment-related needs and worries become simultaneously accessible (hence creating ambivalence), and the child becomes trapped in a cycle of conflict-riddled attempts to meet personal needs while avoiding rejection or mishandling. This condition is similar in some ways to posttraumatic stress disorder, which also involves attempts to avoid unwanted thoughts and memories combined with uncontrollable intrusions of traumatic memories and hyperaroused emotions (see Chapter 13).
Many adult attachment studies indicate that “fearful avoidant” individuals are the 
least secure, least trusting, and most troubled of adolescents and adults, and that their lives may have been scarred by physical or sexual abuse or other attachment-related traumas (see Chapters 4 and 5). Throughout this book, we review studies that find either two main effects of the anxiety and avoidance dimensions (indicating that both, taken between deactivating and hyperactivating strategies.
haphazard, confused, and chaotic manner 
incoherent blend 
fearfully avoidant people often cope by with -
drawing and distancing themselves from relationship partners. 
“fearful
avoidant” individuals continue to experience anxiety, ambivalence, and a desire for their
relationship partners’ love and support. they consciously fear
the possible negative consequences of reliance on others,
both the anxiety and 
the avoidance 
that “fearful avoidant” individuals are the
least secure, least trustin g, and most trou bled of adolescents an d adults, an d that their
lives may have been scarred by physical or sexual abuse or other attachment-related
traumas

A Model of Attachment-System Functioning and Dynamics  41
together, have especially destructive effects) or an interaction between the dimensions 
(indicating that having high scores on both dimensions at the same time is even more destructive than might be expected from the additive effects of the two forms of insecu-rity). For example, fearfully avoidant people have especially negative representations of others (Chapter 6), are more likely to be involved in violent couple relationships (Chapter 10), are cognitively closed and rigid (Chapter 8), exhibit the least empathy for people who are distressed (Chapter 11), and have the most severe personality disorders (Chapter 13).
Model Summary
Our model (Figure 2.1) summarizes the cognitive operations, behavioral strategies, and motivational dynamics of the attachment system in adulthood as well as the goals of each attachment strategy and their psychological manifestations. Whereas the broaden-and-build cycle of attachment security promotes satisfying, high-functioning intimate rela-tionships, expansion of one’s resilience resources, and broadening of one’s perspectives and capacities, secondary attachment strategies are mainly designed to manage attach-ment-system activation and reduce or eliminate the pain caused by frustrated proximity seeking. Hyperactivating strategies keep a person focused on the search for love and security and constantly vigilant regarding possible threats, separations, and betrayals. Deactivating strategies keep the attachment system in check, with serious negative con-sequences for psychological and interpersonal functioning. The framework summarized in Figure 2.1 provides a roadmap for considering the research topics addressed in subse-quent chapters of this book.
ATTACHMENT THEORY AND OTHER THEORETICAL FRAMEWORKS
In the remaining sections of this chapter, we consider similarities and differences between attachment theory and four other broad psychological approaches to understanding the human mind and social behavior: psychoanalytic theory, relational interdependence theory, social cognition theories, and humanistic and “positive psychological” perspec-tives on personal development. In so doing, we hope to deepen our understanding of the implications of our model and build conceptual bridges to other theoretical approaches.
Psychodynamic Foundations of Attachment Theory
The links between attachment theory and psychoanalysis were evident in Bowlby’s early writings (e.g., Bowlby, 1956). As explained in Chapter 1, he was trained as a child psy-chiatrist and psychoanalyst, and like other psychoanalytic thinkers he assumed that the explanation of adult behavior lay somewhere in childhood, especially in early social rela-tionships. Although he was dissatisfied with the psychoanalytic theories and treatment approaches of his era, especially those of Anna Freud and Melanie Klein, he still believed that the quality of a child’s emotional ties with mother had powerful effects on psycho-logical functioning and mental health across the life span. Moreover, Bowlby organized attachment theory around themes that defined most of the psychoanalytic theories of his time: satisfaction and frustration of basic inner wishes (for security and protection), inner conflicts associated with barriers to wish fulfillment, psychological defenses aimed at avoidance or suppression of negative emotions associated with inner conflicts, and emotional problems related to the overuse of defenses.

42 THE ATTACHMENT BEHAVIORAL SYSTEM 
These conceptual commonalities become more evident when one considers the 
basic postulates of contemporary psychodynamic theories. In a comprehensive and very thoughtful review of contemporary psychoanalysis, Westen, Gabbard, and Ortigo (2008) asserted that all contemporary psychodynamic theorists agree on five core postulates: First, a large portion of mental life is unconscious. Second, cognitive and affective pro-cesses operate in parallel so that people can have conflicting motives, thoughts, and feel-ings toward the same situation or person, and psychological defenses are often used to deal with these conflicts. Third, childhood experiences play a crucial role in the forma-tion of adult personality. Fourth, mental representations of self and others are crucial for explaining a person’s behavior in interpersonal and social settings and account for or contribute to psychological disorders. Fifth, healthy personality development is a journey from social dependence to mature autonomy.
Attachment theorists and researchers agree with all five postulates, although they 
consider autonomy to be compatible with mature interdependence (Shaver & Mikulincer, 2005). As explained in this chapter, many components of the attachment behavioral sys-tem operate unconsciously. Activation of the attachment system can occur unconsciously and shape a person’s processing of information before he or she reflects on it consciously. Moreover, deactivating strategies often operate at an unconscious level. Avoidant people seem not to be aware of suppressing or denying attachment needs and attachment-related thoughts and memories. According to Bowlby (1988), these suppressed needs, memories, and thoughts remain alive in unconscious, segregated mental systems and at times resur-face in experience and action when deactivating strategies prove insufficiently strong, given other cognitive or emotional demands on mental resources.
In attachment theory, inner conflict and psychological defense are central to the 
characterization of secondary attachment strategies (Shaver & Mikulincer, 2005). Hyperactivating strategies reflect a compromise between conflicting, ambivalent tenden-cies toward attachment figures—anger and hostility toward unavailable attachment fig-ures combined with intense needs for protection and love from these same frustrating figures. Deactivating strategies are organized around conflicting tendencies at different levels of awareness, with lack of negative emotions and a detached attitude evident at the conscious level while high levels of unresolved attachment-related distress exist at an unconscious level.
Three additional features of attachment theory fit with the remaining postulates of 
contemporary psychoanalysis. According to Bowlby (1973), childhood experiences with primary caregivers have important effects on attachment-system functioning in adult-hood and, as stated earlier, mental representations of self and others (attachment working models) explain how mental residues of these early experiences become building blocks of a person’s later thoughts, feelings, and actions and have a shaping effect on adult emo-tion regulation, interpersonal relations, and mental health. Furthermore, according to attachment theory, attachment security provides a foundation for increased exploration, improved self-regulation, and a flexible balance between self-reliance and reliance on oth-ers, which in turn facilitates growth toward autonomy and maturity. This developmental progression stands in marked contrast with the overly dependent, infantile position of the highly anxious person and the rigidly self-reliant attitude of the highly avoidant person.
The Relational Basis of Attachment Theory
The preceding section highlights the importance of the relational context in which the attachment system is activated. Although attachment-system functioning involves intra-psychic processes, such as a person’s wishes, fears, and defenses, it can be expressed in

A Model of Attachment-System Functioning and Dynamics  43
behavior (e.g., seeking proximity to a relationship partner) and is sensitive to a relation-
ship partner’s particular actions and reactions (e.g., availability and responsiveness). In fact, attachment-system functioning involves real and imagined interactions with rela-tionship partners and can be altered by these partners’ responses to one’s proximity bids. In this respect, attachment theory has much in common with Thibault and Kelley’s (1959) interdependence theory, which focuses on a single interpersonal transaction as the unit of analysis and emphasizes the powerful influence of one person’s responses on a relationship partner’s thoughts, feelings, and behavior (see Van Lange & Balliet, 2015, for a recent account of the theory).
In our model, we acknowledge the huge impact of a partner’s responses on a person’s 
attachment-related thoughts and behaviors in a particular situation. All three modules of attachment-system functioning can be affected by a partner’s behavior. The partner can be a source of danger and therefore trigger attachment-system activation (e.g., by threat-ening abandonment or violence). Also, a partner can affect the appraisal of attachment figure availability as well as the viability of proximity seeking as a means of achieving security. Moreover, a person’s relational cognitions and behaviors depend not only on his or her attachment style but also on a partner’s attachment behaviors. Indeed, several studies have shown that both partners’ attachment styles contribute uniquely to the pre-diction of both partners’ relationship satisfaction (see Chapter 10 for research evidence). Moreover, a person’s attachment anxiety and avoidance can have differential effects on emotions, cognitions, and behaviors depending on the partner’s attachment style. For example, an anxious person may hyperactivate his attachment system more energetically when trying to compel affection or support from an avoidant relationship partner (see Chapter 10 for relevant studies).
It is important to recall, however, that attachment theory is not exclusively relational 
in an external behavioral sense.  As discussed earlier in this chapter, the attachment sys-
tem can be activated intrapsychically without resulting in visible social behavior and without requiring responses from an actual relationship partner. In such cases, a person can search for comfort and security in his or her own mental representations without seeking proximity to or support from anyone outside the self. In our analysis of security-based self-representations (Mikulincer & Shaver, 2004), we argued that these represen-tations can effectively be called upon even in situations that are not explicitly social. In experimental studies we found that secure people, when under stress, were able to call upon both internalized self-soothing processes and some of their internalized attachment figure’s qualities, which then allowed them to tolerate failure in a laboratory task, even though the task itself was not social (see Chapter 6). Another example of strictly internal reactions occurs when an avoidant person processes information related to attachment issues unconsciously, without any observable effect on behavior (see Chapter 7).
Because attachment theory has both intrapersonal and interpersonal aspects, it is 
a prime example of the “person by situation” approach to human behavior that has been popular for years in social/personality psychology (see Shoda, Wilson, Whitsett, Lee-Dussud, & Zayas, 2015, for a recent review of this approach). The person in this case is represented by the “hardwired” programming of the attachment behavioral sys-tem, experience-based attachment working models of self and others, and the proce-dural knowledge implicit in attachment strategies. The situation consists of a relationship partner’s responses and other contextual cues that affect a person’s appraisal of what is happening in the relationship and thereby influence his or her subsequent behavior toward the partner. The complexities in this model stem from the fact that major parts of the “person” component were originally based on variations in the responsiveness of primary caregivers in threatening situations (i.e., in the actual social world—a series of

44 THE ATTACHMENT BEHAVIORAL SYSTEM 
“situations”), and major parts of the “situation” component are shaped by the person’s 
attachment behavior, which may affect a partner’s expressions of love, intimacy, and care. Ignoring either the person or the situation results in transforming attachment the-ory into either an interdependence theory or a psychoanalytic theory, a transformation that we do not favor.
Social-Cognition Approaches and Attachment Theory
The role assigned by attachment theorists to working models of self and others is simi-lar to the role played by cognitive-affective schemas in social cognition theories (Fiske & Taylor, 2013). Both attachment theory and social-cognition theories emphasize the extent to which people subjectively construe social experiences, store representations of these experiences (working models, in attachment-theory terms; schemas, prototypes, or scripts in social-cognition language), and use these representations for understanding new social experiences and formulating action plans. In these theoretical approaches, mental representations guide and coordinate emotion regulation, person perception, and goal striving. Moreover, attachment theory conceptualizes working models in the same way that social-cognition theorists conceptualize mental representations: They are viewed as being stored in an associative memory network, as having excitatory and inhibitory connections with other representations, and as possessing a certain level of accessibility determined by past experiences and current context.
The commonalities between attachment theory and social-cognition theories have 
become especially evident in recent adult attachment studies. As reviewed in later chap-ters of this book, attachment researchers have invested a great deal of energy and inge-nuity in assessing the effects of attachment style on cognitive structures and processes that had previously been conceptualized and examined in social-cognition research, such as person perception, the accessibility and organization of self-representations, expectations about others’ behavior, the accessibility of memories of social interactions, and interpretations of relationship partners’ behavior. This review also reveals that adult attachment research has tended to rely increasingly on research techniques and designs borrowed from social-cognition research, such as implicit attention and memory tasks, semantic priming techniques, and reaction times in lexical decision and Stroop color-naming tasks.
Despite these commonalities, however, it would be a mistake to equate attach-
ment working models with the cognitive structures usually studied in social-cognition research. In their review of the nature, content, and functions of attachment working models, Shaver, Collins, and Clark (1996) identified four differences between these con-structs. As compared with other mental representations, (1) working models also contain, express, or activate a person’s wishes, fears, conflicts, and psychological defenses, and they can be affected by these psychodynamic processes; (2) working models seem to have a larger and more powerful affective component than most social schemas and tend to be more powerfully shaped by emotion regulation processes; (3) working models tend to be construed in relational terms and to organize representations of self, others, and social interactions; and (4) working models are broader, richer, and more complex structures, and can include tandem or opposite representations of the same social experience at epi-sodic, semantic, and procedural levels of encoding. Overall, attachment working models cannot be equated with most other social cognitions, because they evolve not only from simple memories of actual experiences but also from dynamic processes of goal pursuit, emotion regulation, and psychological defenses involved with wishes for proximity and security, and fears of separation and helplessness. As a result, they can distort a person’s

A Model of Attachment-System Functioning and Dynamics  45
perceptions of social reality, even though many were formed originally in social situa-
tions.
These differences call attention to the dialectical tension between the goal-striving 
and emotion regulation functions that attachment working models accomplish. On the one hand, due to the goal-oriented and goal-corrected nature of the attachment system, working models must be what Bowlby called “tolerably accurate reflections of what actu-ally happened” in attachment relationships; otherwise, people would not be able to plan effective goal-oriented behavior and attain important relational goals. In this respect, working models resemble other cognitive representations that store factual knowledge and semantic and procedural information about reality constraints and demands. On the other hand, due to the emotion regulation function of working models, they sometimes have to distort perceptions, thoughts, and actions in order to manage attachment-related fears, worries, and insecurities and protect a person from the distress and pain of attach-ment figure unavailability. This dialectical tension between the goal-striving and emotion regulation functions of working models seems to be unique to attachment theory, which distinguishes it from other social-cognition theories.
Positive Psychology and Attachment Theory
The broaden-and-build cycle of attachment security calls attention to the optimistic, hope-ful, constructive, and actualization-oriented tone of attachment theory, which makes it different from most other psychodynamic, relational, and social-cognition theories. As previously noted, people who possess a stable sense of attachment security generally feel safe and worthy, hold an optimistic and hopeful outlook on life, rely on constructive methods of coping and regulating distress, and interact with others in a confident and open manner. This health- and growth-oriented quality of attachment theory has much in common with the “humanistic psychology” movement of the 1950s and 60s (e.g., Maslow, 1968; Rogers, 1961) and today’s “positive psychology” movement (Seligman, 2002). Both humanistic and positive psychology are attempts to balance psychology’s traditional focus on conflicts, fears, egoistic defenses, destructive tendencies, and psy-chopathology with due consideration of human strengths, developmental potentials, and social virtues that contribute to the development of what Rogers (1961) called a fully functioning person and Maslow (1968) called self-actualization.
According to attachment theory, security is a basic human strength. It facilitates 
the development of other personal qualities that fall under the rubric of “positive” psy-chological traits, such as resilience, optimism, hope, positive affectivity, curiosity and exploration, healthy autonomy, capacities for love, compassion, and forgiveness, feelings of interconnectedness and belongingness, tolerance for human differences, and kindness. Moreover, one can easily recognize major similarities between how the broaden-and-build cycle of attachment security emerges from repeated episodes of attachment figure avail-ability and discussions by humanistic psychologists of the parenting style—unconditional positive regard—that facilitates a child’s pursuit of self-actualization. For example, the notion of having an available, caring, and loving attachment figure and then extending the same kindness and benefits to other people resonates with Maslow’s (1968) concept of B-perception—nonjudgmental, forgiving, loving acceptance of another human being—and with Rogers’s (1961) conception of optimal parenting and psychotherapy based on “unconditional positive regard.” The common idea that recurs across the various “posi-tive” theoretical frameworks is that experiences of being loved, accepted, and supported by others constitute the most important form of personal protection and self-confidence. They provide a secure psychological foundation for confronting adversity and maintaining

46 THE ATTACHMENT BEHAVIORAL SYSTEM 
equanimity in times of stress, without interrupting normal processes of growth and self-
actualization. They also foster an ethically important tolerance of human differences and what Buddhist writers call compassion and loving-kindness.
Despite the theoretical commonalities between attachment theory and humanistic 
or positive psychological theories, the two are not identical. Whereas the positive and humanistic approaches focus mainly on growth-oriented, promotion-focused aspects of personality development (see A. Carr, 2011, for an overview), attachment theory empha-sizes both prevention and promotion aspects of the attachment system. This dual focus is well illustrated in the two basic functions of “safe haven” and “secure base” served by available, responsive, caring, and loving attachment figures. Such figures protect a person from threats and dangers, prevent any negative, painful outcomes of unavoid-able stressors, and help down-regulate the person’s fears and conflicts. At the same time, attachment figures provide a “secure base” from which the person can take risks, explore self and environment, and engage in promotion-oriented activities.
Failure to provide either a safe haven or a secure base results in attachment-related 
doubts and worries as well as psychological defenses that are attempts to compensate for the lack of security, but at the cost of cognitive distortion, rigidity, constriction, alienation, and an increase in interpersonal and intergroup conflict. Unlike positive psy-chology, attachment theory emphasizes both the “dark” and the “light, bright” sides of human nature and experience, and explains how the attachment system deals with fears, anger, conflicts, and defenses, as well as the equally natural capacities for happi-ness, love, growth, and self-actualization. We believe it makes sense to explore positive psychology within a framework that also includes “negative psychology,” since both are very real aspects of the human mind.
AN OUTLINE OF SUBSEQUENT CHAPTERS
Having presented the historical background and basic concepts of attachment theory in Chapter 1, in the present chapter we have organized the major concepts and tenets of the theory in a dynamic model of attachment-system activation and functioning in adulthood. In the remainder of the book we elaborate on various parts of the model and review empirical studies related to it. In Chapter 3 we review studies on the normative processes of attachment-system activation and functioning. In Chapter 4 we describe and evaluate various measures to assess individual differences in adult attachment patterns. In Chapter 5 we summarize what is known about the developmental origins of these dif-ferences and the continuity of attachment patterns over the life span. Chapters 6 through 8 focus on the intrapsychic aspects of attachment-system functioning, including how attachment style is related to mental representations of self and others, emotion regu-lation, and the regulation of behavior and fulfillment of life tasks (identity formation, career development, health maintenance, and finding philosophical or religious meaning in life). Chapters 9 through 12 focus on the interpersonal aspects of attachment-system functioning, including how attachment styles affect patterns of interpersonal related-ness, couple functioning, caregiving behavior, and sexuality. In Chapter 13, we review research on links between attachment insecurities and various forms of psychopathology. In Chapters 14 and 15, we show how adult attachment theory has been applied to the study of psychotherapy and organizational behavior. Chapter 16 sums up the state of the field and considers some of the deep existential implications of attachment theory and research. We hope the book as a whole provides a useful foundation for future attach-ment research and its clinical and educational applications.

Journal of Personalit y and Social Psycholog y
1990, Vol. 58, No. 4, 644-663Copyright 1990 by the America n Psychologica l Association , Inc
0022-3514/90/S00.7 5
Adult Attachment , Working Models, and Relationshi p
Quality in Dating Couples
Nancy L. Collins and Stephen J. Read
University of Southern Californi a
Three studies were conducted to examine the correlates of adult attachment . In Study 1, an 18-item
scale to measure adult attachmen t style dimension s was developed based on Kazan and Shaver's
(1987) categorica l measure. Factor analyses revealed three dimension s underlyin g this measure: the
extent to which an individua l is comfortabl e with closeness , feels he or she can depend on others,
and is anxious or fearful about such things as being abandone d or unloved. Study 2 explored the
relation between these attachmen t dimension s and working models of self and others. Attachmen t
dimension s were found to be related to self-esteem , expressiveness , instrumentality , trust in others,
beliefs about human nature, and styles of loving. Study 3 explored the role of attachmen t style
dimension s in three aspects of ongoing dating relationships : partner matching on attachmen t dimen-
sions; similarity between the attachmen t of one's partner and caregivin g style of one's parents; and
relationshi p quality, including communication , trust, and satisfaction . Evidence was obtained for
partner matching and for similarity between one's partner and one's parents, particularl y for one's
opposite-se x parent. Dimension s of attachmen t style were strongly related to how each partner per-
ceived the relationship , although the dimensio n of attachmen t that best predicted quality differed
for men and women. For women, the extent to which their partner was comfortabl e with closeness
was the best predictor of relationshi p quality, whereas the best predictor for men was the extent to
which their partner was anxious about being abandone d or unloved.
It is generally believed that the nature and quality of one's
close relationship s in adulthoo d are strongly influence d by
affective events that took place during childhood , particularl y
within the child-caretake r relationship . Yet, only recently have
social psychologist s begun to integrate work on adult love rela-
tionships with developmenta l theory and research on the nature
and functionin g of parent-chil d relations (Hartup & Rubin,
1986; Kazan & Shaver, 1987;Hinde , 1979;Hinde&Stevenson -
Hinde, 1986; Shaver & Hazan, 1988; Shaver, Hazan, & Brad-
shaw, 1988; Shaver &Rubenstein , 1980; Weiss, 1982,1986) . Of
particular interest has been the extent to which a child's early
attachmen t relationship s with caretakers shape importan t be-
liefs about the self and social world, which then guide relation-
ships in adulthood .
Recently, Hazan and Shaver (1987) have used infant attach-
ment theory (Ainsworth , Blehar, Waters, & Wall, 1978; Bowlby,
1982,1973,1980 ) as a framewor k for examinin g how adult love
relationship s are related to early parent-chil d interactions . The
Preparatio n of this article was aided by grant BNS-840626 2 from the
National Science Foundatio n to Stephen J. Read. This article is based
in part on a master's thesis conducte d by Nancy L. Collins under the
supervisio n of Stephen J. Read.
We wish to thank Lynn Miller, David Jones, Heidi Lincer, and espe-
cially Phillip Shaver for helpful comment s on previous versions of this
article. We also thank Linda Collins for suggestion s on data analysis
and Fatemah Farahan and Alaine McGinle y for assistance with data
collection and coding.
Correspondenc e concernin g this article should be addressed to Nancy
L. Collins, Departmen t of Psychology , Universit y of Southern Califor-
nia, Los Angeles, Californi a 90089-1061 .present studies extend their work in several ways. First, we de-
veloped a multi-ite m scale to measure dimension s underlyin g
adult attachmen t styles to replace Hazan and Shaver's discrete,
categorica l measure. Second, we explored the mechanism s that
may underlie cross-age continuit y by examinin g in greater de-
tail the relations between adult attachmen t and beliefs about
the self, the nature of romantic love, and the social world in
general. Finally, we examined the role of attachmen t style di-
mensions and attachmen t history in one's choice of love part-
ners and in the quality of dating relationships . We begin with a
brief overview of attachmen t theory to provide a framewor k for
the current work.
Attachmen t Theory and Research
Attachmen t theory is concerned with the bond that develops
between child and caretaker and the consequence s this has for
the child's emerging self-concep t and developin g view of the so-
cial world. Bowlby's theory (1982, 1973, 1980), which was the
first formal statement of attachmen t theory, is an evolutionary -
ethologica l approach (Ainswort h et al., 1978). According to this

view, infant attachmen t behaviors are controlled by a distinct,
goal-correcte d behaviora l system, which has a "set goal" of
maintainin g proximit y to a nurturing adult and a biologica l
function of promoting the child's security and survival (Bowlby,
1982). More recently, attachmen t researcher s have suggested
that the set goal of the attachmen t system is not simply physical
proximity but, more broadly, to maintain "felt security"
(Bischof, 1975;Bretherton , 1985; Sroufe& Waters, 1977).
Bowlby's theory is also a model of social and personalit y de-
velopment (1982, 1973). He argued that the attachmen t rela-
644

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 645
tionship has a profound impact on the child's developin g per-
sonality, and that the nature and quality of this early relation-
ship is largely determine d by the caregiver' s emotiona l
availabilit y and responsivenes s to the child's needs (Bowlby,
1973). Through continued interaction , a child develops internal
"working models" containin g beliefs and expectation s about
whether the caretaker is someone who is caring and responsive ,
and also whether the self is worthy of care and attention. These
working models are then carried forward into new relation-
ships where they guide expectations , perception , and behavior
(Bowlby, 1973). Thus, working models provide a mechanis m
for cross-age continuit y in attachmen t style and are of particu-
lar importanc e in understandin g the role that early relation-
ships have in determinin g adult relationships .
An importan t addition to attachmen t theory was made by
Ainsworth et al. (1978), who explored individua l difference s in
attachmen t relationships . From observation s of infants and
caretakers , three distinct patterns or styles of attachmen t were
identified: secure, anxious/avoidant , and anxious/ambivalent .
And, consisten t with Bowlby's theory, the three styles seem
closely associated with difference s in caretaker warmth and re-
sponsivenes s (Ainswort h et al., 1978; Egeland & Farber, 1984).
These individua l difference s in attachmen t styles are thought
to reflect difference s in the psychologica l organizatio n of the
attachmen t system, a central part of which is the child's percep-
tion of whether the caretaker will be available and responsiv e
when needed. Main, Kaplan, and Cassidy (1985) suggested that
individua l difference s in attachmen t styles can be viewed as
"difference s in the mental representatio n of the self in relation
to attachmen t [and] the secure versus various types of insecure
attachmen t organization s can best be understoo d as terms refer-
ring to particula r types of internal working models of relation-
ships, models that direct not only feelings and behavior but also
attention, memory, and cognition " (p. 67).
Early Attachmen t and Later Social Relations
Attachmen t theory's emphasis on enduring cognitive models
that are carried forward into new relationship s is consisten t
with more general theories of personalit y (e.g., Epstein & Ers-
kine, 1983; Sroufe & Fleeson, 1986) that view social, emo-
tional, and personalit y developmen t as inextricabl y linked to
early social relations. Empirica l support for these ideas is now
being provided as a growing body of longitudina l research finds
attachmen t style to be an importan t predictor of childhood so-
cial behavior through the early elementar y school years (see
Bretherton , 1985, for a review).
However, attachmen t behavior and the influence of early rela-
tionships should be central to social functionin g well beyond
the childhoo d years. Indeed, Bowlby argued that the nature of
the early relationshi p becomes a model for later relationships ,
leading to expectation s and beliefs about oneself and others that
influence social competenc e and well-bein g throughou t life
(Skolnick , 1986). Recently, Kazan and Shaver (1987; Shaver &
Hazan, 1988; Shaver etal., 1988) have used attachmen t theory
as a framewor k for understandin g adult love relationships . They
suggest not only that early relationship s have an impact on adult
love relationship s but that romantic love itself is a process ofbecoming attached that shares importan t similaritie s with
child-caretake r attachment .
Hazan and Shaver (1987) began by translatin g the typology
developed by Ainswort h et al. (1978) into terms appropriat e for
adult relationships , resulting in three attachmen t descriptions .
Respondent s were asked to choose the descriptio n that best
characterize d them, thus categorizin g themselve s as secure,
avoidant, or anxious. Adults with different styles differed pre-
dictably in the way they experience d love. For instance, secure
lovers had relationship s characterize d by happiness , trust, and
friendship , whereas anxious lovers had relationship s marked by
emotional highs and lows, jealousy, and obsessive preoccupa -
tion with their partner. Adult attachmen t was also related to
reports of early parent-chil d relationships . For example, secure
adults reported their parents to have been more respectfu l and
more accepting than did avoidant or anxious adults. Finally,
attachmen t style was related to beliefs about oneself and about
social relationships . For instance, anxious adults had more self-
doubts and felt misunderstoo d by others, whereas secure adults
felt well liked and believed others to be generally well inten-
tioned.
Hazan and Shaver's research is an importan t step toward ex-
ploring the relation between early attachmen t and adult love
experiences . There are, however, many issues that require more

tioned.
extensive examination . First, as Hazan and Shaver acknowl-
edged, further research in this area requires the developmen t of
a more sensitive instrumen t to measure adult attachmen t styles.
Second, if mental models of self and others are indeed the mech-
anisms for cross-age continuity , we must examine in more detail
the contents of these models and their relation with attachmen t
style and attachmen t history. Finally, if attachmen t styles have
important implication s for behavior in relationships , they
should have a role in one's choice of love partners and in the
quality of one's romantic relationships .
This article reports three studies that we conducte d to ad-
dress these issues. In Study 1 we developed and evaluated a scale
to measure dimension s underlyin g adult attachmen t styles. In
Study 2 we explored specific aspects of working models by as-
sessing beliefs about the self, the social world, and romantic
love. Finally, in Study 3 we explored the relations among attach-
ment-style dimensions , partner choice, and relationshi p quality
in dating couples.
Study 1
As described , Hazan and Shaver (1987) translated the three
infant attachmen t styles into terms appropriat e for adult rela-
tionships. They then had subjects choose the one descriptio n
that best characterize d their feelings. Their measure is shown
in Table 1.
Although these description s are reasonabl e translation s of the
infant attachmen t styles, there are limitation s to this discrete
measure. First, each descriptio n contains statement s about
more than one aspect of relationship s (i.e., the "secure" de-
scription includes both being comfortabl e with closeness and
being able to depend on others). Thus, respondent s must accept
an entire descriptio n that may not reflect their feelings on all
dimensions . In addition, we are unable to assess the degree to
which a style characterize s a person. Finally, the discrete mea-
sure assumes that there are three mutally exclusive styles of at-

646 NANCY L. COLLIN S AND STEPHE N J. READ
Table 1
Hazan and Shaver's  (1987) Attachment  Style Measure
Question: Which of the following best describes your feelings?
1. Secure—I find it relatively easy to get close to others and am
comfortabl e dependin g on them and having them depend on me. I
don't often worry about being abandone d or about someone
getting too close to me.
2. Avoidant —I am somewha t uncomfortabl e being close to others; I
find it difficult to trust them, difficult to allow myself to depend on
them. I am nervous when anyone gets too close, and often, love
partners want me to be more intimate than I feel comfortabl e
being.
3. Anxious/Ambivalent —I find that others are reluctant to get as close
as I would like. I often worry that my partner doesn't really love me
or won't want to stay with me. I want to merge completel y with
another person, and this desire sometime s scares people away.
Note. From "Romanti c Love Conceptualize d as an Attachmen t Pro-
cess" by C. Hazan and P. Shaver, 1987, Journal of Personality  and So-
cial Psychology,  52, p. 515, Table 2. Copyrigh t 1987 by the American
Psychologica l Association . Adapted by permission .
tachment. We are unable to examine possible relations among
styles or evaluate whether three styles are the "best" or most
valid descriptio n of adult attachment . The purpose of Study 1
was to develop a more sensitive scale to measure attachmen t
and to gain a better understandin g of the nature of adult attach-
ment styles.
Method
Subjects
Participant s were 406 undergraduate s at the Universit y of Southern
California who participate d for extra credit in their introductor y psy-
chology course. The sample included 206 women and 184 men (16 sub-
jects did not report their sex), ranging in age from 17 to 37, with a mean
of!8.8.
Materials  and Procedure
An initial 21-item scale was developed based on Hazan and Shaver's
(1987) adult attachmen t description s and additiona l characteristic s of
the three attachmen t styles as described in the developmenta l literature .
First, Hazan and Shaver's paragraph s were broken down into their com-
ponent statements , each forming one scale item. This resulted in 15
items, 5 for each attachmen t style.
On the basis of description s of infant attachmen t (Ainsworth , 1982;
Ainswort h et al., 1978; Maccoby, 1980), there seem to be two importan t
aspects of attachmen t not included in Hazan and Shaver's (1987) mea-
sure. The first concerns beliefs about whether the attachmen t figure will
be available and responsiv e when needed, which is a primary dimensio n
thought to underlie difference s in attachmen t style. Therefore we devel-
oped three statements , each characterizin g one of the styles with respect
to confidenc e in the availabilit y and dependabilit y of others. The second
aspect concerns reactions to separatio n from the caretaker , which is an
important criterion for categorizin g infants into styles. We developed
three items, each characterizin g one of the attachmen t styles with re-
spect to separatio n and phrased in terms appropriat e for adult relation-
ships.
The scale contained a final pool of 21 items, 7 for each style. Subjects
rated the extent to which each statemen t described their feelings on a
scale ranging from not at all characteristic  (1) to very characteristic  (5).
The scale, called the Adult Attachmen t Scale, was included in a packet
of questionnaire s that was given to students at the start of the semester
in their introductor y psycholog y class.Results
Factor Analysis
The 21 scale items were factor analyzed using Statistica l
Package for the Social Sciences (SPSS). Initial orthogona l rota-
tion produced a number of items that loaded on more than one
factor, suggestin g that the underlyin g dimension s might be cor-
related. This was supported by an oblique rotation which re-
sulted in several moderatel y correlate d factors and a much
cleaner factor solution. Therefore , oblique rotation (d = 0) was
used to obtain the final solution.
After rotation, the three items concernin g responses to sepa-
ration loaded on a single factor that had an eigenvalu e less than
1 and did not account for substantia l variance. When fewer fac-
tors were rotated, the three items loaded on more than one fac-
tor. Thus, they were deleted from further analyses, leaving 18
scale items. After joint consideratio n of Kaiser's eigenvalu e cri-
terion (retainin g only factors with eigenvalue s greater than 1)
and a scree test, three factors were extracted for the final solu-
tion.
Factor loadings and variance accounted for after rotation are
shown in Table 2. Only loadings of .3 or larger were interprete d
as defining a factor (with the exception of Item 18, whose high-
est loading was .29). The first factor contained items concernin g
the extent to which subjects could trust others and depend on
them to be available when needed. Factor 2 consisted of items

reflecting anxiety in relationships , such as fear of being aban-
doned and not being loved. The third factor containe d items
regarding the extent to which subjects were comfortabl e with
closeness and intimacy . On the basis of the items defining each
factor, we labeled them Depend, Anxiety, and Close, respec-
tively.
Factor 1 (Depend) and Factor 3 (Close) were moderatel y cor-
related (.41), suggestin g that people who felt they could depend
on others tended to be more comfortabl e with getting close. Fac-
tor 2 (Anxiety ) was weakly correlate d with Factor 1 (.18) and
not at all related to Factor 3 (.01).
Internal Consistency
Cronbach' s alpha for the Depend, Anxiety, and Close items
were all reasonable : .75, .72, and .69 respectively . Thus, the six
items defining each factor were summed to form three compos-
ites. Several items were receded so that higher scores repre-
sented greater confidenc e in the dependabilit y of others, higher
anxiety, and more comfort with closeness. Consisten t with the
interfacto r correlations , there was a moderate relation between
the Close and Depend composite s (r = .38) and weak relations
between Anxiety and Close (r = —.08) and Anxiety and Depend
(r = -.24). The composit e scores were used in subsequen t anal-
yses.
Norms
The means and standard deviation s for the Depend, Anxiety,
and Close composite s were 18.3 and 4.7, 16.2 and 5.1, and 21.2
and 4.8, respectively . Male subjects (M = 22.0) were more com-
fortable with getting close than were female subjects (M — 20.6),
F( 1, 387) = 8.15, p < .01. No other sex difference s were found.

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 647
Table 2
Adult Attachment  Scale Items and Factor Loadings
Item Factor 1 Factor 2 Factor 3
Depend
1 . I find it difficult to allow myself to depend on others." (Av)
2. People are never there when you need them.' (Av)
3. I am comfortabl e depending on others. (S)
4. I know that others will be there when I need them. (S)
5. I find it difficult to trust others completely. " (Av)
6. I am not sure that I can always depend on others to be there
when I need them." (Ax)
Anxiety
7. I do not often worry about being abandoned. " (S)
8. I often worry that my partner does not really love me. (Ax)
9. I find others are reluctant to get as close as I would like. (Ax)
10. I often worry my partner will not want to stay with me. (Ax)
1 1 . I want to merge completel y with another person. (Ax)
1 2. My desire to merge sometime s scares people away. (Ax)
Close
1 3. I find it relatively easy to get close to others. (S)
14. I do not often worry about someone getting too close to me. (S)
15.1 am somewha t uncomfortabl e being close to others." ( Av)
16. I am nervous when anyone gets too close." (Av)
17. I am comfortabl e having others depend on me. (S)
1 8. Often, love partners want me to be more intimate than I feel
comfortabl e being." (Av)
Eigenvalu e before rotation
Percentage of variance after rotation15.54
.48
-.58
-.66
.38
.71
.03
.09
.10
.10
-.11
.05
-.16
.07
.05
-.02
-.03
.07
3.49
11.30-.18
.26
.24
-.18
.13
.14
-.48
.64
.47
.62
.49
.55
.02
.01
.04
.20
.08
-.03
1.80
11.50.06
.09
-.09
.03
.12
-.10
-.19
.21
-.13
.15
-.14
-.14
-.45
-.46
.71
.77
-.40
.29
1.01
10.80
Note. (S) Indicates items that originated from the "secure" description ; (Av), items that originated from the "avoidant " description ; and (Ax), items
that originate d from the "anxious" description .
" Item was recoded when forming the composite scores. b Because oblique rotation was used, the percentag e of variance accounted for after rotation
is only approximat e (Tabachnic k & Fidell, 1983).
There were no age differences , although the age range of our
sample was somewha t limited.
Test-Retest  Reliability
A subset (N= 101) of our sample complete d the attachmen t
scale again about 2 months later. Test-retes t correlation s for
Close, Depend, and Anxiety were .68, .71, and .52 respectively .
Items on the Anxiety factor may have been more closely tied to
a particula r relationshi p than were the Close and Depend items,
which may help account for the relatively lower stability of Anx-
iety scores. Overall, scores were fairly stable over a 2-month pe-
riod.
Attachment  Dimensions  Versus Discrete  Types
It is importan t to note that each factor was composed of
items from more than one of the original attachmen t style de-
scriptions . Factors 1 (Depend) and 3 (Close) contained items
from both the secure and avoidant descriptions , and Factor 2
(Anxiety) had items from both the anxious and secure descrip-
tions. Thus, the factor analysis did not provide three factors that
directly correspon d to the three discrete styles (secure, avoid-
ant, and anxious) but, instead, appears to have revealed three
dimension s (Close, Depend, and Anxiety ) that underlie the
styles. (In fact, obtainin g three orthogona l factors that corre-
spond to the three styles would have been highly unlikely. Itwould have suggested , for instance, that a person could be si-
multaneousl y secure and avoidant . Because the attachmen t
styles should be mutually exclusive, they were necessaril y corre-
lated.) As such, examinin g how the dimension s related to the
discrete types would provide a better understandin g and more
precise definition of the attachmen t styles. That is, it may clarify
what we mean when we say that someone has a secure or anx-
ious style of attachmen t in adulthood . In addition, by translat-
ing the dimension s back into styles, we can more clearly inte-
grate the current work with prior research and theory on attach-
ment.
One way to accomplis h this is to examine scores on the at-
tachment scale for people who choose each of Hazan and Sha-
ver's (1987) attachmen t description s (see Table 1). We had a
subset (« = 113) of our sample complete this discrete measure
about 2 weeks later: 63% classified themselve s as secure, 27% as
avoidant, and 10% as anxious. Mean scores on the attachmen t
dimension s for each attachmen t style are shown in the top panel
of Table 3.
To more systematicall y examine the relation between attach-
ment dimension s and attachmen t styles, we performe d a dis-
criminant function analysis on scale scores using paragrap h
choice as the grouping variable. Two discriminan t function s
were calculate d with a combined \2(6, N = 113) = 43.71, p <
.001. After removal of the first function, the second function
still accounted for significan t variance, x2(2, N = 113)= 13.59,

648 NANCY L. COLLIN S AND STEPHE N J. READ
Table 3
Mean Adult Attachment  Scale Scores for the Three Attachment
Types as Classified  by Hazan and Shaver's (1987)
Measure and a Discriminant  Analysis:  Study 1Table 4
Standardized  Discriminant  Function  Coefficients
Adult attachmen t scale
dimension
Hazan & Shaver's measure
n
Close
Depend
Anxiety
Discriminan t analysis
n
Close
Depend
AnxietyAttachmen t style
Secure
71
22.28a
20.13a
14.44a
86
22.49a
20.12a
14.36aAvoidant
31
17.77b
16.39b
15.52a
23
15.17b
14.82b
17.00bAnxious
11
22.36a
19.91a
20.00b
4
23.00a
20.25a
26.00CF
(2, 1 10)
—
14.31**
8.04**
6.62*
—
47.26**
14.22**
15.38**
Note. Scores had a possible range of 6 to 30. Within each row, means
with different subscript s differed significantl y at p < .05 according to a
Scheffetest .
*p<.01. **p<.001 .
p < .001. The two functions accounted for 70.57% and 29.43%,
respectively , of the between-group s variability .
As shown in Figure 1, the first discriminan t function sepa-
rated the avoidant from the secure and anxious types. The sec-
ond function discriminate d the anxious from the secure and
avoidant types.
Standardize d discriminan t function coefficient s are pre-
sented in Table 4. For the first discriminan t function, the pri-
mary variable distinguishin g the avoidant style from the other
two styles was feelings about closeness (Close) and, to a lesser
extent, feelings about the dependabilit y of others (Depend). On
the second function, only feelings about being abandone d or
unloved (Anxiety ) discriminate d the anxious type from the
other two styles.Adult
attachmen t scale
Close
Depend
AnxietyFunction 1
.839
.348
.077Function 2
-.022
.109
1.101
Using the discriminan t weights and prior group membershi p
probabilities , we correctly classified 73% of the total sample.
However, accuracy rates among the separate styles varied con-
siderably. Ninety-tw o percent of the secure group, 45% of the
avoidants, and 27% of the anxious were correctly classified. The
discriminan t functions misclassifie d half of the avoidant sub-
jects into the secure category and about one third of the anxious
subjects as secure and another third as avoidant. Mean scores
on Close, Depend, and Anxiety for each of the types as classified
by the discriminan t analysis are presented in the lower panel of
Table 3. Compariso n of these means with those in the upper
panel, based on Hazan and Shaver's (1987) measure, shows very
similar patterns.
The results in Table 3 indicate that a person with a secure
attachmen t style was comfortabl e with closeness, able to de-
pend on others, and not worried about being abandoned or un-
loved. An avoidant individua l was uncomfortabl e with close-
ness and intimacy, not confident in others' availability , and not
particularl y worried about being abandoned . Finally, an anx-
ious person was comfortabl e with closeness, fairly confident in
the availabilit y of others, but very worried about being aban-
doned and unloved.
Although the discriminan t analysis is an important descrip-
tive tool, it could not completel y overcome the limitation s of
Hazan and Shaver's (1987) measure because it used that mea-
sure to assign people to groups. Of particular concern was that
FUNCTIO N
21.5
1.0-
0.5-
o.o-
-0.5-
-1.0-
-1.5AVOIDAN TANXIOUS
SECURE
-1.5 -1. 0 -0. 5 0. 0 0. 5
FUNCTIO N 11.0 1.5
Figure I. Three group centroids on two discriminan t functions derived
from the three Adult Attachmen t Scale dimensions .

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 649
we were still assuming there were three attachmen t styles and
that by choosing one descriptio n adults could adequatel y assign
themselve s to a category. In addition, the attachmen t scale was
based largely on Hazan and Shaver's (1987) original attachmen t
measure, so using one to validate the other may be problematic .
One way to overcome these problems would be to use a clus-
tering procedure to determin e whether there are distinct clus-
ters of people and whether the clusters differ in ways consisten t
with theoretica l conception s of the three attachmen t styles, in-
dependent of Hazan and Shaver's (1987) measure. Although
cluster analysis is only an explorator y tool, if such clusters were
found it would increase our confidenc e in the three styles as
discrete types, and provide another mechanis m for translatin g
the dimension s into styles.
In order to compare results of the cluster analysis with those
of the discriminan t analysis, the same subsampl e of 113 sub-
jects was examined . A cluster analysis using Ward's method and
squared Euclidea n distance was performe d using the Cluster
subprogra m of SPSSX. Scores on the Close, Depend, and Anxi-
ety scales were used as the clustering variables.
The first task was to determine the number of distinguishabl e
clusters in the sample. Several heuristic technique s have been
suggested for this. One procedur e is to graph the number of
clusters (on the Faxis) against the amalgamatio n coefficien t (on
the X axis), which represents the within-grou p variance or de-
gree of similarit y among cluster member s (Aldenderfe r &
Blashfield , 1984). The curve is then examined for the point at
which it flattens, suggesting that similarity among cluster mem-
bers has been greatly reduced. This is similar to a scree test in
factor analysis. From this, the curve began to flatten after the
three-cluste r solution and was basically flat at the two-cluste r
solution, implying three clusters in the data.
A second, related procedur e is to examine the amalgamatio n
coefficien t for each of various cluster solutions (starting with
the maximum number of clusters and working downward ) to
discover a significan t jump in the value of the coefficient . A
jump implies that two relatively dissimila r clusters have been
merged, suggestin g that the number of clusters prior to the
merger is the most probable solution (Aldenderfe r & Blashfield ,
1984). On this basis, a jump was observed between the three-
and two-cluste r solutions, implying again that the three-cluste r
solution was appropriate . One of the limitation s of this proce-
dure is that it is difficult to determin e what constitute s a large
jump. In the present sample, the jump occurring between the
two- and three-cluste r solution was fairly large; however, there
was a slightly smaller jump between the three- and four-cluste r
solution. This suggested that a four-cluste r solution may be an
appropriat e descriptio n of the sample as well. However, in the
absence of other evidence suggestin g a four-cluste r solution, we
chose a three-cluste r solution.
On the basis of these heuristic procedures , a three-cluste r so-
lution seemed an adequate representatio n of the data. Because
these procedure s are subjective , it was importan t to replicate
the cluster solution with an independen t sample. Therefore , a
cluster analysis was performed on the Study 2 sample and three
clusters were again obtained. Thus, although the heuristic pro-
cedures must be viewed with caution, the cross-validatio n in-
creased our confidenc e in the three-cluste r solution.
Next, we examined the mean scores on Close, Depend, andTable 5
Mean Adult Attachment  Scale Scores
for Three Clusters:  Study 1
Cluster
Adult
attachmen t scale 1 2  3
dimension (Secure ) (Anxious ) (Avoidant ) F(2,110)
n
Close
Depend
Anxiety53
23.36.
21.28.
12.50.43
19.74b
17.45b
20.28b17
16.38C
16.00b
11.71,_
27.32*
14.92*
91.81*
with different subscripts differed significantl y at p < .05 according to a
*p<.001.
Anxiety for subjects within each of the three clusters to see how
they were characterize d (see Table 5).
Difference s between clusters on the attachmen t dimension s
corresponde d closely to the three attachmen t styles as defined
earlier. Subjects assigned to Cluster 1, with high scores on Close
and Depend coupled with low scores on Anxiety, appeared to
have a secure attachmen t style. Cluster 2 revealed high scores
on Anxiety coupled with moderate scores on Close and De-
pend, which fit well with an anxious attachmen t type. Finally,
Cluster 3 had low scores on Close, Depend, and Anxiety, sug-
gesting this may be an avoidant cluster.
Thus, the cluster analysis resulted in clusters that seemed to
correspon d to the three attachmen t styles. However , the per-

centage of subjects assigned to each style (or cluster) differed
somewhat from that obtained by either Hazan and Shaver's
(1987) measure or the discriminan t analysis (see Table 4). The
cluster analysis resulted in more people being identified as anx-
ious, most of whom had been previousl y categorize d as secure.1
In addition, although the three methods of classifyin g resulted
in the same pattern of group difference s on the attachmen t style
dimensions , the cluster analysis appeared to maximiz e these
differences .
Discussion
The attachmen t system in adults is believed to function in
much the same way as the infant system with the set goal of "felt
security." The dimension s measured by Close, Depend, and
1 As indicated previously , there was some evidence to suggest that a
four-cluste r solution may also be an appropriat e description of our sam-
ple. To explore this further, we assigned people to one of four clusters
and examined mean scores on the attachmen t dimension s for each clus-
ter. People previously assigned to the secure and avoidant groups (based
on the three-cluste r solution) did not shift. However, people previously
denned as anxious now split into two clusters: those in the first cluster
had high scores on Close, Depend, and Anxiety, whereas those in the
second cluster had high scores on Anxiety, but very low scores on Close
and Depend. Thus, the four-cluste r solution appeared to differentiat e
two groups of anxious people: those who were anxious but comfortabl e
with closeness (anxious-secure ) and those who were anxious and un-
comfortabl e with closeness (anxious-avoidant) .

650 NANCY L. COLLIN S AND STEPHE N J. READ
Anxiety seem to capture fundamenta l aspects of adult attach-
ment that have important conceptua l links to those thought to
be central to infant attachment . For instance, the most central
theme underlyin g the nature of the infant-caretake r relation-
ship is the child's expectatio n that the caretaker will be available
and emotionall y responsiv e when needed. Both the Depend and
Anxiety scales measured aspects of these expectation s for
adults. Another importan t componen t of the attachmen t orga-
nization is the desire for close contact with the attachmen t fig-
ure and the child's response to that contact. This componen t
was measured by the Close scale.
Further, these dimension s are conceptuall y similar to ones
obtained by Ainswort h et al. (1978). These researcher s ob-
served infants with different attachmen t styles and rated them
on a number of behaviora l scales. Using discriminan t analysis,
they identifie d two dimension s that differentiate d the three
styles. The first dimensio n consisted of behaviors related to
seeking and maintainin g close physical contact with the care-
taker, and it separated the avoidant from the secure and anx-
ious/ambivalen t groups. The second dimensio n reflected severe
separation anxiety, and it differentiate d the anxious/ambivalen t
from the secure and avoidant groups. It is particularl y notewor-
thy that our discriminan t analysis uncovered two conceptuall y
similar dimension s that revealed the same pattern of differen-
tiation among the three styles. Function 1 (made up of Close
and Depend) separated the avoidant from the secure and anx-
ious styles, and Function 2 (made up of Anxiety) differentiate d
the anxious from the secure and avoidant adults.
Thus, we believe that the dimension s measured by the Adult
Attachmen t Scale capture much of the core structure s that are
thought to underlie difference s in attachmen t styles. These di-
mensions can be seen as guiding principle s that determine how
the attachmen t system manifest s itself in adult relationships .
They concern beliefs and expectation s that are fundamenta l to
feelings of security in adulthood , such as whether a partner will
be responsiv e and available when needed, whether one is com-
fortable with close contact and intimacy, and confidenc e about
whether a partner will continue to be loving. And, like child-
hood attachment , beliefs and expectation s about these security
issues should have importan t implication s for behavior in a
wide range of relationship s and situations .
Several consideration s suggest that the Adult Attachmen t
Scale offers practical and theoretica l advantage s over Hazan and
Shaver's (1987) discrete measure. First, by measurin g underly-
ing dimensions , we obtained a more sensitive measure of adult
attachmen t and more precise definitio n of the three styles.
However, although the dimension s can be translated into styles,
there often are advantage s to a dimensiona l analysis. For in-
stance, a limitation of discrete measures is that inevitably some
members "better" represent the category than others. Without
assessment s of the dimension s that define category member-
ship, we lose valuable informatio n on difference s among cate-
gory members , which may weaken or distort difference s be-
tween categories .
This may be one reason why assignmen t to types based on
the cluster and discriminan t analyses did not always match the
assignmen t based on Hazan and Shaver's (1987) measure. For
example, some people who classified themselve s as secure by
Hazan and Shaver's measure were later classified as anxious bythe cluster analysis. This may have been because in addition to
high scores on Close and Depend, this group also had high
scores on Anxiety. Similarly, the discriminan t analysis classified
some of the anxious (accordin g to Hazan and Shaver's measure)
into the avoidant category. Those who shifted tended to have
high scores on Anxious and very low scores on Close and De-
pend. In general, the classificatio n of the anxious group was rel-
atively poor. These findings suggest there may be two types of
anxious people, (see Footnote 1). More important , they demon-
strate that assigning people to discrete categories may result in
groups whose members share some features but differ consider-
ably on other dimensions . A dimensiona l measure of attach-
ment helps us detect these importan t individua l differences .
Finally, when exploring relations between attachmen t and
other variables of interest, a dimensiona l scale helps determine
which componen t of attachmen t most strongly contribute s to a
particular relation. It is relatively easy to make the transition
from dimension s to styles, both conceptuall y and statistically ,
but there is no way to separate out dimension s if we have only
category assignments . Thus, the Adult Attachmen t Scale allows

us to assess dimension s that underlie attachmen t styles without
losing the importan t conceptua l framewor k that ties them to-
gether.
Study 2
The purpose of Study 2 was to examine relations between
adult attachmen t styles and general mental representation s of
oneself, others, and romantic relationships . Hazan and Shaver
(1987) found that difference s in adult attachmen t were related
to different beliefs about oneself and others in ways consisten t
with attachmen t theory. Although their measures were some-
what limited (consisting of 15 true-false items), their work pro-
vided encouragin g initial evidence for the link between adult
attachmen t and working models. Because working models are
central to understandin g continuit y in attachmen t styles, they
must be explored in greater depth.
We began by specifyin g several broad aspects of working
models that should be closely related to attachmen t experience .
Then, as a first step, we relied on existing scales that should
measure aspects of those working models. One set of scales fo-
cused on component s of one's model of self, such as self-esteem ,
belief in one's ability to control the outcomes in one's life, and
various interpersona l qualities such as expressivenes s and re-
sponsivenes s to others. A second set of scales assessed models
of the social world in general, including aspects of trust and
beliefs about human nature such as whether people are altruis-
tic or difficult to understand . Finally, we measured beliefs and
attitudes about romantic love by assessing love styles.
A second aim of this study was to explore the relation be-
tween working models and attachmen t history. We expected to
find a direct associatio n between beliefs about oneself and the
social world in adulthood and reports of relationship s with par-
ents in childhood .
A final aim was to further evaluate the Adult Attachmen t
Scale and compare results using this dimensiona l scale with re-
sults based on discrete styles. As in Study 1, discriminan t and
cluster analyses were performe d and used to assign people to
attachmen t styles. Because of space limitations , the details of

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 651
Table 6
Descriptions  of Parental Caregiving  Style
1. Warm!Responsive —She/he was generally warm and responsive ;
she/he was good at knowing when to be supportiv e and when to let
me operate on my own; our relationshi p was almost always
comfortable , and I have no major reservation s or complaint s
about it.
2. Cold/'Rejecting —She/he was fairly cold and distant, or rejecting,
not very responsive ; I wasn't her/his highest priority, her/his
concerns were often elsewhere ; it's possible that she/he would just as
soon not have had me.
3. Ambivalent/Inconsistent —She/he was noticeably inconsisten t in
her/his reactions to me, sometime s warm and sometime s not; she/
he had her/his own agendas which sometime s got in the way of her/
his receptivenes s and responsivenes s to my needs; she/he definitely
loved me but didn't always show it in the best way.
Note. From Kazan & Shaver's (1986) unpublishe d questionnaire . Re-
printed by permission .
these results are presented in tables only. Our primary focus is
on results based on the Adult Attachmen t Scale dimensions .
Method
Subjects
Subjects were 80 female and 38 male undergraduate s at the Universit y
of Southern Californi a who participate d for extra credit in their intro-
ductory psycholog y class. Subjects ranged in age from 17 to 24, with a
mean of 18.6.
All measures were administere d in a questionnaire . The first section
obtained backgroun d informatio n such as age, sex, race, and religious
preference , as well as the 18-item Adult Attachmen t Scale described in
Study 1. In addition, respondent s were asked to rate on a 9-point scale
the extent to which each of Hazan and Shaver's (1987) three attachmen t
description s characterize d them. To assess perception s of attachmen t
history with parents, we asked subjects to read three paragraph s de-
scribing the caregivin g characteristic s associated with a particula r at-
tachment style: One described a warm/responsiv e parent, a second de-
scribed a cold/rejectin g parent, and the third described an ambivalent /
inconsisten t parent. For each parent, subjects rated on a 9-point scale
the extent to which each descriptio n characterize d their relationshi p
with this parent while they were growing up. These items were devel-
oped by Hazan and Shaver (1987) and are shown in Table 6.
Two measures of self-estee m were included: the Rosenber g Self-Es-
teem Scale (RSE; Rosenberg , 1965), which focuses on general self-ac-
ceptance, and the Texas Social Behavior Inventory (TSBI; Helmreic h &
Stapp, 1974), which measures the extent to which a person feels self-
assured in social situations . Next, subjects completed the Personal Attri-
butes Questionnair e (PAQ; Spence & Helmreich , 1978), which contains
two subscales of interest: Instrumentalit y and Expressiveness.2 The In-
strumentalit y scale measures agency and self-assertiveness , and the Ex-
pressivenes s scale measure s interpersonall y oriented characteristic s
such as being kind and aware of others (Helmreich , Spence, & Wilhelm,
1981; Spence, 1983; Spence & Helmreich , 1980).
Next, subjects complete d the Opener Scale (Miller, Berg, & Archer,
1983), which measures the extent to which people perceive themselve s
to be warm and responsiv e listeners, and able to get others to "open up"
about themselves . Dion and Dion (1978, 1985) argued that response to
another's self-disclosur e is an importan t aspect of intimacy, and theysuggested that early attachmen t relationship s may influence one's ca-
pacity for psychologica l intimacy.
The first scale used to assess models of the social world was the Rotter
Trust Scale (Rotter, 1967), which measures three dimension s of trust
(Stein, Soskin, & Korchin, 1974): belief in the integrity of social role
agents (e.g., elected officials and the judiciary) , belief in the trustworthi -
ness of human motives, and belief in the dependabilit y of others. Next,
subjects completed Wrightsman' s Philosophie s of Human Nature Scale
(PHN; Wrightsman , 1964). This 84-item scale is composed of six sub-
scales measurin g general beliefs about various aspects of human nature
and social behavior: Trustworthiness , Altruism , Independenc e (the ex-
tent to which people maintain their conviction s in the face of social
pressures to conform) , Strength of Will and Rationalit y (the extent to
which people have control over the outcomes in their lives), Complexit y
of Human Nature, and Variabilit y in Human Nature (the extent to
which people are unique and able to adapt or change their basic nature
over time or circumstances) .
To assess beliefs about romantic love, we asked subjects to complete
the revised Love Attitudes Scale (LAS; Hendrick & Hendrick , 1986),
based on Lee's (1973, 1977) typology of love styles. Lee argued that
people experience , show, and think about love differently , and he pro-

posed six styles of loving: Eros (passionat e love), Storge (friendshi p love),
Ludus (game-playin g love), Agape (selfless love), Mania (obsessive/de -
pendent love), and Pragma (logical love). The LAS has six subscales ,
each measurin g one love style. Subjects were asked to complete the scale
with their current or most importan t romantic partner in mind. If they
had never been in love, they were asked to answer in terms of what they
thought their feelings would most likely be.
Subjects complete d the questionnair e in small groups of 5 to 10. They
were allowed as much time as they needed, and most finished within 1
hr. Because of the number of scales and the length of the questionnaire ,
the two self-estee m scales and the trust scale were included as part of
another questionnair e study (N = 118). The two studies were conducted
within 1 month of each other and used the same subject pool.
Results
Assigning  Individuals  to Attachment  Styles
Two methods were used to assign people to attachmen t types.
First, a discriminan t analysis was performe d using scores on
Close, Depend, and Anxiety as the predictor variables and Ha-
zan and Shaver's (1987) discrete measure as the grouping vari-
able. (Because subjects rated each of Hazan and Shaver's three
description s separately , they were assigned to the one category
they rated the highest.) Results were very similar to those ob-
tained in Study 1. Using the discriminan t weights, and prior
group membershi p probabilities , each person was classified as
secure, avoidant, or anxious. Consisten t with Study 1, two dis-
criminant functions were obtained, combined x2(6, N = 118) =
73.74, p < .001. After removal of the first function there was
still significan t discriminatin g power for the second function ,
2 The two subscales of the Personal Attribute s Questionnair e (PAQ)
are more commonl y known as Masculinit y and Femininity . However,
the authors of the PAQ have noted that the subscales do not measure a
wide range of characteristic s associated with being masculin e or femi-
nine. The scales are much more narrowly defined, and the authors urge
users of the PAQ to treat them as measures of "expressiveness " and
"instrumentality " and not traditiona l masculinit y and femininit y
(Helmreich , Spence, & Wilhelm, 1981; Spence, 1983; Spence & Helm-
reich, 1980).

652 NANCY L. COLLIN S AND STEPHE N J. READ
X2(2, N = 118) = 24.82, p < .001. The two functions accounted
for 69.11% and 30.89%, respectively , of the between-group s
variability . Function 1 was defined by scores on Close and De-
pend and discriminate d the secure and anxious types from the
avoidant types. Function 2 was defined by scores on Anxiety
and discriminate d the secure and avoidant from the anxious
types. Using the discriminan t weights and prior group member-
ship probabilities , we correctly classified 76% of the total sam-
ple. Within the three attachmen t categories , 85% of the secure,
65% of the avoidant, and 58% of the anxious subjects were clas-
sified correctly, which is an improvemen t over the classificatio n
match obtained in Study 1.
A cluster analysis was the second method used to assign peo-
ple to attachmen t types, and, as in Study 1, two heuristic proce-
dures were used to determin e the optimal number of clusters.
First, we graphed the number of clusters against the amalgama -
tion coefficient . The curve began to flatten after the three-clus -
ter solution and was basically flat after the two-cluste r solution,
suggesting three clusters in the data. Second, we examined the
amalgamatio n coefficien t and discovered a fairly large jump be-
tween the two- and three-cluste r solution, again suggesting that
the three-cluste r solution was a good representatio n of the data.
These results confirmed those of Study 1 and increased our con-
fidence in the three-cluste r solution. Attachmen t dimensio n
scores for subjects within each cluster were then evaluated. Like
Study 1, the clusters corresponde d well to the three attachmen t
styles. Each cluster was then labeled as one of the styles, thus
categorizin g subjects as secure, avoidant, or anxious. Mean
scores on Close, Depend, and Anxiety for attachmen t styles, as
classified by the two methods, are shown in Table 7.3 Consisten t
with Study 1, both methods resulted in a similar pattern of
mean differences , but the cluster analysis tended to maximize
these differences . Therefore results related to the discrete types
were based on the cluster analysis only.
Working Models of Self
Correlation s between the Adult Attachmen t Scale and the
RSE, the TSBI, PAQ, and Opener Scale are presented in the top
Table 7
Adult Attachment  Scale Scores for the Three Attachment
Types as Classified  by Discriminant
and Cluster Analyses:  Study 2
Adult attachmen t
scale dimension
n
Close
Depend
Anxiety
Cluster analysis
n
Close
Depend
Secure
74
23.21,
20.08a
13.68a
39
23.72a
23.38a
14.95aAvoidant
30
16.03b
16.62b
14.93a
31
19.19b
16.90b
10.07aAnxious
14
19.92C
15.79b
21.86b
49
19.86b
15.96b
17.94bF(2, 116)
—
85.65*
12.30*
28.87*
—
18.01*
94.09*
55.13*
Scheffe test.
*p<Ml.Table 8
Correlations  Between the Adult Attachment  Scale Dimensions
and Mental Models of Self and the Social World
ScaleAdult attachmen t scale
Close Depen d Anxiet y
Rosenberg Self Esteem Scale
(Rosenberg , 1965) .19* * .13 -.29*** *
Texas Social Behavior Inventory
(Helmreic h & Stapp, 1974) .29** * .22** -.30*** *
Personal Attributes Questionnair e
(Spence & Helmreich , 1978)
Instrumentalit y .0 4
Expressivenes s .38*** *
Opener Scale (Miller, Berg, & Archer,
1983) .15 *
Rotter Trust Scale (Rotter, 1967)
Integrity of Social Agents .20* *
Trustworthines s of Human Motives . 14
Dependabilit y of People .22* *
Philosophie s of Human Nature
(Wrightsman , 1964)
Trust .22* *
Altruism .19* *
Independenc e .30*** *
Strength of Will .19* *
Complexit y .  11
Variability .20* *
Love Attitudes Scale (Hendrick &
Hendrick, 1986)-.02
.31****
.13
.20**
.13
.24***-.48****
.01
-.06
-.08
-.10
.02
.30****
.28***
.40****
.35****
.10
.18**.16*
-.27***
.17*
.18**
.30****
.07
Eros
Ludus
Storge
Pragma
Mania
Agape.05
-.33****
-.24***
-.35****
-.15*
.20**.15*
-.16*
-.13
-.15*
-.02
.09-.02
.03
.02
.05
.52****
.16*
Note. All p values are for two-tailed tests.
*/7<.10. **p<.05 . ***/>< .01. ****p<.001 .
section of Table 8. People who were comfortabl e with closeness
and able to depend on others had greater feelings of self-worth
and social confidenc e and were higher in expressiveness . Indi-
viduals who were high on the dimension of Anxiety had a lower
sense of self-worth and social self-confidence , and were much
lower in instrumentality .
Overall, these results suggest that subjects with a more secure
attachmen t style (as indexed by high scores on Close and De-
pend and low scores on Anxiety) had a more positive view of
themselve s than did subjects who were either avoidant (low
scores on Close, Depend, and Anxiety) or anxious (high scores
on Anxiety). This was confirmed by results shown in Table 9,
3 There are several reasons why we did not use Hazan and Shaver's

(1987) measure to assign people to categories . First, as described in
Study 1, there are a number of problems with this measure on a theoret-
ical level. Second, on a more practical level, compared with the other
methods of classifyin g people, Hazan and Shaver's measure resulted in
the smallest difference s between groups on the attachmen t dimension s
(Close, Depend, and Anxiety) . Finally, because assignmen t from the
discriminan t analysis was so similar to that based on Hazan and Sha-
ver's measure (76% classificatio n match), presentin g results for both
would be largely redundant .

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 653
Table 9
Mean Differences  on Mental Models Scales for Three Attachment
Types as Classified  by Cluster Analysis
Scale
Rosenberg Self Esteem Scale (Rosenberg , 1965)
Texas Social Behavior Inventory (Helmreic h &
Stapp, 1974)
Personal Attribute s Questionnair e (Spence &
Helmreich , 1978)
Instrumentalit y
Expressivenes s
Opener Scale (Miller, Berg, & Archer, 1983)
Integrity of Social Agents
Trustworthines s of Human Motives
Dependabilit y of People
Philosophie s of Human Nature (Wrightsman , 1964)
Trust
Altruism
Independenc e
Strength of Will
Complexit y
Variability
Love Attitudes Scale (Hendrick & Hendrick, 1986)
Eros
Ludus
Storge
Pragma
Mania
AgapeSecure
3.53.
3.75.
30.08
33.36.
4.08
2.78.
2.43.
3.24.
3.57
4.11.
4.27.
4.84.
4.36
5.15
3.97
2.36
3.67
2.60.
3.02.
3.62.Avoidant
3.49
3.46
31.74.
30.32b
4.01
2.4Gb
2.16b
2.76b
3.35
3.81
3.86b
4.50
4.00.
4.87
3.76
2.75
3.82
3.15
2.53b
3.26bAnxious
2.26b
3.38b
27.67b
31.80
3.95
2.63.
2.18*
3.14.
3.24
3.64,,
3.7 lb
4.35b
4.40b
5.04
3.74
2.60
3.97
3.01b
3.20,
3.66F
3.64**
5.01***
6.78***
3.72**
ns
5.48***
3.39**
7.12****
2.44*
4.88***
8.32****
6.22***
4.15**
2.44*
ns
ns
2.70*
4.63***
8.85***
3.71**
Note. Within each row, means with different subscript s differed at p < .05 according to a Scheffe test. ivvie. wmiiii cawii luw, means wim unicicm buuaciip
*p<.10. **p<.05 . ***p<.01 . ****p<.001 .
which presents mean scores on our mental models items for the
three attachmen t types as classified by the cluster analysis.
Working Models of the Social World
Rotter Trust Scale and PHN are shown in the middle section of
Table 8. These results indicate that subjects who were comfort-
able with intimacy (Close) and felt others were available when
needed (Depend) were more trusting in general and more likely
to believe people are altruistic, willing to stand up for their be-
liefs (Independence) , able to control the outcomes in their lives
(Strength of Will), and able to adapt their behavior across situa-
tions or over time (Variability) . In contrast, subjects who scored
high on the Anxiety scale believed others to be less altruistic
and more likely to conform to social pressures , and believed
that human nature is complex and difficult to understan d
(Complexity) .
Thus, subjects with a more secure attachmen t style (high
scores on Close and Depend, and low scores on Anxiety) tended
to have more positive views about the social world and about
human nature in general, whereas avoidant and anxious sub-
jects tended to have more negative and mistrustin g views of oth-
ers. This was confirme d by the results based on the discrete
types, as shown in Table 9.
Working Models of Love
LAS are shown in the lower section of Table 8. Subjects com-fortable with closeness were less likely to have a love style char-
acterized as game playing (Ludus), friendship based (Storge), or
logical (Pragma) , and were more likely to be characterize d by
selfless love (Agape). The Depend scale was not significantl y re-
lated to the LAS, but subjects who were worried about being
abandoned or unloved were much more likely to exhibit an ob-
sessive/dependen t love style (Mania).
Overall, higher scores on the Close scale, which are associated
with a more secure attachmen t style, were related to views of
love that were more romantic and less practical, whereas scores
on the Anxiety scale, which is associated with an anxious style,
were strongly related to an obsessive/dependen t love style. This
was confirme d by results shown in Table 9.
Relations  Between Parenting  Style and Working Models
To assess the relation between attachmen t style dimension s
and attachmen t history, we correlated items measurin g percep-
tions of parents' caregivin g style (Table 6) with scores on Close,
Depend, and Anxiety. As shown in the upper section of Table
10, subjects who perceived their relationshi p with their mother
and father as warm and not rejecting were more likely to feel
that they could depend on others and less likely to be anxious
about being abandone d or unloved. In addition, subjects who
remembere d their mother as being warm and responsiv e were
more comfortabl e with closeness and intimacy. Finally, ambiva-
lent/inconsisten t motherin g was associated with low scores on
Depend and higher scores on Anxiety. Thus, consisten t with

654 NANCY L. COLLIN S AND STEPHE N J. READ
Table 10
Correlations  Among Parents' Caregiving  Style, Adult Attachment  Scale
Dimensions,  and Mental Models Scales
Mother Father
Scale WarmCold Inconsisten t Warm Cold Inconsisten t
Adult Attachmen t Scale
Close
Depend
Anxiety
Mental models scales
Rosenberg Self-Estee m Scale
(Rosenberg , 1965)
Texas Social Behavior
Inventory (Helmreic h &
Personal Attribute s
Questionnair e (Spence &
Rotter Trust Scale (Rotter,
1967)
Trustworthines s of Human
Motives
Trust
Altruism
Variability.20**
.41****
-.23***
.25***
.23***
.14
.21**
.10
-.10
.32****
.17*
.18**
.17*
.23***
.12
-.03-.07
-.26***
.21**
-.19**
-.28***
-.08
-.05
.05
.14
-.20**
-.13
-.12
-.09
-.15*
-.04
-.02-.15*
-.27***
.20**
-.15*
-.24***
-.17*
-.03
.02
.14
-.12
.07
-.09
-.04
-.11
.10
.05.09
.21**
-.20**
.05
.14
.17*
.18**
.10
.07
.23***
.03
.11
.06
.18**
-.06
.03-.06
-.23***
.18**
-.01
-.06
-.11
-.11
-.18**
-.07
-.26***
-.20**
-.23***
-.25***
-.27***
.00
-.15*-.08
-.06
-.13
.03
-.05
-.13
-.02
-.05
-.09
-.20**
-.03
-.10
-.05
-.20**
.04
.00
*/><.10. **p<.05 . ***p<.01 . ****p<.001 .
attachmen t theory, memories of relationship s with parents were
related to subjects' feelings about security in adulthood . In gen-
eral, those with a more secure attachmen t style perceived their
parents to have been warm and not rejecting , whereas those
with an anxious attachmen t style reported their parents to have
been cold or inconsistent .
Next, to assess the relation between working models and at-
tachment history, we correlated items measurin g perception s
of parents' caregivin g style with measures of working models of
self and the social world. As shown in the lower section of Table
10, subjects who rated their mothers as cold or inconsisten t were
lower in self-wort h and social confidence , whereas those who
rated their mothers as warm tended to be higher in self-estee m
and expressiveness .
Correlation s with the Rotter Trust Scale showed the strongest
relation for the Dependabilit y of People subscale. Consisten t
with Bowlby's theory, greater trust in the dependabilit y of oth-
ers was related to subjects' perception s of their mothers and fa-
thers as having been warm and responsive , whereas perception s
of rejecting or inconsisten t parenting were associated with less
confidenc e in others.
Examinatio n of the PHN scale showed that subjects who per-
ceived their fathers as cold and rejecting viewed people as lesstrustworthy , altruistic, independent , and able to control the out-
comes in their lives, whereas subjects who perceived their moth-
ers as warm tended to view people more positively on these di-
mensions.
Sex Differences
Each of the preceding analyses was also conducte d separatel y
for men and women. The pattern of results for men and women
was very similar, and few significan t difference s were obtained.
Study 2 provides further evidence that difference s in attach-
ment are indeed linked to different patterns of beliefs about self
and others, in ways consistent with attachmen t theory. For ex-
ample, subjects who were comfortabl e with closeness and able
to depend on others (a more secure attachmen t style) had a
higher sense of self-worth , had greater social self-confidence ,
and were more expressive . Their beliefs about the social world
were also positive; they viewed people as trustworth y and de-
pendable, altruistic , willing to stand up for their beliefs, and
having control over the outcomes in their lives. Finally, subjects

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 655
who were comfortabl e with closeness were less likely to have a
love style characterize d as game playing, obsessive , logical, or
friendship based and more likely to have a style described as
selfless. This is partially consisten t with Levy and Davis's find-
ing (1988) (using Kazan and Shaver's [1987] attachmen t mea-
sure), that subjects with a more secure attachmen t style were
less game playing and more selfless in their love style.
Subjects with a more anxious attachmen t style (as indexed by
higher scores on the Anxiety scale) demonstrate d a very differ-
ent pattern, consisting largely of negative beliefs about self and
others. Greater anxiety in relationship s was associated with a
lower sense of self-worth and social self-confidenc e and lack of
assertivenes s or sense of control. In addition, higher Anxiety
scores were associated with a view of people as less altruistic ,
unable to control the outcomes in their lives, and complex and
difficult to understand . Finally, subjects who scored higher in
anxiety were much more likely to have an obsessive , dependen t
love style. This is consistent with Levy and Davis's (1988) find-
ing of a strong positive relation between anxious attachmen t
and a manic love style.
In addition, evidence was obtained for the relation between
attachmen t style dimension s and attachmen t history. In gen-
eral, subjects who perceived their relationshi p with their parents
as warm and not rejecting were more confident that they could
depend on others and were less anxious about being abandone d
or unloved. In contrast, those who remembere d their parents
as cold or inconsisten t scored higher on Anxiety and lower on
Depend. Moderate evidence was obtained for the link between
working models and attachmen t history. Overall, subjects who
perceived their parents to have been warm and responsiv e were
more likely to have positive views of themselve s and of human
behavior, whereas unresponsiv e or inconsisten t parenting was
associated with a more negative self-imag e and more negative
views of others. For example, subjects who perceived their par-
ents as warm and responsiv e believed others to be trustworth y
and dependabl e and believed that people have control over the
events in their lives. Subjects who perceived their parents as re-
jecting had lower self-esteem and were less likely to view others
as trustworth y or able to control the outcomes in their lives.
Of course, caution must be used in interpretin g these results
because they are based on retrospectiv e reports, which are sub-
ject to reconstructiv e errors and biases. Nevertheless , these
findings are encouragin g and suggest an area for future re-
search.
Finally, results based on the attachmen t dimension s were
very consisten t with those based on discrete types. However, the
attachmen t dimension s did reveal more significan t findings
(there were several cases in which the analysis by dimension s
revealed a relation that was not obtained with the analysis by
styles). Thus, the attachmen t scale provides a more sensitive
measure of attachment . Further, the analysis by dimension s
provides greater insight into the nature of the relations between
attachmen t and other variables , which can be very important ,
as was seen even more clearly in Study 3.
The results of Study 2 provide added support for the Adult
Attachmen t Scale and strong evidence that difference s in adult
attachmen t are related to working models of self and social rela-
tionships. These difference s should have an importan t impact
on interaction s in all types of social encounters , and may beparticularl y importan t in adult romantic relationships . To ex-
plore this further, in Study 3 we examined the relation of attach-
ment style dimension s to the nature and quality of ongoing dat-
ing relationships . In discussing this study, we present results for
the attachmen t dimension s only, because we believe that analy-
sis by dimension s provides the most useful information , and
analyzing by types and dimension s is largely redundant.4
Study 3
In Study 3 we investigate d three hypothese s regarding the im-
pact of attachmen t style dimension s on ongoing dating relation-
ships. First, we explored the possibility that partners would have
similar scores on these dimensions . Considerabl e research has
found partner similarity on a variety of demographi c and per-
sonality characteristic s (see Buss, 1984; Buss & Barnes, 1986).
Thus, there are reasons to anticipate similarity between part-
ners in attachmen t style. For example, because attitude similar-
ity is associated with attraction (Byrne, 1971), people may be
attracted to others who have similar beliefs and expectation s
about love and who behave similarly in relationships .
However, the matching process may be much less direct. At-
tachment styles, and their associated working models, may re-

sult in matching through their organizatio n of behavior and so-
cial perception . Working models about the nature of love and
about oneself as a love object will influence how we respond to
others, how we interpret others' actions, our expectation s about
what a partner should be like, and so on. For example, someone
who is comfortabl e with closeness may be unwilling to tolerate
a partner who avoids intimacy. In addition, because of differ-
ences in behaviora l skills and interactio n styles, it may be easier
to deal with a partner who has a matching style.
We also suspected there would be similarity between the at-
tachment style dimension s of a subject's partner and the care-
giving style of the subject's parents, especially the opposite-se x
parent. As suggested by attachmen t theory, the relation may be
an indirect one resulting from expectation s and beliefs about
oneself and about relationships , which develop out of early par-
ent-child interaction s and are carried forward into later rela-
tionships. Parents teach us what relationship s are like, what we
are like as objects of care and affection, and what relationship s
between men and women are like. The opposite-se x parent in
particular may serve as a model (or analogy) for heterosexua l
relationships . People may not only be more willing to tolerate
4 Although we do not present results for the discrete styles, a classifi-
cation into styles was performe d on the dating couples sample. We
noted that, on the basis of Hazan and Shaver's (1987) measure, only 6
(2 men and 4 women) out of 142 subjects categorize d themselve s as
anxious. This number was reduced to 5 (1 man and 4 women) when
subjects were classified by a discriminan t function analysis. As a result,
an analysis by types would have forced us to eliminate the anxious group
from our analyses. This would be an importan t loss of informatio n be-
cause, as we shall see, the Anxiety dimension turned out to be an impor-
tant predictor of relationshi p quality. This finding also suggests that peo-
ple engaged in relationship s may differ from those who are not. Consis-
tent with this, Hendrick and Hendrick (1986, 1988), in their work on
love styles, found difference s between people who were "in love" and
those who were not.

656 NANCY L. COLLIN S AND STEPHE N J. READ
similar relationship s but may also be more comfortabl e inter-
acting in them. Sroufe and Fleeson (1986) suggested that people
may seek to continue or reestablis h relationship s that are con-
gruent with past relationship s in order to maintain coherenc e
and consistenc y within the self (see also Bowlby, 1973; Epstein,
1980;Swann , 1987; Swann& Read, 198 la, 1981b).
Finally, we predicted that attachmen t style dimension s would
have a significan t impact on relationshi p quality. We were con-
cerned with three broad areas of relationshi p functioning : qual-
ity of communication , trust, and overall satisfaction . We further
anticipate d that subjects' attachmen t scale scores would be re-
lated to their own relationshi p experience s as well as the experi-
ences and perception s of their partner.
There are a number of reasons to suspect that attachmen t
style dimension s would influenc e relationshi p characteristics .
Most important , we believe these dimension s are primary or-
ganizing principle s that guide a wide range of relationa l behav-
iors. For instance, a person who is comfortabl e with closeness
and able to depend on others may be more willing to engage in
behaviors that promote intimacy , such as self-disclosure . Some
evidence for this was obtained in Study 2, which found that
comfort with closeness was related to expressiveness , a quality
that is likely to facilitate communicatio n and intimacy . People
who are anxious about being abandone d or unloved are likely
to be less trusting of their partner, to experienc e jealousy, and
to behave in ways that reflect their lack of confidenc e in them-
selves and in their relationship . Consisten t with this, in Study 2
we found that anxiety was strongly negativel y related to self-
esteem, which has been shown to have importan t implication s
for relationshi p functionin g (Dion & Dion, 1975, 1985), and
to independenc e and self-assertiveness , which may affect one's
ability to get needs met in a relationship . Study 2 also found
that attachmen t dimension s were related to styles of loving,
which have been shown to predict attitudes regardin g relation-
ships (Hendric k & Hendrick , 1987) and relationshi p quality in
dating couples (Hendrick , Hendrick,  & Adler, 1988; Levy &
Davis, 1988).
In summary , Study 3 explored the role of attachmen t style
dimension s in three aspects of ongoing dating relationships :
partner matchin g on attachmen t dimensions ; similarit y be-
tween subjects' partner and parents, particularl y the opposite -
sex parent; and subjects' own and their partner's perception s of
relationshi p quality including communication , trust, and satis-
faction.
Method
Subjects
Participant s were 71 dating couples who were friends and acquain-
tances of members of an undergraduat e research methods class at the
University of Southern California . Couple members ranged in age from
18 to 44, with a mean age of 22. The sample was 61 % White, 15% Black,
15% Asian, 1% Hispanic, and 8% other. The average relationshi p length
was 17 months, ranging from 1 month to 5 years. Ninety-si x percent of
the couples were dating each other exclusively .
Materials
All measures were administere d in a questionnaire . A cover letter
described the purpose of the questionnair e and how responses would bekept confidential . First, we asked for age, sex, religious preference , eth-
nic background , length of relationship , and whether partners were dat-
ing each other exclusively . Next, attachmen t style dimension s were as-
sessed with the Adult Attachmen t Scale, and perception s of attachmen t
history with parents were assessed with the parenting-styl e items de-
scribed in Study 2 (see Table 6).
Subjects then rated several aspects of satisfactio n with their relation-
ship. Many items were adapted from the Dyadic Adjustmen t Scale
(Spanier, 1976), a widely used measure of relationshi p satisfaction ; oth-
ers were developed specificall y for the current purpose. Global satisfac-
tion was measured by two items, one asking subjects to rate on a 9-point
scale how happy they were in the relationshi p and the other asking how
satisfied they were. Subjects' liking for their partner was rated on a 9-
point scale ranging from not at all (I) to a great deal (9). Perceived
conflict was measured by five items asking about frequency and severity
of fights and argument s and the number of times either partner had left
because of conflict. These items were standardize d and summed into a
single composite . Subjects rated perceived closeness on a single 9-point
scale ranging from not at all close (1) to extremely  close (9). Likelihoo d
of marriage was measured by a single item asking subjects to rate on a
9-point scale how likely they were to marry their partner. Subjects also
indicated on a 9-point scale the likelihoo d of leaving the relationshi p
within the next 6 months. Finally, subjects indicated what percentag e

of their available free time they spent with their partner.
Subjects were then asked about the communicatio n in their relation-
ship. First, level of communicatio n was measured by four items asking
about such things as how good their partner was at communicatin g and
how frequentl y they talked things over. These items were standardize d
and summed . Next, subjects indicated their perception s of their part-
ner's responsivenes s to them by rating on a 9-point scale the extent to
which each of nine items, such as "warm" or "responsiv e to my needs
and feelings," fit their impressio n of their partner. Third, subjects filled
out the Miller Topic Survey (Miller et al., 1983) to indicate both their
own and their partner's tendency to disclose intimate informatio n about
themselve s in the relationship . Finally, subjects filled out the Opener
Scale (Miller et al., 1983), which measures the ability to get other people
to open up and talk about intimate information .
Finally, several aspects of trust in one's partner were assessed. First,
subjects filled out an 18-item scale developed by Rempel, Holmes, and
Zanna (1985) to measure three component s of trust in close relation-
ships: predictability , dependability , and faith. Predictabilit y is one's per-
ceived ability to predict a partner's behaviors . Dependabilit y is the ex-
tent to which one feels a partner can be relied on when needed. Faith
measures belief that a partner will continue to be responsiv e and caring.
Items were rated on a 7-point scale from strongly disagree  (1) to strongly
agree (7). Next, subjects judged the extent to which they had experi-
enced or were likely to experienc e jealousy. Five items asked about the
frequency with which they had engaged in five jealous behaviors , on a
scale from never (1) to frequently  (5). Next, five items described different
social situations and asked subjects to indicate how jealous they would
feel in such a situation , from not at all jealous (1) to very jealous (5).
These items were adapted from Salovey and Rodin (1985a, 1985b). Re-
liabilities for measures with multiple items are shown in Table 11.
Procedure
Each member of a research methods class obtained 3 heterosexua l
dating couples among their friends and acquaintance s who were dating
steadily and were willing to fill out a questionnair e regarding their rela-
tionship. To promote honest responding , class members made sure that
partners complete d the questionnaire s independently . To ensure confi-
dentiality, partners were given a manila envelope and were told to seal
the complete d questionnair e in it. Also, they were given three options
for returnin g the questionnaire : by campus mail addressed to the pro-

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 657
Table 11
Reliabilities  of Relationship  Measures:  Study 3
Item Cronbach' s alphaTable 12
Correlations  Between Partners'  Self-Reported  Adult
Attachment  Scale Dimensions
Satisfactio n
Conflict
Partner predictabl e
Partner dependabl e
Faith in partner
Jealous acts
Jealous feelings
Communicatio n
Opener Scale
Partner responsive
Self-disclosure—sel f
Self-disclosure—partne r.93
.76
.86
.77
.76
.79
.91
.68
.84
.92
.86
.89
fessor, by dropping it in the professor' s departmenta l mail box, or by
having their friend return it. Finally, questionnaire s were identified by
code numbers only.
Results
Matching  Between  Partners on Attachment
Style Dimensions
First, to examine whether male and female partners differed
overall on their scores on the three attachmen t dimensions , we
compared the mean scores for men and women. Mean scores
on Close, Depend, and Anxiety for men were 22.86,20.07 , and
12.43, respectively , and the mean scores for women were 23.04,
21.07, and 13.87, respectivel y (scores could range from 6 to 30).
A multivariat e analysis of variance comparin g men and women
on the three dimension s revealed a marginall y significan t multi-
variate effect, F(3, 133) = 2.37, p = .09. Univariat e F tests for
each dimensio n revealed nonsignifican t effects for Close, F( 1,
135) = .056, and Depend, F(l, 135) = 1.44, and a marginall y
significan t effect for Anxiety, F(l, 135) = 3.76, p = .07. Thus,
overall there were no difference s between men and women, al-
though there was a tendency for women to be somewha t higher
in anxiety than were men.
Next, to examine similaritie s between partners, we corre-
lated male and female partners' scores on the attachmen t di-
mensions. As shown in Table 12, correlation s between partners'
self-rated attachmen t style dimension s provided evidence for
matching on certain of the dimension s (diagona l elements) .
Subjects who were comfortabl e getting close to others (high
scores on Close) were more likely to be with a partner who was
also comfortabl e with closeness, and those who felt they could
depend on others (high scores on Depend) tended to be dating
a partner who felt similarly , although this correlatio n was only
marginall y significant . There was no direct matching between
the men and women on their fear of abandonmen t (Anxiety) .
In addition to direct matching on certain dimensions , there
were also relations between different attachmen t dimension s
(off-diagona l elements) . Men who were comfortabl e with close-
ness were more likely to be dating partners who felt they could
depend on others and much less likely to be dating partners who
were worried about abandonment . This same pattern was foundMale
Close
Depend
AnxietyClose
.34***
.21*
-.22*Female
Depend
.23**
.19*
-.22*Anxiety
-.36***
-.15
.04
*p<.10. **p<.05 . ***/><.01 .
for women who were comfortabl e with closeness, although these
correlation s were marginal.
Parent-Partner  Matching
Women. As shown in Table 13, women who perceived their
fathers as having been warm and responsiv e were more likely to
be dating men who felt they could depend on others and tended
to be more likely to date men who felt comfortabl e getting close,
although this relation was marginal. On the other hand, women
who saw their fathers as cold and distant or as inconsisten t were
less likely to be dating such men.
Men. Men who described their mother as cold or inconsisten t
were more likely to be dating women who were anxious. In addi-
tion, men who described their mothers as cold and distant were
somewhat less likely to be dating a woman who felt she could
Table 13
Correlations  Between Parents' Caregiving  Style and Partner's
Scores on Adult Attachment  Scale Dimensions
Male partner's
rating of parents
Mother
Warm
Cold
Inconsisten t
Father
Warm
Cold
Female
partner's
Mother
Warm
Cold
Father
Warm
Cold
Inconsisten tClose
.03
.00
.03
.11
-.15
-.08
Close
.12
.11
-.13
.21*
-.26**
-.16Female partner's attachmen t
Depend Anxiet y
.12 -.21 *
-.20* .33** *
-.02 .25* *
-.05 .0 0
.02 .0 3
-.02 .0 4
Male partner's attachmen t
.17 -.0 9
-.06 -.0 5
-.18 .1 1
.31*** -.0 7
-.33*** .0 1
-.23** -.0 3
*p<.10. **p<.05 . ***p<.01 .

658 NANCY L. COLLIN S AND STEPHE N J. READ
Table 14
Correlations  Between  Partner's Attachment  Dimensions  and
Subject's Own Relationship  Experiences
Subject's own Mal e partner's attachmen t
relationshi p
experience Clos e Depen d Anxiet y
Satisfactio n .25* * .1 1 -.1 5
Conflict -.22 *-.03 -.0 3
Closeness .33** * .05 -.0 5
Like partner .  1 7
Marry .  1 3
Leave -.0 2
Free time .24 *
Predictable .28 *
Dependabl e .42 *
Faith .39 *
Jealous acts -.28 *
Jealousy -.23 *
Communicatio n .33 *
Partner responsive .32 *
Self as opener .1 3
Own disclosure .1 6
Partner self-disclosur e .23*.04 -.0 2
.07 -.28* *
-.17 .0 9
.07 .0 1
.05 .0 7
** .18 .1 2
** .15 .0 2
-.21* .0 4
-.37**** -.02
* .1 6 .1 2
* -.08 .1 5
.08 .0 5
.03 .0 3
.03 .0 2Female partner's attachmen t
Close
.12
-.13
.09
.11
.01
.10
-.02
.20*
.35***
.27**
.03
-.12
.27**
.21*
.07
.25**
.26**Depend
.06
-.17
.14
.03
-.11
.10
.02
.27**
.33***
.16
.08
-.21*
.05
.04
-.02
.09
-.03Anxiety
-.37
.23
-.32
-.36
-.25
.10
-.16
-.22**#*
**
***
***
**
*
-.24**
-.42****
.00
-.05
-.37****
-.17
-.28
-.31
-.17**
***
*p<.10. **p<.05 . ***/>< .01. **p<.001.
depend on others, although this correlatio n was only marginal .
Men's ratings of their father were not related to their partner's
style.
Comparison  of women and men. For both men and women,
only description s of the opposite-se x parent predicted the at-
tachment style dimension s of their partner. However, the com-
ponent of attachmen t style that was predicted was different. For
men, ratings of their mother mainly predicted whether their
partner was worried about abandonment , whereas for women,
ratings of their father predicted whether their partner was com-
fortable with closeness and thought he could depend on others.
Partner Attachment  Style Dimensions  and Subjects'
Own Relationship  Evaluation
Both men's and women's attachmen t style dimension s were
related to their partner's evaluatio n of the relationshi p (see Ta-
ble 14). However, the dimensio n of attachmen t that was most
predictive differed for men and women. Men's degree of com-
fort with closeness (Close) was more consistentl y predictive of
the women's evaluatio n of the relationshi p than were men's
scores on Depend or Anxiety. In contrast, women's fears of
abandonmen t (Anxiety ) much more consistentl y predicted the
men's evaluation s than did the women's scores on Close or De-
pend.
Women's evaluation  of the relationship.  Women whose part-
ners were comfortabl e with closeness (Close) were much more
positive about their relationshi p overall. They were more satis-
fied, felt closer to their partner, and spent more of their free time
with him. In addition, they tended to perceive less conflict in
the relationship .
Women with partners who were high on Close also thought
communicatio n was better. They felt their partners werewarmer and more responsiv e to them, and they rated the general
level of communicatio n more highly. In addition, these women
thought their partners self-disclose d to them more.
Finally, women seemed to be more trusting of partners who
were comfortabl e with getting close. On the trust scale, women
had more faith in their partner and thought he was more pre-
dictable and dependabl e when he was comfortabl e with close-
ness. Related to this, these women were less likely to engage in
jealous behaviors and less likely to respond with jealous feelings
in jealousy-evokin g situations .
In contrast to the findings for men's Close scores, there were
few significan t relations with men's scores on the Depend and
Anxiety scales. Women were less likely to report exhibiting jeal-
ous behaviors or feeling jealous when their partner felt he could
depend on others. Finally, women thought they were less likely
to marry men who were afraid of abandonment .
Men's evaluation  of the relationship.  Men's evaluation s were
related to how comfortabl e their partners were with getting
close, although the relation was not as extensive as those for the
women's evaluations . Women's comfort with closeness did not
predict liking or satisfaction , but it did predict perception s of
trust and communication . Men with a partner who scored high
on Close had more faith in their partner and thought she was
more predictabl e and dependable . However , Close scores had
no relation to jealousy. Men also perceived greater communica -
tion when their partner was comfortabl e with closeness. They
rated the general level of communicatio n as higher and tended
to view their partner as warm and responsive . Further, these
men reported that they self-disclose d more to their partner and
that their partners disclosed more to them.
Although the woman's Depend score was not generally re-
lated to the man's evaluation , it was related to some aspects of

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 659
Table 15
Correlations  Between  Subject's Own Attachment  Dimensions  and
Own Relationship  Experiences
Subject's relationshi p
experience
Conflict
Closeness
Like partner
Marry
Leave
Free time
Predictabl e
Dependabl e
Faith
Jealousy
Partner responsiv e
Self as opener
Own disclosure
Partner self-disclosur eFemale's own attachmen t
Close
.09
-.24**
-.01
-.14
-.01
.00
.05
-.14
.21*
.14
-.14
-.21*
.21*
.13
.36***
.20*
.13Depend
.11
-.11
.03
.04
.03
-.10
-.08
.04
.38****
.21*
-.07
-.09
.14
.20*
.13
.19*
.13Anxiety
-.25**
.17
-.26**
-.12
-.14
.19*
-.10
-.12
-.31***
-.50****
.27**
.28**
-.25**
-.25**
-.19*
-.16
-.22*Male's own attachmen t
Close
.32***
-.06
.32***
.27**
.24**
-.19*
.21*
.18
.20*
.40****
-.14
-.18
.31***
.11
.27**
.34***
.15Depend
.18
.04
.08
.15
.12
-.18
-.02
.22*
.09
.21*
-.05
-.26**
.02
.08
.00
.12
-.05Anxiety
.10
-.02
.01
.03
.02
.03
.11
-.07
-.22*
-.19*
-.03
.09
.09
-.05
.24**
-.07
-.04
*p<.10. **/><.05 . ***p<.01 . ****p<.001 .
trust. Men with partners who felt they could depend on others
thought their partner was more predictabl e and dependable .
These men also tended to be less jealous.
The women's fear of abandonmen t was the strongest predic-
tor of the men's responses . Men evaluated the relationshi p
much more negativel y when their partner was anxious. These
men were less satisfied with the relationship , reported more
conflict, felt less close to their partner, liked her less, and thought
they were less likely to marry her. Men also trusted anxious
partners less; they had less faith in their partner, and thought
she was less predictabl e and dependable . However , there was no
relation with jealousy.
Finally, men with anxious partners perceived communica -
tion problems . These men rated the general level of communi -
cation as lower and said that they self-disclose d less to their part-
ner. Also, men with anxious partners were less likely to view
themselve s as the kind of person who can get others to talk
about themselve s (the Opener Scale).
Subjects' Own Attachment  Dimensions  and
Relationship  Evaluation
Interestingly , the dimension s of an individual' s attachmen t
style that predicted his or her partner's evaluatio n of the rela-
tionship also predicted the individual' s own evaluatio n of the
relationshi p (see Table 15).
Women. In general, women's comfort with closeness did not
predict how positively they viewed the relationship , although
women who were comfortabl e with being close did perceive less
conflict. They also had a tendency to feel their partner was more
dependabl e and to have fewer jealous feelings. Women who
scored high on Close saw themselve s as warm and responsiv e
listeners, tended to rate the level of communicatio n as higher,
and reported greater self-disclosure .Not surprisingly , women who said they felt they could depend
on others thought their partner was more dependabl e and
tended to have more faith in him. These women also tended
to view themselve s as disclosing more highly and viewed their
partner as warm and responsive .
Just as women's Anxiety scores were the best predictor of
their male partner's evaluation , women's fear of being aban-
doned or unloved was also the strongest predictor of their own
relationshi p evaluations . Women who were afraid of being
abandoned generally viewed their relationshi p more negatively .
They reported lower general satisfactio n and felt less close to
their partner.
Women who were anxious also trusted their partners less;
they had much less faith in their partner and thought he was less
dependable . They were also more likely to act and feel jealous.
Finally, anxious women perceived more communicatio n prob-
lems. They rated the general level of communicatio n as lower
and their partner as less responsive . They also tended to think
their partner self-disclose d less and tended to view themselve s
as less responsiv e listeners.
Men. Just as men's Close scores were the best predictor of
the women's evaluation , men's Close scores were also the best
predictor of their own evaluation . Men who were comfortabl e
with closeness viewed their relationshi p more positively . They
were more satisfied, felt closer to their partner, liked her more,
and felt more likely to marry her. Men who were comfortabl e
with closeness were also more trusting of their partner. They
had much more faith in her and tended to feel she was more
dependable .
Finally, men with high Close scores seemed to think their
communicatio n with their partner was better. They rated the
general level of communicatio n as higher and thought they dis-
closed more to their partner. These men also viewed themselve s
as being better at getting people to open up to them.

660 NANCY L. COLLIN S AND STEPHE N J. READ
Although men's belief that they could depend on others was
not related to a broad range of relationshi p characteristics , it
was marginall y related to trust. Men who scored high on De-
pend tended to have more faith in their partner, to think she
was more predictable , and to be less jealous.
Finally, men who were anxious tended to have less faith in
their partner and to feel she was less dependable . These men
also viewed themselve s as better able to get other people to
open up.
Study 3 explored the impact of adult attachmen t style dimen-
sions on three aspects of ongoing dating relationships . Our first
concern was whether partners were matched on these dimen-
sions. Reasonabl e evidence for this was obtained . Individual s
tended to be in relationship s with partners who shared similar
beliefs and feelings about becoming close and intimate with oth-
ers and about the dependabilit y of others. However , subjects did
not simply choose partners who were similar on every dimen-
sion of attachment . For instance, men and women who were
anxious did not seek partners who shared their worries about
being abandone d and unloved. Rather, by choosing partners
who were uncomfortabl e with getting close, they appeared to
be in relationship s that confirme d their expectations . Thus, as
Weiss (1982) suggested , people may seek partners for whom
their attachmen t system is already prepared to respond.
Caution must be used in interpretin g these results because
scores on the Adult Attachmen t Scale may have been influence d
by the subject's current relationship . This may be particularl y
likely for Anxiety. For instance, people who are ordinaril y se-
cure may begin to worry about being abandone d if they think
their partner is avoiding getting close. Nevertheless , if matching
were due simply to the nature of the current relationship , we
would not expect correspondenc e between a subject's partner
and parents.
Our second goal was to examine the relation between the at-
tachment style dimension s of a subject's partner and the per-
ceived caregivin g style of the subject's parents. Moderat e evi-
dence for this was obtained. For both men and women, descrip-
tions of the opposite-se x parent predicte d the attachmen t
dimension s of their partner, but description s of the same-sex
parent did not. However , the componen t of attachmen t that was
predicted was different for men and women. For men, ratings
of their mother mainly predicted whether their partner was anx-
ious. For women, ratings of their father predicted whether their
partner was comfortabl e with closeness and felt he could de-
pend on others.
These findings suggest that the opposite-se x parent may be
used as a model for what heterosexua l relationship s are like or
should be like, and what a person should expect from a roman-
tic partner. Thus, although both parents may contribut e to a
person's beliefs about him- or herself and the social world in
general (as suggested by Study 2), the opposite-se x parent may
play a special role in shaping beliefs and expectation s central to
heterosexua l love relationships .
The correspondenc e between parents and partners, and the
matching between partners, is consisten t with Bowlby's view
that individual s select and create their social environment s inways that confirm their working models and thus promote con-
tinuity in attachmen t patterns across the life span (see also
Sroufe & Fleeson, 1986). However , because we studied couples
in ongoing relationships , we cannot draw any firm conclusion s
regarding the active choices of partners in seeking their current
mate. An importan t area for future research will be to examine
the influence of attachmen t style and attachmen t history on the
processes of mate selection and relationshi p development . In
addition, an examinatio n of relationshi p histories will help de-
termine the extent to which people repeat relationshi p patterns.
Our final aim was to explore the role of attachmen t style di-
mensions in the quality of romantic relationships . The attach-
ment style dimension s of a subject's partner were strong predic-
tors of relationshi p quality, although the dimensio n of attach-
ment that best predicted quality differed for men and women.
Greater anxiety in women was related to more negative experi-
ences and lower overall satisfactio n for their male partners. In
contrast, when men were comfortabl e with closeness and inti-
macy, their partners reported much more positive relationshi p
experience s and greater overall satisfaction .
Why was the female's anxiety most predictiv e of male satis-
faction and relationshi p perceptions ? One possibilit y is sug-
gested by the finding that anxious women were less trusting and
more likely to behave jealously. Men may view a partner's inse-
curity and dependenc e as a restrictio n on their behavior and a

threat to their freedom. This is consisten t with Davis and Oat-
hout's (1987) finding that female possessivenes s was strongly
negatively related to male satisfaction , but male possessivenes s
was much less predictiv e of female satisfaction . However , as
noted earlier, we must be cautious in drawing conclusion s about
causality. In our sample, women who were anxious tended to
have partners whom they perceived as less warm and respon-
sive, and who were uncomfortabl e getting close and dependin g
on others. As a result, the woman's anxiety may reflect the lack
of commitmen t and intimacy within the relationship , rather
than be the cause of it.
On the other hand, why was the best predictor of female satis-
faction the male's degree of comfort with closeness ? Because
men are stereotype d as being less comfortabl e with intimacy , a
man's willingnes s to become close and ability to communicat e
may be particularl y valued. In our sample, men with high scores
on Close rated themselve s as high in disclosur e and as warm,
responsive listeners; their partners tended to perceive them this
way as well. Consisten t with our findings, Davis and Oathout
(1987) found that good communication  by the man (includin g
disclosure and listening skills) strongly predicted the woman's
satisfaction , but good communicatio n by the woman did not
predict the man's satisfaction . A similar pattern was obtained
by White, Speisman , Jackson, Bartis, and Costos (1986), who
found that for married couples, the husband' s degree of "inti-
macy maturity " predicted the wife's marital adjustment , but
the wife's intimacy maturity was unrelated to the husband' s
marital adjustment .
These sex difference s are consisten t with traditiona l stereo-
types and may be due to differentia l socialization . Women are
socialized to achieve emotiona l closeness , whereas men are so-
cialized to develop an independen t identity and to maintain
their personal freedom (Hatfield , 1983). As a result, women
may be particularl y sensitive to their partner's depth of disclo-

ATTACHMENT , WORKIN G MODELS , AND RELATIONSHI P QUALIT Y 661
sure, ability to listen attentively , and willingnes s to become close
and intimate. In contrast, men may be particularl y sensitive
to their partner's dependenc y and attempts to restrict their
freedom.
General Discussio n
Three goals were addressed in these studies. First, in Study 1
a multi-item scale based on Hazan and Shaver's (1987) discrete
measure was developed and evaluated . Analyses revealed three
dimension s underlyin g this measure: (a) the extent to which an
individual is comfortabl e with closeness and intimacy (Close),
(b) the extent to which an individua l believes others can be de-
pended on to be available when needed (Depend) , and (c) the
extent to which an individua l feels anxious about such things
as being abandone d or unloved (Anxiety) . Scores on Close and
Depend were moderatel y positively correlated , and Anxiety was
largely independen t of the others. These dimension s capture
many of the themes that should be central to an attachmen t
system that has a goal of felt security, and they are conceptuall y
similar to dimension s thought to underlie difference s in child-
hood attachmen t styles.
Additiona l analyses demonstrate d that these three dimen-
sions could be used to more clearly define the three discrete
attachmen t styles. For example, a person with a secure attach-
ment style is comfortabl e with closeness , feels others are de-
pendable and available when needed, and is not worried about
being abandone d or unloved. However, although the Adult At-
tachment Scale can be used to retrieve the three discrete styles,
we believe that often an analysis by dimension s has practical
and theoretica l advantage s over an analysis by discrete types. In
addition, in Study 2, when we compared results using the scale
with results based on the discrete attachmen t types, the new
scale resulted in somewha t stronger findings overall. Finally,
Study 3 demonstrate d the importanc e of measurin g the dimen-
sions when one's goal is to understan d relations between attach-
ment and other importan t variables .
Although the Adult Attachmen t Scale measures attachmen t
style dimensions , we are not proposin g that the concept of dis-
crete attachmen t styles be abandoned , because it is importan t
both conceptuall y and theoretically . Indeed, the scale is based
largely on description s of three styles by Hazan and Shaver
(1987), and there are several ways to recapture styles from di-
mensions. In addition, the cluster analyses provide evidence for
discrete groups that differ in ways consisten t with theoretica l
conception s of the three styles. However , these analyses also
offer tentative evidence that three groups may be too limited to
describe adult attachmen t styles. In Ainsworth' s infant typol-
ogy, the three general styles are further broken down into eight
substyles (see Main & Solomon, 1986, for discussion of a fourth
general attachmen t style). We would not be surprised to find
that an equally complicate d category system was needed to ade-
quately describe the full range of adult attachmen t styles. By
specifying importan t underlyin g dimension s of attachment ,
and exploring configuration s of these dimensions , we can begin
to explore additiona l styles. The Adult Attachmen t Scale may
provide a useful tool for this effort.
A second aim of our research was to explore relations be-
tween adult attachmen t dimension s and working models. Study2 extended Hazan and Shaver's work by more systematicall y
identifyin g and measurin g aspects of working models that
should be central to attachment . In addition, we found modest
but encouragin g evidence that these working models are related
to perception s of attachmen t with parents, which had not been
examined previously .
Although the beliefs measured in our research are selected
aspects of very complex cognitive models, even these limited
fragments are likely to influence a wide range of social behav-
iors. Nevertheless , working models, or mental models, include
much more than static beliefs. As Bowlby suggested , mental
models are dynamic representation s that may be altered in re-
sponse to new informatio n and can be mentally "run" to simu-
late the likely outcome of certain interaction s or plans (see also
Bretherton , 1985; Gentner & Stevens, 1983; Main et al., 1985;
Miller & Read, in press; Read & Miller, 1989; Sroufe & Fleeson,
1986). Working models guide behavior, suggestin g what and
how things should be done. They enable us to predict the ac-
tions of others in order to plan or prepare for particula r out-
comes, and to interpret and explain the behavior of others so
that we can understan d our social world.
A promisin g area for future research will be developin g tech-
niques to examine in detail the contents and structure of indi-
vidual models to further explore how they relate to attachmen t

styles and account for difference s in relationshi p experience .
Because some aspects of working models may operate outside
conscious awarenes s (Bretherton , 1985; Main etal., 1985), this
may require a multimetho d approach including in-depth inter-
views and such things as the analysis of problem-solvin g styles,
simulated interactions , and social perceptio n tasks that may re-
veal underlyin g models. We agree with Davis and Roberts
(1985), who noted, "The time appears ripe for an exploratio n
of how individua l difference s in conception s of personal rela-
tionships determine the type of relations sought out and created
by individuals . . .and the nature of the satisfaction s gained in
relationships " (pp. 155-156) .
Additiona l work is also needed to understan d the role of early
relationship s in the formatio n of working models. The attach-
ment history measures we used are fairly simple assessment s of
what are surely very complex relationship s between parents and
children, and future research will benefit from richer, more sen-
sitive measures . One such measure, the Adult Attachmen t In-
terview (George, Kaplan, & Main, 1984), is a long clinical inter-
view that should be a valuable tool in this area. Using this inter-
view with older adolescents , Kobak and Sceery (1988) found
that affect regulatio n and representation s of self and others were
associated with the organizatio n of memorie s concernin g at-
tachment relationship s with parents.
Although people may bring stable patterns into relationships ,
these patterns are likely to be adapted in response to their part-
ner's behaviora l style. Read and Miller (1989) suggested that in
addition to general models of self and others, people develop
working models of specific partners and relationship s (see also
Bowlby, 1982, 1973). Hindy and Schwarz (1984, cited by Ha-
zan & Shaver, 1987) gathered informatio n on anxious attach-
ments in more than one relationshi p and found evidence of
both consistenc y and variation . Future research should focus
not only on enduring styles of people, but on how two people

662 NANCY L. COLLIN S AND STEPHE N J. READ
come together to form a unique relationshi p (Miller & Read, in
press).
The final aim of our research was to explore the role of at-
tachment style dimension s in dating relationships . The results
of Study 3 suggest that scores on these dimension s are likely to
influence who one chooses as a dating partner and may play an
important role in organizin g behaviors , perceptions , and expec-
tations within dating relationships .
In conclusion , it seems time for social psychologist s to begin
integrating developmenta l theory and research into their study
of adult love relationships . To fully understan d adult relation-
ships, we must learn how they are guided by the models we hold
about ourselves and others and how these models are shaped by
early experience . We believe that attachmen t theory can pro-
vide a useful framewor k for continuin g this work.
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Accepted Novembe r 14,1989 •

Original article
Adolescent attachment styles and their relation to the temperament
and character traits of personality in a general population
Jayanti Chotaia,*, Mattias Jonassona, Bruno Hägglöfb, Rolf Adolfssona
aDivision of Psychiatry, Department of Clinical Sciences, University Hospital, University of Umeå, 901 85 Umeå, Sweden
bDivision of Child and Adolescent Psychiatry, Department of Clinical Sciences, University of Umeå, Umeå, Sweden
Received 11 June 2004; accepted 1 November 2004
Available online 19 February 2005
Abstract
Attachment styles as well as personality traits in adolescents and adults have been found to be associated with their health outcomes and
with their personality pathology. In this cross-sectional exploratory study, we study the relationship between attachment styles that derivefrom our data employing the items of Feeney et al. (1994) self-report attachment style questionnaire (ASQ), and personality traits given by thejunior version of Cloninger et al. (1993) self-report temperament and character inventory (TCI), in a sample of 426 adolescents (54% females)from a general population. The secure attachment style was correlated signiﬁcantly negatively with the personality trait harm avoidance (HA),but signiﬁcantly positively with the personality traits novelty seeking (NS), reward dependence (RD), cooperativeness (CO) and self-transcendence (ST). The preoccupied (anxious/ambivalent) attachment style was correlated signiﬁcantly positively with HA and NS, butsigniﬁcantly negatively with self-directedness (SD). The fearful-avoidant category was correlated signiﬁcantly negatively with NS. Our ﬁve-factor solution of the attachment styles and their relation to the TCI point towards a need for a modiﬁcation of the two-axis, four-categoryattachment model of Bartholomew (1990) and Bartholomew and Horowitz (1991), with their category dismissing-avoidant replaced by thetwo categories deﬁned here as dismissing relations (correlated signiﬁcantly negatively with CO) and dismissing others (correlated signiﬁ-cantly negatively with RD and signiﬁcantly positively with SD).© 2005 Elsevier SAS. All rights reserved.
Keywords: Attachment; Personality; Temperament; Character
1. Introduction
Attachment theory was developed by Bowlby [8–10] to
explain how and why infants become emotionally attached totheir primary caregivers and why they often experience emo-tional distress when physically separated from them.Ainsworth et al. [1]delineated three styles of attachment in
infants based on their studies, called secure, anxious/ambivalent and avoidant, respectively. Infants with theavoidant attachment style frequently exhibited the behaviorscalled detachment, and those with the anxious/ambivalentattachment style frequently exhibited behaviors Bowlby calledprotest.
According to Bowlby’s theory, children internalize expe-
riences with caretakers in such a way that early attachmentrelations come to form a prototype for later relationships out-
side the family, during adolescence or adulthood. Therefore,Hazan and Shaver [28]suggested that romantic love in adults
would constitute a process of becoming attached that wouldbe experienced somewhat differently by different adultsbecause of variations in their attachment histories. Theydesigned a self-report measure to assess the attachment stylesof adult respondents. Each of the three attachment styles calledsecure, anxious/ambivalent, and avoidant, respectively, isdescribed by a paragraph that characterizes its behavior. Therespondent is asked to place himself or herself in the cat-egory described by the paragraph that best ﬁts his or herbehavior. This represents a categorical approach, where a sub-ject belongs to only one of several categories. In contrast, forthe dimensional approaches described below, the subject givesa numerical score to each one of the several deﬁned catego-ries, thus indicating to what degree he or she corresponds to
each category.
* Corresponding author. Tel.: +46 90 78 50000; fax: +46 90 13 5324.
E-mail address: jayanti.chotai@vll.se (J. Chotai).European Psychiatry 20 (2005) 251–259
http://france.elsevier.com/direct/EURPSY/
0924-9338/$ - see front matter © 2005 Elsevier SAS. All rights reserved.
doi:10.1016/j.eurpsy.2004.11.008

A single avoidant or detached category may obscure two
conceptually separable patterns of avoidance in adulthood;namely, one in which the subject denies experiencing subjec-tive distress and downplays the importance of attachmentneeds (dismissing-avoidant), and another in which the sub-ject reports feeling distress and discomfort when becomingclose to others (fearful-avoidant). Thus, Bartholomew [5]
developed a four-category model of attachment styles basedon the four combinations obtained by dichotomizing the sub-ject’s abstract image of the self into positive (low depen-dence) or negative (high dependence) on one axis, anddichotomizing the subject’s abstract image of the other intopositive (low avoidance) or negative (high avoidance) on anorthogonal axis. This yielded the four attachment categoriesdenoted by secure (positive self, positive other), preoccupiedwith relationships (negative self, positive other), dismissingof intimacy or dismissing-avoidant (positive self, negativeother), and fearful of intimacy or fearful-avoidant (negativeself, negative other).
Bartholomew and Horowitz [6]tested this four-category
model of attachment by developing the instrument Relation-ship Questionnaire, containing one prototype paragraph foreach of the four attachment styles that describes the charac-teristics of that style. For each of the four descriptions, therespondent indicates how well he or she resembles it on aseven-point rating scale. Grifﬁn and Bartholomew [25] pro-
posed an alternative instrument called Relationship ScalesQuestionnaire (RSQ), where each style is assessed by mul-tiple items, and found strong support for the construct valid-ity of this four-category model obtained by the self- and other-model attachment axes. The items of this RSQ consist ofphrases drawn from the paragraph descriptions of Hazan andShaver’s [28]attachment measure, Bartholomew and Horow-
itz’s [6]Relationship Questionnaire, and Collins and Read’s
[16] Adult Attachment Scale. The respondent gives a rating
on a ﬁve-point scale how well each item ﬁts his or her char-acteristic style in close relationships. Further support for thistwo-axes model was found by Diehl et al. [20].
Feeney et al. [22] constructed an independent instrument
called the attachment style questionnaire (ASQ), stating thatthe underlying goals when developing this instrument werepartly to clarify issues concerning the dimensions involvedand the number of styles that are central to attachment, partlyto design a measure suitable for young adults, and partly todesign a measure suitable for those with little or no experi-ence with romantic relationships. The ASQ contains 40 items,where the subject rates each item on a six-point scale. Theirfactor analysis of the instrument yielded a ﬁve-factor solu-tion with the ﬁve dimensions which they denoted, respec-tively, as conﬁdence, preoccupation with relationships, rela-tionships as secondary (to achievement), discomfort withcloseness, and need for approval.
These ﬁve attachment styles derived by Feeney et al. [22]
do not ﬁt neatly onto the two-axis, four-category attachmentmodel of Bartholomew [5]and Bartholomew and Horowitz
[6]. However, some rough correspondences, albeit overlap-ping, may be approximated as follows [4,22] . The ‘conﬁ-
dence’style signiﬁes secure attachment. ‘Preoccupation withrelationships’ is a principal aspect of Bartholomew andHorowitz’s [5,6] preoccupied group and of Hazan and Shav-
er’s[28] anxious/ambivalent attachment. ‘Relationships as
secondary (to achievement)’ reﬂects Bartholomew andHorowitz’s [5,6] conceptualization of the dismissing attach-
ment style. ‘Discomfort with closeness’relates to the two cat-egories of Bartholomew and Horowitz [5,6] obtained by
restricting to the negative model of other (high avoidance),and therefore more appropriately relates to the avoidant cat-egory in Hazan and Shaver’s [28]three-category model. ‘Need
for approval’ relates to the two categories in Bartholomewand Horowitz [5,6] obtained by restricting to the negative
model of self (high dependence).
Stein et al. [48,49] discuss the psychometric properties of
the above instruments and several other instruments avail-able in the literature that measure adult attachment, andpresent extensive and comparative discussions on their back-ground and their limitations.
All the self-report adult attachment instruments described
above contain a secure attachment style, and a varying num-ber of insecure attachment styles. Insecure attachment styleshave been shown to be associated with personality pathologyin adolescents and adults, as reviewed by Fonagy et al. [23,24]
and by Nakash-Eisikovits et al. [41]; anxious/ambivalent
attachment tended to be associated with measures of with-drawal and internalizing, whereas avoidant attachment tended

to be associated with a variety of personality disorders whichreﬂected a mixture of internalizing and externalizing pathol-ogy. In a prospective study, infants with the preoccupiedattachment style have been shown to be at a higher risk todevelop anxiety disorders during childhood and adolescence[53]. Another prospective study [17] showed that insecure
attachment (particularly avoidant attachment) in adolescencewas a risk factor for adverse relationship outcomes in adult-hood about 6 years later. In a sample of women primary healthcare patients, those with the preoccupied or fearful (inse-cure) attachment styles had a signiﬁcantly greater number ofphysical symptoms and higher primary care visits and costs,as compared to those with the secure attachment style [14].
Persons who differ in attachment styles have been found
to differ in self-esteem and other psychosocial depressive-vulnerability factors [7]and as regards fear of death [39].
Myers [40] found that compared to those having Hazan and
Shaver’s [28] avoidant or ambivalent/anxious attachment
styles, those with the secure attachment style had higher lev-els of personal competence, lower levels of psychological dis-tress, higher self-esteem scores, and relied less often uponthe self-blaming defense mechanism.
It is reasonable to expect that the development of an indi-
vidual’s attachment styles and the development of his or herpersonality characteristics modulate each other during the lifecourse (see Section 4 below). However, until enough prospec-tive studies that address this interaction in a developmentalperspective become available, we have to resort to cross-sectional studies to throw some light on this issue.
252 J. Chotai et al. / European Psychiatry 20 (2005) 251–259

A few studies have examined the relationship between the
individual’s self-reported attachment styles and his or her per-sonality traits measured by the NEO personality instrumentcomprising the ‘Big Five’traits. Grifﬁn and Bartholomew [26]
and Bäckström and Holmes [3]found that positive model of
self as well as positive model of others (which includes thesecure attachment style) were associated with higher extra-version scores and lower neuroticism scores, so that negativemodels of self or others (which include the insecure attach-ment styles) were associated with lower extraversion andhigher neuroticism scores. The insecure attachment styleswere also found to be associated with higher neuroticism andlower agreeableness scores by Shaver and Brennan [46],
Bäckström and Holmes [3], and Rowatt and Kirkpatrick [45].
The goal of the present study was to investigate further
regarding what personality traits that are associated with eachof the different attachment styles, and which personality traits
that distinguish the attachment styles from each other. In ourstudy here with adolescents, we have employed the above-mentioned 40-item instrument by Feeney et al. [22] to derive
various attachment styles by factor analyses of this instru-ment into two, three, four, or ﬁve factors, respectively, andassociate these with the six personality traits obtained from a108-item version of the temperament and character inven-tory (TCI) of personality developed by Cloninger et al. [15],
and adapted for junior temperament and character inventory(JTCI) [13,31] .
2. Materials and methods
2.1. Subjects
The subjects were primarily selected for a normative study
[31] of the Swedish version of the (JTCI). The subjects were
also asked to complete the ASQ. Initially, a total of 684 stu-dents of ages 13–18 years attending high school in the countyof Västerbotten in northern Sweden, were asked to partici-pate, of which 576 (84%) agreed. Of these, 93 subjects wereexcluded due to incorrect answers for at least two of the threevalidity items, added in the JTCI questionnaire in order tocheck that the subject had not answered at random. Of theseremaining 483 (71%) subjects, 47 subjects were excluded dueto incomplete responses to the ASQ. This left in all 426 (62%)subjects to be included in the analyses of the present study(232 females, 194 males), with mean (±S.D.) age 15.3 (±1.6)years.
2.2. The personality questionnaire JTCI
The JTCI is a 108-item version, adapted for juniors, of the
238-item TCI, both developed by Cloninger and associates[15,32,51] . The adult TCI evaluates personality in terms of a
seven-factor psychobiological model comprising the four tem-perament dimensions denoted by novelty seeking (NS), harmavoidance (HA), reward dependence (RD), and persistence(PS), respectively, and the three character dimensions denoted
by self-directedness (SD), cooperativeness (CO), and self-transcendence (ST), respectively [11,15,51] . The Swedish
JTCI evaluates personality in terms of six of the above fac-tors excepting PS, which is instead included as a subscale ofRD[13,31] .
2.3. Attachment style questionnaire
The instrument called ASQ was developed by Feeney et
al.[22] and contains 40 items, where the subject rates each
item on a six-point Likert scale. These items are listed inTable 1 for easy reference. Feeney et al. [22] performed fac-
tor analyses of this instrument, yielding a ﬁve-factor solutionwith the ﬁve dimensions named as conﬁdence, preoccupa-tion with relationships, relationships as secondary, discom-fort with closeness, and need for approval, respectively. Inour study here, we perform factor analyses of these 40 itemswith our data into two-factor, three-factor, four-factor, and
ﬁve-factor solutions as explained below, and associate eachsolution of the factor analyses to the six personality traits ofthe JTCI.
2.4. Statistical methods
The statistical package SPSS for Windows [47] was used
for all the analyses. All statistical tests were two-tailed.
3. Results
Since the ASQ of Feeney et al. [22] derived ﬁve dimen-
sions of attachment, we performed a factor analysis with vari-max rotation of the 40 items into ﬁve factors. Table 2 (ﬁrst set
of rows) lists the item numbers (and the item loadings obtainedin our data) of the items allocated by Feeney et al. [22] to
each of their ﬁve dimensions. It can be seen that 10 of these40 items obtained factor loadings of less than 0.40 for theircorresponding dimension, which suggests that our data donot load satisfactorily onto the dimensions speciﬁed by Feeneyet al. [22].
To explore the dimensional structure of the attachment
styles obtained from the items of Feeney et al. [22] in our

sample, we performed factor analyses of all the items withvarimax rotation, ﬁrst into two factors and then into threefactors, four factors, and ﬁve factors, in turn. For each factor-analytical solution, we required that for an item to be includedin a speciﬁc factor, the loading of that item must not only beat least 0.40 on that factor, but also that this item did not havea loading above 0.40 on any other factor in the same factoranalysis. This means that items that loaded substantially onmore than one factor in the same factor-analytical solution,were considered excluded with respect to this solution.
The item allocations of the two-factor solution obtained
by the above procedure are given by the second set of rows ofTable 2 , these two factors accounting for 31.8% of the total253 J. Chotai et al. / European Psychiatry 20 (2005) 251–259

variance. This solution yielded 16 items for a dimension we
call secure, and nine items for a dimension we call preoccu-pied.
The item allocations of the three-factor solution are also
given in Table 2 , accounting for 38.2% of the total variance.
We obtained the three dimensions denoted here by secure(11 items), preoccupied (12 items), and avoidant (10 items),
respectively. The item allocations of the four-factor solution(Table 2 ) accounted for 42.8% of the total variance. We
obtained the four dimensions denoted here by secure(10 items), preoccupied (13 items), dismissing relations(10 items), and dismissing others (four items), respectively.Table 1
The 40 items of the ASQ of Feeney et al. (1994)
1. Overall, I am a worthwhile person 21. I feel comfortable depending on other people
2. I am easier to get to know than most people 22. I worry that others won’t care about me as much as I care about them3. I feel conﬁdent that other people will be there for me when I need them 23. I worry about people getting too close4. I prefer to depend on myself rather than other people 24. I worry that I won’t measure up to other people5. I prefer to keep to myself 25. I have mixed feelings about being close to others6. To ask for help is to admit that you’re a failure 26. While I want to get close to others, I feel uneasy about it7. People’s worth should be judged by what they achieve 27. I wonder why people would want to be involved with me8. Achieving things is more important than building relationships 28. It’s very important to me to have a close relationship9. Doing your best is more important than getting on with others 29. I worry a lot about my relationships10. If you’ve got a job to do, you should do it no matter who gets hurt 30. I wonder how I would cope without someone to love me11. It’s important to me that others like me 31. I feel conﬁdent about relating to others12. It’s important to me to avoid doing things that others won’t like 32. I often feel left out or alone13. I ﬁnd it hard to make a decision unless I know what other people think 33. I often worry that I do not really ﬁt in with other people14. My relationships with others are generally superﬁcial 34. Other people have their own problems, so I don’t bother them with mine15. Sometimes I think I am no good at all 35. When I talk over my problems with others, I generally feel ashamed or
foolish
16. I ﬁnd it hard to trust other people 36. I am too busy with other activities to put much time into relationships17. I ﬁnd it difﬁcult to depend on others 37. If something is bothering me, others are generally aware and concerned18. I ﬁnd that others are reluctant to get as close as I would like 38. I am conﬁdent that other people will like and respect me19. I ﬁnd it relatively easy to get close to other people 39. I get frustrated when others are not available when I need them20. I ﬁnd it easy to trust others 40. Other people often disappoint me
Table 2
Distribution of the Feeney et al. (1994) ASQ items into various attachment styles, obtained from our factor analyses
Attachment styles Number
of itemsVariance
explained(%)Item number (loading)
Feeney et al. (1994) dimensions 40
Conﬁdence 8 1 (0.58), 2 (0.56), 3 (0.56), 19 (0.60), 31 (0.67), –33 (–0.40), 37 (0.59), 38 (0.69)Discomfort with closeness 10 4 (0.56), 5 (0.18), 16 (0.58), 17 (0.68), –20 (–0.55), –21 (–0.69), 23 (0.22), 25
(0.15), 26 (0.18), 34 (0.18)
Need for Approval 7 11 (0.43), 12 (0.78), 13 (0.56), 15 (0.03), 24 (–0.02), 27 (0.03), 35 (0.32)Preoccupied with relationships 8 18 (0.51), 22 (0.67), 28 (0.35), 29 (0.63), 30 (0.59), 32 (0.46), 39 (0.52), 40
(0.50)
Relationships as secondary 7 6 (0.45), 7 (0.56), 8 (0.76), 9 (0.62), 10 (0.58), 14 (0.48), 36 (0.55)Our two factors 25 31.8Secure 16 19.0 1, 2, 3, –5, –6, –14, –16, 19, 20, –23, 31, –32, –35, –36, 37, 38Preoccupied 9 12.8 11, 13, 15, 22, 24, 25, 29, 30, 39Our three factors 33 38.2Secure 11 13.4 1, 2, 3, 11, 19, 20, 21, 28, 31, 37, 38Preoccupied 12 14.1 13, 15, 16, 18, 22, 24, 25, 26, 27, 29, 30, 39Avoidant 10 10.8 6, 7, 8, 9, 10, 14, 23, 34, 35, 36Our four factors 37 42.8Secure 10 12.1 1, 2, 3, –5, 11, 19, 28, 31, 37, 38Preoccupied 13 13.8 13, 15, 18, 22, 24, 25, 26, 27, 29, 30, 33, 39, 40Dismissing relations 10 10.2 6, 7, 8, 9, 10, 14, 23, 34, 35, 36Dismissing others 4 6.7 4, 16, 17, –21Our ﬁve factors 37 46.0Secure 10 12.4 1, 2, 3, –5, 19, 28, 31, –35, 37, 38Preoccupied 12 13.4 15, 18, 22, 24, 25, 26, 27, 29, 30, 33, 39, 40Dismissing relations 8 9.3 6, 7, 8, 9, 10, 14, 23, 36Dismissing others 4 6.6 4, 16, 17, –21Fearful-avoidant 3 4.3 12, 13, 34254 J. Chotai et al. / European Psychiatry 20 (2005) 251–259

The item allocations of the ﬁve-factor solution ( Table 2 )
accounted for 46% of the total variance. We obtained the ﬁvedimensions denoted here by secure (10 items), preoccupied(12 items), dismissing relations (eight items), dismissing oth-ers (four items), and fearful-avoidant (three items), respec-tively.
We then set out to calculate the partial correlation coefﬁ-
cients between each of the attachment dimensions obtainedabove, and each of the six personality scales of our juniorversion [13,31] of Cloninger et al. [15]JTCI. It is known that
the dimensions of the ASQ and of the TCI are related to ageand gender, so these covariates were controlled for in thesepartial correlations. Also, it is known that the dimensions ofthe ASQ are correlated with each other, and that the dimen-sions of the TCI are correlated with each other. So the partialcorrelation between a speciﬁc attachment dimension and aspeciﬁc personality trait also controlled for all the remainingattachment dimensions and all the remaining personality traitsin the statistical analyses.
The results are given by Table 3 andFig. 1 . As seen in
Table 3 , the secure attachment style in each of our factor ana-
lytic solutions, was correlated signiﬁcantly negatively withHA but signiﬁcantly positively with NS, RD, CO and ST.The preoccupied attachment style, from each of the solu-tions, was correlated signiﬁcantly positively with NS and HA,but correlated signiﬁcantly negatively with SD.
As for the remaining attachment styles, they were corre-
lated signiﬁcantly negatively with NS, RD, or CO. In the ﬁnalﬁve-factor solution, dismissing relations was correlated sig-niﬁcantly negatively with CO, dismissing others was corre-
lated signiﬁcantly negatively with RD (and signiﬁcantly posi-tively with SD), and fearful-avoidant was correlatedsigniﬁcantly negatively with NS.
Fig. 2 is an attempt to depict our ﬁve-factor solution within
the framework of the two-axis (model of self vs. model ofother), four-category, attachment model of Bartholomew [5]
and Bartholomew and Horowitz [6]. We ﬁnd that the cat-
egory containing the attachment style denoted by them asdismissing-avoidant, is replaced in our data by the two cat-egories deﬁned by us as dismissing relations and dismissingothers.
4. Discussion
In this study with adolescents, we related the 40-item ASQ
of Feeney et al. [22] with the three temperament traits NS,
HA and RD, and the three character traits SD, CO and ST ofpersonality, employing the junior version JTCI [13,31] of the
TCI of personality [15]. We performed factor analyses of the
items of the ASQ based on our data, into two-factor, three-factor, four-factor, and ﬁve-factor solutions, respectively.Items that loaded substantially on more than one factor in thesame factor-analytical solution, were considered excludedwith respect to this solution.
Our evidence points towards a need for a modiﬁcation of
the two-axis, four-category attachment model of Bartho-lomew [5]and Bartholomew and Horowitz [6], with their cat-
Table 3
Partial correlation coefﬁcients between each attachment style and each personality trait, controlling for age, gender, and the remaining attachme nt styles as well
as the remaining personality traits
Personality traits
NS HA RD SD CO ST
Feeney et al. (1994) dimensionsConﬁdence 0.05 –0.23*** 0.11* 0.07 0.09 0.12*Discomfort with closeness –0.08 0.05 –0.27*** 0.12* –0.08 0.01Need for Approval –0.02 0.13** 0.07 –0.16*** 0.06 –0.09Preoccupation with relationships 0.15** 0.08 0.08 –0.06 0.02 0.17***Relationships as secondary –0.03 –0.02 0.04 –0.10* –0.25*** –0.02Our two factorsSecure 0.15** –0.28*** 0.32*** 0.04 0.27*** 0.10*Preoccupied 0.15** 0.16*** 0.15*** –0.22*** 0.03 0.07Our three factorsSecure 0.10* –0.19*** 0.23*** 0.02 0.14** 0.12*Preoccupied 0.16*** 0.28*** 0.03 –0.17*** 0.07 0.07Avoidant –0.13** 0.00 –0.11* –0.06 –0.27*** –0.06Our four factorsSecure 0.11* –0.20*** 0.20*** 0.04 0.10* 0.11*Preoccupied 0.14** 0.30*** 0.07 –0.21*** 0.08 0.06Dismissing relations –0.12* –0.01 –0.07 –0.07 –0.25*** –0.06Dismissing others –0.01 –0.04 –0.16*** 0.13** –0.08 0.01Our ﬁve factorsSecure 0.16*** –0.21*** 0.22*** 0.06 0.10* 0.14**Preoccupied 0.20*** 0.27*** 0.09 –0.17*** 0.08 0.09Dismissing relations –0.06 –0.03 –0.00 –0.06 –0.26*** –0.04Dismissing others –0.02 –0.04 –0.17*** 0.13** –0.09 0.01Fearful-avoidant –0.17*** 0.02 –0.08 –0.07 –0.00 –0.05255 J. Chotai et al. / European Psychiatry 20 (2005) 251–259

egory dismissing-avoidant replaced by the two categories
denoted here as dismissing relations and dismissing others(Fig. 2 ).
In all our solutions, there emerged one attachment style
called the secure style, that was correlated signiﬁcantly nega-tively with HA but signiﬁcantly positively with NS, RD, CO
and ST ( Table 3 ,Figs. 1 and 2 ). This is consistent with the
studies by Grifﬁn and Bartholomew [26] and Bäckström and
Holmes [3], employing the NEO personality inventory, who
found a negative correlation with neuroticism and a positive
Fig. 1 .Associations between the attachment styles and the personality traits obtained by our factor analyses of the ASQ into two, three, and four factors,
respectively. The squared brackets contain the personality traits having signiﬁcant partial correlations (capital letters for positive correlat ions and small letters
for negative correlations).
Fig. 2 .Modiﬁcation of Bartholomew and Horowitz’s (1991) model of adolescent attachment styles, suggested by our ﬁve-factor analysis of the ASQ. The
squared brackets contain the personality traits having signiﬁcant partial correlations (capital letters for positive correlations and small lett ers for negative
correlations).256 J. Chotai et al. / European Psychiatry 20 (2005) 251–259

correlation with extraversion for the secure attachment style;
neuroticism has been found to be positively correlated withHA and negatively correlated with SD [19,44] , and extraver-
sion has been found to be positively correlated with NS, RD,CO and ST and negatively correlated with HA [19]. Higher
agreeableness scores found earlier for those with a secureattachment style [3,45,46] , is further consistent with our result
above, since agreeableness has been found to be positivelycorrelated with CO [19]. The secure attachment style has been
shown to predict better health and better well-being than theinsecure attachment styles in various studies.
One insecure attachment style that emerged in all the solu-
tions was what we denote as the preoccupied attachment style,which corresponds to the preoccupied category of Bartho-lomew and Horrowitz [6]and to the anxious/ambivalent cat-
egory of Hazan and Shaver [28]. This style in our study was
correlated signiﬁcantly positively with the TCI personalitytraits of NS and HA, but signiﬁcantly negatively with SD.The remaining three insecure attachment styles in our study(dismissing relations, dismissing others, and fearful-avoidant)showed signiﬁcant negative correlations with one or more ofNS, RD, or CO.
Studies relating the scales of the TCI with health out-
comes have often shown that various personality patterns thatwe here found associated with the insecure attachment styles,are correlated with negative health outcomes. Thus, subjectswith depression were shown to be high in HA, low in SD,and low in CO scores [29]. In a sib-pair study, depression
was associated with high HA, and low NS, SD and RD [21].
Patients with social phobia as compared to controls have
shown high HA, and low SD, CO and ST [38]. Subjects with
obsessive–compulsive disorder [34] as well as subjects with
anxiety and fatigue have shown high HA and low SD [30].
Some limitations of the present study need to be addressed.
Firstly, it should be pointed out that the aim of the presentstudy was not to develop any optimal attachment instrumentor any optimal personality instrument, but rather to explorethe relationships between a published adult attachment ques-tionnaire (ASQ) with a published personality inventory(JTCI).
Secondly, we have so far not discussed the concept of
disorganized/disoriented attachment style among infants, pro-posed by Main and coworkers [33,37] . This infant attach-
ment style was a fourth addition to the three styles delineatedby Ainsworth et al. [1]. It is generally held that for infants
with disorganized/disoriented attachment style, the caregiverhas served as a source of both fear and reassurance, produc-ing strong conﬂicting motivations. The corresponding adultvariant of this category is denoted by unresolved/disorganized[36]. However, the self-report adult attachment instruments
discussed above seem to have developed independently ofthe construction of this attachment category. Some research-ers have found that Bartholomew’s [5,6] fearful-avoidant
attachment category closely resembles the unresolved/disorganized category, theoretically as well as empirically;fearful-avoidant attachment is found in the literature to bepredominant among physically abused and neglected chil-
dren, and during their follow-up as adults [2,12,41] .
Thirdly, it would have been more satisfactory if we had
obtained a factor analysis of the ASQ (with a reasonable num-ber of factors) that explained more than the mere 46% of thevariance explained in our analyses. It may be that the spec-trum of attachment patterns existing in reality may not befully covered by the items of the ASQ. Thus, it cannot beexcluded that inclusion of further items in the attachmentquestionnaire, items that captured more fully the concept ofthe unresolved/disorganized attachment style, would havegiven a more satisfactory factor analysis. However, this issueis beyond the scope of the present work.
Fourthly, it is pertinent to point out that there is a substan-
tial amount of research in the literature investigating the rela-tionships and differences between the concepts of attach-ment and temperament among infants. A comprehensivereview on such research [52] concludes that attachment can-
not be considered as redundant with temperament in the expla-nation of personality or in explanations of qualities of inter-personal action, and that both attachment and temperamentin infants are partly overlapping and depend in part on quali-ties of infant–parent interaction. It is also clear from thatreview that there are several different theoretical and empiri-cal approaches to the concept of temperament in infants.
However, the self-report personality instrument employed

in our study was originally developed for adults, and con-tains four “temperament dimensions” (NS, HA, RD and PS)and three “character dimensions” (SD, CO and ST). Tempera-ment is understood here to denote the automatic associativeresponses to basic emotional stimuli that determine habitsand skills, and conceptualized to be moderately heritable andstable over time. Character refers here to concepts about selfand relations to others that develop over time as a function ofsocial learning and maturation of interpersonal behavior [15].
This seven-factor model has been tested and validated amongadults in many countries including Sweden [11], France [43],
Spain [27], Korea [50], and Australia [42]. Junior versions of
the TCI for adolescents are as yet less widely employed[13,31,32,35] . In a preschool version of the TCI, ﬁrst com-
pleted by maternal reports and then later during follow-up byday caregivers, these personality dimensions could be mea-sured with acceptable levels of internal consistency [18].F u r -
ther research is necessary before the temperament dimen-sions and attachment measurements evaluated in adults andadolescents may be adequately consolidated with correspond-ing measurements evaluated in infants.
Finally, the measurements of attachment styles and per-
sonality traits for each subject in our study were done througha single reporter, the subject’s own self-report. We did notconduct any interviews to assess or verify the responses. Thus,it would be unwise to extrapolate the relationships obtainedhere between attachment and personality to other age groups,for example infants, where other observers evaluate the sub-ject’s characteristics.
257 J. Chotai et al. / European Psychiatry 20 (2005) 251–259

5. Conclusion
In summary, the relationships between the attachment
styles obtained from our factor analyses of the items fromASQ of Feeney et al. [22] (where we exclude the items giv-
ing insufﬁcient or ambiguous loadings on a factor), and thepersonality traits of the TCI, give support for a model ofattachment styles represented by an axis of ‘model of self’orthogonal with an axis of ‘model of other’ as in Bartho-lomew [5]and Bartholomew and Horowitz [6]. However, we
ﬁnd that a further division of their attachment style dismissive-avoidant into the two attachment styles denoted here as dis-missing relations and dismissing others, turns out to be moreappropriate in our analyses. Also, the relationships betweenthe attachment styles and the TCI personality traits appearfairly consistent with earlier studies relating attachment styleswith the personality traits of the NEO personality inventory.
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C:\Works\Data\projects\Python\Diagnosis Project\chat_app\knowledge\documents\Attachment orientations and emotion regulation.pdf

Attachment orientations and emotion regulation
Mario Mikulincer1and Phillip R Shaver2
According to attachment theory, individual differences in the
availability and responsiveness of close relationship partners,beginning in infancy, and the resulting formation of fairly stableattachment orientations are crucial for understanding the wayspeople experience and regulate emotions. In this article,we review what has been learned during the last decade
about attachment-related individual differences in emotion
regulation. We begin with a brief account of the hypothesizedlinks between different forms of attachment insecurity (anxiety,avoidance) and strategies people use in regulating distress andcoping with threatening events. We then review ﬁndings fromcorrelational and experimental studies showing that individualdifferences in attachment orientation are reﬂected in cognitive,behavioral, and neural patterns of emotion regulation.
Addresses
1Interdisciplinary Center (IDC) Herzliya, Israel
2University of California, Davis, USA
Corresponding author: Mikulincer, Mario ( mario@idc.ac.il )
Current Opinion in Psychology 2019, 25:6–10
This review comes from a themed issue on Attachment in adulthood
Edited by [1_TD$DIFF]Jeffry [2_TD$DIFF]A Simpson and [3_TD$DIFF]Gery [4_TD$DIFF]Karantzas
For a complete overview see the Issue and the Editorial
Available online 14th February 2018
https://doi.org/10.1016/j.copsyc.2018.02.006
2352-250/ ã2018 Elsevier Ltd. All rights reserved.
The implications of attachment processes for emotion
regulation received attention in Bowlby’s [ 1–4] seminal
writings, in which he attempted to understand the causes
and consequences of emotions aroused by secure attach-
ment (e.g. love, joy), separation (anxiety, anger), and loss(sadness, despair). The issue of emotion regulation hasreceived much additional attention in our and other
researchers’ theoretical and empirical efforts to delineate
the emotion-regulatory functions of attachment and toexplain how secure attachments help a person survive
temporary bouts of negative emotion and how different
forms of insecurity interfere with effective emotion reg-ulation, social adjustment, and mental health (e.g.
[5,6
/C15/C15,7/C15/C15,8]). In this article, we summarize individual-
difference aspects of emotion regulation and review stud-ies testing hypothesized links between attachment inse-
curities and emotion regulation in adulthood.Attachment insecurities and emotion
regulation: theoretical background
According to Bowlby [ 1,4], the sense of attachment secu-
rity (conﬁdence that one is competent and lovable and
that others will be responsive and supportive whenneeded) is a resilience resource in times of need and a
building block of mental health and social adjustment.
Mikulincer and Shaver [ 6
/C15/C15] reviewed extensive evidence
showing that people who are more secure with respect to
attachment are more optimistic about life and make less
catastrophic appraisals of threats and dangers. They arealso more conﬁdent in their ability to deal with threats and
challenges and tend to employ more constructive and
effective emotion–regulation strategies (e.g. problemsolving, reappraisal, support seeking). Moreover, having
managed threatening events or reappraised them in
benign terms, secure people can remain open to theiremotions, express and communicate feelings freely and
accurately to others, and experience them fully without
distortion.
In contrast, disruptions in the sense of attachment secu-
rity and the subsequent formation of what Main [ 9] called
secondary attachment strategies, measured along two
dimensions, attachment anxiety and attachment-related
avoidance, are risk factors for emotional problems andpsychopathology [ 5,6
/C15/C15]. However, attachment anxiety (i.
e. worries that others will not be available in times of
need; anxious searching for love and support) and avoi-dant attachment (i.e. distrust in others’ intentions and
compulsive self-reliance) are initially adaptive, in the
sense that they adjust a child’s behavior to the require-ments of an inconsistently available or consistently
unavailable attachment ﬁgure. They become maladap-
tive when applied to later relationships in which support-seeking and comfortable interdependence could be
rewarding and help a person maintain a sense of well-
being [ 8]. Moreover, these insecure attachment strategies
encourage repeated activation and suppression of nega-
tive emotions and continued reliance on distorted mental
representations of self and others, which contribute topoor physical and mental health [ 6
/C15/C15].
The early attachment experiences of insecure people
often involve unstable and inadequate distress regulation
[1], which interferes with the development of inner
resources needed for coping successfully with stressors.This impairment is particularly likely during prolonged,
highly demanding stressful experiences that require

active support-seeking and actual confrontation with aproblem [ 10]. In such cases, attachment insecurity can
become extreme, damaging not only a person’s ownAvailable online at www.sciencedirect.com
ScienceDirect
Current Opinion in Psychology 2019, 25:6–10 www.sciencedirect.com

physical and mental health but also that of key relation-
ship partners.
When regulating emotions, avoidant people attempt to
block or inhibit any emotional state that is incongruent
with the goal of keeping attachment needs and tenden-cies deactivated [ 6
/C15/C15]. These inhibitory efforts are
directed mainly at fear, anxiety, anger, sadness, shame,
guilt, and distress, because these emotional states areassociated with threats and feelings of vulnerability. In
addition, anger often implies emotional involvement or
investment in a relationship, and such involvement isincongruent with avoidant people’s preference for inde-
pendence and self-reliance [ 11]. Avoidant individuals also
attempt to block or inhibit emotional reactions to poten-tial or actual threats to attachment-ﬁgure availability
(rejection, betrayal, separation), because such threats
can reactivate unwanted attachment needs [ 12].
Avoidant attachment can cause people to avoid noticing
their own emotional reactions. Avoidant individuals oftendeny or suppress emotion-related thoughts and memo-
ries, divert attention from emotion-related material, sup-
press emotion-related action tendencies, or inhibit ormask verbal and non-verbal expressions of emotion
[6
/C15/C15,8]. By defending against the conscious experience
and expression of unpleasant emotions, avoidant individ-uals make it less likely that emotional experiences will be
integrated into existing cognitive-affective structures,
and less likely that such feelings and mental structureswill be used effectively in subsequent information pro-
cessing and social behavior. Bowlby [ 2] described this
strategy as ‘defensive exclusion,’ resulting in the creationof ‘segregated mental systems.’
Unlike people scoring high on attachment-related avoid-
ance, who tend to view negative emotions as goal-incon-
gruent states that should be ignored or suppressed, people
scoring high on attachment anxiety tend to perceivenegative emotions as congruent with their proximity-
seeking goals and hyperactivation of attachment needs,
and they may focus on and even exaggerate them. Theseindividuals are guided by an unfulﬁlled wish to cause
attachment ﬁgures to pay more attention and provide
more reliable protection and support [ 6
/C15/C15,13]. Therefore,
they tend to exaggerate the seriousness of threats and
over-emphasize their sense of helplessness and vulnera-
bility, partly because signs of weakness and needinesssometimes elicit attachment ﬁgures’ attention and care[14
/C15].
How does anxious hyperactivation work? One method is
to exaggerate the threat-appraisal process, perceptually
heightening the threatening aspects of even fairly benign
events, hold pessimistic beliefs about one’s ability tomanage distress, and attribute threat-related events to
uncontrollable causes or global personal inadequacies[6
/C15/C15]. Another method is to attend to internal indicators
of distress [ 13]. This includes hypervigilant attention to
the physiological aspects of emotional states, heightenedrecall of threat-related experiences, and rumination on
real and potential threats [ 6
/C15/C15]. Still another hyperactivat-
ing strategy is to intensify negative emotions by favoringan approach, counter-phobic orientation toward threaten-
ing situations or making self-defeating decisions and
taking ineffective actions likely to end in failure [ 6
These strategies create a self-amplifying cycle of distress
even after a threat objectively recedes.
Empirical evidence linking attachment
insecurities to emotion regulation
Attachment-related differences in emotion regulation
have been extensively documented in studies of reactions
to stressful events. In these studies, avoidant people are
more likely to cope with threatening events by relying oncognitive distancing and emotional disengagement (e.g.
[15–18 ]). In contrast, attachment anxiety has been asso-
ciated with heightened engagement in distress-exacer-bating mental rumination — moody pondering, or think-
ing anxiously or gloomily about threatening events (e.g.
[19–21 ]) and paying more attention to distress-eliciting
stimuli [ 22]. In one study [ 22], participants were asked to
search for an image while ignoring a previously presented
neutral or distress-eliciting prime. The distress primeinterfered with image search, and this interference was
stronger among participants who scored higher on attach-
ment anxiety. That is, anxious people tend to automati-cally direct attention toward distressing stimuli, which
then interferes with task performance.
Signs of distress hyperactivation in the brains of anxious
people have been reported by De Wall et al. [23]. They
found that in response to a simulated experience of socialexclusion while participants were in an MRI scanner, self-
reports of anxious attachment were related to heightened
activity in regions involved in distress activation: thedorsal anterior cingulate cortex (dACC) and anterior

insula. Of special interest, these brain reactions to social
exclusion were attenuated by asking people to reﬂect ontheir security-providing attachment ﬁgure — that is, by
what we have called ‘security priming’ [ 24].
Attachment-related variations in emotion regulation have
also been documented in studies of emotional memories
(e.g. [ 25
/C15,26,27 ]). For example, Mikulincer and Orbach
[27] asked participants to recall early experiences of
anger, sadness, anxiety, or happiness, and to rate the
intensity of focal and associated emotions in each recalled
event. Avoidant people had the poorest access (longestrecall latencies) to sad and anxious memories; anxious
people had the easiest access to such memories, and
secure people fell in between. Moreover, avoidant indi-viduals rated focal emotions (e.g. sadness when retrieving
a sad memory) and non-focal emotions (e.g. anger whenAttachment and emotion regulation Mikulincer and Shaver 7
www.sciencedirect.com Current Opinion in Psychology 2019, 25:6–10

retrieving a sad memory) as less intense than secure
individuals, whereas anxious individuals reported
experiencing very intense focal andnon-focal emotions
when asked to remember examples of negative emotions.
That is, anxious people exhibited a rapid and extensive
spread of activation among negative emotions.
Avoidant people’s defensive tendency to block the expe-
rience of negative emotions has been noted in studiesassessing thought suppression (e.g. [ 28,29
/C15,30]). For
example, Fraley and Shaver [ 29/C15] asked participants to
write about whatever thoughts and feelings they wereexperiencing while being asked to suppress thoughts
about a romantic partner leaving them for someone else.
Avoidant attachment was associated with greater abilityto suppress separation-related thoughts, as indicated by
less frequent thoughts of loss following the suppression
task and by lower skin conductance during the task. Incontrast, attachment anxiety was associated with poorer
ability to suppress separation-related thoughts, as indi-
cated by more frequent thoughts of loss following thesuppression task and higher skin conductance during the
task. Gillath et al. [30] reported that these attachment-
related variations are also evident in patterns of brainactivation and deactivation when people are thinking
about breakups and losses and attempting to suppress
such thoughts. However, other studies (e.g. [ 31
/C15,32]) have
found that when a high cognitive load is imposed, avoi-
dant people’s ability to suppress negative thoughts is
disrupted and they are overwhelmed by the suppressedmaterial.
The fragility of avoidant defenses was also noted in Chun
et al.’s [ 33] study, where avoidant participants’ ability to
disengage attention from contempt faces was impaired
when they were asked to rehearse a 7-digit number(imposing a cognitive load) while performing the atten-
tion task. The same fragility has been found in studies
examining physiological signs of distress. Speciﬁcally,avoidant attachment has been associated with decreased
heart-rate variability [ 34], impaired blood pressure recov-
ery [35], increased skin conductance [ 36,37 ], and height-
ened diastolic blood pressure [ 38] in response to various
laboratory stressors (e.g. recalling a stressful situation,
performing demanding tasks, discussing relationship pro-blems with a dating partner). Similarly, studies showing
that avoidant people do sometimes show strong negative
emotions and a loss of self-control in response to chronic,uncontrollable, and severely distressing events suggest asimilar breakdown of defenses when these people expe-
rience great stress rather than a simple cognitive load (e.g.
[39]).
Following this line of research, Vrti 9cka et al. [40] scanned
the brains of people who were asked to attend naturally orto cognitively reappraise their emotional responses to
unpleasant scenes. Avoidant participants showedincreased prefrontal and anterior cingulate activation to
unpleasant scenes and exhibited increases in dorsolateral
prefrontal cortex and left amygdala activity during reap-praisal. That is, avoidant people may be less efﬁcient in
using reappraisal strategies and need to engage in more
effortful control for dealing with distress. Anxious parti-cipants showed increases in the right amygdala across all
conditions — another sign of their heightened reactivity.
In fact, using event-related fMRI, Lemche et al. [41]
found that self-reports of attachment anxiety or avoidance
were associated with heightened activation in bilateral
amygdalae to a stressful stimulus. That is, less securepeople tended to react to stress with increased amygdala
activity — a neural indication of distress-related arousal.
Avoidant people usually try to ignore or suppress thisreaction.
There is accumulating evidence that people scoring high
on attachment anxiety or avoidance have serious difﬁcul-
ties in identifying and describing emotions (e.g. [ 42–44 ]).
These problems are also evident in studies examiningindividual differences in mindfulness — the capacity to
maintain mindful attention and awareness to ‘here and
now’ stimuli, sensations, feelings, and thoughts withoutany judgmental attitude. In all such studies, self-reports
of attachment anxiety and avoidance are inversely asso-
ciated with self-reports of mindfulness (e.g. [ 45–47 ]).
Pepping et al. [ 46] also found that difﬁculties in emotion
regulation fully mediated the association between attach-
ment insecurities and mindfulness.
Considering neural correlates of attachment insecurities,
studies have found that these insecurities are associatedwith deﬁcits in the neural structure of brain regions
implicated in emotion regulation. For example, Quirin
et al. [48] found that higher anxiety and avoidance scores
were associated with reduced hippocampal cell density,
and Benetti et al. [49] found that higher anxiety scores

were associated with reduced gray matter in the anteriortemporal lobe. These ﬁndings are compatible with a
neurotoxic model of stressful attachment experiences
than impair both the sense of security and the regulationof emotions.
Attachment-related individual differences in emotionregulation have been documented in a remarkable variety
of behavioral and neuroscientiﬁc studies. These studies
provide strong empirical support for Bowlby’s [ 3] attach-
ment theory and its extension into the realm of adult
dispositions and relationships [ 6
/C15/C15]. However, more
research is needed if we are to better understand thespeciﬁc strategies and defenses anxious and avoidant
people use in particular situations and the ways in which
people scoring high on both attachment anxiety andavoidance regulate their emotions. In addition, future
studies should attempt to determine the kinds of8Attachment in adulthood

therapeutic interventions that can effectively counteract
anxious hyperactivation of attachment-related and dis-
tress-related feelings and thoughts, and interventions thatcan alleviate avoidant distancing from emotional experi-
ences and close relationships.
Conﬂict of interest statement
Nothing declared.
References and recommended reading
Papers of particular interest, published within the period of review,
have been highlighted as:
/C15of special interest
/C15/C15of outstanding interest
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C:\Works\Data\projects\Python\Diagnosis Project\chat_app\knowledge\documents\Attachment Styles View of Self and Negative Affect.pdf

Sacred H eart Universit y
DigitalComm ons@SHU
Psychology Faculty Publications Psychology
12-2002
Attachme nt Styles, V iew of S elf and N egative A ffect
Amy Van Buren
Sacred Heart University, vanbur ena@s acredheart.edu
Eileen L. Cooley
Agnes Sco tt Co llege
Follow thi s and a dditional w orks at:http://d igitalcommon s.sacredheart.edu/ps ych_fa c
Part of the Coun seling Psychology Common s
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ferribyp@s acredheart.edu, lysobeyb@s acredheart.edu.Recomme nded Citation
Van Buren, A . & C ooley, E.L. (2002). A ttachme nt styles, view of s elf and ne gative affect.North American Journal of P sychology 4(3),
417-430.

Author info: Correspondence should be sent to: Dr. Amy Van Buren , Psych. 
Dept., Sacred Heart University, 5151 Park Ave., Fai rfield, CT, 06432. 
 
North American Journal of Psychology , 2002, Vol. 4, No. 3, 417-430. 
 NAJP Attachment Styles, View of Self and Negative 
Affect 
 
Amy Van Buren 
Sacred Heart University 
 
Eileen L. Cooley 
Agnes Scott College 
 
We investigated the relationship between attachment  styles and negative 
affect using Bartholomew and Horowitz’s (1991) mode l of attachment.  
Attachment styles with a negative self view (i.e., preoccupied and fearful) 
were expected to be associated with more distress, especially the fearful 
style which involves negative views of both  self and others. Measures of 
attachment, depression, depression proneness, and s ocial anxiety were 
administered to 293 undergraduates. As predicted, p articipants with 
“negative self” attachment styles reported  more symptoms of depression, 
proneness to depression, and social anxiety, but, c ontrary to prediction, 
those with a  fearful style did not report more symptoms of depre ssion  and 
anxiety  than those with a preoccupied style. Results sugges t that the 
negative view of self significantly predicts depres sion and anxiety.    
Preoccupied and fearful attachment styles may best be described as 
predicting general negative affectivity.  Implications for counseling are 
discussed. 
 
Attachment theory and concepts were originally deve loped to address 
the relationship between infants and their primary caregivers (Bretherton, 
1991). However, in the1980s attachment research shi fted from a primary 
focus on the adult-infant relationship to the appli cation of attachment 
concepts to adult-adult relationships. Early attach ment experiences with 
caregivers are believed to form prototypes or inter nal working models 
that set the stage for patterns and expectations in  later adult relationships 
(Berman & Sperling, 1994; Rothbard & Shaver, 1994).  These internal 
working models incorporate a view of the self as lo veable or not and a 
perspective of others regarding whether others  are likely to meet an 
individual’s needs or provide rejection. These inte rnal working models 
function as templates or attachment styles, influen cing people’s behaviors 
as they interact with and develop adult relationshi ps, thus providing 
continuity between child and adult relationship pat terns (Rothbard & 
Shaver, 1994).

418        NORTH AMERICAN JOURNAL OF PSYCHOLOGY 
Hazan and Shaver (1987) proposed a three-category m odel of adult 
attachment by applying Ainsworth’s three–part model  of infant 
attachment to describe romantic relationships in ad ulthood. They 
demonstrated that secure, anxious-ambivalent, and a voidant styles of 
attachment were each present in adults who  differed in their histories of 
attachment and their cognitive, internal working mo dels. Securely 
attached adults were found to perceive love positiv ely but realistically 
and to view themselves as easy to get to know and l ike.  Individuals with 
an avoidant style of attachment were found to fear interpersonal 
closeness.  People with an anxious-ambivalent type of attachment were 
more likely to describe love with concepts of jealo usy and obsessiveness 
and often felt less confident and misunderstood in interpersonal 
relationships. 
Subsequently, Bartholomew and Horowitz (1991) repla ced the three-
category model with a four-category model of attach ment. In their 
conceptualization of adult attachment, the view of self as positive or 
negative was crossed with the view of other people as positive or 
negative. This created four subtypes of attachment and the avoidant 
classification of attachment was now subdivided int o two types.  In the 
four-category model, there are secure, preoccupied,  fearful and 
dismissive types of attachment. The securely attach ed people see 
themselves favorably and believe that other people will be responsive to 
them.  For the fearful type, both views of self and  others are negative; the 
person doesn’t feel loveable and believes others wi ll be rejecting and 
untrustworthy. For the preoccupied type (the anxiou s-ambivalent 
category in Hazan and Shaver’s scheme) the person h olds a positive view 
of others but a negative self-perspective and thus may be more 
“preoccupied” with relationships , i.e.,  often obtaining a sense of self by 
being valued by other people.  For the dismissive t ype, the person has a 
positive view of the self but a negative view of ot hers and thus may not 
seek or value relationships.  
Using different models of attachment,  security of attachment has been 
studied in relation to general psychopathology and negative mood states.  
Thoughts and behaviors of people with a secure styl e of attachment have 
been compared to those of people with insecure styl es.  For example, 
Mikulincer and Florian (1998) examined the  coping ability of adults 
under stressful situations and found an insecure st yle of attachment was 
associated with more negative responses to stress, while securely attached 
adults managed stress more effectively and positive ly.  In a study of 
college students, Kemp and Neimeyer (1999) also not ed that attachment 
styles were associated with reactions to stress.  S pecifically, preoccupied 
attachment was correlated with more reports of nega tive symptoms and a

Van Buren & Cooley     ATTACHMENT STYLES     419                                                                                                                        
feeling of distress. Administering the MMPI-2 to a low-income sample of 
first-time mothers, Pianta, Egeland and Adam (1996) , using the Adult 
Attachment Interview, similarly found that attachme nt style predicted 
psychiatric symptoms; women with a preoccupied styl e reported the most 
symptoms of distress.  
Other investigations of attachment and psychologica l distress have 
been applied to specific mood states, especially de pression .  Many studies 
have focused on student samples using both three-ca tegory and four-
category models of attachment.   Using the three-category model Roberts, 
Gotlib, and Kassel (1996) found that higher scores on a measure of 
depressive symptomatology were associated with both  the 
anxious/ambivalent and avoidant styles, but in a re gression equation only 
the anxious ambivalent style made a specific contri bution to symptoms of 
depression. Using the same model of attachment, Pri el and Shamai 
(1995) found that anxious/ambivalent students had m ore symptoms of 
depression than avoidant students.  Using Bartholom ew and Horowitz’s 
four-category model, Carnelley, Pietromonaco, and J affe (1994) found 
that depression in college women was associated wit h both preoccupied 
and fearful styles of attachment. 
Insecure styles of attachment also have been associ ated with 
depression in adolescent and adult samples.  Interv iewing psychiatrically-
hospitalized adolescents with the Adult Attachment Interview, Rosenstein 
and Horowitz (1996) found that preoccupied and dism issive styles of 
attachment were correlated with specific diagnoses.  A diagnosis of 
affective disorder was associated with a preoccupie d style of attachment, 
while a dismissing style was associated with conduc t disorder. For 
married women with a history of clinical depression , responses to 
Bartholomew and Horowitz’s model revealed that a fe arful, and not 
preoccupied , style was associated with depression (Carnelley et  al., 
1994).  Similarly, in a study of adult couples, Whi ffen, Kallos-Lilly, and 
MacDonald (2001) reported that depressed women were  more likely to 
have a fearful style of attachment than a compariso n sample.   
These findings on the relationship between depressi on and attachment 
are consistent with Beck’s (Beck, Rush, Shaw, & Eme ry, 1979)  cognitive 
triad model of depression. He proposed that people get depressed because 
of their negative view of the self, experience and the future.  Based on 
Beck’s conceptualization, insecure attachment style s incorporating a 
negative view of the self (i.e., preoccupied or fea rful) would be 
associated with more depressive symptoms than attac hment styles with a 
positive view of the self (i.e., secure or dismissi ve) (Carnelley et al., 
1994).  However, there appear to be inconsistent fi ndings regarding the 
particular style of attachment that is most often l inked with symptoms of

420        NORTH AMERICAN JOURNAL OF PSYCHOLOGY 
depression. Some research suggests the anxious/ambi valent or the 
preoccupied style) is most vulnerable (e.g., Priel & Shamai, 1995; 
Rosenstein & Horowitz, 1996), while other studies p ropose that the 
fearful style best predicts depressive symptoms (e. g., Carnelley et al., 
1994; Whiffen et al., 2001). Carnelley, et al., (19 94) found that both 
preoccupied and fearful styles predicted depressive  symptoms with a 
college student sample. This situation is further c omplicated since these 
studies used different models of attachment and var ied in their use of 
adolescent, adult, or college student samples.  In Hazan and Shaver’s 
(1987) three-category model, the avoidant type incl udes people with both 
positive and negative views of themselves.  Studies  based on this model, 
therefore, don’t directly test the fearful style of  attachment and their 
results of specific attachment styles are then more  difficult to interpret. 
As current research emphasizes the four-category mo del of attachment, 
more research using this model is needed to clarify  the relationship 
between particular types of attachment styles and d epression.  
Furthermore, it remains unclear whether the associa tion between 
depression and attachment represents a finding spec ific to depression or a 
more general finding for negative mood states or di stress.  For example, 
few studies have examined the relationship between attachment style and 
anxiety.  Priel and Shamai (1995) used the State fo rm of the State-Trait 
Anxiety Inventory  in their study of college students (three-category  model 
of attachment) and found that anxious-ambivalent st udents indicated 
more anxiety than avoidant students who , in turn, reported more anxiety 
than secure students. Leondari and Kiosseoglou (200 0) studied university 
students from Greece using the Beck Anxiety Inventory  and the Inventory 
of Parent and Peer Attachment . They found that security of attachment 
predicted anxiety and loneliness but they did not m easure specific styles 
of attachment. It seems likely that participants wi th a negative view of 
themselves would also be more likely to report high er levels of anxiety, 
as they might worry about their performance, especi ally in their 
interpersonal interactions. However, attachment res earch incorporating 
specific types of attachment styles is needed to ex amine the relationship 
between anxiety and attachment. 
The present study sought to refine our understandin g of the 
relationship between styles of attachment, and depr ession and anxiety.  
Previous research suggests that a negative view of the self is likely to be 
associated with symptoms of depression.  We expecte d to replicate this.  
However, prior research has produced mixed findings  regarding which 
attachment style with a negative view of the self i s most likely to be 
associated with depression (i.e., preoccupied or fe arful). Based on Beck’s 
theory of depression and Bartholomew and Horowitz’s  (1991) model of

Van Buren & Cooley     ATTACHMENT STYLES     421                                                                                                                        
attachment, our first hypothesis was that that the fearful style, which 
includes a negative view of the self and others, wo uld be most likely to be 
associated with symptoms of depression. The fearful  style of attachment 
represents a more extreme form of negativity that g oes beyond the self, 
thus expanding the person’s negative perspective an d experience. 
In addition, we examined proneness to depression to  determine if the 
relationship between attachment styles and symptoms  of depression could 
be extended to include a trait perspective of depre ssion. Most prior 
research has focused on immediate depressive sympto ms rather than 
long-term patterns of depression.  Our second hypot hesis was that people 
reporting negative styles of attachment would be mo re likely to report 
being vulnerable to depressive symptoms throughout their lives.  
Our third hypothesis was that attachment styles wit h a negative view 
of the self, particularly the fearful style, would be associated with other 
negative mood states, specifically interpersonal an xiety. Since people 
with the fearful style of attachment were found to be socially inhibited 
and lacking in assertiveness skills (Bartholomew & Horowitz, 1991), they 
also were expected to report higher levels of inter personal anxiety. An 
attachment style incorporating a negative view of t he self and others may 
be associated with negative mood states in general,  rather than 
specifically linked to depression. 
In summary, it was hypothesized that participants w ith a negative 
view of themselves (i.e., preoccupied and fearful) would report more 
symptoms of depression and interpersonal anxiety as  well as a greater 
proneness to depression than participants with a po sitive view of 
themselves (i.e., secure and dismissive).  Furtherm ore, it was predicted 
that participants with a fearful style of attachmen t would indicate the 
highest levels of depression, interpersonal anxiety , and proneness to 
depression.  
METHOD 
Participants 
Participants were 293 undergraduates attending eith er a small liberal 
arts college for women in the southeast ( n = 149) or a private co-
educational liberal arts college in the northeaster n United States ( n = 
144). Eighty-eight percent were women and 12 % were  men. Regarding 
ethnic identity, 78 % were Caucasian, 12% African-A merican, 2% His- 
panic, 3 % Asian-American, and 5% other.  Ninety-fi ve percent of the 
participants were single, 2% divorced or separated,  and 3% married. Of 
the participants who were single, 60% were not dati ng or dating casually 
while 40% reported they were in a serious relations hip. Data were 
collected over a two-year period as part of two sep arate studies on social

422        NORTH AMERICAN JOURNAL OF PSYCHOLOGY 
relationships and attachment.  Therefore the number  of participants varies 
for the various measures in this study. 
 
Measures 
The Relationship Styles Questionnaire (RSQ; Bartholomew & 
Horowitz, 1991).  The RSQ is based on a 4-group mod el of attachment 
proposed by Bartholomew and Horowitz.  It consists of four short 
paragraphs, each of which describes one of the four  attachment styles.  
Participants are asked to indicate which of the fou r descriptions is most 
characteristic of them. Empirical data support the utility of the four-group 
model (Bartholomew & Horowitz, 1991). 
Beck Depression Inventory II  (BDI-II; Beck, Steer, & Brown, 1996).  
The BDI-II is a 21 item self report scale measuring  current depression.  
Each item is rated on a 0-3 scale, with higher scor es corresponding to 
more symptoms of depression.  In this study, item # 9 assessing suicidal 
ideation was omitted. This was done after a faculty  reviewer at one of the 
institutions expressed concern that given the anony mity of the study, 
there would be no way to follow up with a participa nt who answered the 
item in the affirmative. Regarding reliability, the  coefficient alpha for 120 
college students was .93 and the test-retest correl ation for 26 outpatients 
was .93 after a one-week interval (Beck  et al., 1996). The BDI-II is 
positively related to the Beck Hopelessness Scale  ( r = .68) and to the 
Hamilton Psychiatric Rating Scale for Depression  ( r = .71), indicating 
adequate validity (Beck, et al., 1996).  
The Depression Proneness Rating Scale  (DPRS; Zemore, 1983). The 
DPRS is a 13-item scale designed to assess a person ’s tendency to 
become depressed. Participants read each statement and rate each 
depressive symptom for frequency of occurrence over  the past two years.  
Each item is rated on a 9-point scale with higher n umbers indicating 
greater proneness to depression. Coefficient alpha calculated from the 
original subject pool of 360 students, was .83.  Tw o-week, four-week and 
six-week test-retest correlations were .90, .82 and  .72, respectively 
(Zemore & Dell, 1983). As reported in Zemore (1983) , students’ scores 
on the DPRS correlated significantly with depressio n-proneness ratings 
by their parents and peers.   
Interaction Anxiousness Scale  (IAS; Leary, 1983). The IAS is a 15 
item self report measure of the tendency to experie nce subjective social 
anxiety independent of accompanying behaviors. Item s consist of 15 
statements that are responded to on a 5-point scale  ranging from “not at 
all characteristic of me” to “extremely characteris tic of me.”  In terms of 
internal consistency, all items correlate at least .45 with the sum of all 
other items and Cronbach’s alpha exceeds .87. Eight  week test-retest

Van Buren & Cooley     ATTACHMENT STYLES     423                                                                                                                        
reliability is .80 (Leary, 1991). IAS scores correl ate highly with other 
measures of social anxiousness and shyness (Jones, Briggs, & Smith, 
1986; Leary & Kowalski, 1987). In addition, IAS sco res correlate highly 
with self-reported anxiety in real interactions (Le ary, 1983; 1986). For 
the present study, the title of this measure was ch anged to the 
"Interpersonal Interaction Scale ." 
 
Procedure 
The study took place at two locations: a small, pri vate liberal arts 
college for women in the southeast and a small, lib eral arts university in 
the northeast. Participants at both institutions we re recruited through 
psychology classes and were offered extra credit fo r taking part in the 
study by the individual professors teaching those c lasses.  
Participants were tested in small groups and were a dministered the 
above measures in a fixed order as part of a larger  study.  The order was 
as follows: informed consent; demographic questionn aire measuring age, 
gender, relationship status and marital status, yea r in college and major; 
Relationship Styles Questionnaire; Beck Depression Inventory-II; 
Depression Proneness Rating  Scale; and  Interaction Anxiousness Scale.   
 
RESULTS 
Means and standard deviations were computed for eac h of the target 
measures. Since the data were collected as part of more than one study on 
attachment, not all participants completed each of the measures.  For the 
BDI-II there were 238 participants with an overall mean score of 11.19 
(SD  = 8.40), for the DPRS there were 133 respondents w ith a mean of 
54.45 ( SD  = 19.25), while the mean score on the IAS was 41.5 6 ( SD  = 
11.75) for 123 participants.  
Attachment responses were coded based on Bartholome w and 
Horowitz’s (1991) model.  Forty-four percent of the  sample indicated the 
secure description best fit their behavior in close  relationships, 14% the 
dismissive type, 15% the preoccupied type, and 27% the fearful type.  
Participants reporting a secure or dismissive style  of attachment were 
identified as “positive self” (58%) and those indic ating a preoccupied or 
fearful style were labeled as “negative self” (42%) .  
Using the positive v. negative “self” groups, an in dependent t -test 
compared BDI-II scores between groups to test the h ypothesis that people 
with a negative view of themselves would report mor e symptoms of 
depression than people with a positive self view. A s predicted the 
“negative self” styles (i.e., fearful or preoccupie d)), were associated with 
significantly higher BDI-II scores ( M = 14.04, SD  = 9.17) than those with

424        NORTH AMERICAN JOURNAL OF PSYCHOLOGY 
a “positive self” view (i.e. secure or dismissive) ( M = 8.98, SD  = 7.02), t 
(236)  = - 4.82, p < .001, (Cohen’s effect size d = .63, (Cohen, 1988).  
To examine whether the fearful style of attachment was most likely to 
be associated with symptoms of depression, a one-wa y ANOVA was 
conducted using attachment style as the between sub ject’s variable and 
BDI-II scores as the dependent variable. The mean s cores for the secure, 
dismissive, preoccupied and fearful styles of attac hment were: 8.32 
(6.79), 10.91 ( 7.43), 15.05 (9.37), and 13.48 (9.0 9). The ANOVA was 
statistically significant, F (3, 237)  = 8.99, p < .001 (Cohen’s effect size f  = 
.34 (Cohen, 1988) and Scheffe’s post-hoc test showe d that both the 
preoccupied (mean difference = -6.73, p < .01) and fearful (mean 
difference = -5.16, p < .01) attachment groups reported significantly mor e 
depressive symptoms on the BDI-II than the secure g roup. Contrary to 
prediction, these two groups were not significantly  different from each 
other.  
Depression-proneness, a trait perspective on depres sion, was analyzed 
in the same way as the BDI-II. The group with a “ne gative self” view 
reported more proneness to depression ( M = 63.25, SD  = 16.81) than the 
group with a “positive” view of the self, ( M = 48.24, SD  = 18.52) t (131) 
= - 4.78, p < .001, (effect size d = .84).  A one way ANOVA with 
attachment style as the between subject’s factor an d DPRS as the 
dependent variable was statistically significant, F (3,132)  = 8.51, p < .001 
(effect size f = .45). Scheffe’s post-hoc test showed that both th e 
preoccupied (mean difference = -19.85, p < .01) and fearful (mean 
difference = -12.74, p < .02) attachment groups reported more proneness 
to depression than the secure group, but were not s ignificantly different 
from each other. In addition the dismissive group h ad statistically lower 
DPRS scores than the preoccupied group of participa nts (mean difference 
= -16.63, p < .05). The means for the specific attachment type s were as 
follows: secure 47.54 ( SD  = 17.83), dismissive 50.76 ( SD  = 21.22), 
preoccupied 67.39 ( SD  = 21.31), and fearful 60.28 ( SD  = 12.16). 
For interpersonal anxiety, the participants with a negative view of the 
self ( M = 47.24, SD  = 12.63) produced higher scores than participants 
with a positive view of the self ( M = 38.62, SD  = 10.15) on IAS scores, t 
(121) = - 4.10, p < .001(effect size d = .78). A one way ANOVA with 
attachment style as the between subject’s factor an d IAS as the dependent 
factor was statistically significantly, F (3, 122)  = 6.20, p = .001 (effect size f 
= .40).  Scheffe’s post-hoc test demonstrated that both the preoccupied 
(mean difference = -9.62, p < .02) and fearful (mean difference = -9.36, p 
< .01) attachment groups reported significantly mor e anxiety than the 
secure group and the preoccupied and fearful groups  were not 
significantly different from each other. The means for the specific

Van Buren & Cooley     ATTACHMENT STYLES     425                                                                                                                        
attachment types were as follows: secure 37.76 ( SD  = 9.37), dismissive 
41.82 ( SD  = 12.72), preoccupied 47.39 ( SD  = 12.84), and fearful 47.13 
(SD  = 11.75). 
DISCUSSION 
Consistent with our hypothesis and Bartholomew and Horowitz’s 
(1991) four-category model, we found that people wi th a  negative view of 
self (i.e., fearful or preoccupied attachment style ) reported more current 
symptoms of depression than people indicating a pos itive view of the self 
(i.e., secure or dismissive style). This finding su pports Beck’s theory 
(Beck, 1979) regarding the central role of the self  in depression.  It is also 
consistent with previous research (e.g., Carnelley,  et al., 1994; Murphy & 
Bates, 1997) and, given the medium-to-large effect size, suggests a 
meaningful relationship between a negative self vie w and current 
symptoms of depression.   
However, the results did not support the prediction  that people with 
the most depressive symptomatology would be those w ith a fearful style, 
which involves negative view of both  self and others. It turns out that 
participants with a fearful or preoccupied style (w hich involves a negative 
view of self but a positive view of others) did not  differ from each other 
in their report of depressive symptoms. It seems th at regardless of how 
one sees others, it is the negative view of oneself  that is most consistently 
linked to symptoms of depression. However, the natu re of the link 
between negative self-view and depression may diffe r depending on the 
internal working model of other. For example, preoc cupied people who 
are depressed may show a heightened awareness and r eaction to negative 
social cues, which then affects their view of self and may impair their 
ability to see themselves objectively (Lopez, 1995) . In contrast, those 
with a fearful style may shut out constructive soci al feedback or shun 
potentially helpful relationships, which may then f urther impair their self-
views. 
Our findings are consistent with the results of Car nelley, et al. (1994) 
who used the same four-category model with a colleg e student sample.  
However, their sample differed from the present sam ple. The majority of 
their sample (60%) reported they were currently par t of a stable re- 
lationship while, in contrast, the majority of our participants indicated 
they were  not in a serious relationship (60%). Taken together , the results 
of both studies suggest that the opinion one has of  oneself plays a greater 
role in self reported depression than how one feels  about others, 
regardless of whether one is in a serious relations hip. For college 
students, serious relationships may not have contin ued long enough to 
provide a corrective experience that may alter the association between 
depression and attachment style.

426        NORTH AMERICAN JOURNAL OF PSYCHOLOGY 
Attachment styles with a negative self-concept also  were more likely 
to be associated with a long-term proneness to depr ession.  The pattern of 
results demonstrated a large effect size and was si milar to the pattern 
reported for current symptoms of depression. Studen ts with an attachment 
style incorporating a negative self view (i.e., fea rful and preoccupied) 
reported significantly greater proneness to depress ion than those who had 
a positive self view (i.e., secure or dismissive)  and again, the fearful style 
of attachment did not differ from the preoccupied s tyle. These findings 
therefore extend our view of the relationship betwe en depression and 
attachment styles to incorporate both trait and sta te experiences of 
depression.  Having a long-term proneness to depres sion may, in turn, 
make one more vulnerable to developing acute sympto ms.  Again, this is 
true regardless of whether one’s view of others lea ds one to be overly 
dependent on others (i.e., preoccupied style) or to  lack trust in and fear 
involvement with others (i.e., fearful style).   
Finally, we extended the findings on attachment sty le and depression 
to include social anxiety. Consistent with our pred iction, those whose 
attachment style consisted of a negative view of se lf-reported more 
subjective social anxiety with a medium-to-large ef fect size. Once again, 
the fearful style of attachment was not associated with the most 
interpersonal anxiety, as both fearful and preoccup ied styles differed 
from secure styles, suggesting again that it is a p oor self (rather than 
other) representation that is the critical factor .  These findings, however, 
are important in extending the research on attachme nt to other negative 
moods, this time social anxiety. 
There are several conclusions that can be drawn fro m our findings.  
First, it seems clear that attachment styles with a  negative view of self are 
associated with depression and social  anxiety.  However, since ours was a 
college student sample, it is not known whether thi s would also be true 
for a clinical sample with diagnosed affective or a nxiety  disorders.  
Second, while past research has primarily studied t he relationship 
between attachment styles and depression, we have e xtended the 
literature to include the relationship between atta chment styles and both 
trait depression and social anxiety. Our results su ggest that having an 
attachment style with a poor self-view is not speci fic to current symptoms 
of depression, but actually involves a cluster of s ymptoms and personality 
traits.  These include: long-term vulnerability to depressio n, social 
anxiety, and anger (Mikulincer, 1998), which togeth er might be better 
termed “negative affectivity” (Feeney & Noller, 199 6; Watson & Clark, 
1984; Watson & Pennebaker, 1989). 
Developmentally, the relationships among attachment  style, self view 
and negative affectivity are complex. It is likely that biological and

Van Buren & Cooley     ATTACHMENT STYLES     427                                                                                                                        
temperamental factors may set the initial stage for  negative states and 
traits. During the course of early development, att achment experiences 
would then further determine whether the person dev elops an attachment 
style characterized primarily  by a negative self-view. Attachment style 
and negative affectivity would then mutually influe nce one another.  
However, what is not yet known is the direction of the relationship, i.e., 
whether attachment style influences the individual’ s experience of 
negative affect or whether negative affect influenc es the kind of 
attachment style one develops. Further research is needed to investigate 
this relationship. 
Results from the present study have important impli cations for the 
counseling process. Our results indicate that the n egative view of self is 
an appropriate target for intervention in people wi th depression and 
anxiety, as Beck would suggest. However, when the r esults are inter- 
preted within an attachment framework, which takes into account view of 
other s as well as of self, it becomes obvious that simply  focusing 
interventions on the self may not be enough. Becaus e fearful and 
preoccupied people have different self-other schema s, it follows that their 
interpersonal interactions  may be very different. Therefore, an effective 
counseling approach will differ for each style. For  example, preoccupied 
people, whose symptoms may stem from being other-or iented and overly 
attuned to subtle and particularly negative social cues, may need help 
focusing on more objective self-awareness. In contr ast, fearful people, 
whose negative view of others causes them to diseng age may need help 
being more connected to others (Lopez, 1995). Thera py with fearful 
people may need to involve particular attention to the development of a 
therapeutic working alliance.   
These findings must also be interpreted within a de velopmental 
framework. College students are young adults, many of whom have had 
limited experience in adult-adult romantic relation ships. As these students 
develop and have more extensive relationship experi ences, their specific 
attachment styles may be modified. It would be inte resting to follow 
students during and beyond their college years to c atalogue relationship 
experiences and perhaps changing attachment styles that may accompany 
their growth and development. In contrast to the pr esent findings, some 
researchers have found that the fearful style of at tachment was most likely 
to be associated with depression among married wome n (Carnelley et al., 
1994; Whiffen et al., 2001). 
There are several factors specific to this study wh ich may  limit the 
conclusions. Since the majority of the participants  (88%) were women, 
the conclusions are more applicable to women than m en. Depression in 
women may be of a more interpersonal nature than de pression in men and

428        NORTH AMERICAN JOURNAL OF PSYCHOLOGY 
it may be that attachment models of depression are more applicable to 
women.   If attachment models of depression do apply to men , it is 
possible that in men, the underlying relationships between self and other 
are different. If this is so, therapeutic intervent ions need to differ for the 
genders. For example, depression in men may be more  related to the 
dismissive (positive self and negative other) style  and it follows that 
counseling  approaches will need to be different than for fearf ul or 
preoccupied styles. Clearly, more research needs to  be done using the 
four-category model to study attachment and negativ e mood states in 
men. Our study is also limited by the fact that  the measures are self-
report.  In future studies, it will be important to  gather data measuring 
long-term depression proneness and interpersonal an xiety from other 
sources, for example friends and significant others . Finally, it will be 
important to continue this research by using the fo ur-category model to 
find whether the self/other distinction applies to other negative states, 
such as anger and frustration.  It will also be imp ortant to find out 
whether the negative view of self continues to be a ssociated with general 
negative affectivity or only with certain specific negative mood states and 
traits.    
 
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Attachment theory and emotions in close
relationships: Exploring the attachment-related
dynamics of emotional reactions to
relational events
MARIO MIKULINCERaAND PHILLIP R. SHAVERb
aBar-Ilan University andbUniversity of California, Davis
Abstract
Attachment theory is a powerful framework for understanding affect regulation. In this article, we examine the role
played by attachment orientation in shaping emotional reactions to interpersonal transactions within close relation-
ships. Using our recent integrative model of attachment-system activation and dynamics as a guide (M. Mikulincer& P. R. Shaver, 2003), we review relevant evidence, present new findings, and propose hypotheses concerning howpeople with different attachment styles are likely to react emotionally to relational events. Specifically, we focus on
attachment-related variations in the emotional states elicited by a relationship partner’s positive and negative behav-
iors and by signals of a partner’s (relationship relevant or relationship irrelevant) distress or pleasure. In so doing,we organize existing knowledge and point the way to future research on attachment-related emotions in closerelationships.
One of the hallmarks of close relationships is
emotion , both positive and negative. Where
else but in close relationships do people expe-rience such diverse and intense feelings asacceptance, security, love, joy, gratitude, andpride—on the positive side, and frustration,rage, hatred, fear of rejection, humiliation,
grinding disappointment, jealousy, grief, and
despair—on the negative side? Close rela-tionships not only arouse emotions, but arealso affected by the way partners react emo-tionally to positive and negative relationalevents. Theory and research have clearlydocumented the motivational consequences
of emotions (e.g., Lazarus, 1991; Shaver,Schwartz, Kirson, & O’Connor, 1987).Within relational contexts, a person’s emo-tions can affect not only his or her ownaction tendencies, but also the partner’s re-sponses and the resulting quality of the
dyadic interaction. In fact, basic emotions,
such as anger, fear, and joy can motivateparticular kinds of behavior toward a relation-ship partner (e.g., attacking, distancing, ap-proaching), which in turn can elicit variouskinds of relational responses from the part-ner. Close relationships also provide some ofthe most important supports for and disrup-
tors of affect regulation, a process that is in-
creasingly being viewed as a central theme indevelopmental, social, and clinical psychol-ogy (Schore, 2003).
In all three of these fields, Bowlby’s
(1969/1982, 1973) attachment theory is oneof the major conceptual frameworks forunderstanding affect regulation. Bowlby
Mario Mikulincer, Department of Psychology, Bar-Ilan
University, Ramat Gan, Israel; Phillip R. Shaver, Depart-ment of Psychology, University of California, Davis.Preparation of this article was facilitated by a grant from
the Fetzer Institute.
Correspondence should be addressed to Mario
Mikulincer, Bar-Ilan University, Department of Psy-chology, Ramat Gan 52900, Israel, e-mail: mikulm@mail.biu.ac or Phillip R. Shaver, University of Califor-nia, Davis, Department of Psychology, Davis, CA
95616-8686, e-mail: prshaver@ucdavis.edu.Personal Relationships ,12(2005), 149–168. Printed in the United States of America.
Copyright /C2112005 IARR. 1350-4126 =05
149

(1969/1982, 1973) highlighted the anxiety-
buffering and physical protection functions ofclose relationships, conceptualized proximityseeking as a fundamental means of regulatingdistress, and emphasized the importance ofattachment history for understanding individ-ual differences in affect-regulation strategiesacross the life span. Most importantly for sub-
sequent research, Bowlby (1973) delineated
alternative attachment-related strategies ofaffect regulation that result from differentpatterns of interactions with attachmentfigures. In this article, we focus on thesestrategies and elaborate on their emotionalconsequences for close relationships. Specifi-cally, we review relevant evidence, present
new findings from our laboratories, and pro-
pose new ideas about the ways in whichattachment-related strategies shape a person’semotional state during positive and negativetransactions with close relationship partners.
Attachment Theory: Basic Concepts
Bowlby (1969/1982) claimed that human
beings are born with an innate psychobiologi-
cal system (the attachment behavioral system )
that motivates them to seek proximity to sig-nificant others ( attachment figures ) in times of
need. This system accomplishes basic regula-tory functions (protection from threats andalleviation of distress) in human beings of allages but is most directly and transparently
observable during infancy (Bowlby, 1988).
Bowlby (1973) also described important indi-vidual differences in attachment-system func-tioning. Interactions with attachment figureswho are available and responsive in times ofneed facilitate the optimal functioning ofthe attachment system, promote a relativelystable sense of attachment security, and
heighten confidence in support seeking as
a distress-regulation strategy. When a person’sattachment figures are not reliably availableand supportive, however, proximity seekingfails to relieve distress, a sense of attachmentsecurity is not attained, and strategies of affectregulation other than proximity seeking ( sec-
ondary attachment strategies , conceptualized
in terms of two major dimensions, avoidance
andanxiety ) are developed.In studies of adolescents and adults, tests
of these theoretical ideas have generally fo-cused on a person’s attachment style —the
systematic pattern of relational expectations,emotions, and behaviors that results frominternalization of a particular history of at-tachment experiences (Fraley & Shaver,2000; Shaver & Mikulincer, 2002). Initially,
research was based on Ainsworth, Blehar,
Waters, and Wall’s (1978) three-categorytypology of attachment styles in infancy—secure, anxious, and avoidant—and Hazanand Shaver’s (1987) conceptualization ofsimilar adult styles in the romantic relation-ship domain. Subsequent studies (e.g., Bar-tholomew & Horowitz, 1991; Brennan,
Clark, & Shaver, 1998) revealed, however,
that attachment styles are more appropriatelyconceptualized as regions in a two-dimen-sional space. The first dimension, typicallycalled attachment avoidance , reflects the
extent to which a person distrusts relationshippartners’ goodwill and strives to maintainbehavioral independence and emotional dis-
tance from partners. The second dimension,
typically called attachment anxiety , reflects
the degree to which a person worries thata partner will not be available in times ofneed. The two dimensions can be measuredwith reliable and valid self-report scales (e.g.,Brennan et al., 1998) and are associated intheoretically predictable ways with relation-
ship quality and adjustment (see Mikulincer
& Shaver, 2003; Shaver & Clark, 1994;Shaver & Hazan, 1993, for reviews).
Based on an extensive review of adult
attachment studies, we (Mikulincer & Shaver,2003; Shaver & Mikulincer, 2002) proposeda three-phase model of attachment-systemactivation and dynamics, which we will sum-
marize briefly here. Following Bowlby (1969/
1982), we assume that the routine monitoringof experiences and events results in activationof the attachment system when a potential oractual threat is perceived. Once the attach-ment system is activated, an affirmative an-swer to the question ‘‘Is an attachment figureavailable and likely to be responsive to my
needs?’’ results in attachment security and
facilitates the application of security-basedstrategies of affect regulation (Shaver &
150 M. Mikulincer and P. R. Shaver

Mikulincer). These strategies are aimed at
alleviating distress; maintaining comfortable,supportive intimate relationships; and in-creasing personal adjustment. They consist ofoptimistic beliefs about distress management,trusting beliefs about others’ goodwill, anda sense of self-efficacy about dealing withthreats (Shaver & Hazan, 1993). Security-
based strategies also involve acknowledgment
and display of distress without personal dis-organization, support seeking, and instrumen-tal problem solving (Mikulincer & Shaver).These tendencies are characteristic of peo-ple (called securely attached ) who score
relatively low on attachment anxiety andavoidance.
Perceived unavailability of an attachment
figure results in attachment insecurity, whichforces a decision about the viability of prox-imity seeking as a protective strategy. The ap-praisal of proximity as viable or essential—because of attachment history, temperamentalfactors, or contextual cues—can result inenergetic, insistent attempts to attain proxim-
ity, support, and love. In the literature on
attachment, these intense attempts are calledhyperactivating strategies (Cassidy & Kobak,
1988) because they involve constant concernand prodigious effort until an attachmentfigure is perceived to be available and a senseof security is attained. Hyperactivating strate-gies are indicated by attempts to elicit a
partner’s involvement and support through
clinging and controlling responses (Shaver &Hazan, 1993), overdependence on relation-ship partners as a source of protection (Shaver& Hazan), and perception of oneself as rela-tively helpless and incompetent at affect regu-lation (Mikulincer & Florian, 1998).
According to Shaver and Mikulincer
(2002), hyperactivating strategies involve
increased vigilance to threat-related cues anda reduction in the threshold for detecting cuesof attachment figures’ unavailability—thetwo kinds of cues that activate the attachmentsystem (Bowlby, 1973). They also intensifynegative emotional responses to threateningevents and heighten rumination on threat-
related concerns, keeping these concerns
active in working memory. As a result,minimal threat-related cues are easilydetected, the attachment system is chroni-
cally activated, and psychological painrelated to the unavailability of attachmentfigures is exacerbated. These concomitants ofattachment-system hyperactivation accountfor many of the psychological correlates ofattachment anxiety (Mikulincer & Shaver,2003).
Appraising proximity seeking as unlikely
to alleviate distress results in inhibition ofthe quest for support and active attempts tohandle distress alone. These secondary ap-proaches to affect regulation are calleddeactivating strategies (Cassidy & Kobak,
1988) because their primary goal is to keepthe attachment system deactivated in order to
avoid frustration and further distress caused
by attachment-figure unavailability. Thesestrategies involve denial of attachment needsand avoidance of emotional involvement,intimacy, and dependence in close relation-ships. They also involve the dismissal ofthreat- and attachment-related cues and thesuppression of threat- and attachment-related
thoughts. These tendencies are further rein-
forced by assuming a self-reliant attitude thatdecreases dependence on others and discour-ages acknowledgment of personal faults.These aspects of deactivation account for thepsychological manifestations of attachmentavoidance (Mikulincer & Shaver, 2003).
In summary, each attachment-related strat-
egy has a regulatory goal, and cognitive and
affective processes are shaped to facilitategoal attainment. We believe these strategiescan also shape the quality of emotional expe-riences both in general and specifically withinclose relationships. In the next section, wepresent ideas and review research findingsconcerning attachment-related variations in
emotional reactions to relational episodes.
Attachment-Related Variations in
Emotional Reactions to
Relational Episodes
In order to analyze the possible involvement
of attachment-related strategies of affect regu-lation in determining the quality of a person’s
emotional reactions within close relation-
ships, we focus on four broad categories of
Attachment, emotions, and relationships 151

emotion-eliciting relational events. Specifi-
cally, we elaborate on attachment-related var-iations in the emotional states elicited by arelationship partner’s positive or negativebehaviors and by signals of the partner’s(relationship relevant or relationship irrele-vant) distress or happiness. In other words,we consider two ways in which a partner can
evoke emotion in a target person: by acting in
certain ways and by expressing certain emo-tions of his or her own. Table 1 presents anintegrative overview of our ideas aboutattachment-related variations in emotionalreactions to the various kinds of relationalevents.
Emotional responses to a partner’s
negative behaviors
One strong source of emotions in close
relationships is behavior on the part of onerelationship partner that interferes with theother’s goals or that either actually or poten-
tially damages the other’s welfare or relation-
ship quality. A common response to suchthreats and injuries is anger. According to
Lazarus (1991), the core relational theme ofanger is ‘‘ .a demeaning offense against me
and mine’’ (p. 222), an assault or threat toone’s identity or to other important personalgoals and possessions. Researchers with othertheoretical perspectives also view anger as asignal that something important is being
threatened in one’s interpersonal interactions,
often in what is perceived to be an illegitimateway, and that some coping action should betaken to reduce or eliminate the threat, repairthe damage, or prevent further assaults (e.g.,Izard & Kobak, 1991; Shaver et al., 1987). Inthe second volume of his classic Attachment
and Loss trilogy, Bowlby (1973) argued that
anger is also the most common response to
a partner’s attachment-relevant negativebehaviors—for example, a partner’s signs ofunavailability, detachment, or rejection—thatthreaten a person’s attachment needs andsense of security.
Anger is not, however, a simple or mono-
lithic emotional response. Rather, it is a com-
plex, multifaceted emotion that can be
Table 1. An integrative summary of attachment-related variations in emotional reactions to
different kinds of relational events
Relational eventsAttachment
securityAttachment
avoidanceAttachment
anxiety
Partner’s negative
behaviorsFunctional
angerSuppressed anger,
resentment,hostilityResentment, hostility,
dysfunctional anger,despair, sadness
Partner’s positive
behaviorsHappiness, joy,
love, gratitudeIndifference,
detachmentAmbivalent feelings of
happiness, love,
fear, anxiety
Partner’s relationship-
relevant distressGuilt, reparation Resentment,
hostilityShame, despair
irrelevant distressEmpathic
compassionPity, hostility,
contempt,gloatingPersonal distress,
despair
relevant happinessHappiness, joy,
love, prideHubris Ambivalent feelings of
happiness, anxiety,
fear of success
irrelevant happinessEmpathic
happiness,respect,admirationHostile envy Ambivalent mixture of
happiness, fear ofseparation, jealousy152 M. Mikulincer and P. R. Shaver

associated with different goals, expressed in
different ways, and result in different andeven antagonistic relational outcomes (e.g.,Averill, 1982; Mikulincer, 1998; Tangneyet al., 1996). According to Tangney et al.,anger can be motivated by either constructiveor destructive goals, be expressed in func-tional or dysfunctional ways, result in posi-
tive or negative relational behaviors, elicit
positive or negative responses from a relation-ship partner, and have positive or negativeconsequences for relationship quality.
Functional manifestations of anger are mo-
tivated by constructive goals such as, main-taining a relationship, asserting one’s needs,or bringing about a change in a relationship
partner’s behavior (Averill, 1982). In such
cases, anger is typically expressed in a con-trolled manner and does not entail animosity,hostility, or hateful attitudes toward the part-ner. In fact, this kind of anger is not intendedto hurt or destroy the partner but only to dis-courage his or her negative behavior and toreestablish a warm and satisfactory relation-
ship (Averill). Hence, functional manifesta-
tions of anger do not usually lead to physicalor verbal aggression, vengeful criticism, vi-cious retaliation, or deeply hurtful accusa-tions. Rather, they take the form of focusedcomplaints and problem-solving discussions(Tangney et al., 1996).
In contrast, dysfunctional manifestations
of anger include continuing resentment to-
ward one’s partner, hurting the partner emo-tionally or physically, and seeking revenge,which can easily result in lasting ‘‘attachmentinjuries’’ (Johnson, Makinen, & Millikin,2001) and weaken relational bonds (Tangneyet al., 1996). These manifestations of angerare likely to include animosity, hostility, and
hatred; when intense, they may lead to un-
controllable aggression and even violence(Averill, 1982). In some cases, however,these dysfunctional manifestations of angermay be suppressed or redirected, to avoid aconfrontation with the partner, and the angercan then take subtle forms (Tangney et al.).In such cases, the unexpressed anger may
persist in diffuse feelings of resentment and
hostile attitudes toward the partner or maybe internalized and directed toward the self.When redirected toward the self, the angry
person may stew over feelings of self-disgust,helplessness, vulnerability, and despair, which,in turn, produce a mixture of anger, sadness,and depression (Averill; Siegel; Tangney et al.).
In his discussion of emotional reactions to
attachment-related negative behaviors, Bowlby(1973, 1988) also differentiated between func-
tional and dysfunctional manifestations of
anger. According to Bowlby (1973), anger isoriginally a functional response directed to-ward protesting separation from an attachmentfigure or reproaching an attachment figure fornot being available. It is functional in the sensethat it is directed toward either overcomingobstacles to reunion or discouraging the loved
person from going away again. However,
Bowlby (1973, 1988) also noted that anger cansometimes become dysfunctional in variousways, including becoming so intense that it ali-enates the partner or becoming vengeful ratherthan corrective. In particular, Bowlby (1988)discussed how much of family violence can beunderstood as distorted and exaggerated ver-
sions of potentially functional behavior. For
example, he characterizes various coercivebehaviors within close relationships (includingbattering) as strategies designed to control theother and keep him or her from departing. InBowlby’s (1988) view, although violent anduncontrollable outbursts of anger may have aninstrumental function (to discourage a partner’s
future negative behaviors), it is dysfunctional
in its extremity and in its potential to escalateconflict and destroy the relationship.
This analysis of anger as a complex, multi-
faceted emotion provides a preliminary frame-work for conceptualizing attachment-relatedvariations in emotional reactions to a partner’snegative behavior. In the following pages, we
present several working hypotheses and review
relevant studies concerning the ways in whichattachment-related strategies shape angry reac-tions to a relationship partner’s behavior.
Attachment security. The security-based
attachment strategies that characterizesecurely attached individuals include reacting
to a partner’s negative behavior with func-
tional manifestations of anger. The main goalof security-based strategies is to deal with
Attachment, emotions, and relationships 153

threats in a constructive, transformational man-
ner and to maintain stable, reliable, satisfac-tory, and intimate relationships (Mikulincer &Shaver, 2003). These strategies are based onbeliefs that relationship partners generallyhave good intentions, that others’ negative be-haviors are temporary and reversible, and thatone possesses suitable means for dealing con-
structively with the offense or misunderstand-
ing (Mikulincer & Shaver). As a result, whenthreatened by a partner’s negative behavior,secure people should generally express angerin a controlled manner, without extreme ha-tred or hostility, and should attempt to resolveconflicts constructively, with positive effectson relationship quality.
In support of this theoretical analysis,
Mikulincer (1998) found that, when con-fronted with a partner’s negative actions,securely attached individuals held optimis-tic expectations about the partner’s subse-quent behavior and made well-differentiated,reality-attuned appraisals of the partner’sintentions. Only when there were clear con-
textual cues provided by the experimenter,
indicating that a partner actually acted withhostile intent did secure people attribute hos-tility to the partner and react with anger.Furthermore, secure participants’ memories oftheir reactions to a partner’s negative behav-iors were characterized by the constructivegoal of repairing the relationship, engaging in
adaptive problem solving, and experiencing
positive affect following these episodes.
The functional nature of secure individu-
als’ angry reactions has also been documentedin a recent study conducted by Zimmermann,Maier, Winter, and Grossmann (2001). In thisstudy, adolescents who had previously beenclassified as securely or insecurely attached
based on the Adult Attachment Interview
(AAI) performed a frustrating, difficult cogni-tive task with the help of a friend, and theirreports of disappointment and anger duringtask performance, as well as the occurrenceof disruptive behavior toward the friend (e.g.,rejection of the friend’s suggestions with-out discussion), were assessed. The study
revealed that reports of disappointment and
anger were associated with more frequentdisruptive behavior only among insecurelyattached adolescents. Among securely attached
adolescents, these emotions were associatedwith less rather than more disruptive behavior.Therefore, secure people’s anger seems moreregulated and more functionally channeled inuseful directions.
Attachment avoidance. According to our
model, the deactivating strategies of avoidant
individuals include reacting to a partner’snegative behavior with more dysfunctionalmanifestations of anger. Avoidant individuals’attempts to inhibit every emotional state thatis incongruent with their goal of attachment-system deactivation may include suppressinganger from awareness because angry feelings
are associated with threat-related thoughts
that can reactivate attachment needs. In addi-tion, anger implies emotional investment andinvolvement in a relationship, which is incon-gruent with an avoidant person’s preferencefor interpersonal distance (Cassidy, 1994). Asa result, an avoidant person’s anger can beexpressed only in unconscious or unattended
ways (which may be physiologically measur-
able) or can take the form of nonspecific hos-tility or hateful attitudes toward a partner.This hostility can be further exacerbated byavoidant individuals’ lack of confidence intheir relationship partners’ goodwill (Shaver& Hazan, 1993).
Adult attachment studies have consistently
shown that this mixture of suppressed anger
and high levels of hostility (what Mikulincer,1998, labeled ‘‘dissociated anger’’) is corre-lated with attachment avoidance. For example,Mikulincer found that although individualsscoring high on attachment avoidance did notreport overly intense anger in reaction toa partner’s negative behavior, they reported
heightened hostility and exhibited intense
physiological arousal during these episodes.They also used distancing strategies to copewith the partner’s negative behavior and dis-played a tendency to attribute hostility toa partner even when there were clear contex-tual cues about the partner’s nonhostile intent.Signs of heightened hostility have also been
reported in other studies where attachment
avoidance has been assessed with self-reportmeasures (e.g., Buunk, 1997; Mikulincer,
154 M. Mikulincer and P. R. Shaver

Florian, & Weller, 1993, Mikulincer, Horesh,
Eilati, & Kotler, 1999). Using the AAI, Kobakand Sceery (1988) found that dismissivelyavoidant attachment was related to greater dis-positional hostility (as reported by friends),and Kobak, Cole, Ferenz-Gillies, Fleming,and Gamble (1993) reported that avoidantteens displayed more dysfunctional anger than
did secure teens toward their mothers and
engaged in less cooperative dialogue duringa problem-solving interaction.
The dysfunctional nature of avoidant indi-
viduals’ anger toward a relationship partnerhas also been documented during the processof support seeking in a study by Rholes,Simpson, and Orina (1999). In this study,
women were told they would engage in an
anxiety-provoking activity and were asked towait with their dating partners for the activityto begin. During this 5-min ‘‘stress’’ period,the reactions of the support seekers (women)and support providers (men) were video-taped. Women’s avoidance, as assessed by aself-report scale, was associated with more
intense anger toward the partner, and this was
especially the case when women were moredistressed and received less support from theirpartners. It seems that avoidant women’s lackof confidence in their partner’s support mighthave elicited disappointment and anger whilethey were seeking support.
In a recent study of forgiveness within
close relationships, Shaver and Mikulincer
(2003) provided further evidence about avoi-dant individuals’ hostile reactions to theirpartners’ negative behavior. As comparedwith less avoidant individuals, people whoscored high on avoidance were less likely toforgive a partner who had hurt them, asassessed by McCullough, Worthington, and
Rachal’s (1997) forgiveness scale. Instead,
they were more likely to have a strong desirefor revenge and to escape from the situationfollowing a partner’s transgression, as as-sessed by the Transgression-Related Interper-sonal Motivations Inventory (McCulloughet al., 1998). Moreover, when avoidantindividuals were asked to recall an episode in
which they forgave a relationship partner who
had hurt them, their feelings and thoughtswere colored by hostility, resentment, andlack of actual forgiveness. Specifically, avoi-
dant people evinced a negative construal ofthe events calling for forgiveness; their reac-tions were characterized by narcissisticwounds, thoughts about relationship deterio-ration, and lack of understanding of a partner’shurtful actions. Avoidant individuals’ disin-clination to forgive was also noted in a subse-
quent daily diary study in which participants
were asked to report their reactions to theirpartner’s negative behaviors over a period of21 days (Shaver & Mikulincer).
Attachment anxiety. In our view, the hyper-
activating strategies of anxiously attachedindividuals also include reacting to a partner’s
negative behavior with more dysfunctional
manifestations of anger. Anxiously attachedindividuals’ tendencies to intensify the expe-rience of negative emotions and ruminate onthreat-related thoughts may help fuel intenseand prolonged bouts of anger toward a rela-tionship partner. However, their fear of sepa-ration, desperate desire for a partner’s love,
and overly dependent attitude may hold in
check the intense resentment and anger andredirect it toward the self. This self-directedanger can be further exacerbated by anx-ious persons’ doubts about their self-worth(Mikulincer & Shaver, 2003), which mayprovide the context for blaming themselvesfor the partner’s negative behavior and
reproaching themselves for endangering the
relationship. As a result, anxious personsmay react to a partner’s negative behaviorswith a complex mixture of resentment, hostil-ity, anger, self-criticism, fear, sadness, anddepression.
There is already some evidence for this
perspective on anxiously attached individu-
als’ reactions to a partner’s negative behav-
ior. For example, Mikulincer (1998) foundthat anxious people’s recollections of theirresponses to a partner’s negative behavior in-cluded an uncontrollable flood of angry feel-ings, persistent rumination on these feelings,and sadness and despair following conflictualepisodes. Mikulincer also reported that par-
ticipants scoring high on attachment anxiety
held negative expectations about their part-ner’s responses during anger episodes and
Attachment, emotions, and relationships 155

tended to make undifferentiated, negatively
biased appraisals of the partner’s intentions.They attributed hostility to their partner andreacted in kind, even when there were ambig-uous cues (in the experiment) concerning thehostile intent. Using a rather different meth-od, Woike, Osier, and Candela (1996) foundthat self-reported attachment anxiety was
associated with writing more violent pro-
jective stories in response to ThermaticApperception Test (TAT) cards.
The dysfunctional nature of anxious peo-
ple’s anger has also been noted in observa-tional studies of dyadic behavior. Simpson,Rholes, and Phillips (1996) found that self-reports of attachment anxiety were associated
with displaying and reporting more anger,
hostility, and distress while discussing with adating partner an unresolved problem in therelationship. In their study of support seek-ing, Rholes et al. (1999) found no significantassociation between attachment anxiety andanger toward a dating partner while waitingfor an anxiety-provoking activity (‘‘stress
period’’). However, after the participant was
told that she would not really have toundergo the expected stress (‘‘recovery’’period), higher scores on attachment anxietywere associated with more intense anger to-ward the partner. Interestingly, this was par-ticularly true if participants had been moreupset during the stress period and had sought
more support from their partner. It seems that
anxious participants’ strong need for reassur-ance counteracted, or led to suppression of,angry feelings during support seeking. Butafter support was no longer necessary, theangry feelings surfaced, reflecting chronichyperactivating strategies that tend to perpet-uate distress-related feelings.
Another recent study on couple interac-
tions provided important information aboutanxiously attached people’s emotional reac-tions to a partner’s insensitive behavior(Mikulincer, Florian, & Hirschberger, 2002).In this study, newly wed couples completeda daily questionnaire each evening for a pe-riod of 21 days. Each day, participants rated
the extent to which their feelings toward their
spouse were positive or negative and thenindicated which behaviors (from a list pro-vided by the researchers) their partner had
exhibited that day. As compared with thosescoring low on the attachment anxiety dimen-sion, people who scored high produced astronger association, day by day, betweenpartner’s negative behaviors and depression-related feelings. They reported more intensefeelings of depression, weakness, and despair
as a direct function of their perception of
their partner’s negativity on a particular day.This finding remained significant even aftercontrolling for the intensity of anger-relatedfeelings on a particular day.
Emotional reactions to a partner’s
positive behaviors
Another strong source of emotions in close
relationships is positive behavior on the partof the partner that satisfies one’s needs, im-proves one’s welfare, or advances the stabil-ity or quality of the relationship. From anattachment perspective, a partner’s positivebehaviors signal availability, responsiveness,support, and love; lead a person to feel pro-
tected, accepted, and valued; and are crucial
for the development of secure attachmentbonds (Bowlby, 1973; Shaver & Hazan,1994). Considered in relation to the emotions,these behaviors are a source of joy, happi-ness, and gratitude. They intensify feelings oflove for and being loved by the available,supportive partner; foster approach action
tendencies toward the partner; and motivate
the person to be sensitive and responsive tothe partner’s needs. All these reactions fur-ther encourage the partner to be attentive andresponsive to one’s needs, help to sustaina dyadic cycle of positive interpersonalbehaviors, and thereby strengthen the rela-tional bond.
Scholars with different theoretical perspec-
tives agree that the most common emotionalresponse to a partner’s positive behaviors isa blend of joy (being pleased about havingobtained a desirable relational outcome), re-spect and admiration (viewing the partner’sactions as praiseworthy), and love (regardingthe partner in a warm, positive way), which
may also induce feelings of gratitude (e.g.,
Frei & Shaver, 2002; Heider, 1958; Ortony,
156 M. Mikulincer and P. R. Shaver

Clore, & Collins, 1987). For example, Weiner
(1985) claimed that people feel grateful withinclose relationships when they feel happy aboutreceiving a positive outcome and recognizethat their partner was responsible for it.Research has also consistently shown thatwhen people are asked to recall a favorable sit-uation attributed to another person’s behavior,
their most frequent responses are happiness
and gratitude (e.g., Overwalle, Mervielde, &De Schuyter, 1995; Walker & Pitts, 1998).
Although at first sight the links between
a partner’s positive behavior and feelings ofjoy, love, and gratitude seem intuitively natu-ral, automatic, and likely to be universal,they—just like the different forms of anger
we examined—depend on a person’s inter-
action goals and interpersonal cognitions.One precondition for experiencing joy, love,and gratitude following a partner’s supportivebehavior is appraisal of these behaviors aspositive relational outcomes (Heider, 1958;Weiner, 1985). That is, people react toa partner’s positive behavior with gratitude
and happiness mainly when they perceive
these behaviors as congruent with their per-sonal goals. Another prerequisite for experi-encing gratitude is recognition thata partner’s positive behavior reflects his orher good intentions and is altruistically moti-vated (e.g., Lazarus & Lazarus, 1994; Wei-ner, 1985). Therefore, people are likely to
experience gratitude mainly when they attri-
bute their partner’s positive behavior to inter-nal, stable factors and believe that thesebehaviors are altruistically motivated.
This reasoning suggests that attachment-
style differences should be relevant to under-standing individual variations in emotionalreactions to a partner’s positive behavior. For
securely attached persons, whose security-
based strategies include positive beliefs abouttheir partner’s goodwill and are aimed atmaintaining warm and intimate relationships(Mikulincer & Shaver, 2003), a partner’s pos-itive behavior naturally and automaticallyevokes feelings of joy, love, and gratitude. Incontrast, avoidant individuals may react with
less joy, love, and gratitude to a partner’s
kind, generous behavior. They tend not tobelieve in their partner’s goodwill and do notwish to depend on or be supported by their
partner (Mikulincer & Shaver). Moreover,expression of affection toward a partner canbe interpreted as a sign of closeness, which isincongruent with an avoidant person’s prefer-ence for emotional distance.
People who score high on attachment
anxiety may have ambivalent reactions to
a partner’s positive behavior. We believe this
ambivalence results from hyperactivatingstrategies that strengthen the desire for sup-port and love, intensify the appraisal of po-tential threats, and heighten doubts aboutself-worth and self-efficacy (Mikulincer &Shaver, 2003). Anxiously attached peoplemay believe they do not deserve a partner’s
kindness and will not be able to reciprocate it
fully or meet a partner’s needs and expecta-tions, which in turn may muddy happinessand gratitude with fear and anxiety. In addi-tion, for anxiously attached persons, positiveinterpersonal experiences may be reminiscentof previous experiences that began well butended painfully. Once attuned to negative
memories, the anxious mind may suffer
from a spread of negative affect that inter-feres with the experience of happiness andgratitude.
Although adult attachment research has
yet to provide a systematic examination ofattachment-style differences in emotional re-actions to a partner’s positive behavior, there
are a few important pieces of evidence con-
cerning associations between attachment ori-entations and the arousal and experience ofpositive emotions. For example, research hasconsistently shown that securely attachedpeople score higher on self-report measuresof joy, happiness, interest, love, and affectionthan do insecurely attached people (see
Mikulincer & Shaver, 2003, for a review).
For example, in two diary studies, eachlasting a week, participants completed theRochester Interaction Record every time theyengaged in a social interaction lasting 10minutes or longer. Both sets of investigators,Tidwell, Reis, and Shaver (1996) andPietromonaco and Barrett (1997), found that
anxious and avoidant participants experienced
fewer positive emotions than secure partici-pants. Moreover, Rom and Mikulincer (2003)
Attachment, emotions, and relationships 157

reported that both attachment anxiety and
avoidance were associated with relatively lowpositive emotional tone during group in-teractions, and Horppu and Ikonen-Varila(2001) found that a combination of high anxi-ety and high avoidance (fearful avoidance)was associated with fewer positive emotionsduring a college entrance interview.
Attachment-style differences in the experi-
ence of positive emotions have also beendocumented in studies examining the encod-ing of emotion in facial expressions. For ex-ample, Magai, Hunziker, Mesias, and Culver(2000) found that attachment security wasassociated with more facial expressions ofjoy, and Spangler and Zimmermann (1999)
found that avoidant participants (assessed by
the AAI) exhibited relatively low activationof ‘‘smile’’ muscles while watching a positiveemotional film. In addition, several studieshave revealed that high attachment avoidanceis related to low scores on scales assessingexpression of positive emotions (Ducharme,Doyle, & Markiewicz, 2002; Searle & Meara,
1999; Tucker & Anders, 1999) and to high
scores on scales assessing control over posi-tive emotions—the tendency to bottle uppositive emotions and conceal them from arelationship partner (Feeney, 1995, 1999).Adult attachment studies have also docu-mented attachment-style differences in affec-tive reactions to positive relational episodes,
such as reunion with a close relationship
partner following a prolonged separation.In Medway, Davis, Cafferty, and Chappell’s(1995) study of marital separation due tooverseas deployment of husbands during war,securely attached spouses reported more posi-tive emotions and less conflict upon reunionthan anxious and avoidant spouses.
Recently, Shaver and Mikulincer (2003)
presented more direct evidence of attach-ment-style differences in emotional reactionsto a partner’s positive behaviors. Compared toless avoidant people, those scoring high onattachment avoidance were less disposed tofeel gratitude, as assessed by the GratitudeQuestionnaire-6 (McCullough, Emmons, &
Tsang, 2002). Moreover, when avoidant
people were asked to recall an episode inwhich they felt grateful to a relationship part-ner, they tended to remember negative expe-
riences, involving more narcissistic threatsand distrust and less happiness and love.People scoring high on attachment anxietytended to remember more ambivalent experi-ences of gratitude-eliciting episodes. Specifi-cally, anxiously attached people recalledrelatively high levels of security-related feel-
ings, happiness, and love, together with rela-
tively high levels of narcissistic threats andinferiority feelings.
In a diary study in which 55 newly wed
couples reported their emotional reactions toa partner’s positive actions every day for aperiod of 21 days (Shaver & Mikulincer,2003), daily feelings of gratitude were signif-
icantly related to the partner’s (perceived)
behaviors on that day: The higher the level ofa partner’s positive behaviors, the higher thefeelings of gratitude a participant reportedexperiencing toward the partner. In addition,attachment orientations were related to dailyfeelings of gratitude toward a partner: Thehigher the attachment avoidance, the less the
gratitude across the 21 days. More important,
attachment avoidance moderated the associa-tion between partner’s behavior and self’sgratitude: People scoring high on avoidanceexperienced relatively low levels of gratitudeeven on days when they perceived the part-ner’s behavior as positive. Stated in reverse,a partner’s positive behaviors elicited grati-
tude mainly among participants who were not
avoidant.
Emotional reactions to a
partner’s distress
We turn now to another kind of emotion-
eliciting episode within close relationships—a partner’s appraisal of threats or damages
to his or her identity, possessions, or goals
and the consequent expression of distress.According to Clark, Fitness, and Brissette(2001), a partner’s experience of stress anddistress is a potent source of one’s own emo-tions within communal, interdependent rela-tionships because most people feel at leastsomewhat responsible for their partner’s
welfare and may be strongly affected by
changes in the partner’s emotional states. This
158 M. Mikulincer and P. R. Shaver

is a natural consequence of the caregiving
system being part of romantic love (e.g.,Collins & Feeney, 2000; Kunce & Shaver,1994; Shaver, Hazan, & Bradshaw, 1988). Inthese cases, it is important to differentiatebetween two kinds of relational eventsaccording to the source of a partner’s distress:(a) relationship-relevant partner distress—
episodes in which the partner’s distress results
from one’s own negative behavior (e.g.,unavailability, rejection, disinterest, criticism,aggression, betrayal) and (b) relationship-irrelevant partner distress—episodes in whichthe partner’s distress results from threats andlosses that have nothing to do with the rela-tionship itself (e.g., health problems, work
problems). This differentiation is important
for analyzing attachment-style differences inemotions within close relationships becausethe two kinds of episodes differ in the emo-tional responses they typically elicit.
Relationship-relevant partner distress. Re-
lationship episodes in which a person behaves
badly toward a partner, fails to meet the part-
ner’s needs and expectations, or actually orpotentially damages a partner’s well-being orrelationship quality can elicit a wide arrayof emotional responses, ranging from self-conscious emotions, such as guilt and shame,through fear of punishment or retaliation, toanger and hostile attitudes toward the dam-
aged partner (e.g., Lazarus, 1991; Lewis,
2000; Tangney, 1990, 1992). We believe thatthese emotions may have particular signifi-cance for attachment-related dynamics andmay be related to a person’s attachmentorientation.
Consider the case of the self-conscious
emotions of guilt and shame. Occurrence of
these emotions implies that threatening or
harming a partner’s welfare is appraised asan undesirable failure to live up to one’sstandards and ideals (Lazarus, 1991; Lewis,2000; Tangney, 1992). People who react totheir own relationship-damaging behaviorswith guilt or shame are likely to favor thecreation of warm and supportive relationships
and to view protection of their partner’s wel-
fare and the maintenance of relationshipquality as being among their most importantinteraction goals. In fact, these emotions are
inhibited when people minimize interdepen-dence and responsibility for the fate of theirpartner and relationship (Clark et al., 2001).
This seems to be the case for avoidant
individuals, who prefer to minimize emo-tional involvement and interdependence intheir relationships and who often distance
themselves from their partner’s needs (Shaver
& Clark, 1994; Shaver & Mikulincer, 2002).For such people, relationship-relevant partnerdistress may not be perceived as sharply goalincongruent and therefore may not instigatenegative self-conscious emotions.
Although avoidant people may not believe
they have done anything wrong when their
partner expresses distress or injury, they may
nevertheless harbor angry, hostile feelingstoward the partner. These feelings include re-sentment of the partner’s accusations and arelikely to occur when the avoidant person per-ceives the partner as deserving the discomfortand perceives his or her own destructive be-havior as a reasonable payback for the part-
ner’s previous transgressions (Lazarus, 1991).
In such cases, an avoidant person may blamehis or her partner for evoking the self’s hurtfulbehavior, attribute the negative relational out-comes to the partner’s negative traits (ratherthan the self’s), and feel angry toward thepartner for causing the self to behave sobadly.
Attachment-related dynamics are also
important for distinguishing between shameand guilt. Although these two self-consciousemotions have often been viewed as similarand functionally interchangeable, currenttheories highlight differences between themin attentional focus, causal attributions, andaction tendencies (e.g., Lazarus, 1991; Lewis,
2000; Tangney, 1992). Shame involves atten-
tional focus on one’s objectionable personal-ity traits (which Janoff-Bulman, 1979, called‘‘characterological self-blame’’) and attri-bution of one’s own negative behavior toglobal, stable, and uncontrollable aspects ofthe self. Moreover, shame seems to be relatedto feelings of inferiority, worthlessness, and
helplessness as well as a tendency to
withdraw and hide from interactions with theoffended partner. In contrast, guilt involves
Attachment, emotions, and relationships 159

attentional focus on the negative behavior it-
self (a reaction Janoff-Bulman, 1979, called‘‘behavioral self-blame’’) and attribution ofthe negative behavior to specific, unstable,and controllable aspects of self. In addition,guilt seems to be related to feelings of po-tency and mastery and to a tendency to makereparative actions to restore a partner’s wel-
fare and relationship quality.
Based on this conceptualization of shame
and guilt, it is reasonable to suggest that at-tachment anxiety will be related to individualvariations in the propensity to experienceeach of these emotions. Although both se-curely and anxiously attached individuals aremotivated to maintain strong attachment
bonds, seek interdependence and emotional
involvement, and react with self-consciousemotions when their actions hurt a relationshipor relationship partner, the two different kindsof people diverge in their sense of self-worthand self-efficacy (Mikulincer & Shaver,2003) and therefore may experience andexpress different self-conscious emotions.
Whereas secure people, who enjoy a stable
sense of self-worth and frequent feelings ofpotency and mastery, may react to their owndisagreeable behavior with guilt and the cor-responding tendency to repair the damage,anxiously attached people, who often feelworthless and helpless, may attribute theirhurtful behavior to personal deficiencies, per-
ceive no way out of the disgreeable situation,
and hence feel overwhelmed by shame.
Although few adult attachment studies
have examined differences in emotional reac-tions to relationship-relevant partner distress,there is some evidence that attachment orien-tations are involved in the arousal of shame,guilt, and hostility toward an aggrieved part-
ner. For example, Lopez et al. (1997) dis-
covered correlations between self-reportedattachment orientations and a scale measuringshame proneness and guilt proneness (Testof Self-Conscious Affect). Whereas attach-ment security was associated with guilt prone-ness, a combination of high anxiety and highavoidance (fearful avoidance) was positively
associated with shame proneness, and a com-
bination of high avoidance and low anxiety(dismissing avoidance) was negatively associ-ated with shame proneness. Similarly, Gross
and Hansen (2000) found that people whoscore high on both attachment anxiety andavoidance were relatively shame prone (asrevealed by the Brief Shame Rating scale)compared with their secure and dismissivelyavoidant counterparts, and Magai et al. (2000)found attachment anxiety to be positively
associated with facial expressions of shame.
Moreover, in a study by Lutwak and Ferrari(1997), recall of negative experiences withprimary attachment figures was associatedwith higher levels of reported shame.
In a recent study, we attempted to examine
attachment-style differences in emotionalreactions to one’s own destructive behavior
toward a romantic partner. Sixty-five Israeli
university students (41 women and 24 men),each of whom was involved in a seriousromantic relationship, completed the Experi-ences in Close Relationships scale (ECR;Brennan et al., 1998) tapping attachment anx-iety and avoidance and were asked to recallan episode in which they hurt their romantic
partner or failed to meet the partner’s needs.
Then, after writing a brief description of theepisode, they rated the extent to which therecalled episode caused them to feel guilty,ashamed, or hostile toward the partner (asassessed by the State Shame and Guilt scaleand the Hostility subscale of the Multi-dimensional Anger Inventory). We found that
high scores on the attachment anxiety dimen-
sion were positively associated with shame,r(63)¼.39,p,.01, and less intense guilt,
r(63)¼2.42, p,.01. In addition, attach-
ment avoidance was associated with hostilitytoward the aggrieved partner, r(63)¼.40,
p,.01, less guilt, r(63)¼2.43, p,.01,
and less shame, r(63)¼2.35, p,.01. No
significant interaction was found between the
anxiety and avoidance dimensions. Overall,our findings imply that whereas attachment-anxious individuals tend to feel ashamed inresponse to partner distress, avoidant individ-uals tend to feel hostile toward their dis-tressed partner without being aware of anyself-conscious emotions.
Relationship-irrelevant partner distress.
When a close relationship partner feels dis-
160 M. Mikulincer and P. R. Shaver

tressed because of relationship-irrelevant
threats or losses, people may adopt either anapproach or an avoidance orientation to thepartner’s needs—either attending and re-sponding to the distress or distancing them-selves from it. Theory and research haveconnected these tendencies with three relatedbut distinct emotional responses: empathy or
compassion, personal distress, and pity (e.g.,
Batson, 1991; Ben-Ze’ev, 2000; Lazarus,1991). Empathic compassion involves attend-ing to the partner’s needs and providing apartner-sensitive response; it includes feel-ings of sympathy, attachment, and tendernessand fosters supportive behavior designed toalleviate a partner’s suffering (Batson). This
kind of response, which Bowlby (1969/1982)
and his followers (e.g., Collins & Feeney,2000; Kunce & Shaver, 1994) conceptualizein terms of the caregiving behavioral system,is based on a genuinely altruistic concern forthe partner’s plight, which motivates the pro-vision of support and care (Ben-Ze’ev).
Being personally distressed is also com-
patible with an approach orientation toward
a partner’s needs, but it includes self-protec-tive concerns that arouse fear, sadness, anddistress in relation to a partner’s plight(Batson, 1991). Personal distress involvesstrong identification with the suffering part-ner as well as a sense of helplessness andinability to alleviate the partner’s suffering,
which can interfere with taking action to
soothe and support the partner. Research onparental caregiving styles (summarized byGeorge & Solomon, 1999) clearly shows thatan attentional shift from a child’s needs toa parent’s own distress impairs caregivingand encourages intergenerational transmis-sion of anxious and disorganized attachment.
We expect similar dysfunctional consequen-
ces of personal distress in close relationshipsbetween adults.
Unlike empathic compassion and personal
distress, pity reflects an avoidant orientationtoward a partner’s distress. According toBen-Ze’ev (2000) and Snow (1991), pity isbased on perceiving the distressed other as
inferior; reflects a passive, detached attitude
toward the partner’s suffering; allows one tomaintain a safe emotional distance from theother’s suffering; and sometimes stems from
a disinclination to share, or get involved with,another person’s painful predicament. Ac-cording to Lazarus (1991), pity is ‘‘ .a dis-
dainful or contemptuous feeling, in which theother person is regarded as reprehensible,inferior, or responsible for his/her own suffer-ing. In pity, the person holds himself or her-
self apart from the afflicted person’’ (p. 288).
Thus, pity seems to be a blend of condescen-sion (feeling superior to the sufferer), insecu-rity (fearing the possibility of being in thesame situation as the sufferer), and distancing(avoiding involvement with the distressedpartner).
Although attachment theory deals mainly
with results of a partner’s responses to one’s
own needs (with the partner being conceptu-alized as an attachment figure), the theory isalso extremely relevant for explaining one’sown emotional reactions to a partner’s needs.Consider the sense of attachment security. Itis an inner resource that encourages an ap-proach orientation to a partner’s distress, pro-
motes empathic compassion, and inhibits
personal distress. In Bowlby’s (1969/1982)analysis of the attachment system, he arguedthat a sense of attachment security allowspeople to direct attention and energy to otherbehavioral systems. As a result, securely at-tached people can devote more psychologicalresources to a partner’s needs and therefore
provide more sensitive support and care. In
short, security is a foundation for caregiving.
Secure people’s interaction goals and inter-
personal cognitions also foster empathic com-passion and the reduction of personal distress.Their comfort with closeness and interdepen-dence (Hazan & Shaver, 1987) facilitatesapproach to a distressed partner because such
a partner typically seeks closeness and needs
to depend on others (Lehman, Ellard, &Wortman, 1986). A secure person’s expecta-tion that other people will be available andcaring may make it easier to construe a dis-tressed partner as deserving sympathy andcompassion, and so may motivate the secureperson to provide needed comfort to the part-
ner. The secure person’s feelings of potency
and mastery may help him or her to maintainemotional equanimity while addressing a
Attachment, emotions, and relationships 161

partner’s needs, a task that can otherwise gen-
erate a great deal of tension and distress (e.g.,Batson, 1987).
Insecurely attached people may be less
inclined to feel empathic compassion towarda distressed partner. Whereas an anxious per-son’s egoistic focus on personal threats andunsatisfied attachment needs may draw im-
portant resources away from altruistically
attending to a partner’s needs, an avoidantperson’s lack of comfort with closeness andhostile outlook on others may interfere withaltruistic inclinations and inhibit compassion-ate responses to a partner’s plight. This doesnot mean, however, that anxious and avoidantpeople will react in the same way to
a partner’s distress. Whereas the anxious per-
son’s hyperactivating strategies may intensifythe experience of personal distress, the avoi-dant person’s deactivating strategies mayencourage feelings of disdain and pity.
Anxiously attached people may become
emotionally overwhelmed in response to apartner’s distress. Their hyperactivating strat-
egies may facilitate the associative reactiva-
tion of self-focused worries and increaseattentional focus on both the partner’s suffer-ing and the self’s personal distress. Despitetheir focus on the partner’s suffering, how-ever, anxious people’s lack of self-other dif-ferentiation (Mikulincer & Horesh, 1999)may prevent them from reacting with func-
tional empathy and compassion. (There is a
similar distinction in Buddhist psychologybetween effective and ineffective empathiccompassion; Dalai Lama, 1999.) In fact,Batson (1991) claimed that empathic compas-sion involves self-other distinctiveness anda corresponding ability to distinguish betweenthe other person’s welfare and one’s own.
Avoidant, deactivating strategies—dis-
tancing oneself from threats and suppressingpainful thoughts (Shaver & Mikulincer,2002)—may encourage emotional detach-ment from a partner’s plight, inhibit both em-pathic compassion and personal distress, andfavor the arousal of pity. For avoidant per-sons, a distressed partner can act as a mirror
that makes salient the self’s own weaknesses
and vulnerability to life’s adversities. Deacti-vation may require suppression of the senseof vulnerability and distancing of the self
from the source of distress. As a result, theavoidant person may defensively attempt tofeel superior to his or her distressed partner,less weak and vulnerable (‘‘I am immune tosuch misfortunes’’), and hence experienceonly disdainful pity for the suffering partner.In some cases, avoidant persons’ hostile atti-
tudes toward a partner may transform pity
into contemptuous gloating—actual enjoy-ment of a partner’s ill fate (in German, scha-
denfreude ). In fact, Whitman and Alexander
(1968) argued that gloating implies resentmenttoward a distressed partner combined witha boost of one’s own sense of superiority.
Although these ideas are somewhat specu-
lative, recent studies of adult attachment pro-
vide preliminary evidence compatible withthem. For example, Florian, Mikulincer, andHirschberger (2000) reported that whereasself-reports of attachment security were asso-ciated with empathic compassion, self-reportsof attachment avoidance were associated withpity in response to others’ needs. In West-
maas and Silver’s (2001) study of reactions to
a person who had purportedly been diagnosedwith cancer, attachment avoidance was asso-ciated with less empathic compassion and lesssupport for the afflicted confederate. Attach-ment anxiety was related to greater distressduring an interaction with the confederate.
In a series of five experiments, Mikulincer
et al. (2001) documented the facilitatory
effects of attachment security on empathiccompassion for others’ needs. First, both at-tachment anxiety and avoidance (as assessedby the ECR) were associated with lessempathic compassion, and attachment anxi-ety was associated with more personal dis-tress in response to another person’s needs.
Second, contextual heightening of the sense
of attachment security (asking participants torecollect personal memories, read a story, orwatch a picture of supportive others or sub-liminally exposing them to proximity-relatedwords) increased reports of empathic com-passion and reduced reports of personal dis-tress. In contrast, contextual activation of
attachment anxiety or avoidance (asking par-
ticipants to recall personal memories of rela-tional episodes in which they felt attachment
162 M. Mikulincer and P. R. Shaver

anxiety or avoidance) reduced empathic
compassion.
partner’s happiness
In this section, we focus on emotions that occur
in response to a partner’s appraisal of progresstoward personal goals and the resulting expres-sion of happiness. Again, we wish to distinguishbetween two kinds of partner happiness basedon its apparent cause: (a) relationship-relevantpartner happiness—casesinwhichthepartner’s
happiness results from one’s own relationship-
enhancing behavior (e.g., being available andsupportive) and (b) relationship-irrelevantpartner happiness—cases in which the part-ner’s happiness results from attaining goalsoutside the relationship (e.g., career-relatedachievements, personal accomplishments).
Relationship-relevant partner happiness. The
most common emotional response toa partner’s relationship-relevant happiness ispresumably an increase in one’s own happi-
ness, love, and pride. In such cases, one’s
own behavior promotes a partner’s welfare,meets the partner’s needs and expectations,and enhances relationship quality and satis-faction. As a result, the person who behavesbeneficially toward his or her partner is likelyto feel good about the positive outcomesobtained by the partner; if a person takes
some of the credit for the partner’s desirable
outcome, he or she is likely to experiencepride (Lazarus, 1991; Lewis, 2000). Thesepositive reactions can, in turn, further moti-vate people to approach their partner andpromote his or her welfare, thereby contrib-uting to relationship quality and stability.
As in the previous examples we have
considered, however, this straightforward
linkage may depend on a person’s attachmentorientation. For avoidant persons, who do notview promotion of a partner’s welfare andmaintenance of a warm and comfortablyinterdependent relationship as personal goals(Mikulincer & Shaver, 2003), a partner’srelationship-relevant happiness may not
engender one’s own happiness and love.
According to Lewis (2000), people mayexperience these positive emotions mainlywhen they view promotion of the partner’s
welfare and maintenance of relationship qual-ity as desirable personal goals. For anxiouslyattached persons, who harbor serious doubtsabout their value and potency (Mikulincer &Shaver), engendering a partner’s happinessmay not result in a feeling of pride becausethey cannot take credit for a partner’s happi-
ness and attribute the partner’s good outcome
to their own positive qualities. In fact, itsseems possible that only securely attachedindividuals experience the full measure ofjoy, love, and pride, which fit well with theirinteraction goals, stable sense of self-worth,and feelings of potency and mastery (Miku-lincer & Shaver).
We suspect that avoidant individuals may
experience pride of a particular kind, whichthe ancient Greeks called hubris , described
by Lewis (2000) as exaggerated pride result-ing not from success in enhancing a partner’swelfare but from confirming one’s own bril-liance, superiority, and grandiosity. Thisemotion is related to narcissistic construal of
oneself as especially worthy of praise and
success (Morrison, 1989), which is one of themain goals of the avoidant individual’s deac-tivating strategies.
In sharp contrast, anxiously attached indi-
viduals may react to their apparent contribu-tions to a partner’s good outcomes with ‘‘fearof success’’ feelings—distress related to
doubts about their worthiness to claim credit
for the partner’s welfare. These people’sfragile sense of self-worth may cause them tofear that their current success in meeting theirpartner’s needs will increase the partner’s ex-pectations, leading to uncertainty and worryabout future performance.
Unfortunately, adult attachment research-
ers have not yet examined the possible role
of attachment orientation in shaping emo-tional reactions to a partner’s relationship-relevant happiness. In a study described inthe previous section of this chapter, however,we did attempt to fill part of this empiricalgap by collecting preliminary data on theattachment-related dynamics of emotional re-
actions to a partner’s happiness. Participants
were asked to recall an episode in which theymade their partner happy. Then, after writing
Attachment, emotions, and relationships 163

a brief description of the episode, they rated
the extent to which the recalled episode eli-cited pride, positive emotions, and distress-related emotions (as assessed by the pride sub-scale of the State Shame and Guilt scale anda brief version of the Positive and NegativeAffect scale). The results were clear: Attach-ment anxiety was associated with distress-
related feelings, r(63)¼.41,p,.01, and less
pride and positive emotion, r(63)¼2.33,p,
.01 and r(63)¼2.35, p,.01. Attachment
avoidance was also associated with less posi-
tive emotion, r(63)¼2.37,p,.01. No sig-
nificant interaction was found between the twoattachment dimensions.
The findings imply that whereas anxiously
attached individuals are prone to express dis-
tress rather than happiness and pride in re-sponse to a partner’s relationship-relevanthappiness, avoidant individuals are less likelyto express personal happiness in reaction toa happy partner. This is only a tentative con-clusion, however. More systematic researchshould be conducted on how people with dif-
ferent attachment styles react to relational
episodes in which their own actions maketheir partners happy.
Relationship-irrelevant partner happiness.
Although there is not a single empiricalstudy dealing with attachment-style differ-ences in reactions to a partner’s accomplish-
ments, we want to propose some tentative
ideas about the way attachment orientationsmight shape emotional responses to this kindof situation. When a partner feels good aboutattaining positive outcomes outside the rela-tionship, the most common response is whatClark et al. (2001) called ‘‘empathic happi-ness.’’ This reaction includes a sense of
closeness and common fate along with joy
and admiration for a partner’s progress to-ward his or her goals. Like other emotionalreactions to a partner’s fate, however, em-pathic happiness depends on the extent towhich a person feels comfortable withcloseness and positively inclined towardwarm, intimate, and interdependent relation-
ships (Clark et al.). As a result, secure peo-
ple, who feel comfortable with closeness,may be more likely than insecure people toexperience empathic happiness in response to
a partner’s successes.
A partner’s accomplishments may not
elicit happiness in avoidant individuals be-cause their tendency to maintain emotionaldistance may inhibit identification with andempathic feelings toward the successful part-ner. Rather, such people may appraise the
partner’s accomplishments as a threat to their
own grandiose self because the partner’s suc-cesses threaten to blur the illusory asymmetrybetween partner and self. This threat canincrease avoidant individuals’ hostile feelingsand hateful attitudes toward their partners andprovoke hostile envy—wanting what the part-ner has accomplished or destroying/devaluing
the partner’s identity or possessions. Hostile
envy is a negative, destructive emotion thatinvolves feelings of discontent and resent-ment, occurs in situations in which others’accomplishments threaten a person’s self-evaluation and cause feelings of inferiority,and promotes aggressive responses towardthe successful other (e.g., Ben-Ze’ev, 2000;
Ortony et al., 1987; Smith, 1991). Among
avoidant people, this kind of envy may be adefensive attempt to restore a shattered senseof superiority over the partner. Of course, thisaccount is particularly viable for dismissivelyavoidant individuals who do not suffer fromattachment anxieties and self-related doubts.However, it may be less applicable to fear-
fully avoidant people who suffer from a nega-
tive self-image.
For anxiously attached people, a partner’s
accomplishments may evoke a more ambi-valent emotional response. For them,a partner’s accomplishments signal that thepartner is a ‘‘stronger, wiser’’ person—thedefining feature of the kind of security-pro-
viding attachment figure anxious people long
for (Bowlby, 1988). As a result, anxious indi-viduals may feel happy and enjoy their part-ner’s accomplishments because they may feelmore confident in the security and supportthis strong partner can provide in times ofneed. At the same time, however, an anxiousperson may appraise the partner’s accom-
plishments as a potential threat to relation-
ship maintenance because the successfulpartner may search for a more attractive and
164 M. Mikulincer and P. R. Shaver

successful partner. As a result, these accom-
plishments may fuel the anxious person’sfears of separation and abandonment as wellas worries about imaginary rivals who canpoach his or her successful partner (Schachner& Shaver, 2002). Again, anxious people’shyperactivating strategies may not allowthem to fully enjoy a partner’s successes be-
cause they raise the specter of separation and
abandonment.
An Integrative Summary and Some
Concluding Remarks
An integration of the various emotional reac-
tions to relational events reveals that securelyattached individuals display the most differ-
entiated pattern of emotions, ranging from
happiness, admiration, gratitude, and pride tocompassion, guilt, and anger (see Table 1).In addition, their emotional reactions reflecta strong tendency to maintain and enhancerelationship quality and a partner’s welfare,overcome relational obstacles, restore emo-tional equanimity and relationship stability in
times of need, and encourage a partner’s per-
sonal development. These are all qualitiesthat attachment researchers have found to beassociated with security-inducing parentalcare, supporting our belief that, in the adultattachment realm as well, a person’s own at-tachment security is an important foundationfor his or her provision of high quality care to
others. In contrast, insecurely attached individ-
uals exhibit a narrower range of emotions,which are consistently biased by defensivehyperactivation or deactivation of the attach-ment system. Whereas an avoidant person’semotional makeup consists largely of differentkinds of defensive self-enhancement and nega-tive feelings toward a partner (e.g., hostility,
resentment, pity, gloating, contempt, hostile
envy) regardless of the nature of the relationalevent, the anxiously attached person tends tobe overwhelmed by distress-related feelingsduring negative relational episodes and toexpress ambivalent blends of positive and neg-ative emotions during what we would expectto be positive relational episodes.
Despite what we believe is its consider-
able heuristic value, this integrative summaryshould be viewed as a tentative, nonexhaus-
tive schematic representation of attachment-related variations in emotional experiencewithin close relationships and as a preliminaryguide for further research. As mentioned ear-lier, adult attachment research has focusedmainly on a person’s emotional reactions tohis or her partner’s negative behaviors. We
need more systematic research on the attach-
ment-related dynamics of emotional reactionsto other kinds of relational events. In addi-tion, more research is needed on the way com-binations of anxiety and avoidance can shapeemotional reactions. As observed throughoutour review of relevant findings, some emo-tions, such as hostile envy or shame, seem to
vary according to specific combinations of
attachment anxiety and attachment avoidance.
In this article, we have focused mainly on
the role of dispositional attachment orienta-tions in understanding emotional reactionswithin close relationships. However,a person’s attachment orientation within thespecific relationship in which the emotions
arise might also be predictive of his or her
emotional reactions. Future studies shouldassess both dispositional and relationship-specific attachment orientations and assesstheir unique contributions to emotional reac-tions. Future studies should also consider theattachment orientations of both partners ina relationship and examine whether a person’s
emotional reactions are affected by the part-
ner’s attachment orientation. When both part-ners are fully represented in the equation, wewill have a foundation on which to build asystemic model of attachment dynamics atboth the personal and the interpersonal levels,that is, a foundation for understanding dyad-composition effects on emotional experiences
within close relationships. We hope the cur-
rent article stimulates research by other inves-tigators, and together we will create a morecomplete and powerful theory of attachmentand emotion in close relationships.
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A SECURE BASE  
Parent-Child Attachment and Healthy 
Human Development  
JOHN BOWLBY 
 
BASIC BOOKS 
A Member of the Perseus Books Group

-iii-  
Library of Congress Catalogi ng-in-Publication Data  
Bowlby, John.  
A secure base: parent-child attachment and healthy human development / John Bowlby.  
p. cm.  
Bibliography: p. 181 .  
Includes index.  
ISBN 0-465-07598-3 (cloth)  ISBN 0-465-07597-5 (paper)  1. Attachment behavior in children. 2. Parent and child. 3. Child psychopathology. I. Title.  
RJ507.A77B69 1988  155.4′18--dc19 88-47669  
First published in Great Britain by Routle dge 11 New Fetter Lane, London EC4P 4EE 1988  
First published in the U.S.A. by Basic B ooks, A Member of the Perseus Books Group  
Copyright © 1988 R.P.L. Bowlby, R.J.M. Bowlby, and A. Gatling  
Printed in the United States of America  
99 RRD-H 20 19 18 17 16 15  
-iv- To Mary D.S. Ainsworth who intr oduced the concept of a secure base  
-v-

Contents  
 
 Preface  ix   
 Acknowledgments  xi   
 1 Caring for children  1   
 2 The origins of attachment theory  20   
 3 Psychoanalysis as art and science  39   
 4 Psychoanalysis as a natural science  58   
 5 Violence in the family  77   
 6 On knowing what you are not supposed to know and feeling what
you are not supposed to feel  99   
 7 The role of attachment in personality development  119   
 8 Attachment, communication, and the therapeutic process  137   
 9 Developmental psychiatry comes of age  158   
 References  181   
 Name Index  199   
 Subject Index  203   
-vii-

Preface  
In 1979, under the title of The Making and Breaking of Affectional Bonds , I published a small 
collection of lectures that I had given to a variety of audiences during the two preceding 
decades. In this volume I present a further sele ction of the lectures given since then. Each of 
the first five and the ninth were delivered to a particular audience on a particular occasion; 
details of each are described in a brief preambl e. The remaining three are extended versions of 
lectures given in extempore form to audiences  made up of mental health professionals in 
countries of Europe and America. As in the earlier collection, I have thought it best to print 
each lecture in a form close to that in which it was originally published.  
Since the theory of attachment provides the basi s for every lecture some deletions have been 
necessary to avoid an excess of repetition. It is  hoped that such as remains will, by presenting 
the same ideas in different contexts, clarify and emphasize distinctive features of the theory.  
It is a little unexpected that, whereas attachment  theory was formulated by a clinician for use 
in the diagnosis and treatment of emotionall y disturbed patients and families, its usage 
hitherto has been mainly to promote research  in developmental psychology. Whilst I welcome 
the findings of this research as enormous ly extending our understa nding of personality 
development and psychopathology, a nd thus as of the greatest  
-ix-  
clinical relevance, it has none the less been disapp ointing that clinicians have been so slow to 
test the theory's uses. There are probably many reasons for this. One is that initially the data 
drawn on appeared to be unduly behavioural. Anothe r is that clinicians are very busy people 
who are naturally reluctant to spend time tr ying to master a new and strange conceptual 
framework until they have strong reasons for believ ing that to do so will improve their clinical 
understanding and therapeutic skills. For those w ho have decided the time has come to sample 
what this new perspective has to offer I hop e the lectures gathered here may provide a 
convenient introduction.  
-x-  
Acknowledgments  
During the past ten years I have had the great  benefit of frequent communication with staff 
and students at the Tavistock Clinic and also with a number of colleagues engaged in 
pioneering studies of how patterns of attach ment develop during infancy and childhood. To 
all of them I owe a deep debt of gratitude , often for useful suggestions, sometimes for 
necessary corrections, and always for stimulat ion and encouragement. To my secretary, 
Dorothy Southern, I also owe a deep debt of  gratitude for many years of devoted service 
during which she has made my interests her own.

For editorial assistance in preparing these l ectures for publication and for constructing the 
index my thanks are due to Molly Townsend.  
The first six lectures in this book have appeared in other publications and I am grateful to the 
publishers concerned for permission to reprod uce them here. Lecture 1 was chapter 18 in 
Parenthood: A Psychodynamic Perspective  edited by Rebecca S. Cohen, Bertram J. Cohler, 
and Sidney H. Weissman, the Guilford Press, New York ( 1984); Lecture 2 was "'Attachment 
and loss: retrospect and prospect'", American Journal of Orthopsychiatry 52 : 664-78 ( 1982); 
Lecture 3 was "'Psychoanalysis as art and science'", International Review of Psychoanalysis 
6: 3-14 ( 1979); Lecture 4 was "'Psychoa nalysis as a natural science'", International Review of 
Psychoanalysis 8 : 243-56 ( 1981); Lecture 5 was "'Violencein the family as a disorder of the 
attachment and caregiving systems'"  
-xi-  in the family as a disorder of the attachment and caregiving systems', The American Journal 
of Psychoanalysis 44 : 9-27 ( 1984); Lecture 6 was chapter 6 in Cognition and Psychotherapy  
edited by Michael J. Mahoney and Arthur Fr eeman, Plenum Publishing Corporation, New 
York and London ( 1985), expanded from "'On  knowing what you are not supposed to know 
and feeling what you are not supposed to feel'", Canadian Journal of Psychiatry 24 :403-8 ( 
1979).  
The first six lectures in this book and the ninth have appeared in other publications and I am 
grateful to the publishers concerned for perm ission to reproduce them here. Lecture 1 was 
chapter 18 in Parenthood. A Psychodynamic Perspective  edited by Rebecca S. Cohen, 
Bertram J. Cohler, and Sidney H.  Weissman the Guilford Press, New York ( 1984); Lecture 2 
was "'Attachment and loss: retrospect and prospect'", American Journal of Orthopsychiatry 
52: 664-78 ( 1982); Lecture 3 was "'Psychoa nalysis as art and science'", International Review 
of Psychoanalysis 6 : 3-14 ( 1979); Lecture 4 was "'Psycho analysis as a natural science'", 
International Review of Psychoanalysis 8 : 243-56 ( 1981); Lecture 5 was "'Violence in the 
family as a disorder of the atta chment and caregiving systems'", The American Journal of 
Psychoanalysis 44 : 9-27 ( 1984); Lecture 6 was chapter 6 in Cognition and Psychotherapy  
1979). Lecture 9 was "'Developmenta l Psychiatry Comes of Age'", American Journal of 
Psychiatry 145 : 1-10 ( 1988).  
John Bowlby

A Secure Base  
Parent-Child Attachment and Healthy Human Development 
 
-xiii-  
LECTURE 1  
Caring for children  
During the early months of 1980 I was givi ng lectures in the United States. Amongst 
invitations reaching me was one from the psychi atric staff of the Mich ael Reese Hospital in 
Chicago to address a conference on parenting.  
An indispensable social role  
At some time of their lives, I believe, most hu man beings desire to ha ve children and desire 
also that their children should grow up to be healthy, happy, and self-reliant. For those who 
succeed the rewards are great; but for those w ho have children but fail to rear them to be 
healthy, happy, and self-reliant the penalties in anxiety, frustration,  friction, and perhaps 
shame or guilt, may be severe. Engaging in parenthood therefore is pl aying for high stakes. 
Furthermore, because successful parenting is a pr incipal key to the mental health of the next 
generation, we need to know all we can both a bout its nature and about the manifold social 
and psychological conditions that influence its de velopment for better or worse. The theme is 
a huge one and all I can do in this contribution is to sketch the approach that I myself adopt in 
thinking about these issues. That ap proach is an ethological one.  
Before I go into detail, however, I want to make a few more  
-1-  
general remarks. To be a successful parent m eans a lot of very hard  work. Looking after a 
baby or toddler is a twenty-four hour-a-day job seven days a week, and often a very worrying 
one at that. And even if the load lightens a little as children get older, if they are to flourish 
they still require a lot of time and attenti on. For many people today these are unpalatable 
truths. Giving time and attention to children means sacrificing other interests and other 
activities. Yet I believe the evidence for what I am saying is unimpeachable. Study after 
study, including those pioneered in Chica go by Grinker ( 1962) and continued by Offer ( 
1969), attest that healthy, happy, and self -reliant adolescents and young adults are the 
products of stable homes in which both parents gi ve a great deal of time and attention to the 
children.

I want also to emphasize that, despite voices to  the contrary, looking after babies and young 
children is no job for a single person. If the jo b is to be well done and the child's principal 
caregiver is not to be too exhausted, the care giver herself (or himself) needs a great deal of 
assistance. From whom that help comes will va ry: very often it is the other parent; in many 
societies, including more often than is realized  our own, it comes from a grandmother. Others 
to be drawn in to help are ad olescent girls and young women. In most societies throughout the 
world these facts have been, and still are, taken for granted and the society organized 
accordingly. Paradoxically it has taken the world's richest societies to igno re these basic facts. 
Man and woman power devoted to the production of material goods counts a plus in all our 
economic indices. Man and woma n power devoted to the producti on of happy, healthy, and 
self-reliant children in their own homes does not count at all. We have created a topsy-turvy 
world.  
But I do not want to enter into complex political and economic arguments. My reason for 
raising these points is to remind you that the soci ety we live in is not only, in evolutionary 
terms, a product of yesterday but in many ways a very peculiar one. There is in consequence a 
great danger that we shall adopt mistaken norms. For, just as a society in which there is a 
chronic insufficiency of food may take a deplorab ly inadequate level of nutrition as its norm, 
so may a society in which parents of  
-2-  
young children are left on their own with a chro nic insufficiency of help take this state of 
affairs as its norm.  
An ethological approach  
I said earlier that my approach to an unders tanding of parenting as a human activity is an 
ethological one. Let me explain.  
In re-examining the nature of the child's tie to his * mother, traditionally referred to as 
dependency, it has been found usef ul to regard it as the resultant of a distinctive and in part 
preprogrammed set of behaviour  patterns which in the ordi nary expectable environment 
develop during the early months of life and have  the effect of keeping the child in more or 
less close proximity to his mother-figure ( Bo wlby 1969). By the end of the first year the 
behaviour is becoming organize d cybernetically, which means, among other things, that the 
behaviour becomes active whenever certain co nditions obtain and cease s when certain other 
conditons obtain. For example, a child's attachme nt behaviour is activate d especially by pain, 
fatigue, and anything frightening, and also  by the mother being or appearing to be 
inaccessible. The conditions that terminate the be haviour vary according to the intensity of its 
arousal. At low intensity they may be simply sigh t or sound of the mother, especially effective 
being a signal from her acknowledging his pres ence. At higher intensity termination may 
require his touching or clinging to  her. At highest intensity, wh en he is distressed and anxious, 
nothing but a prolonged cuddle will do. The biologi cal function of this be haviour is postulated 
to be protection, especially protection from predators.  
In the example just given the individuals concer ned are a child and his mother. It is evident, 
however, that attachment behaviour is in no wa y confined to children. Although usually less 
readily aroused, we see it also in adolescents  and adults of both sexes whenever they are

anxious or under stress. No one should be su rprised therefore when a woman expecting a 
baby or  
____________________  
*  Throughout this book the child is referred to  as masculine in order to avoid clumsy
constructions.  
-3-  
a mother caring for young children has a strong desire to be cared for and supported herself. 
The activation of attachment behaviour in thes e circumstances is probably universal and must 
be considered the norm. *  
A feature of attachment behaviour of the greatest importance clinically, and present 
irrespective of the age of the individual con cerned, is the intensity of the emotion that 
accompanies it, the kind of emotion aroused depending on how the relationship between the 
individual attached and the attach ment figure is faring. If it goes  well, there is joy and a sense 
of security. If it is threatened, there is jealous y, anxiety, and anger. If broken, there is grief 
and depression. Finally there is strong eviden ce that how attachment behaviour comes to be 
organized within an individual tu rns in high degree on the kinds of experience he has in his 
family of origin, or, if he is unlucky, out of it.  
This type of theory I believe to have many advant ages over the theories hitherto current in our 
field. For not only does it bring theory into close relationship with observed data but it 
provides a theoretical framework for the fiel d compatible with the framework adopted 
throughout modern biology and neurophysiology.  
Parenting, I believe, can usefully be appr oached from the same ethologically inspired 
viewpoint. This entails observing and describing the set of behavi our patterns characteristic of 
parenting, the conditions that activate and termin ate each, how the patterns change as a child 
grows older, the varying ways that parenti ng behaviour becomes organized in different 
individuals and the myriad of experiences that influence how it develops in any one person.  
Implicit in this approach is the assumption that parenting behaviour, like attachment 
behaviour, is in some degree preprogrammed and therefore ready to develop along certain 
lines when conditions elicit it. This means that, in the ordinary course of events, the parent of 
a baby experiences a strong urge to behave in ce rtain typical sorts of way, for example, to 
cradle  
*  An increased desire for care, either from hus band or mother, has been reported in studies o f
representative groups of women by Wenner ( 1966) and Ballou ( 1978).  
-4-  
the infant, to soothe him when he cries, to  keep him warm, protected, and fed. Such a 
viewpoint, of course, does not imply that the appropri ate behaviour patterns manifest 
themselves complete in every detail from the first. Clearly that is not so, neither in man nor in 
any other mammalian species. All the detail is  learned, some of it during interaction with

babies and children, much of it through obser vation of how other parents behave, starting 
during the parent-to-be's own childhood and the wa y his parents treated hi m and his siblings.  
This modern view of behavioural developmen t contrasts sharply with both of the older 
paradigms, one of which, i nvoking instinct, over-emphasized the preprogrammed component 
and the other of which, reacting against ins tinct, overemphasized the learned component. 
Parenting behaviour in humans is certainly not the product of some unvarying parenting 
instinct, but nor is it reasonable to regard it as the product simply of learning. Parenting 
behaviour, as I see it, has strong biological roots,  which accounts for the very strong emotions 
associated with it; but the detailed form that the behaviour takes in each of us turns on our 
experiences -- experiences during childhood es pecially, experiences during adolescence, 
experiences before and during marriage, and experiences with each individual child.  
Thus I regard it as useful to look upon parent ing behaviour as one example of a limited class 
of biologically rooted types of behaviour of which attachment behaviour is a nother example, 
sexual behaviour another, and exploratory behavi our and eating behaviour yet others. Each of 
these types of behaviour contributes in its ow n specific way to the survival either of the 
individual or his offspring. It is indeed because  each one serves so vital a function that each of 
these types of behaviour is in some degree prep rogrammed. To leave their development solely 
to the caprices of indivi dual learning would be the he ight of biological folly.  
You will notice that in sketching this framewor k I am making a point of keeping each of these 
types of behaviour conceptually distinct from the others. This contra sts, of course, with 
traditional libido theory which has treated them as the varying expressions of a single drive. 
The reasons for keeping them  
-5-  
distinct are several. One is that each of th e types of behaviour mentioned serves its own 
distinctive biological function -- protection, reproduction, nutrition, knowledge of the 
environment. Another is that many of the detail ed patterns of behaviour within each general 
type are distinctive also: clinging to a parent  is different from soothing and comforting a 
child; sucking or chewing food is different fr om engaging in sexual intercourse. Furthermore, 
factors which influence the development of one of these types of behaviour are not 
necessarily the same as those that influence the development of another. By keeping them 
distinct we are able to study not only the ways in  which they differ but also the ways in which 
they overlap and interact with each other -- as it has long been evident they do.  
Initiation of mother--infant interaction  
During the past decade or so there has been a dramatic advance in our understanding of the 
early phases of mother--infant interaction, than ks to the imaginative research of workers on 
both sides of the Atlantic. The studies of Kl aus and Kennel are now well known. Of special 
interest here are their observ ations of how mothers behave towards their newborns when 
given freedom to do what they like after deli very. Klaus, Trause, and Kennell ( 1975) describe 
how a mother, immediately after her infant is born , picks him up and begins to stroke his face 
with her finger tips. At this the baby quieten s. Soon she moves on to touching his head and 
body with the palm of her hand and, within five or  six minutes, she is likely to put him to her 
breast. The baby responds with prolonged lickin g of the nipple. 'Immediately after the 
delivery', they noted, 'the mothers appeared to be in a state of ecstasy', and, interestingly

enough, the observers became elated too. From th e moment of birth attention becomes riveted 
on the baby. Something about him tends to draw not only the mother and father but all those 
present to the new arrival. Given the chance, a mo ther is likely during the next few days to 
spend many hours just looking at her new possess ion, cuddling him, and getting to know him. 
Usually there comes a moment when she feels the baby is her  
-6-  very own. For some it comes early; perhaps wh en she first holds him or when he first looks 
into her eyes. For a large minority of primapar ae who are delivered in hospital, however, it 
may be delayed for up to a week, often until th ey are home again ( Robson and Kumar 1980).  
Phenomena of the greatest importance to whic h recent research has drawn attention are the 
potential of the healthy neonate to  enter into an elemental form of social interaction and the 
potential of the ordinary sensitive mother to participate successfully in it. 
*  
When a mother and her infant of two or three weeks are facing one another, phases of lively 
social interaction occur, alternating with phase s of disengagement. Each phase of interaction 
begins with initiation and mutual greeting, bu ilds up to an animated interchange comprising 
facial expressions and vocaliza tions, during which the infant orients towards his mother with 
excited movements of arms and legs; then his activities gradually subs ide and end with the 
baby looking away for a spell before the next phase of interaction begins. Throughout these 
cycles the baby is likely to be as spontaneous ly active as his mother. Where their roles differ 
is in the timing of their responses. Whereas an infant's initiation and withdrawal from 
interaction tend to follow his own autonomous  rhythm, a sensitive mother regulates her 
behaviour so that it meshes with  his. In addition she modifies the form her behaviour takes to 
suit him: her voice is gentle but higher pitche d than usual, her movements slowed, and each 
next action adjusted in form and timing accordi ng to how her baby is performing. Thus she 
lets him call the tune and by a skilful interwea ving of her own responses with his creates a 
dialogue.  
The speed and efficiency with which these di alogues develop and the mutual enjoyment they 
give point clearly to each participant being pread apted to engage in them. On the one hand is  
*  See especially the work of Stern ( 1977), Sa nder ( 1977), Brazelton, Koslowski, and Main ( 
1974) and Schaffer ( 1977). For excellent revi ews see Schaffer ( 1979) and Stern ( 1985).
The state of heightened sensitivity that deve lops in a woman during and especially towards
the end of pregnancy, and that enables her  'to adapt delicately and sensitively' to he r 
infant's needs, is a process to which Winnicott ( 1957) has called attention.  
-7-  
the mother's intuitive readiness to allow her in terventions to be paced by her infant. On the 
other is the readiness with which the infant's rhythms shift gradually to take account of the timing of his mother's interventions. In a happ ily developing partnership each is adapting to 
the other.  
Very similar alternating sequenc es have been recorded in ot her quite different exchanges 
between mother and child. For example, Kaye ( 1977), observing the behaviour of mother and

infant during feeding, has found that mothers te nd to interact with their infants in precise 
synchrony with the infant's pattern of sucking and pausing. During bursts of sucking a mother 
is generally quiet and inactive;  during pauses she strokes an d talks to her baby. Another 
example of mother taking her cue from her infant, in this case an infant within the age range 5 
to 12 months, is reported by Collis and Scha ffer ( 1975). A mother and her infant are 
introduced to a scene in which there are a number of large brightly coloured toys which 
quickly seize their visual attention. Observa tion of their behaviour then shows two things. 
First, both partners as a rule  are looking at the same object at the same time. Secondly, 
examination of the timing shows almost invariab ly that it is the baby who leads and the 
mother who follows. The baby's spontaneous in terest in the toys is evidently closely 
monitored by his mother who almost automatically  then looks in the same direction. A focus 
of mutual interest having been established, mo ther is likely to elaborate on it, commenting on 
the toy, naming it, manipulating it. 'A sharing experience is then brought about, instigated by 
the infant's spontaneous attention to the envi ronment but established by the mother allowing 
herself to be paced by the baby'.  
Yet another example, also reported by Scha ffer ( Schaffer, Collis, and Parsons 1977), 
concerns vocal interchange between mother and ch ild at a preverbal level. In a comparison of 
two groups of children, aged 12 and 24 months, it was found that the ability of the pair to take 
turns and to avoid overlapping was not only stri kingly efficient but as characteristic of the 
younger as of the older infants. Thus, long before  the appearance of words, the pattern of turn-
taking so characteristic of human conversation is already present. Here again the evidence 
suggests that,  
-8-  in ensuring the smooth transitions from one 'speaker ' to the other, mother is playing the major 
part.  
My reason for giving these examples at some le ngth is that I believe they illustrate some basic 
principles both about parenting and about the na ture of the creature who is parented. What 
emerges from these studies is that the ordinary  sensitive mother is quickly attuned to her 
infant's natural rhythms and, by attending to the details of his behaviour , discovers what suits 
him and behaves accordingly. By so doing she not only makes him contented but also enlists 
his co-operation. For, although initially his cap acity to adapt is limited, it is not absent 
altogether and, if allowed to grow in its ow n time, is soon yielding rewards. Ainsworth and 
her colleagues have noted that infants whos e mothers have responded sensitively to their 
signals during the first year of life not only cry less during the second half of that year than do 
the babies of less responsive mothers but are more willing to fall in with their parent's wishes 
( Ainsworth et al.  1978). Human infants, we can safely conc lude, like infants of other species, 
are preprogrammed to develop in a socially coop erative way; whether they do so or not turns 
in high degree on how they are treated.  
This is a view of human nature, you will notice, radically different from the one that has long 
been current in western societies and that has permeated so much of the clinical theory and 
practice we have inherited. It points, of course , to a radically different conception of the role 
of parent.

Roles of mothers and fathers: similarities and differences  
In the examples given so far, the parent concerned has been the mother. This is almost 
inevitable because for research purposes it is re latively easy to recruit samples of infants who 
are being cared for mainly by their mother, wher eas infants being cared for mainly by their 
father are comparatively scarce. Let me therefor e describe briefly one of several recent studies 
which, together, go some way to correct the balance.  
Several hundred infants have now been studie d by means of the strange situation procedure 
devised by Ainsworth ( Ainsworth  
-9-  
et al.  1978) which gives an opportunity to obse rve how the infant responds, first in his 
parent's presence, next when he is left alone, a nd later when his parent returns. As a result of 
these observations infants can be classified as pr esenting a pattern either of secure attachment 
to mother or of one of two main forms of insecure attachment to her. Since these patterns have been shown to have considerable stability during the earliest years of life and to predict 
how a nursery-school child in the age range 41 to 6 years will approach a new person and 
tackle a new task ( Arend, Gove, and Sroufe 1979) , the value of the procedure as a method of 
assessing an infant's social and emot ional development needs no emphasis.  
Hitherto almost all the studies using this procedure have observ ed infants with their mothers. 
Main and Weston ( 1981), however, extended the wo rk by observing some sixty infants, first 
with one parent and, six months later, with the other. One finding was that, when looked at as 
a group, the patterns of attachment that were  shown to fathers resembled closely the patterns 
that were shown to mothers, with roughly the sa me percentage distribut ion of patterns. But a 
second finding was even more interesting. When the patterns shown by each child 
individually were examined, no correlation was found between the pattern shown with one 
parent and the pattern shown with the other. Thus one child may have a secure relationship 
with the mother but not with the father, a second may have it with the father but not with the 
mother, a third may have it with both parents, and a fourth may have it with neither. In their 
approach to new people and new tasks the childre n represented a graded series. Children with 
a secure relationship to both parents were most  confident and most competent; children who 
had a secure relationship to neither were least so; and those with a secure relationship to one 
parent but not to the other came in between.  
Since there is evidence that the pattern of attachment a ch ild undamaged at birth develops 
with his mother is the product of how his mother has treated him ( Ainsworth et al.  1978), it is 
more than likely that, in a similar way, the pattern  he develops with his father is the product of 
how his father has treated him.  
This study, together with others, suggests that, by providing  -10-  
an attachment figure for his child, a father may be filling a role closely resembling that filled 
by a mother; though in most, perhaps all, cultures fathers fill that role much less frequently 
than do mothers, at least when the children are still young. In most families with young 
children the father's role is a different one. He  is more likely to engage in physically active

and novel play than the mother and, especially  for boys, to become his child's preferred play 
companion. *  
Provision of a secure base  
This brings me to a central feature of my c oncept of parenting -the provision by both parents 
of a secure base from which a child or an ad olescent can make sorties into the outside world 
and to which he can return knowing for sure that  he will be welcomed when he gets there, 
nourished physically and emotionally, comforted if distressed, reassured if frightened. In 
essence this role is one of be ing available, ready to respond when called upon to encourage 
and perhaps assist, but to intervene actively only when clearly necessary. In these respects it is 
a role similar to that of the officer commanding a military base from which an expeditionary 
force sets out and to which it can retreat, should  it meet with a setback. Much of the time the 
role of the base is a waiting one but it is none the less vital for that. For it is only when the 
officer commanding the expeditionary  force is confident his base is  secure that he dare press 
forward and take risks.  
In the case of children and adolescents we se e them, as they get older, venturing steadily 
further from base and for increasing spans of time.  The more confident they are that their base 
is secure and, moreover, ready if called upon to re spond, the more they take it for granted. Yet 
should one or other parent become ill or die, the immense significance of the base to the 
emotional equilibrium of the child or adoles cent or young adult is at once apparent. In the 
lectures to follow evidence is presented from  
*  Studies of relevance are those of Lamb ( 1977), Parke ( 1979), Clarke-Stewart ( 1978), an d 
Mackey ( 1979).  
-11-  
studies of adolescents and young adults, as well as  of school children of  different ages from 
nursery school up, that those who are most st able emotionally and making the most of their 
opportunities are those who have parents who, whilst always encouraging their children's 
autonomy, are none the less available and re sponsive when called upon. Unfortunately, of 
course, the reverse is also true.  
No parent is going to provide a secure base for his growing ch ild unless he has an intuitive 
understanding of and respect for hi s child's attachment behaviour and treats it as the intrinsic 
and valuable part of human nature I believe it  to be. This is where the traditional term 
'dependence' has had so baleful an influence. Dependency always carries with it an adverse 
valuation and tends to be regarded as a charact eristic only of the early years and one which 
ought soon to be grown out of. As a result in  clinical circles it has often happened that, 
whenever attachment behaviour is  manifested during later years, it has not only been regarded 
as regrettable but has even been dubbed regres sive. I believe that to be an appalling 
misjudgement.  
In discussing parenting I have focused on the pa rents' role of providing a child with a secure 
base because, although well recognized intuitively, it has hitherto, I believe, been 
inadequately conceptualized. But there are, of course, many other roles a parent has to play. 
One concerns the part a parent plays in influe ncing his child's behaviour  in one direction or

another and the range of techniques he uses to  do so. Although some of these techniques are 
necessarily restrictive, and cert ain others have a disciplinary intent, many of them are of an 
encouraging sort, for example, calling a child's at tention to a toy or some other feature of the 
environment, or giving him ti ps on how to solve a problem he cannot quite manage on his 
own. Plainly the repertoire of techniques used va ries enormously from parent to parent -- from 
largely helpful and encouraging to largely rest rictive and punitive. An interesting start in 
exploring the range of techniques used by the parents of toddlers in Scotland has been made 
by Schaffer and Crook ( 1979).  
-12-  
Peri- and post-natal conditions that help or hinder  
So far in this lecture my aim has been to desc ribe some of the ways in which the parents of 
children who thrive socially and emotiona lly are observed to behave towards them. 
Fortunately, much of this behaviour comes naturally to many mothers and fathers who find 
the resulting interchanges with their children en joyable and rewarding. Yet it is evident that, 
even when social and economic conditions are favourable, these mutually satisfying 
relationships do not develop in every family. Let us consider therefore what we know of the 
psychological conditions that foster thei r doing so and those that impede them.  
At several points I have referred to the ordinary  sensitive mother who is attuned to her child's 
actions and signals, who responds to them more or  less appropriately, and who is then able to 
monitor the effects her behaviour has on her ch ild and to modify it accordingly. The same 
description, no doubt, woul d apply to the ordinary sensitive father. Now it is clear that, in 
order for a parent to behave in these ways, adequate time and a relaxed atmosphere are 
necessary. This is where a parent, especially  the mother who usually bears the brunt of 
parenting during the early months or years, need s all the help she can get -- not in looking 
after her baby, which is her job, but in all the household chores.  
A friend of mine, a social anthropologist, observe d that in the South Sea island in which she 
was working it was the custom for a mother-to- be, both during and after the baby was born, to 
be attended by a couple of female relatives who cared for her throughout the first month, 
leaving her free to care for her baby. So  impressed was my friend by these humane 
arrangements that, when her own baby was born on  the island, she accepted suggestions that 
she be cared for in the VIP way, and she had no ca use to regret it. In addition to practical help, 
a congenial female companion is likely to pr ovide the new mother with emotional support or, 
in my terminology, to provide for her the kind of secure base we all need in conditons of 
stress and without which it is di fficult to relax. In almost all societies an arrangement of this 
sort is the rule. Indeed in all but one of 150 cultures studied by anthropologists a family 
member or friend,  
-13-  
usually a woman, remains with a mother th roughout labour and delivery ( Raphael 1966, 
quoted by Sosa et al. 1980).  
Turning to our own society, preliminary findings th at, if confirmed, are of  the greatest interest 
and practical importance have recently been re ported by the Klaus and Kennell team from a 
study conducted in a hospital mate rnity unit in Guatemala ( Sosa et al. 1980). One group of

women went through labour and delivery accordi ng to the routine prac tice of the unit which 
meant in effect that the woman was left alone  for most of the time. The other group received 
constant friendly support from  an untrained lay woman from the time of admission until 
delivery, one woman during the day and another at night. In the supported group labour was 
less than half as long as in the other, 8.7 hours against 19.3. * Moreover, the mother was 
awake for a greater part of the first hour of the infant's life during which she was much more 
likely to be seen stroking her baby, smiling, and talking to him.  
Effects of a similar kind on the way a mother  treats her baby as a result of her having 
additional contact with him soon after his birth are now well known. Amongst differences 
observed by Klaus and Kennell, when the babies were one month old, was that a mother given 
extra contact was more likely to comfort her baby during stressful clin ic visits and, during 
feeding, was more likely to fondle the baby and engage him in eye-to-eye contact. Differences 
of a comparable kind were observed when th e babies were 12 months  old and again at 2 
years. In these studies the increased contact am ounted to no more than an extra hour within 
the first three hours after birth, with a furthe r five of contact each afternoon during the next 
three days ( Kennell et al. 1974; Ringler et al. 1975).†  
†Since more recent studies, e.g. Svejda, Camp os, and Emde ( 1980), have failed to replicate 
initial findings of the effects of early mother--infant contact,  the issue remains in doubt. It 
may be that in this sensitive area details of how this early contact is arranged and by whom 
would explain discrepancies.  
*  In a further and larger study, also carried out in Guatemala and by the same research group,
all findings were replicated. Samples numbere d 279 in the routine group and 186 in the
supported group. Not only was the duration of la bour halved but the in cidence of perinatal
complications halved also ( Klaus et al. 1986).  
-14-  
Findings of another study of the part these kind s of peri- and post-natal experiences play in 
either assisting a mother to develop a loving  and sensitive relationship to her baby or 
impeding it are reported by Peterson and Mehl ( 1978). In a longitudinal study of forty-six 
women and their husbands, interviewed and obser ved during pregnancy, labour, and on four 
occasions during the infants' first six months , the most significant  variable predicting 
differences in maternal bonding was the length of time a mother  had been separated from her 
baby during the hours and days after his birth. Ot her variables that played a significant but 
lesser part were the birth experience and the attitudes and expectatio ns expressed by the 
mother during her pregnancy.  
Influence of parents' childhood experiences  
There is, of course, much clinical evidence that a mother's feeling for and behaviour towards 
her baby are deeply influenced also by her prev ious personal experiences , especially those she 
has had and may still be having with her own parents; and, though the evidence of this in 
regard to a father's attitudes is less plentiful, what there is points clearly to the same 
conclusion.

On this matter evidence from systematic studies  of young children is impr essive: it shows that 
the influence that parents have on the pattern of caring that their children  develop starts very 
early. For example, Zahn-Waxler, Radke-Yarro w, and King ( 1979) have  found not only that 
aiding and comforting others in distress is a pattern of behaviour that commonly develops as 
early as a child's second year of life, but that  the form it takes is much influenced by how a 
mother treats her child. Children whose moth ers respond sensitively to their signals and 
provide comforting bodily contact are those w ho respond most readily and appropriately to 
the distress of others. * Not infrequently, moreover, what a chil d does in such circumstances is 
a clear  
*  The role of close physical contact with mother during human infancy has been studie d
especially by Ainsworth who finds that ch ildren who develop a secure attachment to
mother are those who, during early infancy, are held longest in a tender and loving way (
Ainsworth et al. 1978).  
-15-  replica of what he has seen and/or experien ced his mother do. The follow-up of a group of 
children showing these early differences would be of the greatest interest.  
Another line of evidence regarding the in fluence of childhood experience on how a woman 
mothers her child comes from studies undertaken in London. For example, a study by 
Frommer and O'Shea ( 1973) shows that women w ho, during their pregnancy, give a history 
of having been separated from one or both pare nts before the age of 11 years are particularly 
likely to have marital and psychological difficul ties after their baby's birth and also to have 
trouble with their infant s' feeding and sleeping. Another st udy, also in London, by Wolkind, 
Hall, and Pawlby ( 1977) is extending this finding  by showing that women with this type of 
childhood history interact significa ntly less with their 5-month-ol d first-born infants than do 
women who have had more settled childhoods. These observations, which were carried out by 
an ethologist, extended over a period long enough to record fifty minutes of the baby's waking 
life, exclusive of any time taken to feed him; this usually necessitated the observer staying for 
the whole morning. Not only did the mothers fr om a disrupted family of origin spend on 
average twice as long as the other mothers out of  sight of their babies, but, even when one of 
them was with her baby, she was likely to sp end less time holding him,  less time looking at 
him and less time talking to him. Moreover, when  asked the question, 'It takes a bit of time to 
begin to see a baby as a person - do you feel this yet?', mothers from a disrupted family were 
much less likely to say they did ( Hall, Pawlby, and Wolkind 1979). The point I wish to 
emphasize is that the study provides firm evidence that women whose childhood has been 
disturbed tend to engage in less interaction with their infants than do mothers with happier 
childhoods -- at a period in their baby's life when the amount of interaction that ensues is 
determined almost entirely by the mother.  
Some of the clearest evidence regarding the en ormous part played by childhood experience in 
determining in later years how a parent treats a child comes from studies of parents known to 
have abused their children physically ( Park e and Collmer 1979). A common picture includes 
a childhood in which parental  
-16-

care was at best erratic and at worst absent altogether, in which cr iticism and blame were 
frequent and bitter, and in which parents or st ep-parents had behaved violently towards each 
other and sometimes though not always towards the children. A feature that emerges from a 
study by DeLozier of mothers known to have abus ed a child physically (a study described in 
detail in Lecture 5) is the high proportion who ha ve lived in constant dread of being deserted 
by one or both parents and therefore of being sent  away to foster home or institution, and who 
have also been threatened frequently with vi olent beatings or worse. Not surprisingly these 
girls have grown up to be perpetually anxious lest husband or boy-frie nd desert, to regard 
physical violence as part of the natural order, and to expect little  or nothing in the way of love 
or support from any quarter.  
Not every woman with childhood experiences of these sorts batters her child, however; nor 
indeed does a woman who physically abuses one of  her children necessar ily abuse the others. 
What accounts for these differences? Evidence su ggests that individuals w ho, thanks to earlier 
experiences, are markedly prone to develop un favourable parental attitudes are more than 
usually sensitive to what happens to them in th e time during and after th e birth of their babies. 
It seems that for these women adverse experiences  during this time can prove the last straw.  
In a study done at Oxford, for example, Lynch ( 1975) compared the histories of twenty-five 
children who had been physically abused with  those of their siblings who had escaped. 
Children who had been abused were  significantly more likely than  their siblings to have been 
the product of an abnormal pregnancy, labour, or delivery, to have been separated from their 
mother for forty-eight hours or more soon after birth, and to have experienced separations of 
other kinds during their fi rst six months of life. During the fi rst year of these children's lives, 
moreover, the abused children were much more likely to have been ill than were the non-
abused siblings; and the mothers also were mo re likely to have been ill during the abused 
child's first year than during the siblings' first year. Since in this study the personalities and 
childhood histories of the parents were the same for the abused siblings as for the non-abused, 
the fate of each seems to have turned in large part on the mother's  
-17-  
experiences with the child during the peri- an d early post-natal period s. The findings of a 
study by Cater and Easton ( 1980) point to the same conclusion. *  
Of the many other disturbed patt erns of parenting that can be traced, in part at least, to 
childhood experience, there is one  that happens also to be we ll documented in studies of 
abusing mothers (e.g. Morris and Gould 1963; Steele and Pollock 1968; Green, Gaines, and 
Sandgrun 1974; DeLozier 1982). This is thei r tendency to expect and demand care and 
attention from their own children, in other word s to invert the relationship. During interview 
they regularly describe how, as children, they  too had been made to feel responsible for 
looking after their parents instead of the parents caring for them.  
Most, perhaps all, parents who expect their child ren to care for them have experienced very 
inadequate parenting themselves. Unfortunatel y, all too often, they then create major 
psychological problems for their children. El sewhere ( Bowlby 1973, 1980) I have argued that 
an inverted parent--child relationship of this ki nd lies behind a significa nt proportion of cases 
of school refusal (school phobia) and agora phobia, and also probably of depression.  
How we can best help

In this contribution I have given principal attention to what we know about successful 
parenting and to some of the variables that ma ke it easier or more difficult for young men and 
women to become sensitive, cari ng parents. In consequence I have been able to say only a 
little about the many and varied patterns of defi cient and distorted parenting that we meet with 
clinically. Another large theme omitted is  how we can best help young men and women 
become the successful parents I believe the great ma jority wish to be. In conclusion, therefore, 
let me state what I believe to be the first principles for such work -- which are  
*  In interpreting the findings of these two studies caution is nece ssary because in neithe r
study is it certain that in every case the ch ild's mother was always the abusing parent.  
-18-  
that we seek always to teach by example, not pr ecept, by discussion, not instruction. The more 
that we can give young people opportu nities to meet with and observe at first hand  how 
sensitive, caring parents treat their offspring, th e more likely are they to follow suit. To learn 
directly from such parents about  the difficulties they meet with  and the rewards they obtain, 
and to discuss with them both their mistakes and their successes, are worth, I believe, 
hundreds of instructional talks. For a programme of  this kind, which in some places might be 
an extension of the mothers' self-help groups now beginning to flourish, we would need to 
enlist the active co-operation of sensitive, caring parents. Fortunately there are still plenty of 
them in our society and I believe many would be willing and proud to help.  
-19-  
LECTURE 2  
The origins of attachment theory  
In the spring of 1981 the American Orthopsychia tric Association invited me to New York to 
receive the Fourth Blanche Ittl eson Award and to address members of the Association on the 
history of my work in the fiel d of attachment and loss. Afte r thanking members for the honour 
they were doing me, I also took the opportunity to express my deep gratitude to the three 
American foundations, the Josiah Macy Juni or, the Ford, and the Foundations Fund for 
Research in Psychiatry, which had supported our  work at the Tavistock Clinic during the 
critical decade starting in 1953.  
After the meeting the editor of the Association's journal asked me to expand my remarks by 
giving an account of what we knew at that time in the field I'have been exploring, how we 
arrived at that knowledge, and the directions which further research should take. In reply I 
explained that I was in no position to be an objective historian in a field that had for long 
been controversial and that all I could attempt wa s to describe the story as I recalled it and to 
point to a few of the empirical studies and theoretical ideas that had been influential in 
shaping it. My personal biases, I explained, would inevitably be everywhere evident.   
During the nineteen-thirties and forties a number  of clinicians on both sides of the Atlantic, 
mostly working independently of each other, were making observations of the ill effects on 
personality development of prolong ed institutional care and/or

-20-  
frequent changes of mother-figure during the early years of life. In fluential publications 
followed. Listing authors in alphabetical orde r of surname, these include the following: 
Lauretta Bender ( Bender and Yarnell 1941, Bender 1947), John Bowlby ( 1940, 1944), 
Dorothy Burlingham and Anna Freud ( 1942, 19 44), William Goldfarb ( 1943 a, b, and c and 
six other papers, summarized 1955), David Le vy ( 1937), and René Spitz ( 1945, 1946). Since 
each of the authors was a qualified analyst (ex cept for Goldfarb who trained later), it is no 
surprise that the findings created litt le stir outside anal ytical circles.  
At that point, late 1949, an imaginative young Br itish psychiatrist, anal ytically oriented and 
recently appointed to be Chief of the Me ntal Health Section of the World Health 
Organisation, stepped in. Requested to contribute to a Unit ed Nations study of the needs of 
homeless children, Ronald Hargreaves * decided to appoint a short- term consultant to report 
on the mental health aspects of the problem and,  knowing of my interest in the field, invited 
me to undertake the task. For me this was a gol den opportunity. After five years as an army 
psychiatrist, I had returned to child psychiatry  determined to explore further the problems I 
had begun working on before th e war; and I had already appo inted as my first research 
assistant James Robertson, a newly qualified psyc hiatric social worker who had worked with 
Anna Freud in the Hampstead Nurseries during the war.  
The six months I spent with the World Health  Organisation in 1950 gave me the chance not 
only to read the literature and to discuss it with the authors, but also to meet many others in 
Europe and the United States with experience of the field. Soon after the end of my contract I 
submitted my report, which was published early in 1951 as a WHO monograph entitled 
Maternal Care and Mental Health . In it I reviewed the far fro m negligible evidence then 
available regarding the adverse influences on pe rsonality development of inadequate maternal 
care during early childhood, called attention to  the acute distress of young children who find 
themselves separated from those they know  
*  Ronald Hargreaves's premature death in 1962, when professor of psychiatry at Leeds, was
a grievous loss to preventive psychiatry.  
-21-  
and love, and made recommendations of how best to  avoid, or at least mitigate, the short- and 
long-term ill effects. During the next few years this report was translated into a dozen other 
languages and appeared also in a ch eap abridged edition in English.  
Influential though the written word may often be, it has nothing like the emotional impact of a 
movie. Throughout the nineteen-fif ties René Spitz's early film Grief. A Peril in Infancy  ( 
1947), and James Robertson's A Two-Year-Old Goes to Hospital  ( 1952) together had an 
enormous influence. Not only did they draw the attention of professional workers to the 
immediate distress and a nxiety of young children in an inst itutional setting but they proved 
powerful instruments for promoting changes in prac tice. In this field Robertson was to play a 
leading part 'e.g. Robertson 1958, 1970).  
Although by the end of the nineteen -fifties a great many of those working in child psychiatry 
and psychology and in social work, and some also  of those in paediatrics and sick children's

nursing, had accepted the research findings and were implementing change, the sharp 
controversy aroused by the early  publications and films contin ued. Psychiatrists trained in 
traditional psychiatry and psychologists who a dopted a learningtheory approach never ceased 
to point to the deficiencies of the evidence and to the lack of an adequate explanation of how 
the types of experience implicated could have the effects on personality  development claimed. 
Many psychoanalysts, in addition, especially  those whose theory focused on the role of 
fantasy in psychopathology to the relative excl usion of the influence of real life events, 
remained unconvinced and someti mes very critical. Meanwhile,  research continued. For 
example, at Yale Sally Provence and Rose Lipton were making a systematic study of 
institutionalized infants in which they compared their development with that of infants living 
in a family ( Provence and Lipton 1962). At th e Tavistock members of my small research 
group were active collecting further data on th e short-term effects on a young child of being 
in the care of strange people in a strange place for weeks and sometimes months at a time (see 
especially the studies by Christoph Heinicke ( 1956) and, with Ilse Westheimer, ( 1966)),  
-22-  whilst I addressed myself to the theo retical problems posed by our data.  
Meanwhile the field was changing. One importa nt influence was the publication in 1963 by 
the World Health Organisation of a collection of articles in which the manifold effects of the 
various types of experience covered by the term 'deprivation of maternal care' were 
reassessed. Of the six articles, by far the mo st comprehensive was by my colleague Mary 
Ainsworth ( 1962). In it she not only review ed the extensive and diverse evidence and 
considered the many issues that had given rise  to controversy but also identified a large 
number of problems requi ring further research.  
A second important influence was the publication, beginning during the late fifties, of Harry 
Harlow's studies of the effect s of maternal deprivation on rhesus monkeys; and once again 
film played a big part. Harlow's work in th e United States had been stimulated by Spitz's 
reports. In the United Kingdom complementary st udies by Robert Hinde had been stimulated 
by our work at the Tavistock. For the next decad e a stream of experimental results from those 
two scientists (see summaries in Harlow  and Harlow 1965 and Hinde and Spencer-
Booth1971), coming on top of the Ainsworth re view, undermined the opposition. Thereafter 
nothing more was heard of the inherent implau sibility of our hypot heses; and criticism 
became more constructive.  
Much, of course, remained uncertain. Even if  the reality of shor t-term distress and 
behavioural disturbance is granted, what evidence is there, it was asked, that the ill effects can 
persist? What features of the experience, or combination of features, are responsible for the 
distress? And, should it pr ove true that in some cases ill eff ects do persist, how is that to be 
accounted for? How does it happen that some children seem to come through very 
unfavourable experiences relatively unharmed? How important is it that a child should be 
cared for most of the time by one principal caregiver? In less developed societies it was 
claimed (wrongly as it turns out) that multiple mothering is not uncommon. In addition to all 
these legitimate questions, moreover, there were misunderstandings . Some supposed that 
advocates of the view that a child should be cared  
-23-

for most of the time by a principal mother-figure held that that had to be the child's natural 
mother -- the so-called blood-tie theory. Others  supposed that, in advocating that a child 
should 'experience a warm intimate and cont inuous relationship with his mother (or 
permanent mother-substitute)', proponents were prescribing a regime in which a mother had 
to care for her child twenty-four hours a day, da y in and day out, with no respite. In a field in 
which strong feelings are aroused and almost ev eryone has some sort of vested interest, clear 
unbiased thinking is not always easy.  
A new look at theory  
The monograph Maternal Care and Mental Health  is in two parts. The first reviews the 
evidence regarding the adverse effects of maternal deprivati on, the second discusses means 
for preventing it. What was missing, as severa l reviewers pointed out, was any explanation of 
how experiences subsumed under the broad head ing of maternal deprivation could have the 
effects on personality development of the kinds  claimed. The reason for this omission was 
simple: the data were not accommodated by any th eory then current and in the brief time of 
my employment by the World Health Organisa tion there was no possibi lity of developing a 
new one.  
The child's tie to his mother  
At that time it was widely held that the reason a ch ild develops a close tie to his mother is that 
she feeds him. Two kinds of drive are postulate d, primary and secondary. Food is thought of 
as primary; the personal relationship, referred to  as 'dependency', as secondary. This theory 
did not seem to me to fit the facts. For example,  were it true, an infant of a year or two should 
take readily to whomever feeds him and this cl early was not the case. An alternative theory, 
stemming from the Hungarian school of psychoa nalysis, postulated a primitive object relation 
from the beginning. In its best -known version, however, the one advocated by Melanie Klein, 
mother's breast is postulated as the  
-24-  
first object, and the greatest emphasis is place d on food and orality and on the infantile nature 
of 'dependency'. None of these features  matched my experience of children.  
But if the current dependency theories were inadequate, what was the alternative?  During the summer of 1951 a friend mentioned to  me the work of Lorenz on the following 
responses of ducklings and go slings. Reading about this a nd related work on instinctive 
behaviour revealed a new world, one in which sc ientists of high calibre were investigating in 
non-human species many of the problems with which we were grappling in the human, in 
particular the relatively endur ing relationships that develop in many species, first between 
young and parents and later between mated pair s, and some of the ways in which these 
developments can go awry. Could this work, I asked myself, cast light on a problem central to 
psychoanalysis, that of 'instinct' in humans?  
Next followed a long phase during which I set a bout trying to master basic principles and to 
apply them to our problems, starting with the nature of the child's tie to his mother. Here 
Lorenz's work on the following response of du cklings and goslings ( Lorenz 1935) was of

special interest. It showed that in some animal species a strong bond to an individual 
motherfigure could develop without the in termediary of food: for these young birds are not 
fed by parents  but feed themselves by catching insects. Here then was an alternative model to 
the traditional one, and one that had a number of  features that seemed possibly to fit the 
human case. Thereafter, as my gr asp of ethological principles in creased and I applied them to 
one clinical problem after another, I became in creasingly confident that this was a promising 
approach. Thus, having adopted th is novel point of view, I deci ded to 'follow it up through the 
material as long as the application of it seems to  yield results' (to borrow a phrase of Freud's).  
From 1957, when The Nature of the Child's Tie to his Mother  was first presented, through 
1969 when Attachment  appeared, until 1980 with the publication of Loss I concentrated on 
this task. The resulting conceptual framework * is designed to accommodate all  
*  This is the term Thomas Kuhn ( 1974) now us es to replace 'paradigm', the term he used in
his earlier work ( Kuhn 1962).  
-25-  those phenomena to which Freud called attenti on -- for example love relations, separation 
anxiety, mourning, defence, anger, guilt, depr ession, trauma, emotiona l detachment, sensitive 
periods in early life -- and so to offer an alternative to the trad itional metapsychology of 
psychoanalysis and to add yet another to the ma ny variants of the clini cal theory now extant. 
How successful these ideals will prove only time will tell.  
As Kuhn has emphasized, any novel conceptual fram ework is difficult to grasp, especially so 
for those long familiar with a previous one. Of the many difficulties met with in 
understanding the framework advocated, I describe only a few. One is that, instead of starting 
with a clinical syndrome of later years and tryi ng to trace its origins retrospectively, I have 
started with a class of childhood traumata and tried to trace the sequelae prospectively. A 
second is that, instead of starting with the private thoughts and feelings of a patient, as 
expressed in free associations or play, and tryi ng to build a theory of personality development 
from those data, I have started wi th observations of the behaviour of children in certain sorts 
of defined situation, including records of the feelings and thoughts they express, and have 
tried to build a theory of personality developmen t from there. Other difficulties arise from my 
use of concepts such as control system (i nstead of psychic energy) and developmental 
pathway (instead of libidinal phase), which, although now firmly established as key concepts 
in all the biological sciences, are still foreign to the thinking of a great many psychologists 
and clinicians.  
Having discarded the secondary-drive, dependency theory of the child's tie to his mother, and 
also the Kleinian alternative, a first task wa s to formulate a replacement. This led to the 
concept of attachment behaviour with its ow n dynamics distinct fr om the behaviour and 
dynamics of either feeding or sex, the two sources of human motivation for long widely 
regarded as the most fundamental. Strong supp ort for this step soon came from Harlow's 
finding that, in another primate species -- rhesus macaques -- infants show a marked 
preference for a soft dummy 'mother', despite its providing no food, to a hard one that does 
provide it ( Harlow and Zimmermann 1959).  
Attachment behaviour is any form  of behaviour that results

-26-  
in a person attaining or maintaining proximity to  some other dearly identified individual who 
is conceived as better able to cope with the world. It is mo st obvious whenever the person is 
frightened, fatigued, or sick, and is assuaged by comforting and caregiving. At other times the 
behaviour is less in evidence. Nevertheless for a person to know that an attachment figure is 
available and responsive give s him a strong and pervasive feeling of security, and so 
encourages him to value and continue the relati onship. Whilst attachment behaviour is at its 
most obvious in early childhood, it can be observ ed throughout the life cycle, especially in 
emergencies. Since it is seen in virtually all human beings (though in varying patterns), it is 
regarded as an integral part of human nature  and one we share (to a varying extent) with 
members of other species. The biol ogical function attributed to it  is that of protection. To 
remain within easy access of a familiar indivi dual known to be ready and willing to come to 
our aid in an emergency is clearly a good insurance policy - whatever our age.  
By conceptualizing attachment in this way, as  a fundamental form of behaviour with its own 
internal motivation distinct from feeding and se x, and of no less importance for survival, the 
behaviour and motivation are accorded a theoreti cal status never before given them -- though 
parents and clinicians alike have long been in tuitively aware of their importance. As already 
emphasized, the terms 'dependenc y' and 'dependency need' that have hitherto been used to 
refer to them have serious disadvantages. In the first place 'dependency' has a perjorative 
flavour; in the second it does not imply an emoti onally charged relationship to one or a very 
few dearly preferred individuals ; and in the third no valuable biological function has ever 
been attributed to it.  
It is now thirty years since the notion of atta chment was first advanced  as a useful way of 
conceptualizing a form of behaviour of centr al importance not only to clinicians and to 
developmental psychologists but to every parent as well. During that time attachment theory 
has been greatly clarified and amplified. The most notable c ontributors have been Robert 
Hinde who, in addition to his own publications  (e.g. 1974), has constantly guided my own 
thinking, and Mary Ainsworth who, starting in  
-27-  
the late fifties, has pioneered empirical studies of attachment behaviour both in Africa ( 1963, 
1967) and in the USA ( Ainsworth and Wittig 1969; Ainsworth et al.  1978), and has also 
helped greatly to develop theory (e.g. 1969,  1982). Her work, together with that of her 
students and others influenced by her (which ha s expanded dramatically since this lecture was 
given and is described in some detail in Lectur e 7), has led attachment theory to be widely 
regarded as probably the best supported theory of socio-emotional development yet available 
( Rajecki, Lamb, and Obmascher 1978; Rutt er 1980; Parkes and Stevenson-Hinde 1982; 
Sroufe 1986).  
Because my starting point in  developing theory was obser vations of behaviour, some 
clinicians have assumed that the theory amount s to no more than a version of behaviourism. 
This mistake is due in large part to the unfam iliarity of the concep tual framework proposed 
and in part to my own failure in early formulat ions to make clear the distinction to be drawn 
between an attachment and attachment behaviour. To say of a child (or older person) that he is 
attached to, or has an attachment to, someone means that he is strongly disposed to seek 
proximity to and contact with that individual and to do so especially in certain specified

conditions. The disposition to beha ve in this way is an attrib ute of the attached person, a 
persisting attribute which changes only slow ly over time and which is unaffected by the 
situation of the moment. Attachment behaviour, by contrast, refers to any of the various forms 
of behaviour that the person engages in from tim e to time to obtain and/or maintain a desired 
proximity.  
There is abundant evidence that almost every child habitually prefers one person, usually his 
mother-figure, to whom to go when distressed bu t that, in her absence, he will make do with 
someone else, preferably someone whom he know s well. On these occasions most children 
show a clear hierarchy of preference so that, in extremity and with no one else available, even 
a kindly stranger may be approached. Thus, wh ilst attachment behaviour may in differing 
circumstances be shown to a variety of indivi duals, an enduring attachment, or attachment 
bond, is confined to very few. S hould a child fail to show such cl ear discrimination, it is likely 
he is severely disturbed.  
-28-  
The theory of attachment is an  attempt to explain both attachme nt behaviour, with its episodic 
appearance and disappearance, and also the e nduring attachments that children and other 
individuals make to particular others. In this theory the key concept is that of behavioural 
system. This is conceived on the analogy of a physiological system organized homeostatically 
to ensure that a certain physiological measure, such as body temperature or blood pressure, is 
held between appropriate limits. In proposing th e concept of a behavioural system to account 
for the way a child or older person maintains his relation to his at tachment figure between 
certain limits of distance or accessibility, no mo re is done than to use these well-understood 
principles to account for a different form of ho meostasis, namely one in which the set limits 
concern the organism's relation to clearly iden tified persons in, or other features of, the 
environment and in which the limits are main tained by behavioural instead of physiological 
means.  
In thus postulating the existence of an intern al psychological organization with a number of 
highly specific features, which in clude representational models of the self and of attachment 
figure(s), the theory proposed can be seen as havi ng all the same basic properties as those that 
characterize other forms of struct ural theory, of which the variants of psychoanalysis are some 
of the best known, and that differentiate th em so sharply from behaviourism in its many 
forms. Historically attachment theory was developed as a varian t of object-relations theory.  
The reason why in this account I have given so much space to the concept and theory of 
attachment is that, once those pr inciples are grasped, there is little difficu lty in understanding 
how the many other phenomena of central con cern to clinicians are explained within the 
framework proposed.  
Separation anxiety  
For example, a new light is thrown on the pr oblem of separation anxiety, namely anxiety 
about losing, or becoming separated from, someone loved. Why 'mere separation' should 
cause anxiety has been a mystery. Freud wrestled with the problem and advanced a number of 
hypotheses ( Freud 1926; Strachey 1959).

-29- Every other leading analyst has done the same. With no means of evaluating them, many 
divergent schools of thought  have proliferated.  
The problem lies, I believe, in an unexamined  assumption, made not  only by psychoanalysts 
but by more traditional psychiatrist s as well, that fear is aroused in a mentally healthy person 
only in situations that everyone would perceive as intrinsically painful or dangerous, or that 
are perceived so by a person only because of hi s having become conditioned to them. Since 
fear of separation and loss does not fit this form ula, analysts have co ncluded that what is 
feared is really some other s ituation; and a great va riety of hypotheses have been advanced.  
The difficulties disappear, however, when an et hological approach is adopted. For it then 
becomes evident that man, like other animals, responds with fear to certain situations, not 
because they carry a high risk of pain or danger,  but because they signal an increase of risk. 
Thus, just as animals of many species, including man, are disposed to respond with fear to 
sudden movement or a marked change in level of  sound or light because to do so has survival 
value, so are many species, including man, disposed to respond to separation from a 
potentially caregiving figure and for the same reasons.  
When separation anxiety is seen in this light, as a basic human disposition, it is only a small 
step to understand why it is that threats to abandon a child, ofte n used as a means of control, 
are so very terrifying. Such threats, and also threats of suicide by a parent, are, we now know, 
common causes of intensified separation anxiety.  Their extraordinary neglect in traditional 
clinical theory is due, I suspect, not only to an  inadequate theory of separation anxiety but to a 
failure to give proper weight to the powerful effects, at all ages, of real-life events.  
Not only do threats of abandonment create intens e anxiety but they also arouse anger, often 
also of intense degree, especially in older child ren and adolescents. This  anger, the function of 
which is to dissuade the attachment figure fr om carrying out the threat, can easily become 
dysfunctional. It is in this light, I believe, that we can understand such absurdly paradoxical 
behaviour as the adolescent, repo rted by Burnham ( 1965), who,  
-30-  
having murdered his mother, exclaimed, 'I couldn't stand to have her leave me.'  
Other pathogenic family situations are readily understood in terms of attachment theory. One 
fairly common example is when a child has such  a close relationship with his mother that he 
has difficulty in developing a social life outside the family, a relationship sometimes 
described as symbiotic. In a majority of such cas es the cause of the trouble can be traced to 
the mother who, having grown up anxiously att ached as a result of a difficult childhood, is 
now seeking to make her own child her attach ment figure. So far from the child being over-
indulged, as is sometimes asserted, he is be ing burdened with having to care for his own 
mother. Thus, in these cases, the normal relation ship of attached child to caregiving parent is 
found to be inverted.  
Mourning  
Whilst separation anxiety is the usual response to a threat or some other risk of loss, mourning 
is the usual response to a loss after it has occu rred. During the early years of psychoanalysis a 
number of analysts identified losses, occurri ng during childhood or in later life, as playing a

causal role in emotional disturbance, especi ally in depressive disorders; and by 1950 a 
number of theories about the nature of mour ning, and other responses to loss, had been 
advanced. Moreover, much sharp controversy had already been engendered. This controversy, 
which began during the thirties, arose from the divergent theories about infant development 
that had been elaborated in Vienna and Londo n. Representative examples of the different 
points of view about mourning are t hose expressed in Helene Deutsch's Absence of Grief  ( 
1937) and Melanie Klein's Mourning and its Relation to Manic-Depressive States  ( 1940). 
Whereas Deutsch held that, due to inadequate  psychic development, children are unable to 
mourn, Klein held that they not only can mour n but do. In keeping wi th her strong emphasis 
on feeding, however, she held that the object m ourned was the lost breast; and, in addition, 
she attributed a complex fantasy- life to the infant. Opposite t hough these theoretical positions 
are, both were con-  
-31-  structed using the same methodology, name ly by inferences about earlier phases of 
psychological development based on observations  made during the analysis of older, and 
emotionally disturbed, subjects. Neither theo ry had been checked by direct observation of 
how ordinary children of diffe rent ages respond to a loss.  
Approaching the problem prospectively, as I di d, led me to different conclusions. During the 
early nineteen-fifties Robertson and I had ge neralized the sequence of  responses seen in 
young children during temporary separation from mo ther as those of protest, despair, and 
detachment ( Robertson and Bowlby 1952). A few years later, when reading a study by Marris 
( 1958) of how widows respond to loss of husba nd, I was struck by the similarity of the 
responses he describes to those of young children . This led me to a systematic study of the 
literature on mourning, especially the mourning of healthy adults. The sequence of responses 
that commonly occur, it became clear, was very different from what clinical theorists had 
been assuming. Not only does mourning in mentally  healthy adults last far longer than the six 
months often suggested in thos e days, but several component re sponses widely regarded as 
pathological were found to be common in health y mourning. These include anger, directed at 
third parties, the self, and sometimes at the pe rson lost, disbelief that the loss has occurred 
(misleadingly termed denial), and a tendency, often though not always un conscious, to search 
for the lost person in the hope of reunion. The clearer the picture of mourning responses in 
adults became, the clearer beca me their similarities to the re sponses observed in childhood. 
This conclusion, when first advanced ( Bowlby  1960, 1961), was much criticized; but it has 
now been amply supported by a number of subs equent studies (e.g. Parkes 1972; Kliman 
1965; Furman 1974; Raphael 1982).  
Once an accurate picture of healthy mourning has been obtained, it becomes possible to 
identify features that are truly indicative of pathology. It becomes possible also to discern 
many of the conditions that promote healthy m ourning and those that l ead in a pathological 
direction. The belief that children are unable to mourn can then be seen to derive from 
generalizations that had been made fro m the analyses of children whose  
-32-  
mourning had followed an atypical course. In ma ny cases this had been due either to the child 
never having been given adequate information about what had happened, or else to there

having been no one to sympathize  with him and help him gradually come to terms with his 
loss, his yearning for his lost pa rent, his anger, and his sorrow.  
Defensive processes  
The next step in this reformulation of theory  was to consider how de fensive processes could 
best be conceptualized, a crucial step since defe nsive processes have always been at the heart 
of psychoanalytic theory. Although as a clinicia n I have inevitably been concerned with the 
whole range of defences, as a research worker I have directed my atten tion especially to the 
way a young child behaves towards his mother after a spell in a hospital or residential nursery 
unvisited. In such circumstances it is common  for a child to begin by treating his mother 
almost as though she were a stranger, but then, af ter an interval, usually of hours or days, to 
become intensely clinging, anxious  lest he lose her again, and angry with her should he think 
he may. In some way all his feeling for his mo ther and all the behaviour towards her we take 
for granted, keeping within range of her and mo st notably turning to he r when frightened or 
hurt, have suddenly vanished -- only to reap pear again after an interval. That was the 
condition James Robertson and I termed detachme nt and which we believed was a result of 
some defensive process operating within the child.  
Whereas Freud in his scientific theorizing felt confined to a conceptual model that explained 
all phenomena, whether physical or  biological, in terms of the disposition of energy, today we 
have available conceptual models of much gr eater variety. Many draw on such interrelated 
concepts as organization, pattern, and info rmation; while the purposeful activities of 
biological organisms can be conceived in terms of  control systems structured in certain ways. 
With supplies of physical energy available to them, these systems become  active on receipt of 
certain sorts of signal and inactive on receipt of  signals of other sorts. Thus the world of 
science in which we live is radically  
-33-  
different from the world Freud live d in at the turn of the century, and the concepts available to 
us immeasurably better suited to  our problems than were the very  restricted ones available in 
his day.  
If we return now to the strange detached be haviour a young child shows after being away for 
a time with strange people in a strange place, wh at is so peculiar about it is, of course, the 
absence of attachment behaviour in circumstan ces in which we would confidently expect to 
see it. Even when he has hurt hi mself severely, such a child shows no sign of seeking comfort. 
Thus signals that would ordinarily activate at tachment behaviour are failing to do so. This 
suggests that in some way and for some re ason these signals are failing to reach the 
behavioural system respons ible for attachment behaviour, that  they are being blocked off, and 
the behavioural system itself is thereby immo bilized. What this means is that a system 
controlling such crucial behaviour as attachme nt can in certain circumstances be rendered 
either temporarily or permanently incapable of being activated, and with it the whole range of 
feeling and desire that normally accompanies it is rendered incapable of being aroused.  
In considering how this deactivation might be e ffected I turn to the work of the cognitive 
psychologists (e.g. Norman 1976; Dixon 1971, 1981) who, during the past twenty years, have 
revolutionized our knowledge of how we per ceive the world and how we construe the 
situations we are in. Amongst much else that is clinically congenial, this revolution in

cognitive theory not only gives unconscious mental processes the central pl ace in mental life 
that analysts have always claimed for them, but presents a picture of the mental apparatus as 
being well able to shut off in formation of certain specified t ypes and of doing so selectively 
without the person being aware of what is happening.  
In the emotionally detached children described ear lier and also, I believe,  in adults who have 
developed the kind of personality that Winnico tt ( 1960) describes as 'f alse self' and Kohut ( 
1977) as 'narcissistic', the information being blocke d off is of a very special type. So far from 
its being the routine exclusion of  irrelevant and potentially di stracting information that we 
engage in all the time and that is readily reversible, what are being excluded in these 
pathological conditions are the  
-34-   
signals, arising from both inside and outside the person, that would activate their attachment 
behaviour and that would enable them both to l ove and to experience being loved. In other 
words, the mental structures responsible for routine selective exclusion are being employed -- 
one might say exploited -- for a special and pot entially pathological purpose. This form of 
exclusion I refer to -- for obvious reasons -- as defensive exclusion, which is, of course, only 
another way of describing repres sion. And, just as Freud regarded repression as the key 
process in every form of defence, so I see the role of defensive exclusion. 
* A fuller account 
of this, an information-processing approach to the problem of defence, in which defences are 
classified into defensiv e processes, defensive beliefs, and de fensive activities, is given in an 
early chapter of Loss ( Bowlby 1980).  
An alternative framework  
During the time it has taken to develop the conceptual framework described here Margaret 
Mahler has been concerned with  many of the same clinical problems and some of the same 
features of children's behaviour; and she al so has been developing a revised conceptual 
framework to account for them , set out fully in her book The Psychological Birth of the 
Human Infant  ( Mahler, Pine, and Bergman 1975). To  compare alternative frameworks is 
never easy, as Kuhn ( 1962) emphasizes, and no  attempt is made to do so here. Elsewhere 
(e.g. Bowlby 1981) I describe what  I believe to be some of the strengths of the framework I 
favour, including its close relatedne ss to empirical data, both clin ical and developmental, and 
its compatibility with current ideas in evolu tionary biology and neurophysiology; whilst what 
I see as the shortcomings of Mahler's framew ork are trenchantly criticized by Peterfreund ( 
1978) and Klein ( 1981).  
In brief, Mahler's theories of normal devel opment, including her postulated normal phases of 
autism and symbiosis, are shown to rest no t on observation but on preconceptions based on 
traditional psychoanalytic theory and, in doing so, to ignore  
*  As Spiegel ( 1981) points out, my term 'defen sive exclusion' carries  a meaning very simila r 
to Sullivan's term 'selective inattention'.  
-35-

almost entirely the remarkable body of new in formation about early infancy that has been 
built up from careful empirical studies over the past two decades. Although some of the 
clinical implications of Mahler's theory are not very different from those of attachment theory, 
and her concept of return to base to  'refuel' is similar to that of use of an attachment figure as a 
secure base from which to explore, the key conc epts with which the two frameworks are built 
are very different.  
Research  
Nothing has been so rewarding as the immense amount of careful research to which the early 
work on maternal deprivation has given rise. The literature is now enormous and far beyond 
the compass of an account of this sort to summar ize. Fortunately, moreove r, it is unnecessary 
since a comprehensive and critic al review of the field has been published by Rutter ( 1979) 
who concludes by referring to the 'continui ng accumulation of evidence showing the 
importance of deprivation and disadvantage on  children's psychological development' and 
expressing the view that the original argumen ts 'have been amply confirmed'. A principal 
finding of recent work is the extent to which two or more adverse experiences interact so that 
the risk of a psychological disturbance followi ng is multiplied, often many times over. An 
example of this interactive effect of adverse ex periences is seen in the findings of Brown and 
Harris ( 1978) derived from their studies of depr essive disorders in women. (During the last 
decade this group has published many further findi ngs of the greatest interest, see Harris (in 
press).)  
Not only is there this strongly interactive ef fect of adverse experi ences but there is an 
increased likelihood for someone who has had one adverse experience to  have another. For 
example, 'people brought up in unhappy or disrupted homes are more likely to have 
illegitimate children, to become teenage mother s, to make unhappy marriages, and to divorce' 
( Rutter 1979). Thus adverse childhood experiences have effects of at  
-36-  
least two kinds. First they make the individual more vulnerable to later adverse experiences. 
Secondly they make it more likely that he or she will meet with further such experiences. 
Whereas the earlier adverse experiences are likely to be wholly independent of the agency of 
the individual concerned, the la ter ones are likely to be the consequences of his or her own 
actions, actions that spring from those distur bances of personality to which the earlier 
experiences have given rise.  
Of the many types of psychological disturbance that  are traceable, at least in part, to one or 
another pattern of maternal deprivation, the ef fects on parental behaviour and thereby on the 
next generation are potentially the most seri ous. Thus a mother who, due to adverse 
experiences during childhood, grows up to be anxi ously attached is prone to seek care from 
her own child and thereby lead the child to become anxious, guilty, and perhaps phobic (see 
review in Bowlby 1973). A mother who as a chil d suffered neglect and fr equent severe threats 
of being abandoned or beaten is more prone th an others to abuse her child physically ( 
DeLozier 1982), resulting in the adverse e ffects on the child's developing personality 
recorded, amongst others, by George and Main ( 1979). Systematic research into the effects of 
childhood experiences on the way mothers and fa thers treat their children has only just begun 
and seems likely to be one of the most fruitful of all fields for further research. Other research 
leads are described in a recent symposium ed ited by Parkes and Stevenson-Hinde ( 1982).

My reason for giving so much space in this acc ount to the development of theory is not only 
because it has occupied so much of my time but  because, as Kurt Lewin remarked long ago, 
'There is nothing so practical as  a good theory', and, of cour se, nothing so ha ndicapping as a 
poor one. Without good theory as a gui de, research is likely to be difficult to plan and to be 
unproductive, and findings are difficult to inte rpret. Without a reasonably valid theory of 
psychopathology, therapeutic techniques tend to be blunt and of uncertain benefit. Without a 
reasonably valid theory of aetiology, systematic and agreed measures of prevention will never 
be supported. My hope is that in the long term  the greatest value of the theory proposed  
-37-  
may prove to be the light it throws on the conditions most likely to promote healthy 
personality development. Only when those conditions are dear beyond doubt will parents 
know what is best for their children and will comm unities be willing to help them provide it.  
-38-  
LECTURE 3  
Psychoanalysis as art and science  
During the summer of 1978 I was invited to give  a number of lectures in Canada. Among the 
invitations was one from the Canadian Psychoanal ytic Society to give their academic lecture 
to the annual meeting of the Society to be he ld in Quebec City. The topic I selected is one 
which had concerned me for some years, and about which I believe there is still a great deal of 
confused thinking.  
In taking as my theme psychoanalysis as art and science I want to draw attention to what I 
believe to be two very different aspects of our  discipline -- the art of psychoanalytic therapy 
and the science of psychoanalytic psychology -- and in doing so to emphasize, on the one 
hand, the distinctive value of each and, on the ot her, the gulf that divides them -- in regard 
both to the contrasting cr iteria by which each should be j udged and the very different mental 
outlook that each demands. In emphasizing these di stinctions, I cannot help regretting that the 
word psychoanalysis came early to be used am biguously as Freud himsel f described it. 'While 
it was originally the name of a particular ther apeutic method', he writes in his autobiography ( 
1925), 'it has now also become the name of a science -- the science of unconscious mental 
processes'.  
The distinction I am drawing, of course, is not confined to psychoanalysis. It applies in every 
field in which the practice of  
-39-  
a profession or a craft gives birth to a body of  scientific knowledge -- the blacksmith to 
metallurgy, the civil engineer to soil mechan ics, the farmer to plant physiology, and the 
physician to the medical sciences. In each of th ese fields the roles di fferentiate. On the one 
hand are the practitioners, on the ot her the scientists, with a limited number of individuals 
attempting to combine both role s. As history shows, this pr ocess of differentiation often 
proves painful and misunderstandings are freque nt. Since I believe differentiation is bound to 
come also in our own field, and is perhaps already overdue, let us consider some of the

difficulties and misunderstandings to which it ma y all too easily give rise in the hope of 
avoiding them or mitigati ng their consequences.  
I start by contrasting the roles of practitioner and research scientist and do so under three 
headings, using the case of medicine as an example.  
Focus of study  
The aim of the practitioner is to take into a ccount as many aspects as he can of each and every 
clinical problem with which he is called upon to  deal. This requires him not only to apply any 
scientific principle that appears relevant but al so to draw on such personal experience of the 
condition as he may have acquired and, especia lly, to attend to that unique combination of 
features met with in each pa tient. Knowing how greatly pati ents differ, the experienced 
clinician recognizes that a form of treatment we ll suited to one would be totally inappropriate 
to another. Taking all factors into account and gi ving each its due weight is the art of clinical 
judgement.  
The outlook of the research scientist is quite diff erent. In his efforts to discern general patterns 
underlying individual variety he i gnores the particular and strives to simplify, risking thereby 
over-simplification. If he is wise he will proba bly concentrate attention on a limited aspect of 
a limited problem. If in making his selection he proves sagacious, or simply lucky, he may not 
only elucidate the problem selected but also develo p ideas applicable to a broader range. If his 
selection proves unwise or  
-40-  
unlucky he may merely end up knowing more and more about less and less. That is the risk 
every researcher runs. The art of research lies in selecting a limited manageable problem and 
the methods that will best help solve it.  This brings me to my second point.  
Modes of acquiring information  
In the methods available to him for acquiring information the practitioner has certain great 
advantages over the research sc ientist but also certain great di sadvantages. Let us start with 
the advantages.  
In his role of giving help the practitioner is permitted access to information of certain kinds 
that remain closed to the scientis t: as a friend of mine is fond of saving, it's only surgeons who 
are allowed to cut you open to see what's inside . In an analogous way it is only by treating a 
patient therapeutically that a psychoanalyst is  given access to much of importance going on in 
a person's mind. In both professions, moreover,  practitioners are permitted to intervene in 
specified ways and privileged to observe what the consequences of such interventions are. 
These are immense advantages and psychoanalyst s have not been slow to exploit them.  
Yet no science can prosper fo r long without enlisting new methods to cross-check on 
observations made and on hypothese s born of older methods. Here the research scientist is 
likely to have the advantage. In the medical sciences, physiologists and pathologists have 
made immense advances by means of animal  experiments, tissue culture, biochemical 
analyses, and a thousand other i ngenious techniques. Indeed, it is a hallmark of a creative

scientist that he devises new means by whic h phenomena, perhaps already well studied by 
other methods, can be observed in some new way.  
It is in this area, I believe, that the ambi guous use of the word psychoanalysis has done 
greatest harm. For it has led some analysts to suppose that the only method of enquiry 
appropriate for the advancement of psychoanaly tic science is that of treating a patient 
psychoanalytically. Since I believe this to be a  
-41-  profound misunderstanding I sh all be saying a good deal more  about it. Before doing so, 
however, I want to say a word about the place of  scepticism and faith in the respective worlds 
of scientist and practitioner.  
Scepticism and faith  
In his day-to-day work it is necessary for a scie ntist to exercise a high degree of criticism and 
self-criticism: and in the world he inhabits ne ither the data nor the theories of a leader, 
however admired personally he may be, are exempt  from challenge and criticism. There is no 
place for authority.  
The same is not true in the practice of a profession.  If he is to be effective a practitioner must 
be prepared to act as though certain principles a nd certain theories were valid; and in deciding 
which to adopt he is likely to be guided by those with experience from whom he learns. Since, 
moreover, there is a tendency in all of us to be  impressed whenever the application of a theory 
appears to have been successful, practitioners are at special risk of placing greater confidence 
in a theory than the evidence available may justify.  
From the standpoint of clinical practice this is no bad thing. On the contrary, there is abundant 
evidence that the great majority of patients are helped by the faith and hope that a practitioner 
brings to his work; whilst it is often the ve ry lack of these qualities that makes so many 
excellent research workers sadly ill-suited to be therapists.  
Yet, though faith in the validity of particular  data and in particular  theories is out of place in 
a scientist, I do not wish to imply that he is nothing but a sceptic. On the contrary, his whole 
way of living is founded on faith, faith that in  the long run the best route to reliable 
knowledge is the application of scientific method.  
I am, of course, aware that there are many psyc hoanalysts who do not share this faith and who 
believe that the types of problem with which we deal lie far outside the scope of science. This 
is a view I respect, though I do not share: nor, of  course, did Freud. Yet even those of us who 
are most enthusiastic about  
-42-  
applying scientific method in ou r field must recognize that there may well be problems that it 
can never solve. We simply do not know. Our ta sk, as I see it, is to apply our method as 
skilfully as we can, on the one hand believing that  the area of reliable knowledge will thereby 
be expanded and, on the other, accepting that there are likely always to remain still greater 
areas lying beyond the scope of any ex isting mode of scientific enquiry.

To many of you, I am afraid, engaged in ther apeutic practice but also hoping to contribute to 
the advance of psychoanalytic science, the contrasts I am drawing between the roles of 
practitioner and scientist will ha rdly be welcome. Yet I believe that it is only by recognizing 
these differences and acting accordingly that the strengths of each role can be used to fullest 
advantage -or that any one person can occupy both of them with any hope of success. As 
practitioners we deal in complexity; as scientists we strive to simplify. As practitioners we use 
theory as a guide; as scientists we challenge that same theory. As practitioners we accept 
restricted modes of enquiry; as scien tists we enlist every method we can.  
Earlier I remarked on the need for every de veloping science to devise new methods for 
obtaining data. The reason for this is that, ho wever productive any one method may be, it is 
bound to have its limitations, whilst there is always a prospect that some other method may 
compensate for them. Thus the new method may be  in no way superior to the old; indeed it 
may have great limitations. Its usefulness lies simply in the fact that its strengths and its 
limitations are different. Perhaps I can illustra te the point by reference to my own work.  
When I qualified in psychoanalysis in 1937, memb ers of the British Society were occupied in 
exploring the fantasy worlds of adults and children, and it was regarded as almost outside the 
proper interest of an analyst to give systematic attention to a person's real experiences. That 
was a time when Freud's famous about-turn of 1897 regarding the aetiology of hysteria * had 
led to the view that anyone who places emphasis on what a child's real experiences  may have 
been, and perhaps still are being, was regarded  as pitifully naïve. Almost by definition  
*  Efron ( 1977) has discussed the circumstances in which Freud's a brupt change of mind 
took place.  
-43-  it was assumed that anyone interested in the ex ternal world could not be interested in the 
internal world, indeed was almost certainly running away from it.  
To me as a biologist this contra st of internal with external, of organism with environment, 
never appealed. Furthermore, as a psychiatrist engaged in work with children and families and 
deeply influenced by the insights of two analyt ically oriented social workers, I was daily 
confronted with the impact on  children of the emotional problems from which their parents 
suffered. Here are two examples I still recall vi vidly. In one a father was deeply concerned 
about his 8-year-old son's masturbation and in reply to my enquiries explained how, whenever 
he caught him with his hand on his genitals, he put  him under a cold tap. This led me to ask 
father whether he himself had ever had any wo rry about masturbation, and he launched into a 
long and pathetic tale of how he had battled w ith the problem all his life. In another case a 
mother's punitive treatment of her 3-year-old's jealousy of the new baby was as quickly traced 
to the problem she had always had with  her own jealousy of a younger brother.  
Observations of these kinds led me to conclude that it is just as  necessary for analysts to study 
the way a child is really treated by his parents as it is to study the internal representations he 
has of them, indeed that the principal focus of our studies should be the interaction of the one 
with the other, of the internal with the extern al. Believing that that would be possible only if 
we had far more systematic knowledge about the effects on a child of the experiences he has 
during his early years within his family, I concen trated my attention on this area. The reasons

that I selected as my special field of study  the removal of a young child from his home to a 
residential nursery or hospital rather than the broader field of parent-child interaction were 
several. First it was an event that I believ ed could have serious ill effects on a child's 
personality development. Secondly there could be no debate whether it had occurred or not, in 
this regard contrasting strongly with the diffi culty of obtaining valid information about how a 
parent treats a child. Thirdly it appeared to be  a field in which preven tive measures might be 
possible. And perhaps I should add, four thly, that I was stimulated by the  
-44-  sheer incredulity with which my views were  met by some, though by no means all, of my 
colleagues when I first advanced them just before the war.  
The results of our ensuing studies, undertaken by  two researchers both of whom subsequently 
qualified as analysts, James Robertson and Christoph Heinicke, are now well-known; and I 
believe them to have had a significant effect on  psychoanalytic thinking. The points I wish to 
make now, however, concern research strate gy. Despite the pioneer work of such 
distinguished analysts as  Anna Freud, René Spitz, Ernst Kris, Margaret Mahler, and others, 
for long there has been a tendency in analytic ci rcles to regard the direct observation of young 
children and the recording of wh at they say as no more than an auxiliary method of research, 
the results of which are of interest when th ey confirm conclusions already reached by the 
traditional method of treating patients but whic h are unable to contribute anything original. 
The notion that the direct observation of children -- in and out of the family setting -- is not 
only a valuable method for advancing psychoanaly tic science but is indispensable to it has 
been slow to be accepted.  
The principal contributions of th ese direct studies, I believe, are to cast light on how children 
develop emotionally and socially, on what the range s of variation are in respect to a very large 
number of relevant parameters, and what types of family experience tend to influence children 
to develop in one way rather than another.  Let me give some examples of findings by 
colleagues working in our sister  sciences of ethology and de velopmental psychology that I 
believe to be highly germane to our clinical understanding.  
The first example is from the work of Mary  Salter Ainsworth ( 1977), formerly at Johns 
Hopkins University and now at the University of Virginia. Trained initially as a clinical 
psychologist, Mary Ainsworth worked with us at the Tavistock during the early fifties and 
then spent a couple of years studying mothers a nd infants in Uganda. Her definitive study has 
concerned the development of mother-infant inte raction during the first year of life in white 
middle-class homes in Baltimore, Maryland. She has had a personal analysis and is keenly 
alive to the types of problem analysts regard as important.  
-45-  During her study of mothers and infants in Ug anda Ainsworth was struck how infants, once 
mobile, commonly use mother as a base fro m which to explore. When conditions are 
favourable an infant moves away from mother on exploratory excursions and returns to her 
again from time to time. By eight months of age almost every infant observed who had had a 
stable motherfigure to whom to become attached  showed this behaviour; but, should mother 
be absent, such organized excursions became much less evident or ceased. As a result of these 
and similar findings, both for human and for monkey infants, the notion has been developed

that an ordinary devoted mother provides a child with a secure base from which he can 
explore and to which he can return when upset or frightened. Similar observations, of course, 
have been made by Margaret Mahler ( Mahler, Pine, and Bergman 1975), though she 
interprets them in terms of a theoretical fram ework different to the one  which Ainsworth and I 
use. This concept of the secure  personal base, from which a child, an adolescent, or an adult 
goes out to explore and to which he returns from ti me to time, is one I have come to regard as 
crucial for an understanding of how an emo tionally stable person de velops and functions all 
through his life .  
In her project in Baltimore, Ai nsworth was not only able to st udy this kind of behaviour more 
closely but described many individu al variations of it to be seen in a sample of twentythree 
infants at 12 months of age. Observations were made of the infa nts' exploratory and 
attachment behaviour, and the balance between them, both when the infants were at home 
with mother and also when they were placed in a slightly strange test situation. In addition, 
having obtained data on the type of mothering each infant had been receiving throughout his 
first year of life (by means of prolonged observa tion sessions at three weekly intervals in the 
child's home), Ainsworth was in a position to  propose hypotheses linking certain types of 
emotional and behavioural development at 12  months with certain types of preceding 
mothering experience.  
The findings of the study (see the review by Ains worth, 1977) show that the way a particular 
infant of 12 months behaves with and without  his mother at home and the way he behaves 
with and without her in a slightly st range test situation have much in  
-46-  common. Drawing on observations of behaviour in both types of situation it is then possible 
to classify the infants into three main groups, according to two criteria: (a) how much or how 
little they explore when with mother or withou t her, and (b) how they treat mother -- when 
she is present, when she departs, a nd, especially, when she returns.  
There were eight children whose overall beha viour at their first birthday Ainsworth was 
disposed to regard as promising well for the futu re. Such infants explored actively, especially 
in mother's presence, and used mother as a base by keeping note of her whereabouts, 
exchanging glances, and from time to time retu rning to her to share in enjoyable mutual 
contact. When mother had been absent for a sh ort time she was greeted warmly on her return. 
I will call these group X.  
There were no less than eleven children whos e overall behaviour gave cause for concern and 
whom I will call group Z. Three of them were pa ssive, both at home and in the test situation; 
they explored little and, instead, sucked a thum b or rocked. Constantly anxious about mother's 
whereabouts, they cried much in her absence bu t were contrary and di fficult on her return. 
The other eight in this group alternated be tween appearing very independent and ignoring 
mother altogether, and then suddenly becoming a nxious and trying to find her. Yet, when they 
did find her, they seemed not to enjoy contact wi th her, and often they struggled to get away 
again. In fact, they presented a cl assical picture of ambivalence.  
The remaining four of the twenty-three childr en studied were judged to occupy a position 
intermediate between those given a good prognosis  on their first birthday and those given a 
guarded one. I will call them group Y.

Since every three weeks throughout these infants' short lives the researchers had spent a three-
hour session in the child's home observing and re cording mother and infant behaviour, they 
had much first-hand data from which to rate  a mother's behaviour towards her child. In 
making these ratings Ainsworth used four distinct  nine-point rating scal es; but, since ratings 
on these scales intercorrelate highly, for present purposes one scale is sufficient -- a scale that 
measures the degree of sensitivity or insensitiv ity that a mother shows to her baby's signals 
and  
-47-  communications. Whereas a sensitive mother seems constantly to be 'tune d in' to receive her 
baby's signals, is likely to inte rpret them correctly, and to respond to them both promptly and 
appropriately, an insensitive mother will ofte n not notice her baby's signals, will misinterpret 
them when she does notice them, and will then re spond tardily, inappropriately, or not at all. 
When the ratings on this scale for the mother s of infants in each of the three groups are 
examined, it is found that the mothers of the ei ght infants in group X are rated uniformly high 
(range 5.5 to 9.0), those of the eleven infants in group Z are rated uniformly low (range 1.0 to 
3.5), and those of the four in group Y are in the middle (range 4.5 to  5.5). Differences are 
statistically significant.  
Plainly a great deal of further wo rk is necessary before it is po ssible to draw conclusions with 
any high degree of confidence. Nevertheless, th e overall patterns of personality development 
and of mother-child interaction visible at 12 mont hs are sufficiently similar to what is seen of 
personality development and of parent-child intera ction in later years for it to be plausible to 
believe that the one is the forerunner of the othe r. At the least, Ainsworth's findings show that 
an infant, whose mother is sensitive, access ible, and responsive to him, who accepts his 
behaviour and is co-operative in dealing wi th him, is far from being the demanding and 
unhappy child that some theories might suggest. In stead, mothering of this sort is evidently 
compatible with a child who is developing a lim ited measure of self-reliance by the time of 
his first birthday combined with a high degree of trust in his mother and enjoyment of her 
company.  
Conversely mothers who are insensitive to thei r children's signals, perhaps because they are 
preoccupied and worried about other things, who ig nore their children, or interfere with their 
activities in an arbitrary way, or simply reject them, are likely to have children who are 
unhappy or anxious or difficult. Anyone who has worked in a clinic seeing disturbed children 
or adolescents will hardly  be surprised by that.  
Although Ainsworth's finding of a correlation betwee n a mother's responsiveness to her infant 
and the infant's way of behaving towards her at  12 months is highly significant statisti-  
-48-  cally and has been confirmed by subsequent studie s, it is always possible to argue that the 
partner who plays the greater role in determini ng whether interaction develops happily or not 
is the infant and not the mother. Some infants are born difficult, so the argument runs, and the 
mothers' adverse reactions to them are only to be expected.  
I do not think the evidence supports this view. For example, the observations made during the 
first three months of these infa nts' lives showed no correlati on between the amount of crying a

baby did and the way his mother was treating him; whereas by the end of the first year 
mothers who had attended promptly to their cr ying babies had babies who cried much less 
than did the babies of mothers who had left them to cry.  
There are other findings, some of which are referred  to in Lecture 6, that also support the view 
that in all but a small minority of cases it is  the mother who is mainly responsible for how 
interaction develops.  
Drawing on her own home observati ons, Ainsworth has given a gr aphic account of what can 
happen. For example, she describes how she has sat in homes hearing a baby crying and 
crying and counted the minutes until the mother ha s responded. In some cases a mother sits it 
out as long as she can bear to, believing that it would be bad for the baby and make him cry 
more were she to attend to him -- a belief that  Ainsworth's findings firm ly disprove. In other 
cases a mother may be too engaged in something el se to go. In yet others it appears as though 
a mother has altogether failed to register that her baby is crying -- a situ ation an observer finds 
extremely painful to sit through. Usually th ese are women suffering from anxiety and 
depression and who are really incapa ble of attending to anything else.  
Now it will be evident to everyone that detail ed and accurate observations of these kinds, 
which demonstrate how enormously  different the experi ences of different children can be, are 
obtainable only by the methods used by these rese archers. Had the observers not been present 
to see and hear what was going on but had reli ed instead on what the mothers told them, the 
pictures they would have got would in many cases  have been entirely false; and all hope of 
finding significant correlations  
-49-  
between the way a child develops and the way he  is treated by his mother and father would 
have vanished. Yet, as we have  seen, when reliable methods of observation are used, even 
with quite small samples, highly si gnificant correlations are found.  
In emphasizing the determining role a mother pl ays in setting the pattern of interaction with 
her baby, to which I believe the evidence clearly  points, I lay no blame. Looking after a baby, 
or a toddler, or an older child for that matter, is not only a skilled job bu t also a very hard and 
exacting one. Even for a woman who has had a happy childhood and who is now enjoying the 
help and support of her husband, and perhaps al so of her own mother, and who has not been 
filled with mistaken advice about the dangers of spoiling her baby, it is a taxing one. That a 
woman with none of these advantages gets into  an emotional hassle is hardly surprising and 
certainly not an occasion for blame. Yet ther e now seems little doubt that when infants and 
young children are the subjects of insensitive mothering, mixed perhaps with occasions of 
outright rejection, and later to separations and threats of separa tion the effects are deplorable. 
Such experiences greatly increase a child's fear of losing his mother, increase his demands for 
her presence and also his anger at her absences , and may also lead him to despair of ever 
having a secure and loving relationship with anyone.  
Although ideas of this sort are much more familiar and also more acceptable in analytic 
circles today than they were a generation ago, thanks to the influence of Balint, Fairbairn, 
Winnicott, and many others, I am inclined to thi nk that their implications, both for theory and 
for practice, are still a long way from being digested.

Let me illustrate the point by considering the aetiological and therapeutic problems presented 
by the type of patient who in the United Kingdo m is likely to be described as a schizoid 
personality ( Fairbairn 1940) or as having a fa lse self ( Winnicott 1960) and in North America 
as being a borderline personality or suffering fr om pathological narcis sism (e.g. Kohut 1971; 
Kemberg 1975).  
The picture such a person presents is one of  assertive independence and emotional self-
sufficiency. On no account is he going to be beho lden to anyone and, in so far as he enters 
into  
-50-  
relationships at all, he makes su re he retains control. For much of the time he may appear to 
manage wonderfully well, but there may be time s when he becomes depressed or develops 
psychosomatic symptoms, often for no reason he  knows of. Only should symptoms or a bout 
of depression become severe is there any possi bility of his seeking treatment, and then more 
likely than not he will prefer drugs to analysts.  
When such a person does come for analysis he is careful to keep the analyst at arm's length 
and to control what happens. What he tells us is  lucid, but he avoids any reference to feeling, 
except perhaps to say how bored he gets. Holid ays or other interruptions he welcomes as 
saving his time. Perhaps he finds the analysis an 'interesting exercise '; although he is not 
convinced it is much use. And in any case he could probably do a better job by analysing 
himself!  
There is, of course, a large literature discus sing the psychopathology of these conditions and 
the therapeutic problems they present; but on what ever issues there may be agreement there is 
none on aetiology. To take two contrasting vi ewpoints: whereas Winnicott ( 1960, 1974) 
attributes the condition squarely to early e nvironmental failure in the form of 'not good 
enough mothering', Kemberg ( 1975) in his system atic treatise gives no more than a couple of 
easily missed paragraphs to the possible role th at mothering plays in influencing development, 
and only a few passing references to the inadequate moth ering certain of his patients may 
have received. That early experience may play th e key role in determin ing these conditions is 
not seriously examined by him.  
Plainly it is of the greatest importance that in due course we shoul d reach some consensus 
about this matter; and in debating the issues I be lieve we should be foolis h not to take account 
of data from as many sources as we can tap. For some conditions epidemiological surveys are 
now proving informative but I doubt whether they have anything yet to tell us about this one. 
At present therefore we have to make do with data from our two familiar sources: (a) the 
analytic treatment of patients, (b) the direct ob servation of young children with their mothers.  
As regards data obtained during treatment, I suspect it would be fr uitful for some open-
minded person to survey the psycho-  
-51-  
analytic literature and draw together all the case reports which record  information about the 
childhood experiences of these pa tients. My guess is that, in so far as any information is 
given, it would strongly support Winnicott's vi ew that these patients have had disturbed

childhoods in which inadequate mothering in on e form or another -- and it can take many -- 
bulks large. Since I have made no such survey, I can do no more than illustrate the kind of 
findings that I would confiden tly expect. The following deta ils come from case reports 
published by three analysts each much  influenced by Winnicott's views.  
One report is by Donald Winnicott's widow  Clare Winnicott ( 1980). The patient, a 
professional woman of 41, presented a classica l picture of the emotionally self-sufficient 
personality who recently had de veloped a variety of psychosom atic symptoms. Only after a 
good deal of analysis did she divulge the even ts of her childhood. Since her mother was in 
full-time work, she was looked after by a German girl who left suddenly when the patient was 
2½. Then, after six months of uncertainty, she was taken by her mother to have tea with a 
friend and later found her mother had disappeared  and she was alone in a strange bed. Next 
day she was taken to the boarding school where her mother's friend worked as matron, and 
she stayed there till she was 9, usually spendi ng the holidays there also. She appears to have 
settled in well (ominous words!) and coped very successfully; but from that time forward her 
emotional life had dried up.  
A second report, by Jonathan Pedder ( 1976), is of a young teacher in her mid-twenties whose 
personality and symptomatology bear a strong  resemblance to Clare Winnicott's patient. 
Although at the initial interview she had given an  idealized picture of her childhood, it soon 
emerged that at the age of 18 months she had been sent to stay w ith an aunt during her 
mother's next pregnancy. After six months there she had come to feel that her aunt was more 
of a mother to her than was her real mother and she had found returning home a painful 
experience. Thereafter, until she was 10, she had been terrified of anothe r separation; but then 
she had 'switched off' her anxiety 'like a ta p', as she put it, and with the anxiety had 
disappeared most of her emotional life as well.  
-52-  
The third report, by Elizabeth Lind ( 1973), concerns a young graduate of 23 who, though 
severely depressed and planning su icide, maintained that his state of mind was less an illness 
than 'a philosophy of life'. He was the eldest  of a large family; and by the time he was 3 two 
siblings had already been born. His parents, he  said, quarrelled both frequently and violently. 
When the family was young, father had been working long hours away from home training 
for a profession. Mother was always unpred ictable. Often she was so distraught by her 
quarrelling children that she would lock herself in  her room for days on end. Several times she 
had left home, taking the daughters with  her but leaving the sons behind.  
He had been told that he had been an unhappy baby, a poor feeder and sleeper, who had often 
been left alone to cry for long pe riods. His crying, it was said, had been just an attempt to gain 
control of his parents and to be spoilt. On one occasion he had had appendicitis and he 
remembered lying awake all night moaning; but his parents had done  nothing and by next 
morning he was seriously ill. Later, during therapy,  he recalled how distur bed he used to be at 
hearing his younger brothers and sisters being le ft to cry and how he hated his parents for it 
and felt like killing them.  
He had always felt like a lost child and had been puzzled to understand why he had been 
rejected. His first day at school, he said, had be en the worst in his life. It had seemed a final 
rejection by his mother; all day he had felt de sperate and had never stopped crying. After that

he had gradually come to hide all desires for love and support: he had refused ever to ask for 
help or to have anything done for him.  
Now, during therapy, he was frightened he  might break down and cry and want to be 
mothered. This would lead his th erapist, he felt sure, to regard him as a nuisance and his 
behaviour simply as attention-seeking; and, were  he to say anything personal to her, he fully 
expected her to be offended and perhaps lock herself in her room.  
In all three cases the patient's recent breakdown had followed the collapse of a significant but 
fragile relationship about which each member of  the pair had had reservations and to the 
ending of which each of the patients had, him or herself, obviously contributed.  
-53-  
In treating these patients all three analysts adopted Winnicott's technique of permitting the 
free expression of what are traditionally termed  'dependency feelings', with the result that 
each patient in due course  developed an intense and anxious attachment to his or her analyst 
(to use the terminology I prefer, (Bowlby 1969, 1973)). This enabled each patient to recover 
the emotional life he or she had lost during childhood and with it to recover a sense of 'real 
self'. Therapeutically the results were good.  
Admittedly, the findings from these three cases prove nothing. Ne vertheless they are 
suggestive and, so far as they go, support Winnicott' s theory of aetiology. Even so it is always 
open to critics to cast doubt on the validity of wh at a patient recalls a bout his childhood and to 
question whether the sequence of events recounte d had the effect on his f eeling life that he so 
explicitly claims. (It is worth noting that the events that each of these three patients held to be 
a turning point had occurred af ter their second birthdays.)  
Now it seems clear that the controversies about aetiology are never going to  be settled as long 
as we rely solely on the retrospective and perh aps biased evidence derived from the analyses 
of patients, whether they be adul ts or children. What is needed is evidence of a different kind 
to provide some sort of crossc heck. This is where I believe the direct observations of young 
children and their mothers are potentially so us eful. Is there any evidence from that source 
that suggests that a child's feeling life can become numbed by the types of experience 
described? The answer, of course, is that there is a great deal.  
Here naturally I point first to the observa tions made by James Robertson ( 1953) and 
confirmed later by Christoph Heinicke and Ilse  Westheimer ( 1965) on how children between 
the ages of 12 and 36 months behave when re moved from home to the care of strange people 
in a strange place, such as a re sidential nursery or hospital, wi th no one person to act as a 
mother-substitute. In such conditions a child come s in time to act as if neither mothering nor 
contact with humans has much significance for him. As his caretakers come and go he ceases 
to attach himself to anyone and after his return  home stays remote from his parents for days, 
and perhaps for much longer if he  is treated unsympathetically.  
-54-  
There is reason to believe, moreover, that a young child can develop this kind of defensive 
numbing in response to a mother who reje cts him and without any major separation. 
Examples of this sequence are to be found in observations recorded by Mahler ( 1971). More

definitive findings are reported by Mary Main ( 1977), a colleag ue of Mary Ainsworth's, who 
has made a special study of a group of children  in the age-range 12 to 20 months, each of 
whom not only failed to greet his mother afte r she had left him with a stranger for a few 
minutes but deliberately avoide d her. Viewing some of Main's videotaped records I was 
astonished to see to what lengths some of th ese children went. One approached her mother 
briefly but with head averted a nd then retreated from her. Anot her, instead of approaching his 
mother, placed himself facing into the corner  of the room, as though complying with a 
punishment, and then knelt down wi th his face to the floor. In every case videotaped records 
of these mothers playing with their toddlers duri ng a later session showed them to differ from 
the mothers of nonavoidant toddlers: they app eared 'angry, inexpressive and disliking of 
physical contact with the infant'. Some scolde d in angry tones, some mocked, others spoke 
sarcastically to or about their child. An obvious  possibility is that by keeping away from his 
mother in this way a child is avoiding being treated in a hostile way again.  
Thus, so far as the cross-checks provided by direct observations of young children and their 
mothers go, they tend to support a Winnicott-type theory. Put briefly, and in my own words, the child, and later the adult, becomes afraid to allow himself to become attached to anyone 
for fear of a further rejection with all the a gony, the anxiety, and the anger to which that 
would lead. As a result there is a massive bloc k against his expressing or even feeling his 
natural desire for a close trusting relationship, fo r care, comfort, and love -- which I regard as 
the subjective manifestations of a ma jor system of instinctive behaviour.  
An explanation of this kind, although much less  complex than some proposed in the literature, 
accounts well for how these people behave both in the world at large and with ourselves as 
analysts. Inevitably they bring their fear of entering into a  
-55-  
trusting relationship with them to analysis, which we experience as a massive resistance. 
Then, when at length their feelings are recovere d, they more than half expect that we shall 
treat them as they recall being treated by their pa rents. In consequence they live in dread of 
being rejected and become inte nsely angry should they suspect us of deserting them. Not 
infrequently, moreover, the way they treat us -- with abuse and rejection -- is found to be a 
version of the treatment to which they recall ha ving themselves been subjected as children.  
You will see that in the explanation of how these patients behave during analysis I have 
advanced a number of interl ocking hypotheses. In a research programme each requires 
scrutiny and testing in the light of further da ta. Among the many methods that I would expect 
to prove of value is the study, in a therapeutic se tting, of parents and ch ildren interacting with 
one another. In addition, there remains an importa nt place for further obse rvations to be made 
during the analysis of individual pa tients; though I believe that, if clinical research is to yield 
its full potential, it has to be pursued in a far more systematic and directed way than hitherto.  
To give an example: it would be  of value were a detailed record to be kept of the responses of 
one or more of these patients before and afte r each successive weekend, each vacation, and 
each unexpected interruption of the sessions, wi th an equally detailed record of how the 
analyst dealt with them. This would enable us  to know the repertoire of responses a given 
patient presents on these occasions, and also the changes in response he presents over time. It 
would also be especially valuable  if we were to have a detail ed account of the conditions in 
which a major therapeutic change occurs. If, perhaps in a collaborative programme, records

could be kept on a number of such patients, it might be possible to discover whether a frank 
and detailed discussion of the painful experiences a patient recalls having had in his 
relationships with his parents a nd the effects these appear to ha ve had and still to be having on 
the ways he treats other people, including of course ourselves, promotes therapeutic change, 
as I predict, or hinders it, as is believed by some analysts.  
Naturally, in embarking on this or any other research pro-  
-56-  gramme an analyst must bear in mind his pr ofessional responsibilities; for with patients who 
present a false self these can be very onerous . Winnicott describes the 'period of extreme 
dependence' through which such patients go dur ing therapy and gives warning that 'analysts 
who are not prepared to go and meet the heavy needs of patients who become dependent in 
this way must be careful so to choose their cases  that they do not incl ude false self types'.  
This brings me back to the art of therapy. To provide, by being ourselves, the conditions in 
which a patient of this kind can discover and reco ver what Winnicott calls his real self, and I 
call his attachment desires and feelings, is not easy. On the one hand, we have really to be 
trustworthy and we have also genuinely to respect all those yearnings for affection and 
intimacy that each of us has but which in thes e patients have become lost. On the other, we 
must not offer more than we ca n give and we must not move fa ster than the patient can bear. 
To achieve this balance requires all the intuitio n, imagination, and empathy of which we are 
capable. But it also requires a firm grasp of what the patient's problems are and what we are 
trying to do. This is why it is so very important that the problems of aetiology and 
psychopathology should be clarifie d as far as the application of scientific method makes 
possible and, further, that an alysts should be thoroughly inform ed about the whole range of 
family experiences, from birth on through adoles cence, that, increasing evidence shows, affect 
how a child's emotional life develops. Only wh en we become armed with that and much 
further knowledge shall we be in a position to meet the exacting demand that Freud makes in 
one of the last papers he wrote, in which he draws attention to 'the kernel of truth' in a 
patient's symptoms and to the therapeutic value of constructions in analysis ( 1937). In it he 
writes: 'What we are in search of is a picture of  the patient's forgotten years that shall be alike 
trustworthy and in all essential respects complete.'  
-57-

LECTURE 4  
Psychoanalysis as a natural science  
In the autumn of  1980I was appointed Freud Memorial Vi siting Professor of Psychoanalysis 
at University College , London . In my inaugural lecture I returned to the theme I had spoken 
on in  Canadatwo years previously. Having always believed that the body of knowledge 
labelled psychoanalysis should become a part of natural science, I was distressed by the 
pressure of the opposition. To accept that ps ychoanalysis should abandon its aim of becoming 
a natural science and instead shou ld regard itself as a hermeneutic discipline has seemed to 
me to be not only a result of obsolete ideas about science but also a counsel of despair; 
because, in a hermeneutic discipline, there are no criteria by the application of which it is 
ever possible to resolve disagreement.   
A problem encountered by every  analyst who has proposed new theoretical ideas is the 
criticism that the new theory is 'not psychoana lysis'. Such criticism turns, of course, on how 
we define psychoanalysis. Most unfortunately, defining it in terms of  Freud's theories is all 
too common. This is in contrast to the definitions adopted by academic disciplines which are 
always in terms of the phenomena to be studied and the problems to be solved. In such 
disciplines progress is frequently signalle d by changes of theory, sometimes of a 
revolutionary kind. So long as analysts continue to define psychoanalysis in terms of any 
particular theory, they must not complain that their discipline is cold-shouldered by 
academics. Furthermore by so defining it they are condemning it to frozen inertia.   
The following version of this lecture differs in a number of ways from   
-58-  
the original, in particular by abbreviating the di scussion of issues already dealt with in the 
preceding lectures.  
From 1895, when Freud made his first attempt to sketch a theoretical framework for 
psychoanalysis, until 1938, the year before he  died, Freud was determined that his new 
discipline should conform to th e requirements of a natural sc ience. Thus, in the opening 
sentence of his Project  he writes: The intention is to furnish a psychology that shall be a 
natural science. . . .' ( Freud 1950, 295); whilst in the Outline  we find a passage in which he 
asserts that, once the concept of psychical  processes being unconscious is granted, 
'psychology is enabled to take its place as a natu ral science like any other' ( Freud 1940, 158).  
Admittedly during the intervening years Freud' s ideas about the scope of his science had 
changed considerably from his early ambiti on 'to represent psychical processes as 
quantitatively determinate states of specifiable material partic les' ( 1950, written in 1895) to 
his later definition of ps ychoanalysis as 'the science of unc onscious mental processes' ( 1925). 
But from first to last there can be no doubt  what sort of discipline Freud intended 
psychoanalysis to be.  
Nevertheless, despite Freud's unwavering intenti on, the scientific stat us of psychoanalysis 
remains equivocal. On the one hand philosophers of science have dubbe d it a pseudoscience

on the grounds that, however large a measure of  truth they may contain, psychoanalytic 
theories are cast in so elastic a form that  they are unfalsifiable. On the other many 
psychoanalysts, disillusioned by the inadequacies of Freud' s metapsychology and preoccupied 
with the personal pers pective which is unquestionably re quired in clinical work, have 
abandoned Freud's aims and claims and have d eclared that psychoanalysis is miscast as a 
science and should be conceived instead as one  of the humanities, e.g. Home ( 1966), Ricoeur 
( 1970), and others in Europe. Both Schafer ( 1976) and George Klein ( 1976), espousing this 
view, have advanced proposals alternative to Freud's: but each of their reformulations, 
different though they be, seems a version of Hamlet  without the Prince. Gone are all concepts 
of causality and theories of biologically  
-59-  rooted impulse and, in Schafer's version, gone also are concepts of repression and 
unconscious mental activity.  
Melanie Klein has made very different proposal s, ones which certainly do not suffer from 
these defects; but it would be diff icult to claim that the form they take or the research they 
have engendered meet scientific requirements.  
Yet by no means do all analysts despair of devel oping their discipline as a natural science. 
Alive to the deficiencies of Freud's metapsychology, especia lly his concepts of psychic 
energy and drive, a few are attempting to re place it with a new conceptual framework 
consistent with current scientific thinking. Central to these new proposals are ideas drawn 
from systems theory and the study of human in formation processing. Those active in this 
enterprise include Rubinstein ( 1967), Peter freund ( 1971, 1982), Rosenblatt and Thickstun ( 
1977), Gedo ( 1979), and myself ( 1969, 1980). Meanwhile there are also a number of 
analysts who have been seeking to extend th e discipline's data-bas e by studying children's 
social and emotional development using direct observations. Some  of these studies have been 
atheotetical, e.g. Offer ( 1969). The authors of others have attempted to put new empirical 
wine into the old theoretical bottles, e.g. Sp itz ( 1957), Mahler ( Mahler, Pine, and Bergman 
1975); whilst others again, e.g. Sander ( 1964, 1980), Stern ( 1977), and myself ( 1958, 1969, 
1973), have searched for new theoretical models . My own search has led not only to control 
theory and information processing but also to the biologically rooted disciplines of ethology 
and comparative psychology. Thus there is no lack  of new initiatives and it will take time to 
see which of them, or perhaps which combin ation of them, proves most productive of 
scientific advance. Here my aim is to describe  one such initiative, my own, and why I think it 
promising.  
In the preceding lecture I described the circum stances which led me to choose as a field of 
research the responses of a young child to bein g removed from his or her mother and placed 
for a time in a strange place with strange pe ople, and how these observations led on to the 
formulation of attachment theory. Among essentia l features of this are that the human infant 
comes into the world genetically biased to develop a set of  
-60-  
behavioural patterns that, given an appropriate environment, will result in his keeping more or 
less close proximity to whomever cares for him, and that this tendency to maintain proximity 
serves the function of protecting the mobile infant and growing child from a number of

dangers, amongst which in man's environment of  evolutionary adaptedness the danger of 
predation is likely to have been paramount.  
A concept that emerged early from ethologicady or iented studies of mother-child relationships 
( Ainsworth 1967) and which has proved of great clin ical value is that of a mother, or mother-
substitute, providing a child with a secure base from which he can explore. By the last months 
of the first year of life an infant brought up in  an ordinary affectionate home is very clear 
whom he prefers to care for him, a preferen ce especially evident should he be tired, 
frightened, or sick. Whoever that may be, and it is  usually his mother, is then able by her very 
presence, or ready accessibility, to create th e conditions which enable him to explore his 
world in a confident way. At the time of his second birthday, for example, a healthy child 
whose mother is resting on a garden seat will make  a series of excursions away from her, each 
time returning to her before maki ng the next excursion. On some occasions, when he returns, 
he simply smiles and makes his number; on others  he leans against her knee; on yet others he 
wants to climb on her lap. But never does he stay  for long unless he is fr ightened or tired or 
thinks she is about to leave. Anderson ( 1972), who made a study of this sort in a London park, observed that during the second and third ye ars it is very rare for a child to go further 
than two hundred feet before returning. Should he lose sight of his mother, exploration is 
forgotten. His top priority then is to regain her, in an older child by searching and in a 
younger one by howling.  
It is evident that there is no way of explaining th is type of behaviour in terms of a build-up of 
psychic energy which is then discharged. An alternative model (alread y described in earlier 
lectures) is to think of the proximity keepin g of a child as being mediated by a set of 
behavioural systems organized cy bernetically. Activation is inte nsified in conditions of pain, 
fatigue, and anything frightening;  and reduced by proximity to  
-61-  
or contact with the mother-figure. We can then  postulate that the behaviour that takes him 
away from his mother into the wide world,  which is conveniently termed exploratory 
behaviour, is incompatible with attachment beha viour and has a lower priority. It is thus only 
when attachment behaviour is relative ly inactive that exploration occurs.  
As an individual grows older his life continue s to be organized in the same kind of way, 
though his excursions become stea dily longer both in time and sp ace. On entering school they 
will last for hours and later for days. During adol escence they may last for weeks or months, 
and new attachment figures are likely to be sought. Throughout adult life the availability of a 
responsive attachment figure remains the source of a person's feeling se cure. All of us, from 
the cradle to the grave, are happiest when life is organized as a series of excursions, long or 
short, from the secure base provi ded by our attachment figure(s).  
In terms of the theoretical model proposed, the pronounced changes in the organization of 
attachment behaviour that occur during individua l development are regarded as being due, in 
part, to the threshold for its activation being raised (perhaps through changes in endocrine 
levels) and, in part, to the control systems b ecoming increasingly sophisticated, in particular 
by their coming to incorporate representationa l models of the environment and important 
people in it and also of the self  as a living active person.

The development during ontogeny of a set of system s of the kind described in humans, as well 
as in individuals of many other species, is attri buted to the action of natural selection, namely 
to individuals well endowed with the potential to develop such systems having survived and 
bred more successfully than t hose less well endowed, in other words to Darwinian evolution. 
Since a disposition to show atta chment behaviour in certain circumstances is regarded as an 
intrinsic part of human nature, reference to it as 'dependency' is not only misleading but 
seriously inappropriate be cause of the word's pejorative overtones.  
Once attachment behaviour and other forms of biologically determined behaviour are 
conceived in terms of control theory, the problem  of the purposiveness of behaviour is solved 
without  
-62-  
abandoning the concept of causation. Furthe rmore the distinction between causation and 
function, sadly neglected in traditional psychoan alytic theory, becomes e xplicit. Activation, in 
which emotional arousal and expr ession play a critical part, a nd subsequently termination and 
change of emotional state are caused when a sy stem constructed in a particular way receives 
information of particular sorts.  Of the various consequences to  which activation leads, the one 
postulated as its biological func tion is the one that, evidence suggests, has led to the system 
having evolved during phylogeny. In the case of attachment behaviour th e function postulated 
is that of diminishing the risk of  the individual coming to harm.  
At this level of analysis the question of whether an individual is aware of what he is doing, let 
alone why he is doing it, has no relevance, in fact no more relevance than has the question of 
whether an individual is aware that he is breath ing and, if so, realizes why he should be doing 
so. Biological systems serving vital functions,  whether at a behaviour al or a physiological 
level, must be capable of operating automatical ly. Nevertheless in the case of a human child 
awareness of what he is doing, and more partic ularly awareness of the conditions that will 
terminate his behaviour, soon emerges, certainly by the end of his first year, and is a factor of 
great importance. For, once it is clear that a child  is aware of the conditions that will terminate 
his behaviour, we begin speaking of intention, of his desire to  achieve a certain goal, of his 
being satisfied and happy when he does so and fr ustrated, anxious, or an gry when he fails, of 
satisfaction bringing pleasure and frustration the reverse.  
At this point I wish to emphasize the shar p distinction between conditions necessary to 
terminate a certain form of behaviour, commonl y referred to as its goal, and the biological 
function the behaviour serves. In the case of a ttachment behaviour in childhood, whereas we 
commonly expect both mother and child to be aware of the conditions necessary to terminate 
it, for example, a certain degree of proximity , we do not expect awareness of function. The 
same holds in the case of eating and sexual beha viour. Most of us are aware that eating food 
will assuage our hunger and we find pleasure in eating; but only the sophisticated are 
concerned with its nutritional function. Similarly  
-63-  sexual desire can be assuaged without awarenes s of reproductive functi on. In both cases all 
but the sophisticated are concerne d only with an urge to behave in a certain way and with the 
pleasure anticipated and received on reaching the terminating conditions (or goal), not with 
the biological function that the behaviour may serve. Often, in fact, when we feel emotionally

impelled to act in a certain way that is readily  explicable in terms of  biological function, we 
concoct 'reasons' for doing so that bear little or no relation to the causes of our behaviour. For 
example, a child or adult, who in order to redu ce risk is biologically disposed to respond to 
strange sounds in the dark by seeking his att achment figure, gives as his reason that he is 
afraid of ghosts. This is analogous to the 'r easons' for his behaviour concocted by someone 
who is, without knowing it, acting on  a post-hypnotic suggestion.  
The distinction I have drawn be tween the function served by a certain form of behaviour and 
our knowledge of, and our striving to reach, the conditions that will term inate that behaviour 
is one of the criteria that distinguish the bi ological realm from the psychological. Another is 
the distinction between, on the one hand, the be havioural system, postul ated as a biological 
given, together with some (though not all) of th e conditions that activate and terminate it, and, 
on the other, our awareness of the urge to reac h a certain goal and our effort to find means to 
do so.  
Earlier I remarked that, in understanding indivi dual development, it is as necessary to 
consider the environment in which each indivi dual develops as the genetic potentials with 
which he is endowed. The theoretical framewor k best suited to this purpose is that of 
developmental pathways proposed by th e biologist, C.H. Waddington ( 1957).  
Within this framework human personality is  conceived as a structure that develops 
unceasingly along one or another of an array of possible and discrete pa thways. All pathways 
are thought to start close together so that, at conception, an individual has access to a large 
range of pathways along any one of which he mi ght travel. The one chosen, it is held, turns at 
each and every stage on an interaction between th e organism as it has developed up to that 
moment and the environment in  
-64-  
which it then finds itself. Thus at conception  development turns on interaction between the 
newly formed genome and the intrauterine envi ronment; at birth it turns on interaction 
between the biological constitution of the neonate , including his germinal mental structure, 
and the family, or non-family, into which he is born; and at each age successively it turns on 
the personality structures then present and the family and later the wider social environment 
then current.  
At conception the total array of pathways potenti ally open to an individual is determined by 
the make-up of the genome. As developmen t proceeds and structures progressively 
differentiate, the number of pathways  that remain open diminishes.  
A principal variable in the development of each individual personality is, I believe, the 
pathway along which his attachment behaviour co mes to be organized and further that that 
pathway is determined in high degree by the wa y his parentfigures trea t him, not only during 
his infancy but throughout his childhood and adolescence as well. A principal means by 
which such experiences influence personality deve lopment is held to be through their effects 
on how a person construes the world about him a nd on how he expects persons to whom he 
might become attached to behave, both of wh ich are derivatives of the representational 
models of his parents that he has built up dur ing his childhood. Evidence suggests that these 
models tend to persist relatively unmodified at an unconscious level and to be far more 
accurate reflections of how his parents have r eally treated him than traditional opinion has

supposed. Within this framework aberrations of behaviour and neurotic symptoms are 
conceived as due to the interactions that ha ve occurred and that may still be occurring 
between an individual's personality  as it has so far developed and the situation in which that 
individual now finds himself.  
Let us pause here for a moment. In thus far sketching the conceptual framework I favour, I 
have doubtless said enough for you to see a numb er of points at which it differs from the 
traditional one. For example, the theory of mo tivation advanced differs radically from Freud's 
theory of psychic energy and drive, and the th eory of developmental pathways differs in 
similar degree from his theories of  libidinal phases , fixation, and  
-65-  
regression. Furthermore the concep t of attachment behaviour sees it as distinct from and of a 
status equal to that of  eating and sexual behaviour, and as  a characteristic present throughout 
life. Where lie the origins of these differences?  
During the formative period of Freud's thought  he was deeply interested in biology and 
concerned to formulate psychological theory in  terms consistent with current biological 
thinking. This led him to explore the ideas of Da rwin and other evolutionists of the period. At 
that time, the turn of the century, Darwin's th eory of variation and natural selection as the 
agents of evolution was far from being the domi nant theory it is today. On the contrary, 
Lamarck's theories regarding the inheritance of acquired characte ristics and the influence that 
an animal's 'inner feeling of need' was thought to have on its structure were popular. So also 
was Haeckel's biogenetic law which, clai ming that ontogeny recapitulates phylogeny, 
overlooks the fact that selection pressures operate at all phases of the life cycle and that new 
species often spring from the immature forms of  earlier ones (neoteny). Freud, we know, was 
deeply influenced by both Lamarck and Haeckel and he commends their ideas repeatedly to 
his students. * The outcome was that much of his metapsychology and all his developmental 
psychology came to be founded on principl es long since abandoned by biologists.  
If, therefore, psychoanalysis is to become  the natural science based on sound biological 
principles that Freud intended, there are comp elling reasons for drastic changes in some at 
least of its basic assumptions. The framewor k I am advancing, based on neo-Darwinian 
principles and current work in developmenta l psychology and human information processing, 
is one such attempt.  
Although psychoanalysis is avowedly a developm ental discipline, it is nowhere weaker, I 
believe, than in its concepts of development.  Many of the most influential of them, for  
*  For Freud's adherence to Lamarckian ideas see volume 3, chapter 10, of Ernest Jones's
biography of Freud ( Jones 1957). For the infl uence of Haeckel's bi ogenetic law see James
Strachey's long editorial footnote to his translation of Freud's Moses and Monotheism (SE 
23,102) and especially Frank Sulloway's enquiry into the origins of Freud's
metapsychology ( Sulloway 1979).  
-66-

example, that of libidinal phases, stem  straight from Haeckel. Thus in his Introductory 
Lectures  of 1916-17, Freud emphasizes that the deve lopment of both ego and libido are to be 
understood as 'abbreviated reca pitulations of the development which all mankind passed 
through from its primeval days' ( Freud 1917, 35 4), whilst the development of the libido is 
also seen in terms of phylogeny and the vari ous forms taken by the genital apparatus in 
animals. In a case study published about the sa me time, he attributes  a person's ideas of 
'observing parental inte rcourse, of being seduced in childho od and of being threatened with 
castration . . . [to] an inherited endowment, a ph ylogenetic heritage'; and he claims also that 
the Oedipus complex is among the 'phylogenet ically inherited schemata' ( Freud 1918, 97 and 
119 ). All these ideas are repeated in  his final work, e.g. Freud 1939, 99 .  
Now it may be that few analysts today would s ubscribe to Freud's orig inal formulations; yet 
there can be no doubt of their pervasive influence not only on what is taught but on the 
prevailing assumptions of how our  understanding of emotional and social development is best 
furthered. Thus pride of place continues to be  given to reconstructions based on what is 
observed and inferred during treatment sessions, coupled with a persisting, if weakening, 
reluctance to give serious attention to the enormously important work now going on in the 
field of developmental psychology. Since in  many previous publications I have drawn 
attention to the relevance of this work, I need  say only that I believe all the developmental 
concepts of psychoanalysis will have to be re-e xamined, and that most of them will in due 
course be replaced by concepts now current among those who are studying the development 
of affectional bonds in infa nts and young children by means of  direct observation. The 
understandable reserve with which many clinicians have viewed this type of work in the past 
would, I believe, be dispelled, were they to  become familiar with the observations and ideas 
of such present leaders in the field as, for example, Mary Ainsworth ( 1977), John and 
Elizabeth Newson ( Newson 1977), a nd Colwyn Trevarthen ( 1979).  
Ignorant though many analytic theorists appear still to be of the va lue or even the very 
existence of these studies, there are, I  
-67-  
am glad to say, an increasing number of anal ytic therapists who draw on them in their 
treatment of patients. Let us tu rn therefore to the clinical fi eld and consider the account given 
by a Californian analyst of his treatment of a woman patient, many of whose problems he 
attributes, I believe rightly, to events followi ng her parents' divorce a nd the long period during 
her fifth and sixth years when she wa s in an institution. This account * not only illustrates the 
kinds of distressing personal problem to which e xperiences of these sort s give rise, including 
intense ambivalence, but serves also to pose ques tions of how issues of defence and affect are 
answered within the conceptual framework I am proposing.  
The problems for which Mrs G came for analysis  were that she felt ir ritable and depressed 
and filled, as she put it, with hate and evil . In addition she found herself frigid with her 
husband, emotionally detached, and wondering whether she was capable of loving anyone.  
Mrs G had been 3 years old when her parents di vorced. Her father left home and her mother, 
who began working long hours, had little time fo r her daughter. A year later, when Mrs G was 
4, her mother placed her in an orphanage where she remained for eighteen long months. 
Thereafter, although she was back with her moth er, family relationships continued to be

disturbed and unhappy. As a result  Mrs G left home during her teens and, before she was 21, 
had already been married and divorced twic e. Her present husband was her third.  
In the early phases of the analysis Mrs G was ex tremely reluctant to recall the painful events 
of her childhood; and when she did so she br oke down into tears and sobbing. Nevertheless 
her analyst encouraged her to reflect on them further and to do so in minute detail since he 
believed this would help her. At the same time he paid at least equal attention to her 
relationship with himself in which, as would  
*  The account given here is derived from th e contribution by Thomas Mintz to a symposium
organized by the American Psychoanalytic Asso ciation on the effect s on adults of objec t
loss during the first five ye ars of life ( Mintz 1976).  
-68-  
be expected, all the interpersonal difficulties she had had in other close relationships recurred.  
Amongst much else in her childhood that was painful, Mrs G recalled how sad she had felt on 
being parted from her pets when she was sent  away to the orphanage. Sometimes she dreamed 
about her time there with feelings of being overwhelmed. She recalled  feeling very small 
among the many children, how there were no toys , the harsh treatment meted out and how she 
had sometimes misbehaved deliberately in order to get smacked [which at least meant she was 
given some attention -- J B).  
After four years of analysis Mrs ( G's financial difficul ties led to the decision to end treatment 
in six months' time. Inevitably the emotional conflicts she had in her relationship with her 
analyst became more acute. She now dreamed a nd day-dreamed more openly of him. From 
the first she had realized that parting would be painful. Separations  had always made her 
angry and, as she put it now, 'anger makes me sad because it means the end. . . . I'm afraid 
you'll leave me or kick me out or put me away.'  The analyst reminded her of how she had felt 
when sent to the orphanage. Struggling to think of herself as self-suffi cient, she explained: 
'I'm clinging on to me . . . I'm taking care of me all by myself.'  
A few months later, as termination approached, she linked how she felt about her analyst with 
how she had felt earlier about her mother: 'I don't want to releas e my mother -- I don't want to 
let her go -- she's not going to get rid of me.' By this stage of her analysis her active yearning 
for love and care had returned together with her anger at those who had denied it her.  
The radical change that had occurred in this woman was confirmed in other episodes. For 
example, during the early days of  the analysis her cat had died  but she had felt indifferent 
about it. As she had then explained: 'If I let it hurt me, I'd be saddened by everything. One will 
trigger off the rest.' But now, towards the end of the analysis, when another cat died, she wept.  
Although therapy had restored this patient's feel ing life and had resulted in her becoming able 
to make improved  
-69-

relationships, including that with her mother, a follow-up five years late r showed, as would be 
expected, that she remained vulnerable to situa tions that arouse anxiet y and sadness, such as 
separation and loss.  
Let us examine the change that had occurred in this woman, whose condition might be 
described clinically as schizoid ( Fairbairn 1940 ), or as false self ( Winnicott 1960, 1974) or 
as narcissistic ( Kohut 1971). Before the analys is she had felt emotionally detached and had 
wondered whether she was capabl e of loving anyone; a loss left her feeling indifferent. Now 
she had become aware how deeply she longed fo r love and care, and how angry she felt at not 
being given it; and a loss led to tears. Thus, in situations where they were missing before, responses laden with deep  affect now appeared.  
To account for such a change traditional e xplanations tend to use an hydraulic metaphor: 
affect has been dammed up and has now been discharged. The dam is regarded as a defence 
against an exessive quantity of excitation that  is in danger of overw helming the ego. Other 
explanations invoke processes postulated to occur in earliest infancy, for example, fixation in 
a phase of narcissism or a split in the ego resulting from the projection of a death instinct.  
An explanation of this woman's condition that I believe to be much closer to our present 
knowledge of the early developmen t of affectional bonds and c onsistent with what we know 
about human information processing  runs as follows: as a result of the intense pain caused her 
during her early years by the prolonged and prob ably repeated frustration of her attachment 
behaviour, experienced as frustration of her urge nt desire for love and care, the behavioural 
system(s) governing her attachme nt behaviour had become deactivated and had remained so 
despite her wishes to the contrary. As a result the desires, thoughts, and feeling that are part 
and parcel of attachment behaviour were absent  from her awareness. The deactivation itself 
can be understood as due to the selective exclus ion from processing of any information that, 
when processed, would lead to activation of the system.  
The selective exclusion postulated,  which, as recent experi-  
-70-  mental work shows, is well within the capab ilities of our cognitive apparatus ( Dixon 1971; 
Erdelyi 1974) and which I term defensive exclusi on, requires constant c ognitive activity at an 
unconscious level. The fact that the behaviou ral systems remain intact and capable in 
principle of being activated, and so may on oc casion show brief or incipient activation, can 
account for all those phenomena that led Fre ud to his ideas about a dynamic unconscious and 
repression. In fact, the defensive exclusion that  I postulate is no more  than repression under 
another name, a name more in keeping with  the conceptual framework adopted here.  
The process of therapeutic change in this patient  can then be understood as due to the patient, 
thanks to the relatively secure base provided by the analyst, developing sufficient courage to 
permit some of the information hitherto exclude d to go forward for processing. This includes 
both information stemming from the present situa tion, for example, evidence of the analyst's 
genuine concern to help his patient and the conf licting thoughts, feelin gs, and behaviour that 
that arouses, and also information stored in memory, for example, memories of the very 
painful events of childhood and the thoughts, fe elings, and behaviour aroused by them. As a 
rule information from the two sources is recove red as a chain in which information from the 
present, especially the transference, alternates with information from th e past, with each link

leading on to the next. Once the relevant inform ation becomes accepted, of course, attachment 
behaviour is reactivated, together with the urges and desires, thoughts, and feeling that go 
with it. In traditional terms, the unconscious ha s been made conscious and the repressed urges 
and affects released.  
Not infrequently, as with this patient, an analys t has the task of drawing a patient's attention to 
memories he believes of importance and encouragi ng her to reflect on them instead of turning 
her back on them. In doing this an analyst is  guided, of course, by whatever theories of 
personality development and psychopathology he  may espouse. This is a point at which 
analysts of different schools diverge. For some the events thought to be important might refer 
to feeding and weaning and fantasies about th em during the earliest months of life; for  
-71-  
others to toilet training or witnessing the pr imal scene during the second year; for others again 
to Oedipal situations and wishes during the thir d or fourth. In the case of Mrs G the analyst 
drew on his knowledge of responses of young children to events surrounding a prolonged 
separation from mother during se veral of the early years.  
It is well recognized that not every child who has been in an institution for eighteen months 
during his fifth and sixth years develops psychologically along th e kind of pathway followed 
by Mrs G. In her case other factors almost ce rtainly entered in. In considering what they 
might have been, I am influenced by remarks Mrs G made during the final phases of the 
analysis, for example, her fear lest her analys t should 'kick her out' or 'put her away' and her 
memory of how determined she had been that he r mother should not 'get rid' of her. This 
suggests that as a method of disciplining her da ughter the mother may have repeatedly used 
threats to send her back to th e institution, threats we know fr om other evidence are far from 
rare and that not only have a terrifying effect on a young child but  are likely also to generate 
intense hatred in him. The better an analyst' s knowledge of childhood conditions likely to lead 
to disturbed development, the better ca n he understand and help his patients.  
Inevitably a patient's spontaneous or guide d recollections of his childhood are of only 
suggestive value as evidence bearing on theories  of personality development. What a patient 
tells us about his childhood and especially what an analyst subsequently reports his patient to 
have said are probably influenced as much or  more by the analyst's preconceptions as by 
anything the patient may in fact have said or done; this is why I regard  the systematic study 
by direct observation of children developing wi thin different patterns of family care as 
indispensable for progress. Yet I also believe th at observations made dur ing therapy still have 
considerable research po tential, although that potential will  not be realized unless studies are 
conducted along far more systematic lines than have hitherto been usual and data obtained 
during therapy are constantly compared wi th data derived from other sources.  
The research strength of the therapeutic situation lies not in what it tells us about the patient's 
past but in what it tells us  
-72-  
about disturbances of personal ity functioning in the present,  especially, I would claim, 
disturbances in a person's capac ities to make secure attachments and the conditions in which 
these disturbances become ameliorated. The case of Mrs G can be used as an introduction to a

research proposal, since there is much both in the personality disturbance she presents and in 
the course of her analysis that we have  reason to believe are fairly typical.  
Drawing on case reports already in the literatu re it would be possible to make a number of 
generalizations which could then be treated as predictions to be tested in further therapeutic 
work with patients showing similar clinical fe atures. All such predictions, which would be 
conditional on the particular pattern  of therapy to be followed, * could be couched in terms of 
what can be observed at first hand. They would include statem ents about how a patient would 
be expected to behave towards the analyst, the to pics he would be expected to talk about or, in 
particular, avoid talking about, the affect he would be expected to  show or not to show, and in 
what situations. Of special interest would be changes in behaviour, topic, and affect that 
would be expected to occur in relation to certain  types of current event, both those occurring 
in the patient's everyday life and those occurring within the analysis. Events of the latter sort 
would include how the analyst behaves, what he  says, and how he says it, with particular 
reference to interruptions in the analysis due to holidays, sickness, or other circumstances. 
Tape recording of sessions to avoid biased reporting would, of course, be necessary.  
By following the procedures proposed it would be possible over a period of time to gather 
comparable bodies of data from two sources. One body of data would be gathered by means 
of direct observation of the development and patterning of affectional bonds during infancy 
and childhood in children experi encing different types of care. The other would be gathered, 
also by direct observation, of change s in the patterning of affectional  
*  The technique of analysis adopted by Mint z appears to have much in common with that
adopted in the United Kingdom by Donald Wi nnicott; see the account by Guntrip ( 1975). 
-73-  bonds during the course of a certain type of th erapy. Provided that the conceptual frameworks 
used in making both sets of obs ervations and the questions each set addresses are the same, 
findings could be compared and developmental hypotheses tested.  
This is but one way in which psychoanalysi s as a body of knowledge about personality 
development and psychopathology might move to wards becoming the natural science Freud 
always intended it to be.  
The conceptual framework sketched here serv es, I believe, to accommodate a substantial 
proportion of the data that psychoanalysis has selected as within its domain and already 
guides productive research programmes (e.g. Parkes a nd StevensonHinde 1982). The 
framework has the advantage of being compatible with evolutionary biology and 
neurophysiology and promises greater economy a nd internal consistency than do traditional 
ones. Nevertheless what its strengths and weaknesses will prove to be cannot be known 
without extensive testing of its powers to solv e problems not yet studied, which include, for 
example, those of sexual development and devi ation, and a far more intensive examination 
than has yet been possible of its usefulness in solving the problems already given attention.  
Finally let us consider the issues raised by thos e who maintain that psychoanalysis is not and 
never can be a natural science. Their argument, we find, stems from the belief that scientific 
method is inseparable from l ogical Positivism and reductionism. Although confidently and

often dogmatically held earlier this century, th is model of science is now discarded and its 
place taken by a philosophy of evolutionary epistemology ( Popper 1972; Latakos 1974). This 
holds that all knowledge is conjectural and that science progresses through new theories 
coming to replace older ones when it becomes clear that a new theory is able to make sense of 
a greater circle of phenomena than are compre hended and explained by an older one and is 
able also to predict new phenomena more accurately. * This same method  
*  The criterion of falsifiability on which Popper formerly laid great emphasis is no longe r
given so much prominence; though the cons tant comparison of theoretically derived
predictions with an ever increasing a rray of observed data remains central.  
-74-  
is held to be applicable in all theoretical or  generalizing sciences, whether they deal with 
physical, biological, or social  phenomena. Furthermore, since to understand phenomena at 
any one level of complexity demands concepts appropriate to that level, the notion that 
complex phenomena must be explained in terms of concepts appropriate to a lower level of 
complexity, namely reductionism, is now re cognized as fallacious. How these new ideas 
apply to our field is ably discussed by Holt  ( 1981), Blight ( 1981), and Radford ( 1983).  
Invaluable though scientific method is as a way of obtaining relatively  reliable knowledge, 
resolving differences of opinion and making us eful predictions, its limitations are nonetheless 
considerable. One is that science deals in generalities but has little to say about singular 
specific events . This is a vital distinction, as the physicist, Weisskopf ( 1981), points out. In 
the physical sciences it does not matter since phys icists and engineers have no interest in the 
future of any particular atom or molecule. Once  we move to the biological sciences, however, 
it does matter because biologists are frequently interested in individual organisms, all of 
which differ. In certain of the human sciences, moreover, the individual example is the very 
essence of the case. History, for instance, whether it deals with societies or persons or ideas, is 
always concerned with an appa llingly complex sequence of highl y specific interacting events 
which no amount of science can enable us to e xplain adequately, let alone predict. Thus the 
distinction between the natural sciences and the historical sciences is  not that they use a 
different method of obtai ning knowledge but that the problems that they strive to understand 
and the criteria they adopt are qui te different. One is concerned to formulate general laws in 
terms of probabilities, the other to understand singular specific ev ents in as much detail as 
possible. The distinction is central to the whole argument.  
Under the label 'psychoanalysis', it is clear, two complementary di sciplines are stri ving to live 
and develop. In so far as we are trying to  understand the general principles accounting for 
personality development and ps ychopathology, necessary, for example, if we are to know 
what forms of child care tend to produce what sorts of personality formation, we adopt the 
criteria of the natural sciences. And we do the same when we  
-75-  are trying to understand the essent ial features of effective ther apy. In these fields we are 
dealing with statistical probabil ities. In so far as we are concerned to understand the personal 
problems of a given individual and what events may have contributed to their development, 
necessary if we are to help him (though far from  sufficient), we adopt  the criteria of the

historical sciences. Each approa ch contributes to our understanding;  but, as I have pointed out 
in the previous lecture, only if we are clear-h eaded about what belongs to each, shall we be 
able to make progress.  
-76-  
 
LECTURE 5  
Violence in the family  
In the spring of 1983 I was invited to give the thirty-first annual Karen Horney Lecture by the 
Association for the Advancement of Psychoanalysis at the conference it was holding in New 
York City. A principal reason why I selected violence in the family as my theme was that 
research using the perspective of attachment theo ry was beginning to throw a shaft of light on 
a tragic but puzzling problem which, until recent years, had gone almost completely 
unrecognized by all those in the mental  health field, not excluding myself.   
Introduction  
It seems to me that as psychoanalysts and psycho therapists we have been appallingly slow to 
wake up to the prevalence an d far-reaching consequences of  violent behaviour between 
members of a family, and especially the violen ce of parents. As a theme in the analytic 
literature and in training programmes it has been  conspicuous by its absence. Yet there is now 
abundant evidence not only that it is much co mmoner than we had hitherto supposed but that 
it is a major contributory cause of a numb er of distressing and puzzling psychiatric 
syndromes. Since, moreover, viol ence breeds violence, violence in familes tends to perpetuate 
itself from one generation to the next.  
Why family violence as a causal factor in psychiatry should  
-77-  
have been so neglected by clinicians -- though, of course, not by social  workers -- would be a 
study in itself and cannot be entered on here. Bu t the concentration in analytic circles on 
fantasy and the reluctance to examine the impact of real-life events has much to answer for. 
Ever since Freud made his famous, and in my view disastrous, volte-face in 1897, when he 
decided that the childhood seductions he had be lieved to be aetiologically important were 
nothing more than the products of his patie nts' imaginations, it has been extremely 
unfashionable to attribute psychopat hology to real-life e xperiences. It is not an analyst's job, 
so the conventional wisdom has gone, to consid er how a patient's parents may really have 
treated him, let alone to entertain the possibility , even probability, that a particular patient 
may have been the target for the violent words and violent deeds of one or both his parents. 
To focus attention on such possibilities, I have  often been told, is to be seduced by our 
patients' prejudiced tales, to take sides, to make  scapegoats of perfectl y decent parents. And in 
any case, it is asserted, to do so could be of no help to the patient, would in fact be 
antitherapeutic. It was indeed largely because the adverse behaviour of  parents towards their 
children was such a taboo subjec t in analytic circles when I wa s starting my professional work

that I decided to focus my research on the effect s on children of reallife events of another sort, 
namely separation and loss.  
Of course, Karen Horney, in whose honour we  are meeting today, did not share those 
prejudices. On the contrary, she is quite explicit in attributin g many of her patients' problems 
to the adverse influences they had met with as children. As she writes in the opening pages of 
her book, Neurosis and Human Growth  ( 1951), these adverse influences 'boil down to the 
fact that the people in the environment are too wr apped up in their own neuroses to be able to 
love the child, or even to conceive of him as th e particular individual he is . . .'; and she goes 
on to list some of the many ways in which,  unfortunately, parents can exert a harmful 
influence on their children. But I know well that  these views were not always well received by 
her colleagues.  
Today the scene is changing -- though still far too slowly. For example, no one with eyes to 
see can any longer doubt that all too many child ren are battered by their parents, either 
verbally  
-78-  
or physically or both, nor that all too many women are battered by husband or boy-friend. 
Moreover, our horror that parents can behave  so is nowadays mitigated by our increasing 
knowledge of the kind of childhoods these parents have themselves had. Whilst horror at their 
acts is inevitable, greater understanding of how they have come to behave in these violent 
ways evokes compassion rather than blame. So fa r from wishing to scapegoat parents we wish 
to help them. So far from refusing to see that  parents sometimes engage  in horrific behaviour, 
we seek ways to succour the casualties, old as well as young, psyc hological as well as 
physical. Above all we seek ways  of preventing violent patterns developing in new families. 
Let us hope that the policy of head-in-sand has had its day.  
Conceptual framework  
In seeking to understand the more extreme exampl es of violence in the family it is useful to 
consider first what we know about the more mo derate and everyday example of members of a 
family getting angry with each other. Y oung children -- and often older ones too -- are 
commonly jealous of the attention mother gi ves the new baby. Lovers quarrel when one 
thinks the other is looking elsewhere -- and the same is true after marriage. Moreover a 
woman may get very angry with her child if he does something dangerous, like running into 
the roadway, and also with her husband if he risks life or limb by taking unnecessary risks. 
Thus we take it for granted that, when a relati onship to a special loved person is endangered, 
we are not only anxious but are us ually angry as well. As  responses to the risk of loss, anxiety 
and anger go hand in hand. It is  not for nothing that they have the same etymological root.  
In the situations described anger is ofte n functional. When child or spouse behaves 
dangerously, an angry protest is likely to de ter. When a lover's partner strays, a sharp 
reminder of how much he or she cares may work wonders. When a child finds himself 
relatively neglected in favour of the new baby,  assertion of his claims may redress the 
balance. Thus in the right place, at the righ t time, and in right degree, anger is not only 
appropriate  
-79-

but may be indispensable. It serves to deter fr om dangerous behaviour, to drive off a rival, or 
to coerce a partner. In each case the aim of the angry behaviour is the same -- to protect a 
relationship which is of very spec ial value to the angry person.  
This being so, it is necessary  to be clear why certain spec ific relationshi ps, often called 
libidinal relationships, should become so very important in the lives of each one of us.  
In his attempts to solve this problem Freud looked to the physics and biology of his day. 
Libidinal relationships, he proposed, were cons equent on the individual's needs for food and 
sex. Subsequently, to account for some of th e more puzzling manifestations of anger, he 
stepped outside biology to propose a death instin ct. These hypothese s, framed in terms of the 
accumulation and discharge of psychic energi es, led to a metapsychology so remote from 
clinical observation and experience that a grea t many analytically oriented clinicians have, 
implicitly or explicitly, abandoned it. To th e resulting vacuum one reaction has been the 
development of a school of thought  that has decided not only to  divorce psychoanalysis from 
biology but to dispense altogether  with scientific method and in stead to espouse hermeneutics. 
Another and opposite reaction has been to explor e the principles found useful in modern 
biology, principles totall y different from those of Freud's day,  to see whether they are more in 
tune with our clinical observations and mi ght therefore be used to construct a new 
metapsychology, or conceptual fr amework as it would now be called. That is the course that I 
and a number of others are following.  
The specific relationships, threats to which ma y arouse anger, are of three main types: 
relationships with a sexual partner (boyfriend, girl-friend, or spouse) , relationships with 
parents, and relationships with offspring. Each ty pe of relationship is shot through with strong 
emotion. In high degree indeed, a person's whol e emotional life -- the underlying tone of how 
he feels -- is determined by the state of thes e long-term, committed re lationships. As long as 
they are running smoothly he is content; when they are threatened he is anxious and perhaps 
angry; when he has endangered them by his own actions he feels guilty; when they are broken 
he feels sad; and when they are resumed he is joyful.  
-80-  
In helping us understand why the state of th ese relationships should have such a profound 
effect on a person's feeling lif e two branches of modern bi ology -- ethology and evolution 
theory -are extremely illuminating. Not only do all three of the relations hips in question have 
counterparts in a wide range of other species but all three are intimately concerned with the 
vital biological functions of reproduction and, es pecially, the survival of young. It is therefore 
more than likely that a human being's powerful propensity to make these deep and long-term 
relationships is the result of a strong gene-det ermined bias to do so, a bias that has been 
selected during the course of evolution. With in this frame of refe rence a child's strong 
propensity to attach himself to his mother and his father, or to whomever else may be caring 
for him, can be understood as having the function of reducing the risk of his coming to harm. 
For to stay in close proximity to, or in easy communication with, someone likely to protect 
you is the best of all possible insurance policies. Similarly a parent's concern to care for his or 
her offspring plainly has the function of contribu ting to the child's survival. That success in 
the maintenance of these long -term relationships should us ually bring satisfaction and 
contentment, and that failure s hould bring frustration, anxiety, and sometimes despair are, on 
this reading, the prizes and penalties selected during evolution to guide us in our activities.

It is within this evolutionary perspective that I believe we can understand how angry 
behaviour between members of a family can often be  functional. For, as I said earlier, in the 
right place, at the right time, and in right degree, anger can serve to maintain these vitally 
important long-term relationships. But, as is very obvious, anger can be overdone. My thesis 
is simply that a great deal of the maladaptive violence met with in families can be understood 
as the distorted and exaggerated ve rsions of behaviour that is pot entially functional, especially 
attachment behaviour on the one hand a nd caregiving behaviour on the other.  
There is now a considerable literature on th e nature of the child's tie to his mother, 
traditionally referred to as dependency and now conceived in terms of attachment and 
careseeking. But in general terms,  attachment behaviour results in one individual, usually the 
one who is less able to cope, maintaining  
-81-  proximity to, and/or communication with, another i ndividual, seen as better able to cope. This 
behaviour is elicited especia lly by pain, fatigue, or anythi ng frightening, and also by the 
caregiver being or appearing to be, inaccessible. Although conceived as being in part 
preprogrammed, there is now abundant evid ence that the particular pattern in which 
attachment behaviour becomes organized during development is much influenced by how it is 
responded to by a child's principal caregivers, in the huge majority of cases his mother and 
father. Briefly, it seems clear that sensitiv e loving care results in a child developing 
confidence that others will be helpful when appealed to, becoming increasingly self-reliant 
and bold in his explorations of the world, co -operative with others, and also -- a very 
important point -- sympathetic and helpful to ot hers in distress. Conversely, when a child's 
attachment behaviour is responded to tardily and unwillingly and is regarded as a nuisance, he 
is likely to become anxiously attached, that is, apprehensive lest his car egiver be missing or 
unhelpful when he needs her and therefore re luctant to leave her side, unwillingly and 
anxiously obedient, and unconcerned about the troubles of others. Shoul d his caregivers, in 
addition, actively reject him, he  is likely to develop a pattern of behaviour in which avoidance 
of them competes with his desire for proximity  and care, and in which angry behaviour is apt 
to become prominent. I shall say more about this later.  
One further point about attachment behaviour I wish  to emphasize is that it is a characteristic 
of human nature throughout our lives -- from the cr adle to the grave. Admittedly it is usually 
less intense and less demanding in adolescents and adults than it is in earlier years. Yet an 
urgent desire for love and care  is natural enough when a person is  anxious or distressed. It is 
therefore most unfortunate that, due to misleadi ng theory, the pejorative adjectives 'infantile' 
and 'regressive' are now so widely  current in clinical circles. They are words I never use.  
Whilst the systematic study of attachment  behaviour, and especially the conditions 
influencing how it develops, has been in progres s for twenty years, the systematic study of 
caregiving, or parenting, and how it develops is  only in its beginnings. The approach I regard 
as the most promising is again an ethological one.  This assumes that in humans as well as in 
other species  
-82-  
parenting behaviour, like attachment behavi our, is in some degree preprogrammed and 
therefore ready to develop along certain lines when  conditions elicit it. This means that in the

ordinary course of events the parent of a baby experiences a strong urge to behave in certain 
typical sorts of way, for example, to cradle the infant, to soothe him when he cries, to keep 
him warm, protected, and fed. Such a view point, of course, does not imply that the 
appropriate behaviour patterns ma nifest themselves complete in every detail from the first. 
Clearly that is not so, neither in man nor in any other mammalian species. All the detail is 
learned, some of it during interaction with ba bies and children, much of it through observation 
of how other parents behave, starting during th e parent-to-be's own childhood and the way his 
parents treated him and his siblings.  
Research findings  
In considering what is now known of the indi viduals involved in family violence, and the 
circumstances in which it takes place, I start with women who physically assault their children 
and, next, with the effects on the children of su ch assaults. My reason for doing so is that in 
these two areas the research findings seem most adequate. And in the li ght of those findings 
we can proceed to consider what is known about  men who batter wives or children, a problem 
area just as important but at present less well researched.  
The findings of the many studies of women know n to have battered their children show 
considerable agreement (see review by Spinetta and Rigler 1972). Though probably 
commoner among families of lower socio-economic status, child abuse occurs also in middle-
class families where it is likely to be hidden behind a façade of ultra-respectability.  
On the surface abusing individuals vary from be ing cold, rigid, obsessi onal, and censorious to 
being passive, unhappy, and disorganized. Ye t emotionally they have much in common. 
Among features reported as especially fr equent among abusive mothers we find the 
following: prone to periods of intense anxiety punctuated by out bursts of violent anger, they 
are said  
-83-  
to be impulsive and 'immat ure'. Although their 'dependenc y needs' are described as 
exceptionally strong, they are extremely distrust ful and consequently unable or unwilling to 
make close relationships. Socially they are is olated. Having no one else to turn to, many of 
them seek care and comfort from one of their own children whom they treat as though they were much older than they are ( Morris and Gould 1963).  
As regards childhood experience many researchers ha ve noted that most of such women have 
had a miserable childhood and, as one pair of re searchers put it, 'have been deprived of basic 
mothering' ( Steele and Pollock 1968). An appr eciable minority were themselves battered as 
children. 
*  
To anyone thinking in terms of attachment theory  the notion at once suggests itself that these 
woman are suffering from an extreme degree of  anxious attachment and consequently that 
experiences of long or repeated  separations and/or of being repeatedly threatened with 
abandonment would be a common feature of their childhoods. In a relatively small study these 
hypotheses have now been tested by Pauline De Lozier ( 1982), working in Los Angeles. Her 
samples consisted of eighteen  working-class women known to have assaulted their children 
physically and eighteen others from the same  socio-economic class, and matched for age 
(most in their thirties) and number of children, who had not done so. All subjects were given a

semistructured interview and a questionnaire to  complete and were tested on the Hansburg 
Separation Anxiety Test (Hansburg 1972). In the la tter a series of pictures depicting scenes 
either of a child leaving his pa rents or of parents leaving the child is shown and the subject 
invited to describe what she would feel  and do in the situation concerned.  
*  In a study by Baldwin ( 1977) of thirty-eight  children who had been physically abused to 
an exceptionally severe degree, two-fifths of  the parents had suffered physical abuse as 
children and more than half severe or prol onged mental abuse. Baldwin calls attention to
the marked tendency of many of these pa rents, when interviewed, to make broa d
generalizations about their childhood in which an  idealized picture is presented, a picture
that stands in stark contrast to the grim episodes described when detailed questions are
asked. In this field inexperi enced clinicians and interviewers are likely to be gravely
misled.  
-84-  
The results of the Separation A nxiety Test showed, as expected, that most of the abusing 
mothers were extremely sensitive to any type of  separation situation, even the most everyday 
and commonplace, with responses indicative of high levels of anxiety and/or anger. The 
responses showed, in addition, that, while thes e women yearned for care, all they expected 
was rejection. Supporting another of the initial hypotheses was a high incidence of responses 
indicating anxious concern for the welfare of parents. For all these features the incidences in 
the control group, although not negligible, were  significantly lower. For example, whereas 
twelve of the eighteen abusing mothers were ra ted as showing the highest degree of anxious 
attachment, only two of the control group were so rated.  
As regards the childhood experiences of these wo men, the results, as reported in interview 
and qiestionnaire, supported some of the in itial hypotheses but did not  support others. For 
example, in view of previous reports DeLozi er had expected to fi nd a significantly higher 
incidence of separations from parents in the childhoods of the abusive mothers but this was 
not found. By contrast, her expe ctation that a high proporti on of these women would have 
experienced their parents as having repeatedly  threatened to abandon them was fulfilled, a 
finding in keeping with the view that repeated threats to abandon are as pathogenic as actual 
separations and probably more so (Bowlby 1973). In a similiar way, a lthough actual violence 
from a parent had apparently not been comm on, many of the abusing mothers had suffered 
repeated threats of being beat en, maimed, or even killed.  
Another striking feature of the childhoods of th e abusing mothers, also in keeping with 
expectations, was that only a minority of them (s even) had felt they could turn to mother for 
help when in distress. Amongst those who coul d not were some who de scribed someone else, 
a relative or neighbour, who woul d have been helpful; but four of the eighteen had known of 
absolutely no one. Amongst the controls, by contra st, all but three had felt they could turn to 
mother, and each of the others ha d at least known of someone else.  
Thus, unlike a girl who grows up in an ordi nary reasonably happy home who can rely on her 
mother in an emergency, a  
-85-

majority of these women could never do so. Inde ed, and again as predicted, for many of them 
the relationship of daughter to  mother had been reversed and it was they who had been 
expected to care for the parent. *  
Given the childhood experiences these women had had, it is not difficult to understand why 
they had grown up as they had. Threats to abandon a child make her (or him) intensely 
anxious about any separation, however routine it  might appear to others, and also intensely 
angry with her parent for threatening her so. Moreover failures to respond helpfully when a 
child is in distress, combined with repeated an d impatient rejections, lead her to be deeply 
suspicious of everyone else. Thus, whilst consta ntly yearning for the love and care she has 
never had, she has no confidence she will ever receive it; and she will mistrust any offer she 
may receive. Small wonder therefore, if wh en a woman with this background becomes a 
mother, that there are times when, instead of being ready to mother her child, she looks to her 
child to mother her. Small wonder too if when  her child fails to oblige and starts crying, 
demanding care and attention, that sh e gets impatient and angry with it.  
It is against this background, I believe, that a mother's violent assaults on a child can be 
understood. Although I have never treated a woman who actually assaulted her child 
physically, I have treated one who came  perilously close to doing so.  
The reason I began seeing this woman, whom I will call Mrs Q, was that the doctor at the 
well-baby clinic she attended was concerned ab out her son, aged 18 months; he was refusing 
to eat and was losing weight. When I saw them both, it was at once apparent that Mrs Q was 
intensely anxious and depressed and had been so since the boy's birth. On enquiry I found that 
she was terrified lest her son di e and was therefore pestering him to eat. She also told me that 
she had sometimes had impulses to throw the baby out of the window. Only much later did 
she tell me that on occasion she became hyst erical, smashed the dishes, and battered the 
baby's pram. She was intensely anxious talking  
*  DeLozier's study has now been repeated by Mitchell (in preparation) on samples o f
Mexican-American mothers with closely similar results.  
-86-  
to me and fully expected me to turn on her angr ily. On my suggestion she came to see me for 
psychotherapy once a week.  
The picture she gave me of her childhood, to ld reluctantly in fragments but always 
consistently, was one I now know to be typica l. She recalled bitter quarrels between her 
parents in which they assaulted one another and threatened murder, and how her mother 
would repeatedly bring pressure on the family by  threatening to desert. On two occasions Mrs 
Q had returned from school to find her mother with her head in the gas oven, and at other 
times her mother would pretend to have desert ed by disappearing for half a day. Naturally 
Mrs Q grew up terrified that if she did anythi ng wrong her mother would go. Moreover things 
were made even worse by her mother insistin g that she breathe not a word about these 
terrifying events to anyone outside the home.  
Mrs Q, who had been a skilled technician be fore marriage, was known as a very helpful 
neighbour and did all she could to be a good wife and mother -- in which for the most part she

succeeded. Yet she was subject to these violen t and destructive outbursts which frightened 
and puzzled her and about which she felt intense shame.  
After some time I had little doubt that the an gry outbursts were to be understood as the 
expression of intense anger which, generate d initially and over many years by her mother's 
repeated threats to abandon the family, had early in her life become directed away from her 
mother and towards less dangerous targets. Te rrified then and later of ever expressing her 
anger directly, she redirected * it towards something which, or someone who, could not 
retaliate. As a child, Mrs Q recalled, she had so metimes retreated to her room and attacked her 
dolls. Now it was her crockery, the pram, and al most but not quite the baby. Each current 
outburst, I suspected, was triggered by her mother  who, dominating and interfering as ever, 
still visited her daughter every day.  
*  Because it is less ambiguous, I find the ethol ogist's term 'redirection' preferable to its
clinical equivalent 'displacement'. The redi rection of hostile behaviour away from a more
dominant animal is well known in other species.  
-87-  
This explanation fits what facts we have and has the merit, not always appreciated in clinical 
circles, of being simple. Not su rprisingly, other workers in the field have also proposed it (e.g. 
Feinstein, Paul, and Pettison 1964). In other cases,  it is clear, a husband  has violently abused 
his wife and she, violently angry in return , has redirected it against their child.  
In turning next to the effects on the personalit y development of children who are assaulted, 
we have to bear in mind that the physical assa ults are not the only epis odes of hostility from 
parents that these children have experienced. In  very many cases indeed the physical assaults 
are but the tip of an iceberg -the manifest signs  of what have been repeated episodes of angry 
rejection, verbal as well as physical. In most cases therefore the psychological effects can be 
regarded as the outcome of prolonged hostil e rejection and neglect. Nevertheless the 
experiences of individual children can vary greatly. A few, for example, may receive 
reasonably good care and only very occasionally su ffer an outburst of parental violence. For 
these reasons it is no surprise that the socio- emotional development of the children varies 
also. Here I describe findings that appear to be fairly typical.  
Those who have observed such children in thei r homes or elsewhere describe them variously 
as depressed, passive, and inhibited, as 'd ependent' and anxious, an d also as angry and 
aggressive ( Martin and Rode heffer 1980). Gaensbauer and Sands ( 1979), in endorsing this 
picture, emphasize how disturbing to a caregive r such behaviour can be. The children fail to 
participate in play and show l ittle or no enjoyment. Expression of feeling is often so low key 
that it is easy to overlook, or else is am biguous and contrary. Cryi ng may be prolonged and 
unresponsive to comforting; anger is easily arou sed, intense, and not readily resolved. Once 
established, these patterns tend to persist.  
An issue much discussed in the literature is the degree to which an infant's prematurity, ill-
health, or difficult temperament may have c ontributed to a mother's problems and so 
ultimately to its having been ill-treated. In some  cases these factors play a part, but they do so 
only when a mother reacts

-88-  
unfavourably to the baby and thereby sets up a vicious circle. * Such a sequence, of course, is 
all too likely to occur when a mother has herself had a difficult childhood, has grown up 
emotionally disturbed, and has little or no em otional support or help after her baby is born.  
Towards his or her parent an abused toddle r often shows a striking picture of frozen 
watchfulness, hyper-alert for what  might happen. But some show  also an unusual sensitivity 
to the needs of their parents ( Malone 1966). Th ere are, in fact, good reasons for thinking that 
some children learn early that it is possible to placate a disturbed and potentially violent 
mother by constant attention to her wishes. **  
In a nursery setting battered infants and toddle rs have a reputation fo r finding it difficult to 
make relationships, either with caregivers or with other chil dren, and also for being very 
aggressive. In recent years these observations  have been confirmed and extended by more 
systematic research which has focused attenti on both on the particular patterns of behaviour 
shown and on details of the situations in whic h each occurs. The findings that follow stem 
from a study being conducted at Berkeley by Main and George ( George and Main 1979; 
Main and George 1985).  
Their aim was to compare the behaviour in a da y-nursery setting of two groups of children in 
the age-range 1 to 3 years. One group of ten were  known to have been physically assaulted by 
a parent. The other group of ten were matched for all relevant variab les but had not been 
assaulted; they were, however, in nurseries set up to care for children from families known to 
be under stress. To obtain data each child was obse rved for four periods each of thirty minutes 
on four different days  
*  There is now good evidence that, given sens itive mothering, diffi cult infants develop
favourably, with only few exceptions ( Same roff and Chandler 1975) and, conversely, tha t 
a potentially easy baby is likely to develop unfavourably if given insensitive care ( Sroufe
1983).  
**  I am indebted for this point to Pat Crit tenden (personal communication) who has observe d
such apparently placatory behaviour in young abused children, some less than two years
old. Similar behaviour has been observed also in young children whose mothers are
seriously depressed ( Pound, 1982).  
-89-  
spread over three weeks. Observers were instruct ed to record all socially relevant behaviour, 
including such small movements as head-turning or stepping backwards.  
In analysing the data, the children's social behaviour was divided into four categories: 
approach, avoidance, approachavoid, and aggres sion. It was also divided according to whom 
the behaviour was directed -- another child or  a caregiver. Another distinction was between 
behaviour initiated by the observed child and behaviour which occurred in response to a 
friendly approach by another child or adult. Results are expressed in terms of the mean 
number of incidents of a particular type of beha viour of the children in each group or else of 
the number of children in each group who showed that type of behaviour.

As regards occasions when a child initiated soci al contact, either with another child or a 
caregiver, no appreciable differences were obse rved between the children in each group. By 
contrast, very striking differenc es were observed in the ways the children responded to a 
friendly approach from the other.  Characteristic respons es of the abused children were either 
to take straight avoiding action or else to s how both approach and a voidance behaviour, either 
in quick succession or in some combination of th e two. Examples are: 'she creeps towards him 
but suddenly veers away', and 'she crawls toward s the caregiver but with  head averted'. Thus, 
when the overtures come from a caregiver, the abused toddlers were three times more likely 
than the controls to take avoiding action; whilst  seven of them, compared to only one, showed 
the curious combination of alternation of appr oach and avoidance. When the overtures came 
from other children, the differences were even  more marked. For example, whereas none of 
the controls showed approach-avoidance, all ten of the abused toddlers did so.  
Aggressive behaviour was fairly  common in both groups of toddl ers, though, as predicted, it 
was significantly more so in the abused group.  Not only did the abused toddlers assault other 
children twice as often as the controls, but five of them assaulted or threatened to assault an 
adult, behaviour seen in none of  the controls. In addition the a bused toddlers were notable for 
a particularly disagreeable t ype of aggression, termed  
-90-  'harassment' ( Manning, Heron,  and Marshall 1978). This cons ists of malicious behaviour 
which appears to have the sole intent of maki ng the victim show dist ress. Almost always it 
occurs suddenly without any evident cause and so contrasts with hosti lity which occurs in 
reaction to a provocation. Such attacks, coming unpredictably out of the blue, are frightening 
and invite retaliation. Clinical st udies, referred to later, report them to be directed especially 
towards an adult to whom the child is becoming attached.  
In view of the behaviour so far described it is not surprising to find that abused toddlers are 
singularly unsympathetic to age-mates in distress. The studies of Zahn-Waxler and 
RadkeYarrow have shown that infants and pre- school children who ha ve affectionate and 
caring parents commonly express concern when another child is distressed and often make 
moves to comfort him or her ( Zahn-Waxler,  Radke-Yarrow, and Ki ng 1979). This type of 
behaviour was also seen at least once in five of the control children in the Main and George 
study; but on no occasion did any of  the abused toddlers show the slightest hint of it. Instead, 
and unlike the controls, they reacted with some combination of fear, di stress, or anger; and 
three behaved hostilely to the crying child. Fo r example, one small boy of 2 years 8 months 
slapped a little girl w ho was crying, exclaiming repeatedly 'Cut it out, cut it out'. He 
proceeded then to pat her back and next to hiss  at her with bared teeth; before anyone could 
intervene, his patting had turned to beating.  
My reasons for giving so much attention to th ese observations of young children will, I am 
sure, be apparent. They show with unmistakable cl arity how early in life certain characteristic 
patterns of social be haviour -- some hopeful for the fu ture, others ominous -- become 
established. They leave no doubts either about what types of family  experience influence 
development in one direction or another. Again and again we see details in the behaviour of a 
toddler, or in what he says, that  are plainly straight replicas of how that toddler has himself 
been treated. Indeed the tendency to treat others  in the same way that we ourselves have been 
treated is deep in human nature; and at no time is it more evident than in the earliest years. All 
parents please note!

-91-  
Firm evidence of how these children deve lop must await an appropriately designed 
longitudinal study. There is evidence that, if  conditions of care improve, some recover 
sufficiently to pass for normal ( Lynch and Roberts. 1982); others  do not. Some have suffered 
serious brain damage and become diagnosed as mentally handicapped (e.g. Martin and 
Rodeheffer 1980). For many others adverse condit ions of care continue. Furthermore, once a 
child has developed the types of disagreeable beha viour described, it is not easy for an adult, 
whether parent, fosterparent, or professional, to give him the continuous affectionate care he 
needs, whilst treating such children by ps ychotherapy is extremely taxing. The sudden 
unprovoked attacks, which in older children can ea sily be damaging, are especially hard to 
take.  
Some of these emotionally disturbed children, we know, reach psychiat ric clinics where the 
origin of their condition, I suspect, more often than not goes unrecognized. Amongst those 
who have treated these children, some of them psychotic, and who have traced the source of 
their troubles are Stroh ( 1974), Bloch ( 1978), and Hopkins ( 1984). Each notes the extreme 
degree of ambivalence to be expected: one moment  the child is hugging the therapist, the next 
he is kicking her. During a dolescence and early a dult life, some, mostly male, become 
diagnosed as aggressive psyc hopaths and/or violent delin quents (e.g. Farrington 1978). 
Others, especially females perhaps, are found to be suffering from multiple personality ( Bliss 
1980). Once psychiatrists become aware of the profound and farreaching effects of childhood 
abuse and rejection, and the extent to which re levant information is suppressed and falsified 
by parents and overlooked by clin icians, many more cases are sure to be identified.  
A significant proportion of reject ed and abused children grow up to perpetuate the cycle of 
family violence by continuing to respond in social  situations with the very same patterns of 
behaviour that they had deve loped during early childhood.  
A type of response found to be characteristic of many abusive parents, and of a kind which we 
have already seen to be charact eristic of abused toddlers, is reported, for example, by Frodi 
and Lamb ( 1980). In a laboratory study, in which videotapes of  
-92-  crying infants were shown, abusive mothers were  found to respond to a crying infant with less 
sympathy than did a group of non-abusive mother s and also with more annoyance and anger. 
Furthermore these same adverse responses we re shown by the abusive mothers even when 
they were shown video tapes of smiling infants,  which suggested they disliked any form of 
interaction with an infant.  
Let us turn now, rather belatedly, to the beha viour of men who ill-treat girl-friend or wife.  
Two of my social work colleagues at the Tavist ock, Janet Mattinson and Ian Sinclair ( 1979), 
describe a man, Mr S, who was apt, inexplicably  and unpredictably, to a ttack his wife. At the 
time when he asked for an interview his wife had recently left him; she had just had their first 
baby. Although hesitant at first, Mr S fairly so on began telling the social worker how much he 
feared his own violence. He love d his wife, he said, and felt hi s violent behaviour to be quite 
unwarranted, akin to madness. Subsequently, sp eaking of his childhood, he described how he 
had been a member of a large working-class fami ly in which he had received little more than

harsh and unsympathetic treatment. His parents, he said, were constantly engaged in violent 
quarrels. Exploring in later interv iews how he had felt as a chil d, struggling for the love he 
never got, he was struck by the suggestion that it was probably a mixture of anger and despair. 
This made sense to him, he said: it relieved hi m of his fear that his vi olence was inexplicable. 
The outbreaks that had led to his wife's departure, it was noted,  had occurred soon after the 
baby's birth. Since we know fr om other studies, e.g. Marsden and Owens ( 1975), that intense 
jealousy of a wife's attention to the children is a common precipitant of a husband's violence, 
Mr S's outbursts were in all likelihood triggered by the baby's arrival.  
Sudden and on the surface inexplicable outbursts of violence, similar to those of Mr S, are 
found to be characteristic of a significant propo rtion of men who batter wives; for example, 
they occurred in five out of the nineteen ca ses investigated by Marsden and Owens ( 1975). 
The hypothesis that most of such  
-93-  
men are ill-treated and battered children now grown up is supported by several findings. In 
one study ( Gayford 1975) information from th e wives was that fift y-one out of a hundred 
violent men had themselves been battered as  children. Moreover thirtythree of the hundred 
had already been convicted of ot her violent offences and, as al ready noted, studies show that 
most violent offenders come from homes in wh ich they were subjected to cruel and brutal 
treatment ( Farrington 1978).  
Finally we find that many of the wives who ar e battered have come from disturbed and 
rejecting homes, in which a significant minor ity were themselves battered as children ( 
Gayford 1975). These experiences had led them to leave home in their teens, to link up with 
almost the first man they met, all too often fr om a similar background, and quickly to become 
pregnant. For the unprepared and anxiously attach ed girl, having to care for a baby creates a 
thousand problems; moreover her attention to  the baby provokes intense jealousy in her 
partner. These are some of the processes by wh ich an inter-generation al cycle of violence 
becomes perpetuated.  
Let us return now to the study of Mattinson and Sinclair ( 1979) who describe patterns of 
interaction that they found were common in certain families.  
The interviews with Mr S were part of a study u ndertaken in order to find out more of what is 
happening in the kind of intens ely disturbed family that creates endless problems for the 
medical and social services and which is known to be extraordinarily difficult to help. In these 
families, it seemed, violence or threats of viol ence occurred almost daily. Time and again the 
couple had separated only to come together again after a few days or weeks. Sometimes, after 
hard words from his wife, a hus band would go off on his own, only to hive back again a short 
time later. Or a wife, physical ly assaulted by her husband, woul d leave with the children but 
return within days to the very same situation.  What seemed so extraordinary to the workers 
was the length of time some of these marri ages had lasted. One question they asked 
themselves therefore was what was keeping the partners together.  
What they found was that, whilst the violence of a husband and the angry threatening remarks 
of a wife seemed to dominate  
-94-

the scene, each partner was deeply, if anxiously , attached to the other and had developed a 
strategy designed to control the other and to  keep him or her from departing. Various 
techniques were in use, mainly coercive, and many of them of a kind that to an outsider would 
appear not only extreme but count erproductive. For example, thre ats to desert or to commit 
suicide were common, and suicid al gestures not infrequent. These were usually effective in 
the short term by ensuring the pa rtner's concerned attention, t hough they also aroused his or 
her guilt and anger. Most of the suicide attemp ts, it was found, were reactions to specific 
events, particularly desertions either actual or threatened.  
A coercive technique, used especially by the men,  was to 'imprison' the wife by such means as 
locking her in the house, or padlocking her clothe s, or else retaining all the money and doing 
the shopping so as to prevent her from s eeing anyone else. The intensely ambivalent 
attachment of one man who adopted this technique  was such that he not only locked his wife 
in but he also locked her out. He would throw her out of the house telling her never to return 
but, after she had got to the street, would run after her and pull her back to their flat.  
A third coercive technique was battering. As  one man put it, in his family asking for 
something was always done with fists. No wife  enjoyed this treatment, but some got a wry 
satisfaction from it. For example, one woman,  when explaining why she did not wish for a 
separation, announced with a note of triumph in  her voice that her husband had threatened he 
would come to 'get her' if she moved out. He needed her too, she insisted. In most of these 
marriages, it was found, each party was apt to stress how much the other needed them, whilst 
disclaiming their own need for the partner. By need, of course, they meant what I am calling 
their desire for a caregiving figure. What  they dreaded most was loneliness.  
Preventive measures  
This ends my description of the problems me t with in violent families and the theoretical 
perspective in which I believe it useful to appr oach them. What actions then are called for?  
-95-  Much skilled and devoted work has gone into helping families in wh ich abuse has already 
occurred, and much thought given to problems of management ( Helfer and Kempe, 1976; 
Lynch and Roberts 1982). Since every study has shown how very difficult and time-
consuming all such work is, we ask about prosp ects for prevention. Here lies hope. In what 
follows I describe a type of service which has been pioneered in the United Kingdom and 
which is now spreading steadily with encouragement from government. No doubt similar 
services are to be found in va rious parts of the United States  also, but naturally I know less 
about them.  
The service pattern which is so promising, at least for some families, is one known as Home-
Start (which was begun in Leicester) ( Harrison 1981). 
* It is an independently organized 
home-visiting scheme which offers support, friendship, and practical assistance to young 
families experiencing difficulties. It is staffe d by volunteers who work in close liaison with 
the related statutory services and who also re ceive support and guidanc e from a professional. 
All visits are by invitation of the family and on their terms. There are no contracts and no time 
limits.

Each volunteer is a mother who undertakes to ma ke regular visits to one or, at most, two 
families with the aim of esta blishing a relationship in which time and understanding can be 
shared. Every effort is made to encourage the parents' strengths and to reassure them that 
difficulties in caring for children are not unusual, and also that it is possible for family life to 
be enjoyable. New volunteers, who are mainly  between the ages of 30 and 45, attend a 
preparatory course, one day a week for ten weeks, and receive regular ongoing training 
afterwards.  
There are many advantages in the visitors bei ng volunteers. First a volunteer has time: in 
practice it was found in the pioneer scheme th at the average time each volunteer was spending 
with her family in its own home was six hour s a week. Secondly she meets the mother on a 
level of equality and feels free  to contribute to household ac tivities in any way that seems 
appropriate. Thirdly  
*  Another initiative, serving a severely depr ived area in inner London and known as Newpin, 
is also promising (Pound and Mills 1985).  
-96-  
she can compare notes and talk about experience s with her own children. Fourthly, and very 
important, she can sometimes make herself availabl e to be contacted during an evening or at a 
weekend.  
The families visited are, of course, ones in wh ich difficulties are either already present or 
appear imminent. Since the service is not aime d specifically at abusing families, a family 
participating need not feel labelled in any wa y. Nevertheless the serv ice deals with a fair 
number of families who have one or more children on a register of children at risk of abuse. In 
the first eight years of the pioneer scheme no less  than a quarter of the families visited were in 
that category.  
Often visiting is started whilst a mother is still pregnant. Most of those visited are young, 
impulsive, and dreadfully isolated and have never experienced affection, care, or security. In 
such cases the principal role of the volunteer is to mother the mother and so, by example, to 
encourage her to mother her own child. She will also talk and play with the children, again 
providing the mother with an example she has ne ver had. Perhaps later,  once confidence has 
grown, the volunteer may assist by helping the mother acquire basic household skills she has 
never learned. The key to the relationship is that the volunteer is herself a mother who knows 
all the problems from the inside.  
There are many cases which are recognized to be unsuited for inclusion in a service of this 
sort. * For those suitable the degree of success repo rted is most encouraging, as shown by an 
evaluation of the first four years' work of the pioneer service, carried out by an independent 
researcher whose monograph ( van der Eyke n 1982) gives a full account of the project. 
Taking a random sample of one in five of the 288 families visited, he  asked those concerned 
how they assessed the outcome at the end of th e volunteer's visiting, using a three-point scale: 
no change, some change, considerable change. Th e results showed that the volunteers were 
the most pessimistic, rating only half the families  
____________________

*  Harrison ( 1981) lists the following: where a pa rent is known to be chronically ill mentally,
is suffering from a serious degene rative illness, is a recidivist , or is intent on the children
being admitted to care. Also excluded are families  in which the children are at risk of abuse 
by a mother's cohabitee.  
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as showing considerable change and one in ten as failures. The social workers who had 
referred cases were more hopeful,  rating rather more than half as showing considerable 
change and the remainder as showing at least some. Those most enthusiastic for the work 
were the health visitors (public health nurses) and the families themselves. Of the fifty-eight 
families who assessed themselv es, forty-seven (85 per cent) cl aimed a considerable change 
had occurred, six claimed some change a nd only two believed there had been none.  
In a field that is both deeply troubling and not oriously difficult these findings give hope.  
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LECTURE 6  
On knowing what you are no t supposed to know and feeling what you are not 
supposed to feel  
Early in  1979I was invited to contribute to a special number of the  Canadian Journal of 
Psychiatryto honour  Emeritus Professor  Eric Wittkowerwho had held a chair of psychiatry at  
McGill University  in Montrealfrom  1952to  1964and was then celebrating his eightieth 
birthday. This I was very glad to do. The resulting paper, with the above title, also formed the 
basis of lectures that I gave on various occa sions during subsequent years. On one such 
occasion, in  Rome , I met with two cognitive therapists,  Giovanni Liottiand  Vittorio Guidano , 
and was surprised and delighted to find how much we had in common. One consequence of 
our meeting was an invitation to contribute to a volume on  Cognition and Psychotherapy  
being edited by Michael Mahoney and Arthur Freeman. This provided an opportunity to 
expand the original brief paper and led to the version that follows.   
The evidence that adverse experi ences with parents during childhood, such as those described 
in the previous lecture, play a large part in causing cognitive disturbance is now substantial. 
For example, at least some cases in which perc eptions and attributions are distorted and some 
states of amnesia, both minor and major, incl uding cases of multiple personality, can be 
shown with considerable confidence to be the outcome of such experiences. Yet systematic 
research into these causal sequences is still scarce, and it is clearly a field calling urgently for a major research effort. Why then has it been so woefully neglected?  
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One adverse influence, referred to  in the preceding lecture, is the strong tradition within the 
psychoanalytic school of thought of focusing attention on fantasy and away from the real-life 
experiences a person may have had during childhood. Another is  the undoubted difficulty of 
doing systematic research in the field. For example, those engaged in seeing only adult 
patients are usually ill-placed to investigat e events alleged to have occurred many years 
earlier. Those whose childhoods have been spent amongst reasonably stable families and who,

like all too many psychiatrists and psychothera pists, are ignorant of the recent family and 
child development literature have no norms agai nst which to match their patients' stories. 
Above all clinicians are often faced with a blan ket of silence, from patie nt and family alike, 
which neither their training nor their experience has qualified them to penetrate. It is little 
wonder therefore that the likelihood that many cases of psychiatric disorder, both mild and 
grave, have had their origins in adverse even ts of childhood has been discounted or else 
completely ignored -- not only by general psychi atrists but by psychotherapists as well. Even 
the fact that some children are physically or sexually assaulted by their own parents, often 
repeatedly and over long periods, has been mi ssing from discussions of causal factors in 
psychiatry.  
At long last the scene is changing. First, knowle dge of parent-child interactions in general, 
including a wide range of potent ially pathogenic relationships and events, is increasing in 
both quality and quantity as syst ematic research is applied.  Secondly the psychological 
consequences for the children exposed to thes e relationships and events are becoming much 
better understood and documented. As a result there are now many occasions when a clinician 
is on reasonably firm ground in drawing aetiologi cal conclusions. This is  so especially when 
(a) his patient presents problems and symptoms  which resemble the known consequences of 
certain types of experience and (b) when in the course of skilled history-taking, or perhaps 
much later during therapy, he is told of expe riences of these same types. In reaching his 
conclusion the reasoning a psychiatrist uses diffe rs in no way from that of a physician who, 
having diagnosed a patient as su ffering from mitral stenosis, proceeds unhesitatingly to  
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attribute the condition to an attack of rheu matic fever suffered by the patient many years 
earlier.  
When considering childhood antecedents of cogn itive disorders a good place to start is with 
amnesia.  
In one of his classical papers on analytic  technique Freud ( 1914) made an important 
generalization the truth of which probabl y every psychotherapist would endorse:  
Forgetting impressions, scenes or experiences ne arly always reduces itself to shutting them 
off. When the patient talks about these 'forgotten ' things he seldom fails to add: 'As a matter 
of fact I've always known it; only I've never thought of it.'( 1914, 148)  
Such observations call for explanations of at leas t three kinds. First, are there special features 
that characterize the impressions, scenes, and experiences that tend to become shut off? 
Secondly, how do we best conceive of the proc esses by which memories become shut off and 
apparently forgotten? Thirdly, what are the ca usal conditions, internal and external to the 
personality, that activate the shutting-off process?  
The scenes and experiences that tend to be come shut off, though often continuing to be 
extremely influential in affect ing thought, feeling, and behavi our, fall into at least three 
distinct categories: (a) those that parents wish  their children not to know about; (b) those in 
which parents have treated chil dren in ways the children find too unbearable to think about; 
(c) those in which children have done, or pe rhaps thought, things about which they feel 
unbearably guilty or ashamed.

Since a great deal of attention has for long been  given to the third category, here I discuss 
only the first two. We start with the first.  
Children not infrequently observe scenes that pa rents would prefer they did not observe; they 
form impressions that parents would prefer they  did not form; and they have experiences that 
parents would like to believe they have not ha d. Evidence shows that many of these children, 
aware of how their parents feel, proceed then to  conform to their parents' wishes by excluding 
from further processing such information as they already  
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have; and that, having done so, they cease cons ciously to be aware that they have ever 
observed such scenes, formed such impressions, or had such experiences. Here, I believe, is a 
source of cognitive disturbance as  common as it is neglected.  
Yet evidence that parents sometimes press their children to shut off fr om further, conscious 
processing information the children already have  about events that the parents wish they had 
never observed comes from several sources. Perhap s the most vivid concerns the efforts made 
by a surviving parent to obliterate his or her chil d's knowledge of the (othe r) parent's suicide.  
Cain and Fast ( 1972) report findi ngs from their study of a series  of fourteen children, aged 
between 4 and 14, all of whom had lost a pare nt by suicide and all of whom had become 
psychiatrically disturbed, many of  them severely so. In reviewing their data the authors were 
struck by the very large roles played in the children's symptomatology by their having been 
exposed to pathogenic situations of two types, namely situati ons in which intense guilt is 
likely to be engendered (not discussed here) an d situations in which communications between 
parent and child are gravely distorted.  
About one quarter of the children studied had pe rsonally witnessed some as pect of the parent's 
death and had subsequently been subjected to pr essure from the surviving parent to believe 
that they were mistaken in what they had seen or heard, and that the death had not been due to 
suicide but to some illness or accident. 'A boy who watched his father kill himself with a 
shotgun . . . was told later that night by his mother  that his father died of a heart attack; a girl 
who discovered her father's body ha nging in a closet was told he had died in a car accident; 
and two brothers who had found their mother with  her wrists slit were told she had drowned 
while swimming' ( Cain and Fast 1972, 102). Wh en a child described what he had seen, the 
surviving parent had sought to discredit it eith er by ridicule or by insisting that he was 
confused by what he had seen on television or  by some bad dream he had had. Such confusion 
was sometimes compounded, moreover, by the ch ild hearing several different stories about 
the death from different people or even from his surviving parent.  
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Many of the children's psychological problems s eemed directly traceable to their having been 
exposed to situations of these kinds. Their probl ems included chronic distrust of other people, 
inhibition of their curiosity, distrust of thei r own senses, and a tendency to find everything 
unreal.  
Rosen ( 1955) describes an adult patient, a ma n of 27, who developed acute symptoms after 
his fiancée had jilted him, because she ha d found him too moody and unpredictable. The

patient began to feel that the world about him and also his own being were fragmenting, and 
that everything was unreal. He became depresse d and suicidal; and he experienced a variety 
of peculiar bodily sensations, which included a feeling that he was c hoking. His thoughts, he 
said, felt like cotton-wool . Sometime during the second year of therapy the analyst, struck by 
a series of associations the patient gave, and bearing in mind the life history, ventured a 
reconstruction, namely that the patient's mother  may have made a suicidal attempt during the 
patient's childhood that he (the patient) had wi tnessed. No sooner had this suggestion been 
offered than the patient became racked with co nvulsive sobbing. The session proved a turning 
point. Subsequently the patient described how it  had seemed to him that, when the analyst 
made his suggestion, it was not so much that he was restoring a memory as giving him (the 
patient) permission to talk about somethi ng he had always in some way known about.  
The authenticity of the memory was vouched for by the patient's father  who admitted, when 
pressed, that the patient's mother had made several suicide attempts during the patient's 
childhood. The one the patient had witnessed oc curred some time during his third year. His 
nurse had heard sounds in the bathroom and had arrived in time to prevent his mother from 
strangling herself. It was not clear just how mu ch the little boy had seen. But whenever later 
he had mentioned the event both father and nur se had disconfirmed his memories by alleging 
that it was something he must have imagined or  had simply been a bad dream. The father now 
claimed that he had felt it woul d have been harmful to his son to have remembered such an 
incident; but he also admitted that his attitude was dictated partly by his wish that the incident 
be kept secret from friends  
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and neighbours. A year or so later the nurse had been discharged be cause the mother had 
found her presence too painful a reminder of the incident.  
During one of the sessions befo re the vital reconstruction was offered the patient had recalled 
the discharge of his beloved nurse as an event wh ich he had always felt had been in some way 
his fault. Among many associations to it were  recurrent references to his having been, as a 
child, witness to something that had changed hi s life, though he did not know what. He also 
had the notion that his nurse had been the one  witness on his behalf. Thus, although the 
memory had been shut away from conscious pro cessing, it continued to  influence both what 
he thought and how he felt.  
Elsewhere ( Bowlby 1973) I have drawn attenti on to the far from negligible incidence of 
suicidal attempts made by parents, and perhaps the even higher incidence of their threatening 
suicide, and have remarked how little attention ha s been given to either attempts or threats in 
the psychiatric and psychotherape utic literature. Perhaps there are many more cases similar to 
Rosen's than has yet been realized.  
Among the many other situations that parents may wish a child had not observed, and that 
they may press him to suppose he never did, are those concerning their sexual activities. An 
example of this was told to me by a speech therapist who was trying to help an extremely 
disturbed little girl who hardly spoke at all.  That she was well able to speak was, however, 
shown on certain dramatic occasions. She would si t a teddybear on a chair in a corner, then go 
over and, shaking her finger at him, would scol d him in tones of extreme severity: 'You're 
naughty -- naughty Teddy -- you didn't  see that -- you didn't see that, I tell you!' This she 
repeated again and again with increasing vehe mence. What the scenes were that Teddy was

being instructed he never saw was not difficult to  guess: the little girl's mother was a teenage 
prostitute.  
Clearly the purpose of these pressures by parents is to ensure that their children develop and 
maintain a wholly favourable picture of them. In the examples thus far given the form of 
pressure exerted is crude. More frequent perhap s and just as damaging are instances in which 
the pressures are more subtle.  
-104-  During the past two decades renewed attent ion has been paid to incest, both to its 
unrecognized high incidence and to its pathoge nic effects on children. Much the commonest 
forms are between father and daughter or st ep-father and step-daughter. Among the various 
problems and symptoms in the children and adoles cents concerned that are believed to be due 
to these experiences, the commonest include wit hdrawal from all intimate relationships, sleep 
disturbances, and suicidal intentions ( Me iselman 1978; Adams-Tucker 1982). An account of 
conditions likely to cause c ognitive disturbance was given me by a colleague, Brendan 
MacCarthy, but never published. He suspected th at disturbance is especi ally likely when the 
children are prepubertal. In what fo llows I draw on his conclusions.  
When a sexual liaison develops between a fa ther and his adolescent daughter, MacCarthy 
reports, the liaison is usually ack nowledged by the father during the course of daily life by 
such means as secret glances, secret touching, and innuendoes. In  the case of a younger child, 
however, a father is likely to make no such ac knowledgements. Instead he behaves during the 
day as though the nightly episodes never occurred ; and this total failure to acknowledge them 
is commonly maintained even long after th e daughter has reached adolescence.  
MacCarthy describes the case of a married woma n, Mrs A, whom he treated for depression, 
reliance on tranquillizers, and alcohol. She men tioned the ten years of sexual interference she 
had suffered from her adoptive father only after she had been in therapy for four months. It 
had begun when she was 5 or 6, soon after her adoptive mother had died, and had continued 
until she was 16, when she had fled. Among her many problems were frigidity and finding 
intercourse disgusting, and a se nse of inner blackness, of 'a black stain'. Her problems had 
become exacerbated when her own daughter was 4 years old. Whenever the daughter became 
affectionate to her father and sat near him, Mrs A felt agitated, protective, and jealous; on 
these occasions she could never leave them  alone together. During therapy she was 
obsequious and terrified, and intensely vi gilant of the analyst's every move.  
In regard to the incestuous relationship, Mrs A described how her adopti ve father would never 
at any time during the day  
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allude to his nocturnal visits to her room, which had always remained darkened. On the 
contrary, he had lectured her incessantly on the dangers of allowing boys to go too far, and on 
the importance of chastity before marriage. When  at the age of 16 she had fled the home, he 
not only insisted she tell no one, but added sa rcastically: 'And if you do no one will believe 
you.' This could well have been so since her adoptive father was a headmaster and the local 
mayor.

In commenting on this and similar cases MacC arthy emphasizes the cognitive split between 
the respected and perhaps loved father of daytim e and the very different father of the strange 
events of the night before. Warned on no account to breathe a word to anyone, including her mother, the child looks to her father for some confirmation of those events and is naturally 
bewildered when there is no response. Did it  really happen or did I dream it? Have I two 
fathers? Small wonder if, in later years, all men are distrusted, and the professional stance of a 
male therapist is seen as a mere façade that hides a predatory intent. Small wonder also that 
the injunction on no account to tell anyone remain s operative, and that the expectation that in 
any case no one would believe you ensures silence. How often, we may wonder, do ill-
informed therapists discourage a patient fr om telling the truth and, should she do so 
nonetheless, confirm her expectation th at no one will believe her story?  
In the examples so far described the information a parent is pressing a child to shut away is 
information relating to events in the outside worl d. In other situations the information to be 
shut away relates to events in the child's priv ate world of feeling. Nowhere does this occur 
more commonly than in situations of separation and loss.  
When a parent dies the surviving parent or other relative may not only provide the children 
with inadequate or misleading information but he  or she may also indicate that it would not be 
appropriate for the child even to be distress ed. This may be explicit: A. Miller ( 1979) 
describes how, when a 6-year-old's mother died, his aunt told him: 'You must be brave; don't 
cry; now go to your room and play nicely.' At other times the indicati on is only implicit. Not 
infrequently widows or widowers, afraid to ex press their own distress, in effect encourage 
their  
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children to shut away all the feeling they ar e having about their loss. Palgi ( 1973) describes 
how a small boy whose mother was chiding him fo r not shedding tears over his father's death 
retorted: 'How can I cry when I have never seen your tears?'  
There are in fact many situations in which a chil d is expressly told not to cry. For example, a 
child of 5 whose nanny is leaving is told not to cry because that would make it more difficult 
for nanny. A child whose parents leave him in ho spital or residential nursery insist he should 
not cry, otherwise they will not visit him. A ch ild whose parents are frequently away and who 
leave him with one of a succession of au pair gi rls is not encouraged to recognize how lonely, 
and perhaps angry, he feels at their constant ab sence. When parents separate, it is often made 
plain to a child that he is not expected to miss the departing parent or to pine for the parent's 
return. Not only is sorrow and crying condemned as inappropriate in such situations but older 
children and adults may jeer at a distressed child for being a cry-baby. Is there any wonder 
that in such circumstances fee ling should become shut away?  
All these situations are plain e nough but have, I believe, been seri ously neglected as causes of 
information and feeling becoming excluded from  consciousness. There are, however, other 
situations also, more subtle a nd hidden but no less common, that have the same effect. One 
such is when a mother, who herself had a ch ildhood deprived of love, seeks from her own 
child the love she has hitherto lacked. In doing this she is inverting the normal parent-child 
relationship, requiring the child to act as pa rent whilst she becomes a child. To someone 
unaware of what is going on it may appear that the child is being 'overi ndulged', but a closer 
look shows that mother is placing a heavy burden on him. What is of spec ial relevance here is

that more often than not the child is expected to  be grateful for such care as he receives and 
not to notice the demands being ma de upon him. One result of this is that, in conformity with 
his mother's wishes, he builds up a one-sided picture of her as wholly loving and generous, 
thereby shutting away from cons cious processing much inform ation also reaching him that 
she is often selfish, demanding, and ungrateful. Anot her result is that, also in conformity with 
his mother's wishes, he admits to  
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consciousness only feelings of l ove and gratitude towards her a nd shuts away every feeling of 
anger he may have against her for expecting him to care for her and preventing him from 
making his own friends a nd living his own life.  
A related situation is one in which a parent, ha ving had a traumatic childhood, is apprehensive 
of being reminded of past miseries and so be coming depressed. As a result her children are 
required always to appear happy a nd to avoid any expression of sorrow, loneliness, or anger. 
As one patient put it to me after a good deal of th erapy: 'I see now that I was terribly lonely as 
a child but I was never allowed to know it.'  
Most children are indulgent towards their parents,  preferring to see them in a favourable light 
and eager to overlook many defici encies. Yet they do not willingl y conform to seeing a parent 
only in the light the parent requires or to feeling towards him or her only in the way 
demanded. To ensure that, pressure must be exer ted. Pressure can take different forms but all 
forms depend for their effectiveness on the child' s insistent desire to be loved and protected. 
Alice Miller ( 1979), who has given these problem s much attention, reports the words of an 
adult patient who was born the eldest chil d of an insecure professional woman:  
I was the jewel in my mother's crown. She often said: 'Maja can be relied upon, she will cope.' 
And I did cope. I brought up the smaller children for her so that she could get on with her 
professional career. She becam e more and more famous, but  I never saw her happy. How 
often I longed for her in the evenings. The little  ones cried and I comforted them but I myself 
never cried. Who would have wanted a crying chil d? I could only win my mother's love if I 
was competent, understanding and controlled, if  I never questioned her actions nor showed 
her how much I missed her; that would have limited her freedom which she needed so much. 
That would have turned her against me.  
In other families pressures are less subtle. One form, threatening to abandon a child as a 
means of controlling him, is an extremely powerful weapon, especially with a young child. 
Faced with such threats, how could a child do other than  
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conform to his parents' wishes by excluding from further proces sing all that he knows they 
wish him to forget? Elsewhere I have given reas ons for believing that threats of this sort are 
responsible for much acute and chronic an xiety ( Bowlby 1973) and also for a person 
responding to bereavement in la ter life with chronic depressi on in which the dominant belief 
is one of having been deliberately abandone d, as a punishment, by the dead person ( Bowlby 
1980).

The hypothesis advanced, that various forms of cognitive disturbance seen in children and 
also in later life are to be traced to influences  acting initially during the pre-adolescent years, 
is compatible with indications that during these years children's minds are especially sensitive 
to outside influence. Evidence of this, alre ady emphasized, is the extent to which young 
children are vulnerable to threats by parents to reject or even abandon them. After a child has 
reached adolescence, clearly his vulnerability to such threats diminishes.  
The extent to which the minds of pre-adolescent children are prone to the influence of parents 
is well illustrated by an expe riment of Gill ( 1970). The sample comprised 10-year-old 
children, drawn from a London primary school, and their parents. Of the forty non-immigrant 
families invited to participate, twenty-five agreed. Each family was visited in its own home 
and a series of ten pictures shown on a screen, each for two minutes.  
Of the pictures used, five came from pictur e book or film and the rest from thematic 
apperception tests. Some were emotionally beni gn, for example, a mother watching a small 
girl holding a baby. Some showed scenes of an aggressive and/or frightening sort. Three 
depicted a sexual theme: a woman obviously pr egnant lying on a bed; a couple embracing on 
the grass; and a woman clutching the shoulders of a man who seems to be pulling away, with 
the picture of a semi-nude woman in the background.  
The series of ten pictures was presented thre e times in succession. On the first showing, 
father, mother, and child were asked to write down independently what they saw happening in 
the picture. On the second members of the family  were asked to discuss each picture for the 
two minutes it was shown.  
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During the third showing, each member was as ked again to write down independently what 
they now saw happening.  
When the children's responses to the three pict ures depicting sexual themes were examined, it 
was found that, whereas half  the children (12) described the sexual themes in a fairly direct 
matter-of-fact way, the other half  failed to do so. For example, to the picture of the obviously 
pregnant woman, one child's candid response ra n: 'She's having a rest. I can see that she's 
expecting a baby. She's asleep, I think.' Descri ptions of the same picture by other children 
omitted all reference to pregnancy. 'Somebody is  asleep in bed,' and 'There's a man on a bed. 
He is asleep.'  
A second step was to analyse how the parents di scussed the picture in the child's presence 
during the second showing. This was done by a psychologist blind to th e children's responses. 
Here again it was evident that, whereas some parents were candid about the scene depicted, 
others made no reference to it and/or expresse d disgust. For example, in the case of the 
pregnant woman, the mother of one child rema rked frankly and on three occasions that the 
woman was expecting a baby and was having an afternoon rest. By contrast, the parents of 
another child completed their two-minute discus sion without any such reference. Instead they 
concentrated on emotionally neutral details such as the woman's hairstyle, the material of her 
dressing gown, and the quality of the furnitu re. Not surprisingly there was a high correlation 
between the way the children responded to the pictures and the way the parents had discussed 
them subsequently.

On the third showing the descriptions given by all the children improved in accuracy; but 
those of the twelve who had responded candidly on the first showing improved more than did 
the descriptions given by the thirteen who had fa iled to report the pict ures' content on the first 
occasion.  
There could be little doubt that during their discussion of the pi ctures some of the parents 
were, consciously or unconsciously, avoiding refere nce to the content of the pictures. It was a 
reasonable inference also that their children's fa ilure to describe the sexual theme on the first 
showing was in some way influenced by the 'clim ate' they had experienced in their homes. 
What the  
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experiment could not show, of c ourse, was whether these children  had truly failed to perceive 
the scene depicted or whether they had perceive d it but had failed to report what they saw. 
Since pre-adolescent children tend to be slow and often uncertain in their perceptions, my 
guess would be that at least some of the children in the experiment had truly failed to register 
the nature of what was happening. Others may have known intuitively that the scene was one 
they were not supposed to know a bout and so avoided seeing it.  
At first sight the notion that information of a ce rtain meaning can be shut off, or selectively 
excluded from perception, appears paradoxical.  How, it is asked, can a person selectively 
exclude from processing a particular stimulus un less he first perceives the stimulus which he 
wishes to exclude? This stum bling block disappears, however , once perception is conceived 
as a multistage process as nowadays it is. I ndeed experimental work on human information 
processing undertaken during the pa st decade or so enables us to have a much better idea of 
the nature of the shutting-off processes we ha ve been discussing than was possible when 
Freud and others in the psychodynamic tradition we re first formulating the theories of defence 
that have been so very influential ever since. In  what follows I give a brief sketch of this new 
approach.  
Studies of human perception ( Erdelyi 1974; Norm an 1976) have shown that, before a person 
is aware of seeing something or hearing so mething, the sensory inflow coming through his 
eyes or ears, has already passed through many stages of selection, interpretation, and 
appraisal, during the course of which a large proportion of the origin al inflow has been 
excluded. The reason for this extensive exclusion is that the channels responsible for the most 
advanced processing are of limited capacity an d must therefore be protected from overload. 
To ensure that what is most re levant gets through and that only  the less relevant is excluded, 
selection of inflow is under central, or we might  say ego, control. Although this processing is 
done at extraordinary speeds and almost all of it  outside awareness, much of the inflow has 
nonetheless been carried to a very advanced st age of processing before being excluded. The 
results of experiments on dichotic li stening provide striking examples.  
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In this type of experiment tw o different messages are transmitted simultaneously to a person, 
one message to each ear. The person is then told  to attend to one of these messages only, say 
the one being received by the right ear To ensu re he gives it continuous attention, he is 
required to 'shadow' that message by repeating it word for word as he is hearing it. Keeping 
the two messages distinct is found to be fairly ea sy, and at the end of the session the subject is

usually totally unaware of the content of the unattended message. Yet there are significant 
exceptions. For example, should his own name or  some personally significant word occur in 
the unattended message, he may well notice and remember it. This shows that, even though 
consciously unattended, this message is being subjected to continuous and fairly advanced 
processing during which its meaning is being m onitored and its content appraised as more or 
less relevant; and all this without the person be ing in any way aware of what was going on.  
In the ordinary course of a person's life the cr iteria applied to sensory inflow that determine 
what information is to be accepted and what is  to be excluded are readily intelligible as 
reflecting what is at any one ti me in the person's best intere sts. Thus, when he is hungry, 
sensory inflow concerned with food is given priority, whilst  much else that might at other 
times be of interest to him is  excluded. Yet, should danger thre aten, priorities would quickly 
change so that inflow concerned with issues of danger and safety would take precedence and 
inflow concerned with food be temporarily excluded. This cha nge in the criteria governing 
what inflow is to be accepted and what exclud ed is effected by evaluating systems central to 
the personality.  
In thus summarizing the findings  from a neighbouring discipline the main points I wish to 
emphasize are first that throughout a person's life he is engaged in excluding, or shutting out, 
a large proportion of all the information that is  reaching him; secondly that he does so only 
after its relevance to himself has been assessed;  and thirdly that this  process of selective 
exclusion is usually carried out without his being in any way aware of its happening.  
Admittedly, so far, most of these experiment s have been concerned with the processing of 
current sensory inflow, namely  
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with perception, and not with the utilization of  information already stored in memory, namely 
with recall. Yet it seems likely that the same ge neral principles apply. In each case criteria are 
set by one or more central evaluating systems and it is these criteria that govern what 
information is passed through for further, and conscious, processing and what is excluded. 
Thus, thanks to the work of cognitive psyc hologists, there is no longer any difficulty in 
imagining, and describing in operational terms,  a mental apparatus capable of shutting off 
information of certain specified types and of doi ng so without the person being aware of what 
is happening.  
Let us consider next the second category of scen es and experiences that tend to become shut 
off and forgotten, whilst at the same time continui ng to be more or less influential in affecting 
a person's thoughts, feeling, and behaviour. Thes e are the scenes and experiences in which 
parents have treated children in ways the ch ildren find too unbearable  to think about or 
remember. Here again not only is there amnesia, partial or complete, for the sequence of 
events but also exclusion from  consciousness of the thoughts, feelings, and impulses to action 
that are the natural responses to such events. This results in major disorders of personality 
which in their commoner and less severe forms te nd to be diagnosed as cases of narcissism or 
false self and in their more severe forms may be  labelled as a fugue, a psychosis, or a case of 
multiple personality. The experiences which gi ve rise to such disorders have probably 
continued or been repeated over several years of childhood, perhaps starting during the first 
two or three but usually conti nuing during the fourth, fifth, si xth, and seventh years, and no 
doubt often for longer still. Th e experiences themselves includ e repeated rejection by parents

combined with contempt for a child's desire for love, care, and comforting, and, especially in 
the more severe forms, physical violence (batte ring), repeated and sometimes systematic, and 
sexual exploitation by father or mother's boy- friend. Not infrequently a child in this 
predicament is subjected to a co mbination of such experiences.  
We start at the less severe end of what appears to be a spectrum of related syndromes.  An example of a patient labelled as 'false self' has already  
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been given in an earlier lecture (see p. 53 
). This concerned a severely depressed and suicidal 
young graduate who recalled during analysis how his mother had consistently rejected him, 
ignored his crying, locked herself away in he r room for days on end, and had several times 
left home. Fortunately he had been in the ha nds of a therapist who understood his problem, 
gave full credence to the childhood experiences he described, and sympathetic recognition 
both of his unrequited yearning for love and care and also for the violent feelings toward his 
mother that her treatment of him had aroused , and which initially were directed towards 
herself (the therapist). A patient with rather  similar problems but whose experiences included 
also a period of eighteen months  in an impersonal institution, starting when she was 4 years 
old, is reported in lecture 4. Although both these patients made rewarding progress during 
treatment, both remained more sensitive than others to further misfortune.  
A number of patients, both children and adults, whose disorders appear to  have originated in 
similar though mainly worse expe riences and to have resulted in personality splitting of an 
even greater degree have been described by ther apists during the past decade. An example is 
Geraldine, aged 11, who had been found wand ering in a dazed state and who had lost all 
memory both of her mother's terminal illness and of events of the three subsequent years. At 
the end of a long period of therapy, descri bed in great detail by McCann (in Furman 1974), 
Geraldine summed up the experiences which ha d preceded her amnesia: 'With Mama, I was 
scared to death to step out of line. I saw wi th my own eyes how she attacked, in words and 
actions, my Dad and sister and, after all, I was just a little kid, very powerless. . . . How could 
I ever be mad at Mama -- she was really the only security I had . . . I blotted out all feelings -- 
things happened that were more than I could endure -- I had to keep going. If I had really let 
things hit me, I wouldn't be here. I'd be dead or in a mental hospital.' *  
The complex psychological state of Geraldine a nd also the childhood experiences held to have 
been responsible for it bear  
*  A long abstract of Mc Cann's account is given in Loss ( Bowlby 1980, 338-44).  
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close resemblance to the state of patients suffering from multiple personality and to the 
childhood experiences held responsible for them.  
In an article by Bliss ( 1980), based on clinical examinations and therapy carried out by means 
of hypnosis, a description is gi ven of fourteen patients, all female, diagnosed as suffering 
from multiple personality. The hypothesis Bliss advances is that the subordinate personalities

that take possession of a patient from time to time are the cognitive cr eations of the principal 
personality when, as a child of between 4 and 7 years, she was subjected for extended periods 
to intensely distressing events. According to Bliss, each such personality is created initially to 
serve a distinct purpose or role. Judged from the examples he gives, the roles are of three 
main kinds. The simplest and mo st benign is to act as a companion and protector when the 
creating personality is feeling lonely or isolated, as, for example, when parents are 
persistently hostile and/or absent and there is no  one else to turn to. A second role is to be 
anaesthetic to unbearably distress ing events, as in the case of a child of 4 or 5 who shared a 
room with her mother who, dying of cancer, spent hours screaming in pain. The third role is 
more complex, namely to shoulder the responsibili ty for thinking, feeling, and acting in ways 
that the patient cannot bear to accept as her own. Examples given by  Bliss include feeling 
violent hatred of a mother who had attempted to kill the patient when a child, a hatred 
amounting to an intent actually to murder her;  feeling and acting sexually after having been 
raped as a child; and feeling frightened and tearful after cryi ng had led to punishments and 
threats from parents.  
Since findings derived from hypnotic  procedures are controversial,  it is important to note that 
a clinical research group at the University of  California at Irvine, which uses conventional 
procedures and which has studied a number of  cases ( Reagor, personal communication), has 
reached conclusions very si milar to those of Bliss. * The therapeutic procedures proposed 
have  
*  See also Bliss ( 1986). Further evidence that  multiple personality di sorder develops during
childhood as a defence against ove rwhelming trauma, usually seve re abuse, is reported i n
Kluft ( 1995).  
-115-  much in common also and are, moreover, strongl y in keeping with the concepts of therapy 
described in the final lecture.  
Lastly, a number of child psychiatrists and ch ild psychotherapists (e.g . Stroh 1974; Rosenfeld 
1975; Bloch 1978; Hopkins 1984), have described children w hose thought and behaviour 
make them appear either nearly or frankly psychotic, who show pronoun cedly paranoid ideas, 
and whose condition, the evidence suggests, ca n be attributed to persistently abusive 
treatment by parents. Such children are of ten charming and endearing one moment and 
savagely hostile the next, the change occurri ng suddenly and for no apparent reason. Their 
greatest violence, moreover, is most likely to be  directed against the very individual to whom 
they appear, indeed are, most closely attached . Not infrequently these children are tormented 
by intense fear that some monster will attack them and they spend their time trying to escape the expected attack. In at least some of these cases  there is cogent evidence that what is feared 
is an attack by one or other parent but, that  expectation being unbear ably frightening, the 
expected attack is attributed  to an imaginary monster.  
As an example, let us consider the case of 6- year-old Sylvia, reported by Hopkins ( 1984), one 
of whose principal symptoms was a terror that the chairs and other items of furniture, which 
she called Daleks, would fl y across the room to strike her. 'Her terror was intense and when 
she kept cowering and ducking as though about to receive a blow from a Dalek or some other 
monster, I thought she was hallucinating.' From th e first Sylvia also expressed the fear that

her therapist would hit her like her mother did. Not only did she constantly attack her therapist 
but she often threatened to kill her.  
The father had died in an automobile accident two years earlier. During many months of twice 
weekly interviews with a social worker, the mo ther was extremely guarded and told little of 
family relations. At length, however, after nearly  two years the veil was lifted. She admitted 
her own massive rejection of Sylvia from the time of her birth, and the murderous feelings 
both she and father had had for her. Her treatmen t of Sylvia, she confessed, had been 'utterly 
brutal'. The father had had an extremely violent temper and in his not infrequent rages had  
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broken the furniture and thrown it across the room. He had frequently beaten Sylvia and had 
even thrown her across the room.  
Thus the identity of the Daleks was not in doubt.  Behind the 'fantasy' of a Dalek attack lay a 
serious reality-based exp ectation of an attack by father or mother. As Bloch ( 1978) has put it, 
a basic premise of the therapeutic approach she and others like her advocate for these cases is 
that what is so facilely dubbed as fantasy be recognize d as a reflection of a grim reality, and 
that an early therapeutic task is to identify  the real-life experiences lying close behind the 
deceptive camouflage.  
Not only are the childhood experiences of these near-psychotic children the same as those 
believed characteristic of adult patients with  multiple personality, but the states of mind 
described by the respective therapists have feat ures strikingly similar too. It seems highly 
likely therefore that the two conditions are closel y related. It should be noted furthermore that 
these findings give support to the hypothesi s advanced by Niederland ( 1959a and b, 
discussed by Bowlby 1973) that the paranoid delusions of Judge Schreber, on which Freud 
based his theory of paranoia, were distorted vers ions of the extraordinary pedagogic regime to 
which the patient's father had subjected him from the early months of life.  
In this contribution, as in almost all my work, I have focused at tention on psychopathology 
and some of the conditions that give rise to it.  My reason for doing so is the belief that only 
with a better understanding of aetiology and psyc hopathology will it be  possible to develop 
therapeutic techniques and, more especially, prev entive measures that will  be at once effective 
and economical in skilled manpower.  
My therapeutic approach is far from original . The basic hypothesis can be stated simply. So 
long as current modes of percei ving and construing situations, and the feelings and actions 
that ensue therefrom, are determined by emoti onally significant events and experiences that 
have become shut away from further conscious processing, the personality will be prone to 
cognition, affect, and behaviour maladapted to the current situation. When yearning for love 
and care is shut away, it will  
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continue to be inaccessible. When there is anger, it will continue  to be directed at 
inappropriate targets. Similarly anxiety will cont inue to be aroused by inappropriate situations 
and hostile behaviour be expected from ina ppropriate sources. The therapeutic task is 
therefore to help the patient discover what these events and experiences may have been so that

the thoughts, feelings, and behaviour that the situ ations arouse, and that continue to be so 
troublesome, can be linked again to the situations  that aroused them. Then the true targets of 
his yearning and anger and the tr ue sources of his anxiety and fear will become plain. Not 
only will such discoveries show that his modes of cognition, fe eling, and behaviour are far 
more intelligible, given the circumstances in which they originated, than they had seemed 
before but, once the patient has grasped how and w hy he is responding as he is, he will be in a 
position to reappraise his responses and, should he wish, to u ndertake their radical 
restructuring. Since such reappraisal and re structuring can be achieved only by the patient 
himself, the emphasis in this formulation of th e therapist's task is on helping the patient first 
to discover for himself  what the relevant scenes and e xperiences probably were and secondly 
to spend time pondering on how they have continued to influence him. Only then will he be in 
a position to undertake the reorganization of his modes of construing the world, thinking 
about it, and acting in it  which are called for.  
The concepts of therapeutic process outlined he re are similar to those described in much 
greater detail by others. Exam ples are publications by Pete rfreund ( 1983) and by Guidano 
and Liotti ( 1983). Although the authors of these two books started their therapeutic work 
from radically different positions, namely tr aditional versions of psychoanalysis and of 
behaviour therapy respectively, the principles that now guide their work show a striking 
convergence. Similarly current forms of bere avement therapy, which focus on distressing 
events in the comparatively recent past, are f ound to be based on the very same principles, 
even when developed within equally different traditions ( Raphael 1977; Melges and DeMaso 
1980). However divergent tactics may still appe ar, strategic thinking is on a convergent 
course.  
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LECTURE 7  
The role of attachment in personality development  
Evidence regarding the role of attachment in personality development has been accumulating 
apace during the nineteen-eighties. Earlier findings have been replicated on samples of 
diverse origin; methods of observation have been refined and new methods introduced; and 
the role of easy two-way communication between parent and child in making for healthy emotional development has been emphasized. Si nce I believe this new work to have far-
reaching clinical implications, my aim in this lecture has been to present a review of these 
findings in a form suited to those working as psychotherapists in the mental health field. For 
the convenience of the reader I begin by restatin g in summary form some of the features most 
distinctive of attachment theory.   
Some distinctive features of attachment theory  
It will be remembered that attachment theory was formulated to explain certain patterns of 
behaviour, characteris tic not only of infants and young chil dren but also adolescents and 
adults, that were formerly conceptualized in terms of dependency and overdependency. In its 
original formulation observations of how young children respond when placed in a strange 
place with strange people, and the effects su ch experiences have on a child's subsequent 
relations with his parents, were especially in fluential. In all subsequent work theory has 
continued to be

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tied closely to detailed observations and inte rview data of how i ndividuals respond in 
particular situations. Hi storically the theory wa s developed out of the ob ject-relations tradition 
in psychoanalysis; but it has drawn also on c oncepts from evolution theory, ethology, control 
theory, and cognitive psychology. One result is the reformulation of psychoanalytic 
metapsychology in ways compatible with mode rn biology and psychology and in conformity 
with the commonly accepted criteria of natural science (see Lecture 4).Attachment theory 
emphasizes:  
 the primary status and biological func tion of intimate emotional bonds betwee n 
individuals, the making and maintaining of wh ich are postulated to be controlled by a
cybernetic system situated within the central  nervous system, utilizing working models o f
self and attachment figure in relationship with each other. *  
 the powerful influence on a child's developmen t of the ways he is treated by his parents,
especially his motherfigure, and  
 that present knowledge of infant and ch ild development requires that a theory o f
developmental pathways should replace th eories that invoke specific phases o f
development in which it is held a person ma y become fixated and/or to which he may
regress.  
The primacy of intimate emotional bonds  
Attachment theory regards the propensity to make intimate em otional bonds to particular 
individuals as a basic component  
*  In earlier publications I have sometimes used the term 'representational model' as a 
synonym for 'working model' because representa tion has been the more familiar concept i n
clinical literature. In a dynamic psychol ogy, however, working model is the more
appropriate term, and it is also the term that is now coming into use among cognitive 
psychologists (e.g. Johnson-Laird 1983). Within  the attachment framework the concept o f
working model of an attachment figure is in many respects equivalent to, and replaces, the
traditional psychoanalytic concept of internal object.  
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of human nature, already present in germinal form in the neonate and continuing through 
adult life into old age. During infancy an d childhood bonds are with parents (or parent 
substitutes) who are looked to for protecti on, comfort, and support. During healthy 
adolescence and adult life these bonds pe rsist, but are complemented by new bonds, 
commonly of a heterosexual nature. Although food and sex sometimes play important roles in 
attachment relationships, the relationship exis ts in its own right and has a key survival 
function of its own, namely pr otection. Initially the only me ans of communication between 
infant and mother is through emotional expr ession and its accompanying behaviour. Although 
supplemented later by speech, emotionally medi ated communication nonethe less persists as a 
principal feature of intimate relationships throughout life.  
Within the attachment framework therefore in timate emotional bonds are seen as neither 
subordinate to nor derivative from food and sex.  Nor is the urgent desire for comfort and 
support in adversity regarded as childish, as dependency theory implies. Instead the capacity 
to make intimate emotional bonds with other in dividuals, sometimes in the careseeking role

and sometimes in the caregiving one, is regarded as a principal feature of effective personality 
functioning and mental health.  
As a rule careseeking is shown by a weaker and less experienced indi vidual towards someone 
regarded as stronger and/or wiser. A child, or  older person in the careseeking role, keeps 
within range of the caregiver, the degree of cl oseness or of ready accessibility depending on 
circumstances: hence the concep t of attachment behaviour.  
Caregiving, the major role of parents and comple mentary to attachment behaviour, is regarded 
in the same light as careseeking, namely as a basic component of huma n nature (see Lecture 
1).  
Exploring the environment, including play and vari ed activities with peers, is seen as a third 
basic component and one antithetic to attachment  behaviour. When an individual (of any age) 
is feeling secure he is likely to explore aw ay from his attachment figure. When alarmed, 
anxious, tired, or unwell he feel s an urge towards proximity. Th us we see the typical pattern 
of inter-  
-121-  action between child and parent known as explor ation from a secure base, first described by 
Ainsworth ( 1967). Provided the parent is known to  be accessible and will  be responsive when 
called upon, a healthy child feels secure enough to  explore. At first th ese explorations are 
limited both in time and space. Around the middle of  the third year, however, a secure child 
begins to become confident enough to increase time and distance away -- first to half-days 
and later to whole days. As he grows into adol escence, his excursions are extended to weeks 
or months, but a secure home base remains i ndispensable nonetheless for optimal functioning 
and mental health. Note that the concept of secu re base is a central feature of the theory of 
psychotherapy proposed.  
During the early months of life an infant s hows many of the component responses of what 
will later become attachment behaviour, but the organized pattern does not develop until the 
second half of the first year. Fr om birth onwards he shows a germ inal capacity to engage in 
social interaction and pleasure in doing so ( Stern 1985): thus there is no autistic or 
narcissistic phase. Within days, moreover, he is  able to distinguish between his mother-figure 
and others by means of her smell and by hear ing her voice, and also by the way she holds 
him. Visual discrimination is not  reliable until the second quart er. Initially crying is the only 
means available to him for signalling his need  for care, and contentment the only means for 
signalling that he has been satisfied. During the second month, however, his social smile acts 
strongly to encourage his mother in her mi nistrations and his repertoire of emotional 
communications rapidly extends  ( Izard 1982; Emde 1983).  
The development of attachment behaviour as an organized system, having as its goal the 
keeping of proximity or of accessibility to a discriminated mother-figure, requires that the 
child should have developed the co gnitive capacity to keep his mother in mind when she is 
not present: this capacity develops during th e second six months of life. Thus from nine 
months onwards the great majority of infants respond to being left with a strange person by 
protest and crying, and also by more or less prolonged fretting and rejection of the stranger. 
These observations demonstrate that during these months an infant is becoming

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capable of representation and that his working model of his mother is becoming available to 
him for purposes of comparis on during her absence and for recognition after her return. 
Complementary to his model of his mother, he  develops a working model of himself in 
interaction with her; likewise for father.  
A major feature of attachment theory is the hypot hesis that attachment behaviour is organized 
by means of a control system within the central nervous system, analogous to the 
physiological control systems that maintain phys iological measures such as blood pressure 
and body temperature within set limits. Thus th e theory proposes that, in a way analogous to 
physiological homeostasis, the attachment contro l system maintains a pe rson's relation to his 
attachment figure between certain limits of distance and accessibility, using increasingly 
sophisticated methods of communi cation for doing so. As such, th e effects of its operation can 
be regarded as an example of what can usef ully be termed environmental homeostasis ( 
Bowlby 1969, 1982). By postulating a control sy stem of this sort (with analogous systems 
controlling other forms of behaviour) attachment theory contains within itself a theory of 
motivation that can replace trad itional theories which invoke a postulated build-up of energy 
or drive. Among several advantages of control theo ry are that it gives as much attention to the 
conditions terminating a behavioural  sequence as to those initiating it and is proving a fruitful 
framework for empirical research.  
The presence of an attachment control system an d its linkage to the working models of self 
and attachment figure(s) that are built in th e mind during childhood are held to be central 
features of personality functioning throughout life.  
Patterns of attachment and conditions determining their 
development  
The second area to which attachment theory pays  special attention is the role of a child's 
parents in determining how he develops. There is today impressive and mounting evidence 
that the pattern of attachment that an indivi dual develops during the years of immaturity -- 
infancy, childhood, and  
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adolescence -- is profoundly influenced by the way his parents (or othe r parent figures) treat 
him. This evidence derives from a number of sy stematic research studies, the most impressive 
being prospective studies of socio-emotiona l development during the first five years 
undertaken by developmental psychologists who ar e also clinically so phisticated. Pioneered 
by Ainsworth ( Ainsworth, Blehar, Waters, and Wall 1978; Ainsworth 1985) and expanded, 
notably by Main ( Main, Kaplan, and Cassid y 1985) and Sroufe ( 1983, 1985) in the United 
States and by Grossmann ( Grossmann, Gro ssmann, and Schwan 1986) in Germany, these 
studies are now multiplying fast. Their finding s are remarkably consistent and have the 
clearest of clinical significance.  
Three principal patterns of attachment, firs t described by Ainsworth and her colleagues in 
1971, are now reliably identified, together wi th the family conditions that promote them. 
These are first the pattern of secure attachment  in which the individual is confident that his

parent (or parent figure) will  be available, responsive, a nd helpful should he encounter 
adverse or frightening situations. With this assu rance, he feels bold in his explorations of the 
world. This pattern is promoted by a parent, in the early years especially by mother, being 
readily available, sensitive to her child's sign als, and lovingly responsive when he seeks 
protection and/or comfort.  
A second pattern is that of anxious resistant attachment in which the individual is uncertain 
whether his parent will be available or responsive or help ful when called upon. Because of 
this uncertainty he is always prone to separation  anxiety, tends to be clinging, and is anxious 
about exploring the world. This pattern, in which conflict is evident, is promoted by a parent 
being available and helpful on some occasions but not on others, and by separations and, as 
clinical findings show, by th reats of abandonment used as a means of control.  
A third pattern is that of anxious avoidant attachment in which the individual has no 
confidence that, when he seeks care, he will  be responded to helpfu lly but, on the contrary, 
expects to be rebuffed. When in marked degree such an individual attempts to live his life 
without the love and support of others, he trie s to become emotionally self-sufficient and may 
later be diagnosed as narcissistic or as having a false self of the type  
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described by Winnicott ( 1960). This pattern, in wh ich conflict is more hidden, is the result of 
the individual's mother constantly rebuffing hi m when he approaches her for comfort or 
protection. The most extreme cases re sult from repeated rejections.  
Although in most cases the pattern observed confor ms fairly closely to one or another of the 
three well-recognized types, there have been  puzzling exceptions. During the assessment 
procedure used in these studies (the Ainsworth Strange Situation), in which infant and mother 
are observed in interaction during a series of br ief episodes, certain infants have appeared to 
be disoriented and/or disorganized. One infant  appears dazed; another freezes immobile; a 
third engages in some stereotypy; a fourth star ts a movement, then stops unaccountably. After 
much study Main and her colleagues have concl uded that these peculiar forms of behaviour 
occur in infants who are exhibiti ng a disorganized version of one of the three typical patterns, 
more often than not the anxious resistant on e ( Main and Weston 1981; Main and Solomon in 
press). Some instances are seen in infants k nown to have been physically abused and/or 
grossly neglected by the parent ( Crittenden 1985). Othe rs occur in dyads in which the mother 
is suffering from a severe form of bipolar af fective illness and who treats her child in an 
erratic and unpredictable way ( Radke-Yarrow et  al. 1985). Yet others are shown by the 
infants of mothers who are still preoccupied wi th mourning a parental figure lost during the 
mother's childhood and by those of mothers wh o themselves suffered physical or sexual abuse 
as children ( Main and Hesse, in press). Cases showing these deviant pa tterns are clearly of 
great clinical concern, and much atte ntion is now being given to them.  
Knowledge of the origins of these deviant patter ns confirms in the clearest possible way the 
influence on a child's pattern of attachment of the parent's way of  treating his or her child. Yet 
further confirmatory evidence comes from deta iled observations of the way different mothers 
treat their children during a laboratory session arranged when the child is 2 1/2 years old ( 
Matas, Arend, and Sroufe 1978). In this study the child is given a small but difficult task for 
the solution of which he requires a little assistance, and his mother is free to interact with him. 
In this situation, it is found, the way she treats him correlates closely

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with the pattern of attachment her child showed  towards her eighteen months earlier. Thus the 
mother of a child earlier assessed as securely attached is found to  be attentive and sensitive to 
his performance and to respond to his successes and difficulties in a way that is helpful and 
encouraging. Conversely the mother of a child ea rlier assessed as insecure is found to be less 
attentive and/or less sensitive. In some cases  her responses are ill-timed and unhelpful; in 
others she may take little notice of what he is doing or how he is feeling; in yet others she 
may actively discourage or reject  his bids for help and encouragement. Note that the pattern 
of interaction adopted by the mother of a secu re infant provides an excellent model for the 
pattern of therapeutic intervention advocated here.  
In thus underlining the very great influence that a child's mother has on his development, it is 
necessary also to consider what has led a moth er to adopt the style of mothering she does. 
One major influence on this is the amount of emo tional support, or lack of it, she herself is 
receiving at the time. Another is the form of mo thering that she herself received when a child. 
Once these factors are recognized, as they have been by many analytically oriented clinicians 
long since, the idea of blaming parents evaporat es and is replaced by a therapeutic approach. 
Since the emotional problems of parents stemmi ng from the past and their effects on children 
has now become a field for systematic research, a brief description of current work is given at 
the end of Lecture 8.  
Persistence of patterns  
If we return now to the patterns of attachment  observed in oneyear-olds, prospective studies 
show that each pattern of attachment, once develope d, tends to persist. One reason for this is 
that the way a parent treats a child, whether for better or for worse, tends to continue 
unchanged. Another is that each pa ttern tends to be self-perpetuating. Thus a secure child is a 
happier and more rewarding child to care for an d also is less demanding than an anxious one. 
An anxious ambivalent child is apt to be whiny and clinging; whilst an anxious avoidant child  
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keeps his distance and is prone to bully other ch ildren. In both of these last cases the child's 
behaviour is likely to elicit an  unfavourable response from the parent so that vicious circles 
develop.  
Although for these reasons patterns, once formed , are apt to persist, this is by no means 
necessarily so. Evidence shows that during th e first two or three years the pattern of 
attachment is a property of the relationship, for example, child to mother or child to father, 
and that if the parent treats the child differe ntly the pattern will change accordingly. These 
changes are amongst much evidence reviewed by Sroufe ( 1985) that stability of pattern, 
when it occurs, cannot be attributed to the ch ild's inborn temperament as has sometimes been 
claimed. Nevertheless, as a child grows older, the pattern becomes increasingly a property of 
the child himself, which means that he tends to impose it, or some derivative of it, upon new 
relationships such as with a teacher, a foster-mother, or a therapist.  
The results of this process of  internalization are evident in  a prospective study which shows 
that the pattern of attachment characteristic of a mother-child pair, as assessed when the child 
is aged 12 months, is highly predictive of how th at child will behave in a nursery group (with

mother absent) three and a half years later. Th us children who showed a secure pattern with 
mother at 12 months are likely to be describe d by nursery staff as co-operative, popular with 
other children, resilient, and resourceful. Thos e who showed an anxious avoidant pattern are 
likely to be described as emotionally insulated,  hostile or antisocial and, paradoxically, as 
unduly seeking of attention. Thos e who showed an anxious resist ant pattern are likely to be 
described as also unduly seeki ng of attention and as either  tense, impulsive, and easily 
frustrated or else as passive and helpless ( Sroufe 1983). In view of these findings it is hardly 
surprising that in two other pr ospective studies, a pioneering one in California ( Main and 
Cassidy 1988) and a replicative one in German y ( Wärtner 1986), the pattern of attachment 
assessed at 12 months is found to be highly pred ictive also of patterns  of interaction with 
mother five years later.  
Although the repertoire of a 6-year-old's behaviour towards a parent is vastly greater than that 
of a one-year-old, the earlier  
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patterns of attachment are nonetheless readily disc ernible to an educated eye at the older age. 
Thus children who are classified as being securely attached at 6 years are those who treat their 
parents in a relaxed and friendly way, who enter into easy, and often subtle, intimacies with 
them, and who engage in freeflowing conversatio n. Children classified as anxious resistant 
show a mixture of insecurity, including sadness  and fear, and of intimacy alternating with 
hostility, which is sometimes subtle and at othe rs overt. In some of these cases the child's 
behaviour strikes an observer as self-conscious , even artificial. As though they were always 
anticipating a negative response from the parent , they try to ingratiate themselves by showing 
off, perhaps by being cute or especially ch arming ( Main and Cassidy, in press; Main, 
personal communication).  
Children aged 6 years classified as anxious a voidant tend quietly to keep the parent at a 
distance. Such greetings as they give are formal and brief; topics of conversation stay 
impersonal. He or she keeps busy with toys or  some other activity and ignores or is even 
dismissive of a pare nt's initiatives.  
Children who at 12 months appeared to be di sorganized and/ or disoriented are found five 
years later to be conspicuous for their tendency to control or dominate a parent. One form of 
this is to treat the parent in a humiliating and/or  rejecting way; another is to be solicitous and 
protective. These are clear examples of what c linicians have labelled as an inversion, or 
reversal, of the child and parent roles. Convers ations between them are fragmented, sentences 
begun but left unfinished, topics broached but changed abruptly.  
In considering the persistence of a 6-year-old's  patterns of interaction with parents and with 
other parental figures, a critical question arises: to what extent are the patterns at this age 
ingrained within the child's personality and to wh at extent are they a reflection of the way the 
parents still treat him or her? The answer, to wh ich clinical experience points, is that by this 
age both these influences are at work so that the most effective interventions are those that 
take both into account, e.g. by means either of fa mily therapy or else by giving help in parallel 
to parents and child.  
As yet too little is known about how the influence on

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personality development of interactions with th e mother compares with the influence of those 
with the father. It would hardly be surprising we re different facets of personality, manifest in 
different situations, to be infl uenced differently. In addition,  their respective influences on 
males may be expected to differ from their resp ective influences on fema les. It is clearly a 
complex area that will require much research. Meanwhile it seems likely that, at least during 
the early years of an individual's life, the model of self interacting with mother is the more 
influential of the two. This would hardly be surprising since in every culture known the huge 
majority of infants and young children interact far more with the mother th an with the father.  
It must be recognized that, so far, prospective st udies of the relative persistence of patterns of 
attachment, and of the features of personality characteristic of each, have not yet been carried 
beyond the sixth year. Even so, two cross-secti onal studies of young adults show that the 
features of personality characteris tic of each pattern during the early years are also to be found 
in young adults ( Kobak and Sceery 1988; Ca ssidy and Kobak 1988; Hazan and Shaver 1987); 
and it is more than likely that, except in cases where family relations have changed 
substantially in the interval, they have been pr esent continuously. All our clinical experience 
strongly supports that view.  
A theory of internalization  
In order to account for the tendency for patter ns of attachment increasingly to become a 
property of the child himself, attachment theo ry invokes the concept of working models of 
self and of parents already described. The wo rking models a child builds of his mother and 
her ways of communicating and be having towards him, and a comp arable model of his father, 
together with the complementary models of hims elf in interaction with each, are being built 
by a child during the first few years of his life and, it is postulated, soon become established 
as influential cognitive structures ( Main, Ka plan, and Cassidy 1985). The forms they take, 
the evidence reviewed strongly suggests, are ba sed on the child's real-life experience of day-
to-day interactions  
-129-  
with his parents. Subsequently th e model of himself that he builds reflects also the images that 
his parents have of him, images that are co mmunicated not only by how  each treats him but 
by what each says to him. These models then govern how he feels towards each parent and 
about himself, how he expects each of them to  treat him, and how he plans his own behaviour 
towards them. They govern too both the fears a nd the wishes expressed in his day dreams.  
Once built, evidence suggests, these models of a parent and self in interaction tend to persist 
and are so taken for granted that they come to operate at an unconscious  level. As a securely 
attached child grows older and hi s parents treat him di fferently, a gradual up-dating of models 
occurs. This means that, though there is always  a time-lag, his currently operative models 
continue to be reasonably good simulations of hi mself and his parents in interaction. In the 
case of the anxiously attached ch ild, by contrast, this gradual up-dating of models is in some 
degree obstructed through defensive exclusion of  discrepant experience and information. This 
means that the patterns of interaction to wh ich the models lead, having become habitual, 
generalized, and largely unconsc ious, persist in a more or less uncorrected and unchanged

state even when the individual in later life is dealing with persons who treat him in ways 
entirely unlike those that his pare nts adopted when he was a child.  
The clue to an understanding of these differences  in the degree to which models are up-dated 
is to be found in the profound differences in the freedom of communication between mother 
and child that characterize pairs of the two type s. This is a variable to which Bretherton ( 
1987) has drawn especial attention.  
It will be noticed that in Main's long itudinal study described above the pattern of 
communication between a 6-year-old child and his mother, as observed in a pair that, five 
years earlier, had shown a secure pattern of attach ment, is very different from that observed in 
a pair who had earlier shown an insecure pattern. Whereas the secure pairs engaged in free-
flowing conversation laced with expressions of feeling, and t ouching on a variety of topics 
including personal ones, the insecure pairs did no t. In some, conversation was fragmented and 
topics abruptly changed.  
-130-  
In others, notably the avoidant pairs, conversation was limited, t opics kept impersonal, and all 
reference to feeling omitted. These striking diffe rences in the degree to which communication 
is either free or restricted are postulated to be of great relevance for understanding why one 
child develops healthily and another becomes disturbed. Moreover it will not have escaped 
notice that this same variable, the degree to which communication between two individuals is 
restricted or relatively free, has for long been  recognized as one of central concern in the 
practice of analytic psychotherapy.  
For a relationship between any two individuals to proceed harmoniously each must be aware 
of the other's point-of-view, his goals, feelings, and intentions, and each must so adjust his 
own behaviour that some alignmen t of goals is negotiated. This requires that each should have 
reasonably accurate models of self and other which ar e regularly up-dated by free 
communication between them. It is here that th e mothers of the securely attached children 
excel and those of the insecure  are markedly deficient.  
Once we focus on the degree to which communi cation between a parent -child pair is free-
flowing or not, it quickly becomes apparent that, fr om the earliest days of life, the degree of 
freedom of communication in the pairs destined to develop a secure pattern of attachment is 
far greater than it is in those who do not  ( Ainsworth, Bell, and Stayton 1971; Blehar, 
Lieberman, and Ainsworth 1977). Thus it is char acteristic of a mother  whose infant will 
develop securely that she is continuously monito ring her infant's state and, as and when he 
signals wanting attention, she registers his si gnals and acts accordingly. By contrast, the 
mother of an infant later found to  be anxiously attached is likely  to monitor her infant's state 
only sporadically and, when she does noti ce his signals, to respond tardily and/or 
inappropriately. By the time an infant has reached his first birthday, moreover, these 
differences in freedom of co mmunication have been found to be clearly evident during the 
Ainsworth Strange Situation proc edure ( Grossmann, Grossmann, and Schwan 1986). Even in 
the introductory episode, when infant and mother are alone together, more of the secure pairs 
were observed to engage in direct  communication, by eye contact,  
-131-

facial expression, vocalization, and showing or giving toys, than did the insecure pairs. As the 
stress on the child increases, so do the differe nces between the pairs. Thus in the reunion 
episode after the second separation all but one of  sixteen secure pairs communicated in direct 
fashion in contrast to a minority of the inse cure ones. There was one other very striking 
difference moreover. Whereas every infant classified as secure was seen to be in direct 
communication with his mother, not only when  he was content but also when he was 
distressed, the infants cl assified as avoidant, when they di d engage in direct communication, 
did so only when they were content.  
Thus already by the age of 12 months there are children who no longer express to their 
mothers one of their deepest emotions or th e equally deep-seated desire for comfort and 
reassurance that accompanies it. It is not diff icult to see what a very  serious breakdown of 
communication between child and mother this repr esents. Not only that but, because a child's 
self-model is profoundly influenced  by how his mother sees and treats him, whatever she fails 
to recognize in him he is likely to fail to reco gnize in himself. In this way, it is postulated, 
major parts of a child's developing personality can become split off from, that is, out of 
communication with, those parts of  his personality that his moth er recognizes and responds to, 
which in some cases include feat ures of personality that she is  attributing to him wrongly.  
The upshot of this analysis is that obstruction to communication  between different parts of, or 
systems within, a personality, which from the ear liest days Freud saw as the crucial problem 
to be solved, is now seen as a reflection of the differential responses and communications of a 
mother to her child. When a mother respo nds favourably only to certain of her child's 
emotional communications and turns a blind eye or  actively discourages others, a pattern is 
set for the child to identify with the favour ed responses and to disown the others.  
It is along these lines that attachment theory ex plains the differential development of resilient 
and mentally healthy personalities, and also of personalities prone to anxiety and depression, 
or to developing a false self or  some other form of vulnerability  to mental ill-health. Perhaps it 
is no coincidence  
-132-  
that some of those who approach problems of  personality developm ent and psychopathology 
from a cognitive standpoint, but who also give weight to the pow er of emotion, e.g. Epstein ( 
1980, 1986) and Liotti ( 1986, 1987), have been  formulating theories that are essentially 
compatible with this one.  
Variations in a mother's way of recalling her childhood 
experience  
The conclusion so far reached about the role of  free communication, em otional as well as 
cognitive, in determining mental health is st rongly supported by an important recent finding 
from Main's longitudinal study. As a result of in terviewing the mothers of the children in the 
study, Main found a strong correlation between how a mother describes her relationships with 
her parents during her childhood and the pattern of attachment her child  now has with her ( 
Main, Kaplan, and Cassidy 1985; see also Mo rris 1981 and Ricks 1985). Whereas the mother 
of a secure infant is able to talk freely and with feeling about her childhood, the mother of an 
insecure infant is not.

In this part of the study an interviewer as ks the mother for a de scription of her early 
relationships and attachment-related events and for her sense of the way these relationships 
and events affected her personality.  In considering results, as much or more attention is paid 
to the way a mother tells her story and deals with probing questions about it as to the 
historical material she describes. At the simplest  level, it was found that a mother of a secure 
infant is likely to report having had a reasonab ly happy childhood and to show herself able to 
talk about it readily and in detail, giving due  place to such unhappy events as may have 
occurred as well as to the happy ones. By contrast , a mother of an insecure infant is likely to 
respond to the enquiry in one of two differe nt ways. One, shown by mothers of anxious 
resistant children, is to descri be a difficult unhappy relationship with her own mother about 
which she is still clearly  disturbed and in which she is st ill entangled mentally, and, should 
her mother be still alive, it is evident that she is entangled with her in reality as well. The other, shown by mothers of anxious  
-133-  
avoidant children, is to claim in a generali zed matter-of-fact way that she had a happy 
childhood, but not only is she unable to give any supporting detail but may refer to episodes 
pointing in an opposite direction. Frequently such a mother will insist that she can remember 
nothing about her childhood nor how she was tr eated. Thus the strong impression of 
clinicians, that a mother who had a happy ch ildhood is likely to have a child who shows a 
secure attachment to her, and that an unhappy childhood, more or less cloaked by an inability 
to recall, makes for difficulties, is clearly supported.  
Nevertheless a second finding, no less interesting and one of es pecial relevance here, arises 
from a study of the exceptions to the general rule. These are the mothers who describe having 
had a very unhappy childhood but who nonethele ss have children showing secure attachment 
to them. A characteristic of each of these moth ers, which distinguishes them from mothers of 
insecure infants, is that, despite describing much rejection and unhappiness during childhood, 
and perhaps tearful whilst doing so, each is able to tell her story in a fluent and coherent way, 
in which such positive aspects of her experien ces as there were are given a due place and 
appear to have been integrated with all the ne gative ones. In their capacity for balance they 
resemble the other mothers of secure infants. It  seemed to the interviewers and those assessing 
the transcripts that these exceptional mother s had thought much about their unhappy earlier 
experiences and how it had affect ed them in the long term, and also about why their parents 
might have treated them as they had. In fact, they seemed to have come to terms with their 
experience.  
By contrast, the mothers of children whose patt ern of attachment to them was insecure and 
who also described an unhappy childhood did so  with neither flue ncy nor coherence: 
contradictions abounded and went unnoticed. Mo reover, it was a mother who claimed an 
inability to recall her childhood and who did so both repeatedly and strongly who was a 
mother whose child was insecu re in his relation to her. 
*  
*  In further examination of the data it has b een found that all these correlations also hold true
for fathers ( Main, personal communication).  
-134-

In the light of these findings Main and her co lleagues conclude that free access to, and the 
coherent organization of information relevant to  attachment play a determining role in the 
development of a secure personality in adul t life. For someone who had a happy childhood no 
obstacles are likely to prevent free access to both the emotional and the cognitive aspects of 
such information. For someone who suffered much unhappiness or whose parents forbade him 
or her to notice or to remember adverse even ts, access is painful and difficult, and without 
help may indeed be impossible . Nevertheless, however she ma y accomplish it, when a woman 
manages either to retain or to regain access to such unhappy memories and reprocess them in 
such a way that she can come to terms with them, she is found to be no less able to respond to 
her child's attachment behaviour so that he deve lops a secure attachment to her than a woman 
whose childhood was a happy one. This is a finding  to give great encouragement to the many 
therapists who for long have sought to help mother s in just this kind of way. Further reference 
to techniques for helping disturbed mother s is made at the end of Lecture 8.  
Pathways to personality development  
There is one further way in which attachment  theory differs from traditional types of 
psychoanalytic theory, namely its rejection of the model of development in which an 
individual is held to pass th rough a series of stages in an y one of which he may become 
fixated or to which he may regress, and its re placement by a model in which an individual is 
seen as progressing along one or another of an array of potential developmental pathways. 
Some of these pathways are compatible with h ealthy development; others deviate in one or 
another direction in ways incompatible with health.  
All variants of the traditional model invok ing phases of development are based on the 
assumption that, at some phase of normal deve lopment, a child shows psychological features 
that, in an older individual, would be regard ed as signs of pathology. Thus a chronically 
anxious and clinging adult might  
-135-  
be regarded as being fixated in or having re gressed to a postulated phase of orality or of 
symbiosis; whilst a deeply withdrawn individual  might be regarded as  having regressed to a 
postulated phase of autism or of narcissism. Systematic and sensitive studies of human 
infants, such as those reported by Stern ( 198 5), have now rendered this model untenable. 
Observations show that infants are socially  responsive from birth onwards. Healthily 
developing toddlers do not show  anxious clinging except when they are frightened or 
distressed; at other times they  explore with confidence.  
The model of developmental pathways regards an infant at birth as having an array of 
pathways potentially open to him, the one along which he will in fact proceed being 
determined at every moment by the interacti on of the individual as he now is with the 
environment in which he happens then to be. E ach infant is held to have his own individual 
array of potential pathways fo r personality development which, except for infants born with 
certain types of neurological damage, include ma ny that are compatible with mental health 
and also many that are incompatible. Which particular pathway he proceeds along is 
determined by the environment he meets with , especially the way his parents (or parent 
substitutes) treat him, and ho w he responds to them. Childr en who have parents who are 
sensitive and responsive are enabled to deve lop along a healthy pathway. Those who have 
insensitive, unresponsive, neglec tful, or rejecting parents are li kely to develop along a deviant

pathway which is in some degree incompatible with mental health and which renders them 
vulnerable to breakdown, should th ey meet with seriously advers e events. Even so, since the 
course of subsequent developmen t is not fixed, changes in the way a child is treated can shift 
his pathway in either a more favourable di rection or a less favourable one. Although the 
capacity for developmental change diminishes wi th age, change continues throughout the life 
cycle so that changes for better or for worse ar e always possible. It is  this continuing potential 
for change that means that at no time of li fe is a person invulnerable to every possible 
adversity and also that at no time of life is a person impermeable to favour able influence. It is 
this persisting potential for change that gi ves opportunity for effective therapy.  
-136-  
LECTURE 8  
Attachment, communication, an d the therapeutic process  
In the second part of my 1976 Maudsley Lecture,  'The making and breaking of affectional 
bonds' ( 1977), I described some of my ideas on the therapeutic implications of attachment 
theory. Much that has been learned since then has strengthened my confidence in the approach. The present account therefore should  be regarded as an amplification of the 
earlier one. In it I give more detailed attenti on to the ways a patient's earlier experiences 
affect the transference relationship and discuss further the therapist's aim as being that of 
enabling his patient to reconstruct his working models of himself and his attachment figure(s) 
so that he becomes less under the spell of fo rgotten miseries and better able to recognize 
companions in the present for what they are .  
a thing which has not been understood 
inevitably reappears; like an unlaid ghost, 
it cannot rest until the mystery has been resolved and the spell broken.  
Sigmund Freud 1909  
Those who cannot remember the past are condemned to repeat it.  
George Santayana 1905  -137-  
Five therapeutic tasks  
The theory of personality development and psyc hopathology outlined above can be used as a 
framework to guide each one of the three prin cipal forms of analytic  psychotherapy in use 
today -- individual therapy, family therapy, and group therapy. Here I deal only with the first.  
A therapist applying attachment th eory sees his role as being one of providing the conditions 
in which his patient can explore his representa tional models of himself and his attachment 
figures with a view to reappraising and re structuring them in the light of the new 
understanding he acquires and the new experiences he has in the therapeutic relationship. In

helping his patient towards this end the therap ist's role can be described under five main 
heads.  
The first is to provide the patient with a secu re base from which he can explore the various 
unhappy and painful aspects of his life, past and present, many of  which he finds it difficult or 
perhaps impossible to think about and recons ider without a trusted companion to provide 
support, encouragement, sympathy, and, on occasion, guidance.  
A second is to assist the patient in his explora tions by encouraging him to consider the ways 
in which he engages in relationships with sign ificant figures in his current life, what his 
expectations are for his own feelings and be haviour and for those of  other people, what 
unconscious biases he ma y be bringing when he selects a person with whom he hopes to make 
an intimate relationship and when he create s situations that go badly for him.  
A particular relationship that the therapist en courages the patient to examine, and that 
constitutes the third task, is the relationship betw een the two of them. Into this the patient will 
import all those perceptions, constructions, and e xpectations of how an attachment figure is 
likely to feel and behave towards him that his working models of parent s and self dictate.  
A fourth task is to encourage the patient to consider how his current perceptions and 
expectations and the feelings and actions to whic h they give rise may be the product either of 
the events and situations he en countered during his childhood and  
-138-  adolescence, especially those with his parents,  or else as the products of what he may 
repeatedly have been told by them. This is  often a painful and difficult process and not 
infrequently requires that the therapist sanction his patient to consider as possibilities ideas 
and feelings about his parents th at he has hitherto regarded as unimaginable and unthinkable. 
In doing so a patient may find himself moved by  strong emotions and ur ges to action, some 
directed towards his parents and some toward s the therapist, and many of which he finds 
frightening and/or alien and unacceptable.  
The therapist's fifth task is to enable his pa tient to recognize that his images (models) of 
himself and of others, derived either from past painful ex periences or from misleading 
messages emanating from a parent, but all too often in the literatu re mislabelled as 'fantasies', 
may or may not be appropriate to his present and future; or, indeed, may never have been 
justified. Once he has grasped the nature of his governing images (models) and has traced 
their origins, he may begin to understand what ha s led him to see the world and himself as he 
does and so to feel, to think, and to act in the ways he does. He is then in a position to reflect 
on the accuracy and adequacy of those images (models), and on the ideas and actions to which 
they lead, in the light of his current experi ences of emotionally si gnificant people, including 
the therapist as well as his parents, and of hi mself in relationship to each. Once the process 
has started he begins to see the old images (m odels) for what they are, the not unreasonable 
products of his past experiences or of what he ha s repeatedly been told, and thus to feel free to 
imagine alternatives better fitted to his curr ent life. By these means the therapist hopes to 
enable his patient to cease being a slave to old and unconscious stereotypes and to feel, to 
think, and to act in new ways.

Readers will be aware that the principles set out have a great deal in common with the 
principles described by other analytically tr ained psychotherapists who regard conflicts 
arising within interpersonal relationships as the key to an understan ding of their patient's 
problems, who focus on the transference and w ho also give some weight, albeit of varying 
degree, to a patient's earlier experience with his parents.  
-139-  Among the many well-known names that could be mentioned in this context are those of 
Fairbairn, Winnicott, and Guntrip in Britain,  and Sullivan, Fromm-Reichmann, Gill, and 
Kohut in the United States. Among recently pub lished works that contain many of the ideas 
prescribed here are those by  Peterfreund ( 1983), Casement ( 1985), Pine ( 1985), and Strupp 
and Binder ( 1984), and also  those of Malan ( 1973) and Horowitz et al. ( 1984) in the field of 
brief psychotherapy. In particular, I wish to dr aw attention to the ideas of Horowitz and his 
colleagues who, in their description of the treatment of patients suffering from an acute stress 
syndrome, employ a conceptual framework closely similar to that presented here. Although 
their technique is aimed to help patients recover from the effects of a recent severely stressful 
event, I believe the principles informing their work are equally applicable to helping patients 
recover from the effects of a ch ronic disturbance resulting from stressful events of many years 
ago, including those that occurred during their earliest years.  
Although in this exposition it is convenient to list th e therapist's five tasks in a logical way, so 
interrelated are they that in practice a productive  session is likely to involve first one task, 
then another. Nevertheless, unless a therapist can enable his patient to feel some measure of 
security, therapy cannot even begi n. Thus we start with the role  of the therapist in providing 
his patient with a secure base. This is a role very similar to that described by Winnicott as 
'holding' and by Bion as 'containing'.  
In providing his patient with a secure base from which to explore and express his thoughts 
and feelings the therapist's role is analogous to  that of a mother who provides her child with a 
secure base from which to explore the world. The therapist strives to be reliable, attentive, and 
sympathetically responsive to his patient's explorations and, so fa r as he can, to see and feel 
the world through his patient's eyes, namely to be empathic. At the same time he is aware that, 
because of his patient's adverse experiences in the past, the patient may not believe that the 
therapist is to be trusted to behave kindly or to understand his predicament. Alternatively the 
unexpectedly attentive and sympathetic respons es the patient receives may lead him to  
-140-  
suppose that the therapist will provide him with al l the care and affection which he has always 
yearned for but never had. In the one case theref ore the therapist is seen in an unduly critical 
and hostile light, in the other as re ady to provide more than is at all realistic. Since, it is held, 
both types of misunderstanding and misconstruction, and the emotions and behaviour to 
which they give rise, are central features of th e patient's troubles, a therapist needs to have the 
widest possible knowledge of the many forms thes e misconstructions can take and also of the 
many types of earlier experience from which th ey are likely to have sprung. Without such 
knowledge a therapist is poorly placed to see and feel the world as his patient is doing.  
Even so, a patient's way of construing his rela tionship with his therapist is not determined 
solely by the patient's history: it is determined no less by the way the therapist treats him.

Thus the therapist must strive always to be aw are of the nature of hi s own contribution to the 
relationship which, amongst other influences, is likely to reflec t in one way or another what 
he experienced himself during his own childhood.  This aspect of therapy, the counter-
transference, is a big issue of its own and the subject of a large literature. Since it is not 
possible to deal with it furt her here, I want to emphasize not only the importance of the 
counter-transference but also that the focus of therapy must always be on the interactions of 
patient and therapist in the here and now, and th at the only reason for encouraging the patient 
at times to explore his past is for the light it throws on his current ways of feeling and dealing 
with life.  
With that proviso firmly in mind, let us consid er some of the commoner forms that a patient's 
misconstructions can take and how they are likely  to have originated. This is the aspect of 
therapy in which the work of a therapist who adopt s attachment theory is likely to differ most 
from one who adopts certain of the traditio nal theories of personality development and 
psychopathology. Thus, for example, a therapis t who views his patient' s misperceptions and 
misunderstandings as the not unreasonable pr oducts of what the patient has actually 
experienced in the past, or has repeatedly been  told, differs sharply fr om one who sees these 
same misperceptions and  
-141-  
misunderstandings as the irra tional offspring of autonomous  and unconscious fantasy.  
In what follows I am drawing on several di stinct sources of information: studies by 
epidemiologists; the studies by developmental psychologists already re ferred to; observations 
made during the course of family therapy; an d not least what I have learned from patients 
whom I have treated myself and from t hose whose therapy I have supervised.  
Influence of earlier experiences on the transference 
relationship  
It not infrequently happens that a patient is acutely apprehensive lest  his therapist reject, 
criticize, or humiliate him. Sinc e we know that all too many children are treated in this way 
by one or other, or both, of their parents, we can be reasonably confident that that has been 
our patient's experience. Should it seem likely that the pati ent is aware of how he is feeling 
and how he expects the therapist to treat him, the therapist will indicate that he also is aware 
of the problem. How soon the therapist can link these expectations to the patient's experiences 
of his parents, in the present perhaps as well as  the past, turns on how willing the patient is to 
consider that possibility, or whether, by contrast, he insists that his parents' treatment of him is 
above criticism. Where the latter situation obtai ns, there is the prior problem of trying to 
understand why the patient should insist on retaining this favourable  picture when such 
evidence as is available points to its being mistaken.  
It happens in some families that one or other parent insists that he or she is an admirable 
parent who has always done  everything possible for the child and that, in so far as friction is 
present, the fault lies exclusively with the child. This attitude of the parent all too often cloaks 
behaviour that, by ordinary standards, has been far from perfect. Yet, since the parent insists 
that he or she has given the child constant af fection and that the child must have been born

bad and ungrateful, the child has little option bu t to accept the picture, despite being aware 
somewhere in his mind that the picture is hardly fair.  
-142-  An added complication arises when a patient has, as a child, been subjected to the strongest of 
instructions from a parent on no account to te ll anyone of certain ha ppenings within the 
family. These are usually quarrels in which the parent is aware that hi s or her behaviour is 
open to criticism; for example, quarrels between the parents, or between a parent and a child, 
during which dreadful things have been said or done. The more insistent a therapist is that his 
patient tell everything, the more distressing th e dilemma is for his patient. Injunctions to 
silence are not uncommon in families and have been much neglected as sources of what has 
traditionally been called resistan ce. It is often useful for a th erapist to enquire of a patient 
whether he may have been subjected to such pr essures and, if so, to help him resolve the 
dilemma.  
So far we have been considering cases in whic h a patient is in some degree aware of his 
expectations of being rejected, criticized, or humiliated. Not infrequently, however, a patient 
seems wholly unaware of any such feelings despite his attitude to the therapist exuding 
distrust and evasion. Evidence shows that these states of mind occur especially in those who, 
having developed an anxiously avoi dant pattern of attachment dur ing early years, have striven 
ever since to be emotionally selfcontained a nd insulated against intimate contacts with other 
people. These patients, who are of ten described as being narcissist ic or as having a false self, 
avoid therapy as long as they can and, should they undertake it, keep the therapist at arm's 
length. If allowed to, some will talk ince ssantly about anything and everything except 
emotionally charged relationships, past or presen t. Others will explain that they have nothing 
to talk about. One young woman, whose every move indicated deep distrust of me, spent the time boasting of her delinquent exploits, many of them fictitious I suspected, and pouring 
contempt on what she insisted was my dull and narrow life. To treat such deeply distrustful 
people was compared many years ago by Adrian Stephen ( 1934) with trying to make friends 
with a shy or frightened pony: both situatio ns require a prolonged,  quiet, and friendly 
patience. Only when the therapist is aware of the constant rebuffs  the patient is likely to have 
been subjected to as a child whenever he sought comfort or help, and  
-143-  
of his terror of being subjected to something si milar from the therapist, can the latter see the 
situation between them as hi s patient is seeing it.  
Another and quite different caus e of wariness of any close c ontact with a therapist for the 
patient is dread lest the therapist trap him into  a relationship aimed to serve the therapist's 
interests rather than his own. A common origin of such fear is a childhood in which a parent, 
almost always mother, has sought to make the child her own attachment figure and caregiver, 
that is, has inverted the re lationship. Very often this is done unconsciously and using 
techniques that, to an uninformed eye, may appe ar to be overindulgence but that are really 
bribes to retain the child in a caregiving role.  
Not infrequently a patient shifts during the th erapy from treating his therapist as though he 
was one or other of his parent s to behaving towards him in the way one of his parents had 
treated him. For example, a patient who has been  subjected to hostile threats as a child may

use hostile threats to his therapist. Experiences of scornful contempt from a parent may be re-
enacted as scornful contempt of the therapist. Sexual advances from a parent may reappear as 
sexual advances to the therapist. Such beha viour may be understood in the following way. 
During his childhood a person learns two principal forms of behaviour and builds in his mind 
two principal types of model. One form of beha viour is, of course, that of a child, namely 
himself, interacting with a parent, his mo ther or his father. The corresponding working 
models he builds are those of himself as a ch ild in interaction with each parent. The other 
form of behaviour is that of a parent, namely hi s mother or his father, interacting with a child, 
himself. The corresponding models  he builds are those of each  parent in interaction with 
himself. Therefore, whenever a therapist is puz zled by, or resentful of, the way he is being 
treated by a patient, he is always wise to e nquire when and from whom the patient may have 
learned that way of treating othe r people. More often than not it  is from one of his parents. *  
*  Within traditional theory this shift of role by a patient is likely to be termed a case o f
identification with the aggressor.  
-144-  
With some patients the therapeutic relationship is  one in which anxiety, distrust, and criticism, 
and sometimes also anger and contempt, are overt and predominate, and the therapist seen in 
dark colours. Such sentiments as gratitude for the therapist's efforts or respect for his 
competence are conspicuous by their absence. The ta sk then is to help the patient grasp that 
much of his present resentment stems from past mistreatment at  the hands of others and that, 
however understandable his anger may be as a result, to continue fighting old battles is 
unproductive. To accept that an unhappy past cannot be changed is usually a bitter pill.  
With other patients the situation is reversed : the transference relationship becomes one in 
which overt gratitude, admiration,  and affection are readily expressed, and the therapist seen 
in a glow of rosy perfection. Dissatisfaction a nd criticism are notably absent, and anger at the 
therapist's shortcomings, especially absences, unimaginable. Such idealization of the therapist 
springs, I believe, partly from unrealistic hopes and expectations of what  the therapist is able 
and willing to provide, and partly from a childhood in which criticism of a parent is forbidden 
and compliance enforced, either by some guilt-induc ing technique or else by sanctions such as 
threats not to love, or even to abandon, the ch ild. With this type of childhood experience, the 
patient's unconscious assumption is that the therapist will expect the same degree of 
obedience as his parent s had expected and will enforce it by techniques or by threats similar 
to the ones they used.  
Unfortunately there has been a tendency in so me quarters to confuse the theory advanced 
here, which regards the way cert ain parents treat their childre n as being a major cause of 
mental ill-health, with an attitude of mind that  simply blames parents. No one who works in 
the fields of child psychiatry and family ther apy is likely to make this mistake. On the 
contrary, as already remarked, it has long been  recognized that the mi sguided behaviour of 
parents is more often than not the product of their own difficult and unhappy childhood. As a 
result much skilled time has al ways been devoted to helping pa rents escape from the adverse 
influences of their own childhoods.  
-145-

Furthermore, during the treatment of an individu al (of any age) who has suffered at the hands 
of his parents, the therapist, whilst accepti ng the patient's account, avoids moral judgement. 
On the contrary, whenever opportunity offers, he  will encourage his pa tient to consider how 
and why the parent under discus sion may have behaved as he or she has done. In raising these 
questions, it is always useful for the therapist to enquire of the patien t what he knows of the 
childhood experiences that the parent in questi on may have had. Not infrequently this leads 
the patient to gain some understanding of how things had developed and, from understanding, 
often to move on to a measure of forgiveness a nd reconciliation. In family sessions it can be 
especially valuable if a parent can be encouraged to give an account of his or her childhood. 
This enables all those present -- the parent him- or herself, the spouse, the children, and the 
therapist -- to gain some insight into how and why family life has developed as it has and how 
each can best help improve it . As already mentioned (p. 133 ), this strong tendency for 
attachment problems to be transmitted across generations, through the influence on parenting 
behaviour of relationship probl ems stemming from the parent's  own childhood, is at last 
receiving the research attention it deserves.  
Some pathogenic situations and events of childhood  
A therapist, I believe, cannot be too well informed about the di sguised and distorted 
relationships that can occur in some families, a nd the terrible things that can happen in others, 
for it is only if he is so informed that he can  have a reasonably clear idea of what probably lies 
behind his patient's defences, or of the origins of his anxiety, anger, and guilt. Once he is 
adequately informed, he is well placed not only to appreciate the truth of what his patient may 
be describing as having happened to him but also  to broach, more or less tentatively, some of 
the kinds of situation to which the patient ma y well have been exposed but to which he may 
be either unable or unwilling to refer. In list ing the following situations I am doing no more 
than indicating  
-146-  
some that are both common and have, until recent ly, been neglected in the psychotherapeutic 
literature. *  
Threats not to love a child used as a means of control  
It is easy for a mother to say to a child that sh e will not love him if he behaves in such and 
such a way. What this means is that the moth er is threatening not to provide affection or 
comfort at times when her child is upset, frighten ed, or distressed, and not to provide help or 
encouragement at other times. If such threats are used systematically by either parent, or both, 
the child inevitably grows up intensel y anxious to please and guilt-prone.  
Threats to abandon a child  
Threats to abandon are a degree more frightening to a child than threats no longer to love him. 
This is especially so if the parent enacts a threat, perhaps by disapp earing herself for a few 
hours or by packing her child's suitcase and walki ng him up the street, allegedly to the home 
for bad boys. Since threats to abandon often ta ke a highly idiosyncratic form, a patient may 
deny that he was ever subjected to them. In  such cases the truth may emerge with its 
accompanying emotion only when the special wa y in which the threat was phrased is

recollected. One example is a mother who had concocted the story that a yellow van would 
draw up and take her son away. Another is a fa ther whose story was that his daughter would 
be sent to a school on a remote rock surrounded by sharks ( Marrone 1984). Thus, in the first 
case, all the mother had to say was 'Well the yell ow van will come', and, in the second, for the 
father to say Then it will be the rock school', fo r the child instantly to desist from whatever he 
or she was doing. In a third case, the code word  was 'margarine', the mother having coupled 
her threat to send her son away to a children's home with an insistence that he would have to 
eat margarine there. For these patients a general phrase  
*  Since in previous publications I have given much attention to the ill effects on personality
development of bereavements and prolonged separations, these themes are omitted from
what follows.  
-147-  like 'threat to abandon' had failed to ring a be ll. Only when the code word was unearthed was 
the original terror experienced afresh and the source of the separation anxiety located.  
Threats to commit suicide  
Sometimes a distraught parent threatens to commit suicide if some distressing situation 
continues. This may occur duri ng quarrels between parents, whic h the child overhears, or may 
be directed at the child himself. In either cas e such threats strike terror. One lesson to be 
learned from these cases is that, whenever a pati ent refers to his parents as having quarrelled, 
the therapist should always enquire 'What did they say to each other?' Not infrequently a 
patient blocks at this. In a fit of temper quarre lling parents may say appalling things to each 
other. This is bad enough. What makes it far wo rse is when, after cooling down, they disclaim 
having said any such thing.  
Disclaimers and disconfirmations  
Examples of disclaimers by a parent of what he or she has said or done, and persistent efforts 
to disconfirm what a child has seen or heard, are given in some detail in Lecture 6 and the 
adverse effects on pers onality development of such pressures emphasized. During therapy 
these effects emerge as great uncertainty in a pa tient as to whether some family episode did or 
did not occur and guilt about adumbrating it. Here, as so often, a key role for the therapist is 
to sanction the patient's exploration of all the various possibilities, both those favourable to 
his parents and those unfavourable to them, and to encourage him to weigh the evidence 
available, whilst he (the therapist) remains re solutely open-minded as to where the truth may 
lie.  
Thus far in this exposition I ha ve not considered the critical  issue of how far we can and 
should rely on the validity of ou r patients' reports. Memories are certainly fallible, and there 
are various occasions when an experienced therap ist will rightly question the truth of what his 
patient is saying. What then are th e criteria by which we should judge?  
-148-

First, broad generalizations about the kind of pa rent the mother or father was and about the 
kind of parenting received are never to be give n credence unless and until they are supported 
by detailed examples of how each treated the pati ent as a child in particular situations. For 
example, the glowing account of a wonderful  mother may well go unsupported when detail 
becomes available. Valid accounts of affectionate parenting not only give plenty of favourable 
details but are likely also to be interlaced with occasional criticism, so that the parent can be 
seen in the round. Similarly, disparaging accoun ts of parents in uniform ly adverse terms need 
close examination. Invalid accounts of either sort tend to be sweeping and extreme, to be 
either white or black. Detail is either lacking or, should it be given, is at variance with the 
portrait presented. By contrast, whenever plenty of consistent detail is  given and the picture 
that emerges conforms to what we know, from other sources, does happen in other families, 
and also to the known antecedents of the types of problem besetting the patient, it is absurd to 
doubt its overall validity, even if some points remain in question.  
The origin of these extremes is not infrequent ly external pressure. For example, one parent 
has insisted that the child take sides with him or her against the other parent who is 
represented as being all bad. Or  else a parent who has many s hortcomings insists that he or 
she is above criticism.  
Another occasion when a therapist is right to doubt  the patient's story is when there is reason 
to suspect that the patient is a pathological liar.  Such cases are comparatively rare and, if only 
for that reason, may go undetected for a time. Sooner or later, however, mounting 
inconsistencies and improbabilities, as well as  the way the patient tells his story, engender 
first doubt and, later, certainty that the patient is not to be believed.  
Apart from these exceptions I believe patients'  accounts are sufficiently trustworthy that a 
therapist should accept them as being re asonable approximations to the truth; * and 
furthermore that it is anti-therapeutic not to do so. Constantly to query the  
*  For research purposes, however, criteria for accepting retrospective information as vali d
must be much stricter.  
-149-  
validity of the patient's story, even if only by implication, and insisten ce on the distorting role 
of imagination or fantasy, is the reverse of empathic. It conveys to the patient that the 
therapist does not understand him and may indeed  convince him that the therapist is behaving 
exactly as his parent had predicted. Thus some pa rents, having insisted that their child not tell 
of something the parent is ashamed of, may then add that, in any case, were he to do so no one 
would believe him.Among the large range of ad verse events and situations not so far 
mentioned in this lecture that a therapist should have in his mind as likely to have occurred in 
the life of one patient or another are the following:  
 a child may never have been wanted by one or both parents;   a child may be of the wrong sex in a family in which parents had set their hearts on a boy 
or a girl;  
 a child may have been made the family scapegoat, sometimes as a result of a family
tragedy that, with greater or less plausibilit y, has always been attributed to him;  
 a parent may have used guilt-inducing t echniques to control a child, for example,
frequent claims that the child's  behaviour makes mother ill;

a parent may have sought to make one of her children her attachment figure by
discouraging him from exploring the world aw ay from her and from believing that he 
will ever be able to make his way on his own;  
 a child's unusual role in a family may be the result of his mother having had an extra-
marital affair during her marriage so that the ch ild's putative father is not his real father;  
 another cause of a child's u nusual role is when one or ot her parent identifies one chil d
with a relative, often one of the child's gr andparents, with whom he or she has had a
difficult relationship, and who then re-enacts that relationship with the child;  
-150-  
 a child may have been the target of more or  less serious physical abuse from a parent o r
step-parent;  
 a child may have been involved in sexual ab use from a parent, step-parent, or older 
sibling for short or long periods of time.  
For those unaware of the commoner effects on personality development of exposure to 
situations of these kinds, a number of refe rences are given in an Appendix (pp. 173 -4).  
Inevitably the influential events of an individual's first two or  three years will either never 
have been registered in his memory or else can not now be recalled. Here , of course, the best a 
therapist can do is to infer, on the basis of the transference situation and of such information 
as the patient has gleaned about his early year s, combined with such wider knowledge of 
personality development as the therapist has ac quired, what the nature of those events may 
have been. In other words, he resorts to recons truction; but in doing so he can in future draw 
on a much wider and more reliable knowledge  of family influences on personality 
development than has traditionally been availabl e to analytically trained psychotherapists.  
The therapist's stance  
In this account of therapeutic principles, therapists  will recognize much that has long been 
familiar, though often under a different name. The therapeutic alliance appears as a secure 
base, an internal object as a working, or repr esentational, model of an attachment figure, 
reconstruction as exploring memori es of the past, resistance (somet imes) as deep reluctance to 
disobey the past orders of parents not to tell or not to remember. Among points of difference 
is the emphasis placed on the therapist's role as  a companion for his patient in the latter's 
exploration of himself a nd his experiences, and less on the therapist interpreting things to the 
patient. Whilst some traditional therapists might be described as adopting the stance 'I know; 
I'll tell you', the stance I advocate is one of  'You know, you tell me'. Thus the patient is 
encouraged to believe that, with support and  
-151-  
occasional guidance, he can discover for himsel f the true nature of the models that underlie 
his thoughts, feelings, and actions and that, by examining the natu re of his earlier experiences 
with his parents, or parent subs titutes, he will understand what has led him to build the models 
now active within him and thus be free to re structure them. Fortunately the human psyche, 
like human bones, is strongly inclined towards se lf-healing. The psychoth erapist's job, like 
that of the orthopaedic surgeon's, is to provide  the conditions in which self-healing can best 
take place.

Amongst those who have recently given detailed  accounts of the special value of adopting a 
modest and tentative approach are Pe terfreund ( 1983) and Casement ( 1985).  
In the foregoing description the therapist's role  has been likened to that of a mother who 
provides her child with a secure base from which to explore. Th is means, first and foremost, 
that he accepts and respects hi s patient, warts and all, as a fellow human being in trouble and 
that his over-riding concern is to promote his pa tient's welfare by all means at his disposal. To 
this end the therapist strives to be reliable, attentive, empathic, and sympathetically 
responsive, and also to encourage his patient to explore the world of his thoughts, feelings, 
and actions not only in the presen t but also in the past. Whilst always encouraging his patient 
to take the initiative, the therapist is in no sense passive. On the one hand he tries to be 
attentive and sensitively responsive. On the other,  he recognizes that there are times when he 
himself should take the initiative. For exampl e, when a patient wastes time talking about 
everything and anything except his thoughts and fe elings about people, it will be necessary to 
draw his attention to his avoidance of the area, and perhaps also to his deep distrust of the 
therapist's efforts to be helpful or of his capacity to keep c onfidences. With another patient, 
who perhaps is very willing to explore memori es of childhood, there will be many occasions 
when a therapist can usefully ask for more de tail or raise questions  about situations of 
childhood that the patient has so far not refe rred to directly, but which seem plausible 
possibilities in the light of what he has been desc ribing, and in the light also of the particular 
problems from which the patient  is suffering. In doing  
-152-  so, moreover, the therapist must never forget that his patient may still be strongly influenced 
by his parents' injunctions not to know about events he is not  supposed to know about and not 
to experience feelings he is  not supposed to experience.  
An interruption to therapy probably always gene rates some reaction in a patient; sometimes it 
is conscious, at others unconscious, but noneth eless evident. When conscious, it may take the 
form of overt complaint or angry protest; when  unconscious it may manifest itself by the 
patient disparaging therapy or missing a sessio n or two before the break. How a therapist 
evaluates these reactions and responds to them will reflect his theoretical position. Someone 
who adopts attachment theory will respect his pa tient's distress or anger about the separation 
and will regard them as the natural responses of someone who has become attached to another 
-- a respect that will be implicit in anything he says or does. At the same time he will give 
attention to the form his patient's reaction take s. If openly expressed, he  will be sympathetic 
and may be able to ease the patient's distre ss by giving him informati on about how he could 
communicate during the break. In addition, the th erapist will consider how the patient is 
construing the interruption and, should there be  evidence of misconstruction, will attempt to 
discover how it may have originated. If, for ex ample, the patient is apprehensive that the 
therapist will not return, the possibility of the patient having been exposed to threats by a 
parent to abandon him might be  explored. In cases where th e interruption is due to the 
therapist being unwell, he will be alert to the po ssibility that the patient may be apprehensive 
lest something he (the patient) has done or said is responsible. Were that to be so, the therapist 
would explore whether one of th e patient's parents had sought to  control him by claiming that 
the way he behaved was making mother or father ill.  
Similarly, should a patient react to an inte rruption by disparaging therapy or missing a 
session, a therapist who adopts attachment theory  would ask himself why his patient is afraid

to express his feelings openly and what his ch ildhood experiences may have been to account 
for his distrust.  
It is not unlikely that the description just gi ven of a therapist's mode of responding to his 
patient's reactions to an interruption  
-153-  
will contrast with that of a therapist who adopts  and applies one or another of the traditional 
psychoanalytic theories. For example, one such therapist might regard his patient's reactions 
as being rather childish, even infantile, and as indicating that the patient was fixated in an oral 
or a symbiotic phase. What the therapist then mi ght say, and especially the way he might say 
it, could well be experienced by the patient as la cking in respect for his (the patient's) current 
feelings of attachment, distress, or anger. Here again there woul d be danger that the therapist 
might appear to be responding in a cold unsympa thetic way and all too lik e one or other of the 
patient's parents. Were that so the exchange would be anti-therapeutic.  
How far a therapist can wisely go in meeting a patient's desire to keep in communication 
during breaks, e.g. by telephone, and for comfor ting when distressed during a session, turns 
on many personal factors in their relationship. On the one hand, there is danger of the 
therapist's appearing to lack sympathy for the patient's distress or even to seem rejecting. On 
the other is the risk of his appearing to offer more than he is prepared to give. There are 
occasions when it would be inhuman not to allo w a distressed patient to make some form of 
physical contact: the roles are then explicitly comforter and co mforted. Yet there is always 
danger that physical contact can elicit sexual feelings, especially when sexes are different. 
Depending on the situation each therapist must  make his own decisions and draw his own 
lines. The more alive to such issues a therapist is the better will he be able to avoid the 
pitfalls.  
Emotional communications and the restructuring of 
working models  
When a therapist utilizes the kind of technique advocated here, it can sometimes happen that 
therapy gets into a rut in which the patient persis ts endlessly in describi ng what a terrible time 
he had as a child and how badl y his parents treated him, without any progress being made. 
One cause of such perseveration, I suspect, is that the patient is convinced that his therapist 
does not accept the truth of what he is saying: hence his endless  
-154-  
repetition of it. This may be due to the patient  having always been scoffed at by those to 
whom he has told the story in the past or, and perhaps more commonly, to the therapist 
himself having indicated scepticis m or disbelief. This can be done in a myriad of ways, by 
tone of voice, by querying the deta ils, by failing to attach any pa rticular weight to what the 
patient describes.  
Evidently when the problem lies in the therapist' s incredulity the way out is for him to make it 
plain that he knows all too well that such thi ngs do happen to children  and has no reason to

doubt the patient's account. Even so the impasse ma y continue: the story is told and retold in a 
flat cynical way with no s how of feeling whatever.  
This situation has been discussed by Selma Frai berg who, with colleagues, set out to help 
vulnerable mothers at risk of either neglecting or abusing their infant s ( Fraiberg, Adelson, 
and Shapiro 1975). They describe making visits to the homes of two such mothers and listening to the distressing tales these women had to tell. Each told a story of gross cruelty 
during childhood -- being subjected to violent b eatings, being locked out in the cold, often 
deserted by mother, being shunted from one place  to another, and of having no one to go to 
for help or comfort. Neither gave a hint of how  they might have felt nor what they may have 
felt like doing . One, a girl of sixteen who avoide d touching or holding her baby (who 
screamed hopelessly), insisted: 'But what's the use of talking? I always kept things to myself. I 
want to forget. I don't want to think.' This was the point at which the therapist intervened -- by 
herself expressing all the feelings that any and every child would be expected to have in the 
situations described: how fri ghtened, how angry, how hopeless one would feel, and also how 
one would long to go to someone  who would understand and provi de comfort and protection. 
In doing so the therapist not only showed an unde rstanding of how the pa tient must have felt, 
but communicated in her manner that the expressi on of such feeling and desire would be met 
with a sympathetic and comforting response. On ly then was it possible for the young mother 
to express all the grief, the tears, 'and the unspeakable anguish for herself as a castoff child' that she had always felt bu t had never dared express.  
-155- In this account of Fraiberg's methods of helping a patient express the emotions she 
dares not show I have delibera tely emphasized the link between emotion and action. Failure to 
express emotion is due very largely to unconsciou s fear lest the action of which the emotion is 
a part will lead to a dreaded outcome. In many families anger with an adult leads to 
punishment which can sometimes be severe. More over a tearful appeal for comfort and help 
can lead to rejection and humiliation. It is pe rhaps too often forgotten by clinicians that many 
children, when they become distressed and weep y and are looking for comfort, are shooed off 
as intolerable little cry-babies. Instead of  the comforting provided by an understanding and 
affectionate parent, these children meet with an  unsympathetic and critical rebuff. No wonder 
therefore if, should this pattern prevail during  childhood, the child learns never to show 
distress or seek comfort and, should he undertake therapy, assume s that his therapist will be as 
intolerant of anger and tears as his parents always were.  
Every therapist who adopts a psychoanalytic pe rspective has long recognized that, to be 
effective, therapy requires that a patient not  only talks about his memories, his ideas and 
dreams, his hopes and desires, but also expres ses his feelings. The di scussion of Fraiberg's 
technique for helping a cynical and frozen young woman to discover the depth of her feelings and to express them freely to her therapist is therefore a fitting note on which to end.  
In writing this lecture I have throughout been aw are that, by using terms such as 'information', 
'communication', and 'working mode ls', it would be easy for an  unwary reader to suppose that 
these terms belong within a psychology concer ned only with cognition and one bereft of 
feeling and action. Although for many year s it was all too common for cognitive 
psychologists to omit reference to emotion, it is  now recognized that to do so is artificial and 
unfruitful ( Hinde, Perret-Clermont, and Steven son-Hinde 1985). There are, in fact, no more 
important communications between one human being and another th an those expressed 
emotionally, and no information more vital for constructing and reconstructing working 
models of self and

-156-  
other than information about how each feels to wards the other. During the earliest years of 
our lives, indeed, emotional expression and its reception are the only means of 
communication we have, so that the foundatio ns of our working models of self and 
attachment figure are perforce laid using info rmation from that source alone. Small wonder 
therefore, if, in reviewing his attachment rela tionships during the course of psychotherapy and 
restructuring his working models, it is the em otional communications between a patient and 
his therapist that play the crucial part.  
-157-  
LECTURE 9 Developmental psychiatry 
comes of age  
When I was invited by the American Psychiatric Association to give the Adolf Meyer Lecture 
at its annual meeting (for the second time after an  interval of twenty-five years), I thought it a 
good opportunity to give an account of the pres ent state of developmental psychology and 
developmental psychopathology to an audience, many of whom were unfamiliar with current 
advances and notably prone to question the scientific status of the field. The lecture was 
delivered in Washington, D.C, in May 1986 .  
Although there are a few passages that repeat mate rial to be found in Lecture 7, they have 
been retained so as to avoid weakening this one.  
During the first third of this century ther e were two great proponents of developmental 
psychiatry -- Adolf Meyer and Si gmund Freud. Both believed that the seeds of mental health 
and ill-health were sown in childhood and th at, if we are to understand the present-day 
functioning of a person, it is necessary to know how he or she has become the man or woman 
we meet with today.  
In their approaches to the field Meyer and Fr eud took very different routes. Initially Freud 
focused on traumatic family relationships, in cluding incest, but soon, and for reasons that 
remain obscure, he claimed that the real-life ev ents he had originally invoked as pathogenic 
had never occurred and that the patient had only imagined them. Thenceforward the em-  
-158-  
 
phasis was on fantasy. Consequent ly Freud's interests became focused on a person's internal 
world of mental processes, especially on th e powerful influence that unconscious processes 
have on the way a person feels, thinks, and beha ves and, above all, on the defensive processes 
that actively keep them unconscious.  
Meyer, by contrast, continued to emphasize the part played by real-life events in shaping 
personality, but he was never very specific about the nature of the ones that matter, nor did he 
advance any theory of how being exposed to some  event or situation affects a person's mental

state. Nonetheless, Meyer's approach played a major part in promoting the mental hygiene 
movement and child psychiatry. In both these revolutionizing movements the notion that the 
environment in which a child grows up plays a cr itical part in determin ing his future mental 
health has always been a stubbornly held if il l-defined assumption. Moreover, these are the 
fields in which Freud's original ideas about  the role of childhood trauma not only have 
persisted but have borne  valuable fruits.  
We can see now that the tremendous strides be ing made today in developmental psychiatry 
owe a great deal to both these pioneers. To Adolf Meyer is due  the credit for having continued 
to emphasize the influential role of the events  and situations a pers on meets with during his 
development. To Sigmund Freud is due the cr edit for having emphasi zed the influence on 
how a person thinks, feels, and behaves that is  exerted by his internal world, namely by the 
way he perceives, construes, a nd structures the events and situ ations he encounters. Today we 
know that the central task of developmental psyc hiatry is to study the endless interaction of 
internal and external and how the one is cons tantly influencing the other, not only during 
childhood but during adolescence and adult life as well.  
Evidence that happenings within the family during childhood and adolescence play a major 
role in determining whether a person grows up to be mentally healthy or not is now 
formidable, and a review of the important epidemiological findings has recently appeared ( 
Rutter 1985). For that reason, in this lectur e I am presenting only a limited amount of data, 
some  
-159-  
epidemiological and retrospective and some etho logical and prospective, and am giving most 
attention to the conceptual framework within wh ich I believe the different sets of findings can 
best be comprehended.  
As an example of retrospectiv e data I draw on the findings of the group led by George Brown 
and Tirril Harris, which has been undertaking so phisticated epidemiologi cal studies to explore 
the roles of family experience and other social  variables as antecede nts of depressive and 
anxiety disorders in adult life. As an example of prospective data, probably as yet little known 
among general psychiatrists, I draw on the work of those developmental psychologists who 
have been inspired by and are busy expanding  the brilliant pioneering studies of Mary 
Ainsworth into the development of a young child' s capacity to make intimate emotionally 
mediated relationships with parents. Since the findings fr om these two quite different 
approaches are highly compatible, the resulting scientific structure can be likened to a 
trilithon made up of two stout pillars of evid ence and a crosspiece of theory. A major 
conclusion is that, whatever influence varia tions in genetic endowment may be exerting on 
personality development and ps ychopathology, an immense infl uence is unquestionably being 
exerted by environmental variables of the kinds now being system atically explored.  
Emotionally mediated bonds and mental health  
For many years sensitive clinicians have been aware that a person's mental state is deeply 
influenced by whether his intimate personal rela tionships are warm and harmonious; or tense, 
angry, and anxious; or else emotionally remote ; or possibly non-existent. Among clinicians so 
oriented a variety of terms are in use: 'significa nt other', 'dependency', 'symbiosis', and 'object 
relations. Nevertheless, although it is a field of  manifest importance to psychiatry, there has

been no agreement how best to conceptualize it . A number of theoretical systems have been 
proposed, almost all of them derived in so me sort of way from psychoanalysis, and a 
mountain of  
-160-  
jargon has accumulated. Yet none has generate d sustained productive research. In scientific 
quarters the whole field still struggles for recognition.  
Some years ago, as a family psychiatrist re searching the effects on young children of being 
removed from home to the care of strange peop le, I was faced with a problem. Since a young 
child in that situation is intensely distressed an d shows every sign that he desperately wishes 
to recover his mother, the question arises: how do  we understand the origin and nature of this 
extraordinarily strong tie between child and mother ? The only theory extant at that time was 
that a child becomes emotionally linked to his mother because she feeds him. Dissatisfied 
with that explanation, I was lucky enough to be  introduced to the ideas of Konrad Lorenz. 
Ethologists, I discovered, were just as intere sted in the strong bonds between offspring and 
parents in a range of animal sp ecies as I was in those of the human species. Moreover, as 
professional biologists, their a pproach was radically different from anything I had met with 
among psychologists and psychiatrists. Bonds be tween individuals, I learned, which occur in 
a great array of mammalian and avian species, could be studi ed experimentally and their 
survival function considered in the light of evolution theory.  
Here, then, was a possible new approach to our problem and one that seemed to fit our data. 
Not only that, but the ethologists had develope d sensitive means for obs erving and recording, 
and were sophisticated scientists with their feet  firmly planted in the biological sciences. The 
upshot was that I fell for this approach and deci ded to explore its potentials. Now, thirty years 
later, I am glad I embarked on the gamble. Than ks to the work of many gifted colleagues, the 
bare bones of theory are becoming clothed with  hard-wearing empirical garments; and there 
are now several productive research progra mmes studying the differe nt ways in which 
intimate personal relationships can develop, wi th their causes and c onsequences -- research 
programmes, I emphasize, that are as firmly  rooted in biology as  are those of the 
physiological psychiatrists who ha ve improperly kidnapped the labe l 'biological psychiatry'.  
Not only are ethological concepts proving extrem ely fruitful when appl ied to our field but 
there are many others also, not  
-161-  
available to Meyer or Freud, wh ich present-day science provides to help us explain our data. 
For example, additional concepts of high explan atory value in our field come from control 
theory and cognitive psychology, including huma n information processing.Among principal 
propositions of this new approach ( Bowl by 1969/ 1982, 1973, 1980) are the following:  
a.  that emotionally significant bonds between individuals have basic survival functions an d
therefore a primary status;  
b.  that they can be understood by postulating c ybernetic systems, situated within the central 
nervous system of each partner, which have th e effect of maintaini ng proximity or ready
accessibility of each pa rtner to the other;  
c.  that in order for the systems to operat e efficiently each partner builds in his mind
working models of self and of other, and of the patterns of interaction that have

developed between them;  
d.  that present knowledge requi res that a theory of developm ental pathways should replace
theories that invoke specific phases of development in which it is postulated a person 
may become fixated and/or to which he may regress.  
The bonds with which developmental psychiatry is  principally concerned are that of child to 
parent and the complementary bond of parent to child. The key hypothesis is that variations in 
the way these bonds develop and become orga nized during the infancy and childhood of 
different individuals are major determinants of  whether a person grows up to be mentally 
healthy or not. Before discussing variations, ho wever, it is necessary to consider how the 
bonds themselves are best conceived.  
Function and organization of emotional bonds  
Ethological theory regards the propensity to  make strong emotional bonds to particular 
individuals as a basic component of human natu re, already present in germinal form in the 
neonate and continuing through adult life into old age. During infancy  
-162-  
and childhood bonds are with parents (or parent s ubstitutes) who are looke d to for protection, 
comfort, and assistance. During  healthy adolescence and adult li fe these bonds persist but are 
complemented by new bonds, commonly of a he terosexual nature. Although food and sex 
sometimes play important roles in such relations hips, the relationship exists in its own right 
and has an important survival function of it s own, namely protection. Thus, within the 
attachment framework, bonds are seen as neithe r subordinate to nor derivative from food and 
sex. Nor is the urgent desire for comfort and support in adversity regarded as childish, as 
dependency theory implies. Instead, the capac ity to make bonds with other individuals, 
sometimes in the careseeking role and sometimes  in the caregiving one, is regarded as a 
principal feature of effective persona lity functioning and mental health.  
regarded as stronger and/or wiser. A child or older person in the careseeking role keeps within 
range of the caregiver, the degree of closen ess or of ready acces sibility depending on 
Another basic component of human nature is the urge to explore the environment, to play and 
to take part in varied activities with peers.  This behaviour is, of course, antithetic to 
attachment behaviour. When an in dividual of any age is feeling se cure he is likely to explore 
away from his attachment figure. When alarmed, anxious, tired, or unwell he feels an urge 
towards proximity. Thus we see the typical patte rn of interaction betw een child and parent 
known as exploration from a secure  base. Provided the parent is known to be accessible and 
will be responsive when called upon, a healthy ch ild feels secure enough to  explore. At first 
these explorations are limited in both time a nd space. Around the middle of the third year, 
however, a secure child begins to become co nfident enough to increase time and distance 
away -- first to half-days and later to whol e days. As he grows into adolescence, his 
excursions are extended to weeks or months, bu t a secure home base remains indispensable 
nonetheless for optimal functioning and mental health. No concept within the attachment 
framework is more

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central to developmental psychiatry than that of the secure base.  
An obvious way to conceptualize the behaviour observed is to postulate the existence of a 
control system within the central nervous sy stem, analogous to the physiological control 
systems that maintain physiological measures, such as blood pressure and body temperature, 
within set limits. Thus the theory proposes  that, in a way analogous to physiological 
homeostasis, the attachment control system ma intains a person's relation to his attachment 
figure between certain limits of di stance and accessibility. As such, it can be regarded as an 
example of what can usefully be termed environmental homeosta sis ( Bowlby 1973). Among 
situations that activate careseeking are anything th at frightens a child or si gnals that he is tired 
or unwell. Among situations that terminate care seeking and release him for other activities are 
comfort and reassurance. Since control systems are themselves sources of activity, traditional 
theories of motivation which invoke a build up of psychic energy or drive are rendered 
obsolete.  
It is in the nature of a control system that it can operate effectively only within a specified 
environment. For example, the system regul ating body temperature cannot maintain an 
appropriate temperature when e nvironmental conditions become either too hot or too cold, 
which means that whenever conditions go beyond certain limits the whole organism becomes 
stressed or dies. Viewed in an evolutionary pers pective, it is evident that variation and natural 
selection have resulted in each organism's physiological systems being so constructed that 
they operate effectively in the environment to which the species has become adapted and that 
they will become stressed or fail in others.  
An evolutionary perspective is necessary also if  we are to understand psychological stress and 
the environmental conditions that cause it. Li ke other control systems, the system governing 
attachment behaviour is constructed so as to promote survival in the environment in which 
man evolved. Since in such an environment it is essential for survival that an infant or older 
child has an attentive and responsive caregiver to  whom to go in emergency, it follows that 
his attachment sys-  
-164-  tem will be constructed so as to  operate most efficiently in interaction with a person whom the 
child believes will respond promptly and effec tively when called upon. It is not surprising, 
therefore, that a failure in response of his fa miliar caregiver, whether due to physical absence 
or a failure to respond appropriately, should alwa ys cause stress and sometimes be traumatic.  
This leads to consideration of the third major component of human nature relevant to this 
exposition, namely caregiving, which is the pr ime role of parents and complementary to 
attachment behaviour. When looked at in te rms of evolution theory, the occurrence of 
altruistic care of young is readily understood si nce it serves to promote the survival of 
offspring (and often of other relatives as we ll) and thereby the individual's own genes. 
Nevertheless, this form of e xplanation constitutes a radical shift from most psychological 
theorising, including Freud's, which has mistak enly assumed that individuals are by nature 
essentially selfish and that they consider the interests of others  only when constrained to do so 
by social pressures and sanctions. Nothing,  I believe, that stems from an ethological 
perspective has more far-reaching implications for understandi ng human nature than this.

Returning now to the attachment control system within the child, it is evident that for it to 
operate efficiently it requires to  have at its disposal as much information as possible about self 
and attachment figure, no t only in regard to their respective locations and capabilities but also 
in regard to how each is likely to respond to  the other as environmental and other conditions 
change. Observations lead us to conclude th at during the second year of life a child is 
acquiring a considerable knowledge  of his immediate world and that during subsequent years 
this knowledge is best regarded as becoming  organized in the form of internal working 
models, including models of self and mother. The function of these models is to simulate 
happenings in the real world, thereby enabling th e individual to plan his behaviour with all the 
advantages of insight and foresight. The more  adequate and accurate the simulation, of 
course, the better adapted the behaviour based on it is likely  to be ( Johnson-Laird, 1983). 
Although our knowledge of the  
-165-  rate at which these models develop during th e earliest years is still scanty, there is good 
evidence that by the fifth birthday most childre n are using a sophisticated working model of 
mother which includes knowledge of her interest s, moods, and intentions, all of which he can 
then take into account ( Light 1979). With a co mplementary model of himself, he is already 
engaging in a complex intersubjective relationshi p with his mother, who, of course, has her 
own working models both of her child and of he rself. Because these models are in constant 
use, day in and day out, their influence on th ought, feeling, and behaviour becomes routine 
and largely outside of awareness.  
Since as clinicians we know that long before a child reaches the age of 5 the patterns of 
interaction between him and his mother range vastly in diversity, from smooth running and 
happy to being filled with fricti on and distress of every kind a nd degree, and are also apt to 
persist, the more we know about how they originat e the better. It is here that recent research 
by developmental psychologists has made such huge strides.  
Patterns of attachment and their determinants  
Three principal patterns of attachment pres ent during the early years are now reliably 
identified, together with the family conditions that promote them. One of these patterns is 
consistent with the child's developing health ily, and two are predictive of disturbed 
development. Which pattern any one individual develops during these years is found to be 
profoundly influenced by the way his parents (or other parent-type figures) treat him. This 
conclusion, which is as important as it has been  controversial, is unpopular in some circles 
and, in consequence, is constantly challenged . Yet the evidence for it is now weighty and 
derives from a number of prospective research studies of socioemoti onal development during 
the first five years. This research tradition was first set by Ainsworth during the 
nineteensixties ( Ainsworth et al.  1978; Ainsworth 1985) and has since been exploited and 
expanded, notably in the USA by Main ( Main and Weston 1981; Main and Stadtman 1981; 
Main et al.  1985), Sroufe ( 1983, 1985), and Waters ( Waters et al.  1980;  
-166-  
Waters and Deane 1985), and in Germany by  Grossmann ( Grossmann, Grossmann, and 
Schwan, 1986).

The pattern of attachment consistent with health y development is that of secure attachment, in 
which the individual is confident that his pa rent (or parent-figure) will be available, 
responsive, and helpful should he encounter a dverse or frightening situations. With this 
assurance, he feels bold in his e xplorations of the world and also  competent in dealing with it. 
This pattern is found to be promoted by a pa rent, in the early years especially by mother, 
being readily available, sensitive to her child' s signals, and lovingly responsive when he seeks 
protection and/or comfor t and/or assistance.  
about exploring the world. This pattern is prom oted by a parent being available and helpful on 
some occasions but not on others, by separations , and, later, especially by threats of 
abandonment used as a means of control.  
confidence that, when he seeks care, he will be responded to helpfully; on the contrary, he 
expects to be rebuffed. Such an individual a ttempts to live his life without the love and 
support of others. This pattern is the result of the individual's mother constantly rebuffing him 
when he approaches her for comfort or prot ection. The most extreme cases result from 
repeated rejection and ill-treatment, or prol onged institutionalisation. Clinical evidence 
suggests that, if it persists, th is pattern leads to a variety of personality disorders from 
compulsive self-sufficiency to persistent delinquency.  
There is much evidence that, at least in fa milies where caregiving arrangements continue 
stable, the pattern of attachment between child and mother, once established, tends to persist. 
For example, in a sample studied at Berkeley the pattern of attachment to mother at 12 months 
was found, with but few exceptions, still to be present at 6 years ( Main and Solomon, in  
-167-  
press). Furthermore, prospective studies in Minneapolis have shown that the pattern of 
attachment characteristic of the pair, as assess ed when the child is aged 12 months, is highly 
predictive also of behaviour outside the home in  a nursery group, three and a half years later. 
Thus children who showed a secure pattern with mother at 12 months are likely to be 
described by their nursery teachers as cheerful  and co-operative, popular with other children, 
resilient, and resourceful. Those who showed an  anxious avoidant pattern are likely to be 
described later as emotionall y insulated, hostile or antisoc ial, and as unduly seeking of 
attention. Those who showed an anxious resistant pattern are al so likely to be described as 
unduly seeking of attention and eith er as tense, impulsive, and easily frustrated or else as 
passive and helpless.  
Ample confirmation of the teacher's descrip tions comes from independent observers and 
laboratory assessments of the same children ( Sroufe 1983; La  Frénier and Sroufe 1985). 
Similarly, an experimental study done in Ge rmany ( Lütkenhaus, Grossmann, and Grossmann 
1985) shows that at 3 years of age children earl ier assessed as securely  attached respond to 
potential failure with increased effort, wherea s the insecurely attached do the opposite. In 
other words, the securely attached children are responding with confidence and hope that they 
can succeed whilst the insecure are already s howing signs of helplessness and defeatism.

In a number of these studies detailed observati ons have been made of the way the children's 
mothers treated them. Great variability is seen, with high correlations between a mother's 
style of interaction and the child' s pattern of attachment to her. For example, in one such study 
( Matas, Arend, and Sroufe 1978), made when th e children were 2½ years old, mothers were 
observed whilst their children were attempting a task that th ey could not manage without a 
little help. A mother of a secure toddler enabled her child to focus on the task, respected his 
attempts to complete it on his own, and res ponded with the required help when called upon: 
communication between them was harmonious. The mother of an insecure infant was less 
sensitive to the toddler 's state of mind, either not giving sup-  
-168-  
port and help when appealed to or else intruding when the child was striving to solve the 
problem himself.  
In discussing these and similar findings, Br etherton ( 1987) emphasizes the easy flow of 
communication between a mother and her child in a secure partnership a nd concludes that this 
easy communication is possible only when a mother is intuitively alive to the crucial part she 
plays in providing her child with a secure ba se, variously encouragi ng autonomy, providing 
necessary help, or giving comfort acco rding to her child's state of mind.  
Mothers of insecure infa nts deviate from this sensitive patte rn of mothering in a great variety 
of ways. One, common amongst mothers of avoidant infants, is to scoff at her child's bids for 
comfort and support ( Main, Kaplan, and Cassi dy 1985). Another, well known to clinicians 
and the effects of which are now bein g observed by developmentalists ( Sroufe et al.  1985; 
Main and Solomon, in press), is a mother who fails to respect her chil d's desire for autonomy 
and discourages exploration. This  is usually a mother who, not having had a secure home base 
during her childhood, is consciously or unconsci ously seeking to invert the relationship by 
making her child her own attachment figure. In th e past this has too often been labelled 'over-
indulgence' or "spoiling', which ha s led to appalling confusion about what is best for a child.  
It is not difficult to understan d why patterns of attachment, onc e developed, tend to persist. 
One reason is that the way a parent treats a ch ild, whether for better or for worse, tends to 
continue unchanged; another is th at each pattern tends to be self-perpetuating. Thus a secure 
child is a happier and more rewarding child to care for, and also is less demanding than an 
anxious one. An anxious ambivalent child is apt to be whiny and clingi ng, whilst an anxious 
avoidant child keeps his distance, is bad-tempered and prone to bully other children. In each 
of these cases the child's behavi our is likely to elicit an unfa vourable response from the parent 
so that vicious circles develop.  
Although for the reasons given, pa tterns, once formed, are likely to persist, this is by no 
means necessarily so. Evidence  
-169-  
shows that during the first two or three years pattern of attachment is a property of the 
relationship - for example, a child's pattern to mother may differ from pattern to father - and 
also that if the parent treats the child differe ntly the pattern will ch ange accordingly. These 
when it occurs, cannot be attributed to the child's inborn temperament as has often been

claimed. On the contrary, the evidence points unmistakeably to the conclusion that a host of 
personal characteristics traditionally termed temp eramental and often ascribed to heredity are 
environmentally induced. True, neonates differ from each other in many, many ways. Yet the 
evidence is crystal clear from repeated studies that infants described as  difficult during their 
early days are enabled by sensitive mothering to become happy, easy toddlers. Contrariwise, 
placid newborns can be turned into anxi ous, moody, demanding, or awkward toddlers by 
insensitive or rejecting mothering. Not only di d Ainsworth demonstrate this in her original 
study, but it has been found again and again in subsequent ones. Those who attribute so much 
to inborn temperament will have to think again.  
Thus, during the earliest years features of person ality crucial to psychiatry, because from the 
first responsive to the environment, are still rela tively open to change. As a child grows older, 
however, clinical evidence shows that both the pattern of attachment and the personality 
features that go with it become increasingl y a property of the child himself and also 
increasingly resistant to change. This means that he tends to impose it, or some derivative of 
it, upon new relationships, as wi th his teacher in the Minneapol is study. Similarly, experience 
shows that he tends also to impose it or some  derivative of it on to a foster-mother or a 
therapist.  
These tendencies to impose earl ier patterns onto new relationships, and in some measure to 
persist in doing so despite absence of fit, are,  of course, the phenomena that gave birth to 
psychoanalysis. They are also the phenomena that during recent decades have led an 
increasing number of analysts to embrace an obj ect-relations version of psychoanalytic theory 
and, in my own case, to advanc e the attachment version with  
-170-  
its postulate of internal working models of self and attachment figure in interaction. Thus far, 
therefore, the picture presente d can be looked upon as a much  modified and updated variant 
of traditional psychoanalytic thinking in whic h great emphasis is placed on the particular 
pattern into which each personality comes to be  organized during the earl y years, with its own 
distinctive working models or, to use the trad itional term, internal world, and on the strong 
influence thereafter that each individual's models have in shaping his or her life.  
Continuity and discontinuity: vulnerability and resilience  
One of the long-running debates between analysts and others in our field turns on the extent to 
which it is believed that personal ity, once developed during the early years, is open to change. 
Analysts have emphasized a strong tendency towards stability and continuity and have 
explained it as due to the powerful influence of the indivi dual's existing internal world on how 
he construes and responds to every new situation.  Critics have emphasized the extent to which 
an individual's performance can change give n changed conditions of life. Today I hope we 
can agree that, if we are to do justice to the pl ethora of data now available, we must abandon 
simple dichotomies.  
First, a sharp distinction must be drawn between current functi oning, measured in terms of 
presence or absence of psychiatric disorder, an d personality structure, measured in terms of 
more or less vulnerability to adverse life events  and situations. Linked closely to degrees of 
vulnerability, moreover, are the very different ways  that people feel about their lives, either as

mostly enjoyable and to be lived to the full or else as a burden to be endured, as an 
emotionally rich and varied experi ence or as an emotional desert.  
Secondly, we have at all times to think in term s of the interactions an d transactions that are 
constantly occurring between an ever developing  personality and the environment, especially 
the people in it. This means th at it is necessary to think of  each personality as moving through 
life along some  
-171-  developmental pathway, with the particular pa thway followed always being determined by the 
interaction of the personality as it has so far de veloped and the environment in which it is then 
finding itself. If as developmenta l psychiatrists we adopt these ways of thinking, we need to 
picture each personality as moving through life along its own unique pathway. So long as 
family conditions are favourable the pathway w ill start and continue within the bounds of 
healthy and resilient development; but should conditions become suffici ently unfavourable at 
any time, it may deviate to a lesser or greater  extent towards some form of disturbed and 
vulnerable development. Conversel y, should an infant be born into unfavourable conditions, 
the pathway along which it develops may become deviant very early; yet once again, should 
there be change for the better there is a chance  of the deviation diminishing to a lesser or 
greater extent.  
This leads me back to patterns of attachme nt, since my hypothesis is that the pathway 
followed by each developing individual and the ex tent to which he or she becomes resilient to 
stressful life events is determined to a very si gnificant degree by the pattern of attachment he 
or she develops during the  
 
FIGURE 1 Developmental Pathway Deviating Toward Anxious Attachment and Depression   
-172-

FIGURE 2 Developmental Pathway Deviating Toward Hostility and Delinquency   
early years. Furthermore, this implies that, in identifying the family experiences that result in 
different children developing di fferent patterns of attachment, my colleagues are identifying 
also some of the major determinants of each pe rson's future resilience or vulnerability to life's 
hazards as well as the extent to which he or she will be able to enjoy life.  
To date, unfortunately, the deta iled prospective studies describe d earlier of how some of the 
different patterns of att achment come into being, and of thei r relative persistence, have so far 
not been carried beyond the sixth year. This m eans that the hypothesis, however plausible, 
will be without rigorous testing for some year s yet. Meanwhile, however, backers of the 
hypothesis point to much supporting evidence coming  from the other major school of research 
referred to earlier, namely epidemiological stud ies of adults who are suffering from one or 
another of a wide range of psychiatric disab ilities, which include anxiety and depressive 
states, suicidal behaviour, borderline c onditions, and sociopathic personality.  
From among a large array of epidemiological studies I have chosen the work of George 
Brown and Tirril Harris to illustrate my thesis because it is not only of the highest quality but 
also gives attention to variables of the kind that the prospective  
-173-  
research already described is s howing to be so very influential. In addition, they use a 
sophisticated model of devel opmental pathways for interpre ting their findings. Brown and 
Harris have studied no less than four large re presentative samples of the female population, 
two in inner London boroughs, one in an outer boro ugh, and one in a remote rural area of the 
Scottish Highlands. Their aim has been to id entify women suffering from depression of an 
incapacitating degree and to compare them to the other women in the same community who 
are not depressed in order to di scover whether there are any family or other social variables 
that distinguish the two groups. The findings of the first such study, done in the inner London 
borough of Camberwell, were published ten ye ars ago and are becoming well known ( Brown 
and Harris 1978). In it the researchers identifi ed four classes of variable that were found

significantly more frequently among the depre ssed members of the population. Three of these 
concern current events and conditions:  
 a severe adverse event, usually involving an  important personal loss or disappointment, 
that had occurred within th e year prior to onset,  
 the absence of a companion in whom to confide, and  
 chronically difficult li ving conditions, in cluding extremely bad housing an d
responsibility for caring for a number of children under the age of 14.  
The fourth variable associated with current incapacitating depression is an historical  one, 
namely a woman's loss of her mother due to deat h or prolonged separation before her eleventh 
birthday. * In subsequent studies of two other larg e and mainly working class samples, in 
Walthamstow and Islington, findi ngs of a similar sort have been  the rule ( Brown, Harris, and 
Bifulco 1985; Bifulco 1 985; Bifulco, Brown, and Harris 1 987). The incidence of a current 
depressive disorder in women who  
*  Among samples of depressed women there is often also a higher in cidence, compared to
controls, of loss of father during childhood; an d in two of their studies the effects of this
have been explored. Since detailed analyses ha ve shown that loss of father has much less
influence on vulnerability than loss of moth er, further reference to it is omitted.  
-174-  
had lost mother before their eleventh birthda y compared to those who had not were, in the 
three samples, 43 versus 14 per cent, 25 vers us 7 per cent, and 34 versus 17 per cent. 
Moreover, in the second and third studies it was found that women who had lost mother 
during adolescence (between their eleventh and seventeenth birthdays) were also more prone 
to develop depression than the controls, though le ss so than those who had lost mother when 
they were younger.  
The consistency of these findings, together wi th findings from a long- term prospective study 
reported by Wadsworth ( 1984), now gives strong support to the clinically derived hypothesis 
that childhood loss of mother is likely to lead a person to become excessively prone to 
develop psychiatric symptoms, and to do so espe cially when current personal relationships go 
wrong.  
In their Walthamstow study members of th e Brown-Harris group undertook a prolonged and 
extensive interview with each wo man in order to gain as much information as possible about 
the family circumstances during her childhood a nd adolescence and also about her subsequent 
life-course, including, for example, the jobs  she had had, her boy-friends, any premarital 
pregnancy, and her husband and ch ildren (if any). With the sample deliberately structured to 
include a high proportion of women who ha d suffered a childhood loss or prolonged 
separation, it became possible to analyse out th e extent to which family variables other than 
loss may have contributed to a woman's current vulnerability.  
In keeping with expectations, it  was found that both the family circumstances that had led to 
the childhood loss and the adequacy of care a girl had received afte rwards, were of great 
consequence. The worse the family circumstances before the loss and the more inadequate the 
care after it, the more vulnerable to  depression the girl had become.

The very detailed analyses of these data car ried out by the researchers have led them to 
explain their findings in term s of developmental pathways that, through the continuing 
interactions of social and personality factors, result in an apallingly high risk of becoming 
depressed for a working class girl in London who lost her mother for any reason. In the first 
place,  
-175-  they found, such a loss carried with it a high likelihood that she would thereafter not receive 
adequate care: in the Walthamstow study th e chances were found to be no better than 
fiftyfifty. Subsequently, her tr oubles were likely to snowball . Should the care she received 
have been poor, risks were high that she would become pregnant before marriage and/or that 
she would venture on an early and ill-advised marriage. These two occurrences were found to 
be strongly associated with later incapacita ting depression, in part because they usually 
resulted in her living in very unfavourable condit ions at high risk of suffering a severe adverse 
event and with no one in whom to confide. For these reasons a working class girl who had lost 
her mother was all too likely to find herself on a slippery slope. Girls in middle class families 
were found not to be at such hazard, largely beca use after their loss they were far more likely 
to receive reasonabl y adequate care.  
On  
figure 3  
the thick upper line represents the girl's mental  state. The middle line represents what may for 
convenience be described as  her family environment. The thin  lower line represents her socio-
economic environment, in this case urban workin g class. The broken lines  indicate the endless 
ways in which mental state and environment interact, wi th environmental happenings 
affecting mental state and ment al state, in turn, affecting the way the girl or young woman 
deals with aspects of her environment.  
Two further findings, both from the Islington st udy, illustrate this interaction ( Bifulco et al.  
1987). A girl who received inadequate care, either  in or out of her family, is found extremely 
likely to have developed a negative self-ima ge when compared to a girl who received 
adequate care. The figures are 54 per cent compar ed to 27 per cent. Furthermore, the marriage 
she entered on was far more likely to fail than was that of the more fortunate girl. Here the 
figures are 36 per cent and 23 per cent.  
The high risk of her marriage failing is probably to be explained in terms of two processes. 
The first is that when a girl  has no caring home base she may become desperate to find a boy-
friend who will care for her and that that, comb ined with her negative self-image, makes her 
all too likely to settle for  
-176-

FIGURE 3 Female Pathways to Depression.  Adapted from Harris et al.  
some totally unsuitable young man. The second is that, having married him, the effects of her 
previous adverse experiences are apt to lead her either to make unduly heavy demands on him 
and/or to treat him badly.  
Gloomy though these conclusions are, we must re member always that a disastrous outcome is 
not inevitable. The more secure an attachment a girl has experienced during her early years, we can confidently predict, the greater will he r chances be of escaping the slippery slope.  
Conclusions  
In concluding this lecture I refer, first, to some of the many scientific problems that clamour 
for attention and, secondly, to some of the pr actical implications of  our present knowledge.  
A first scientific task is to e xplore and test the hypothesis, stat ed earlier, that each person's 
resilience or vulnerability to stressful life events  is determined to a very significant degree by 
the pattern of attachment he or  she develops during the early y ears and, more especially, to 
clarify to what degrees and in what ways the early-developed patterns influence subsequent 
development. Since, however, there are many sub-pat-  
-177-  
terns of each of the three main patterns, to elucidate the influence of each will be a long and 
time-consuming task. An integral part of such research, moreover, is the further examination 
of precisely what environmental conditions, impi nging earlier and/or later, enable a person to 
retain or attain a greater degree of resilience and, conversely, what push him or her towards 
greater degrees of vulnerability.  
Yet another substantial group of  variables to be taken into account are the inevitable 
differences which must be assume d to exist between different indi viduals in their capacity to 
deal with the various environmental hazards, es pecially inadequate parenting, that influence 
vulnerability.  
In undertaking such a series of research progr ammes an early requirement is the development 
of psychological methods for assessing patterns of attachment and their derivatives at each 
phase of the life cycle. Main and other deve lopmental psychologists ar e already making some 
promising moves in this direction (see review  by Ainsworth 1985). To cast light on problems 
of continuity and discontinuity, both of patterns of  attachment and also of different degrees of 
resilience and vulnerability, prospective st udies following persona lity development through

different phases of the life-cycle and in diffe rent environments are plainly indispensable, 
despite their being very costly.  
This brief sketch represents what will be an enormous programme of research and one that 
will clearly require generations of  research workers. Both in magnitude and in the biological 
principles informing it, it can best be compared  to the vast programme of research which has 
been undertaken in immunology. Here, as in ou r own fields, research workers are concerned 
with the extraordinarily complex interactions a nd transactions that occu r between an organism 
as it develops over the years and the array of hazards present and potentially present in its 
environment. Concepts analogous to those in  our field include the degree to which an 
organism is immune or not to a wide variety of hazards and the extent to which an existing 
state of immunity will persist or change over time.  
What then are the practical implications of our present knowledge? For the clinician 
concerned with the assessment  
-178-  
and treatment of a wide range of  psychiatric patients of all ag es it provides a developmental 
psychopathology that is biologica lly based, coherent, and alrea dy empirically well supported. 
As such it can provide guidance for understa nding how a patient's problems and symptoms 
have evolved in his transactions with the part icular environments he has encountered from 
infancy to the present day, thus providing an updated and detailed version of the Life Chart 
which Adolf Meyer ( 1919) so rightly advocated . Furthermore, it can provide guidance also 
for planning therapeutic intervention. Though mu ch detailed work is still required in these 
areas, promising starts have been made (e .g., Heard 1981, 1982; Belsky and Nezworski, in 
press; Lieberman and Pawl, in press).  
What, however, is even more important, and woul d be especially welcom e to Adolf Meyer is 
the firm guidance it gives for prevention. As I have emphasized throughout, I believe there is 
already sufficient evidence, coming from divers e and independent source s, that points to the 
very substantial influence on personality deve lopment and mental health of the way an 
individual's parents (or in some cases parent substitutes) treat him or her. Given affectionate 
and responsive parents who throughout infancy, childhood, and adolescence provide a boy or 
girl with a secure base from which to explor e the world and to which to return when in 
difficulty, it is more than likely that he or she will grow up to be a cheerful, socially co-
operative, and effective citizen, and to be unlik ely to break down in adversity. Furthermore, 
such persons are far more likely than those who come from less stable and supportive homes 
to make stable marriages and to provide their children with the same favourable conditions for 
healthy development that they enjoyed themselv es ( Quinton and Rutter 1985; Dowdney et al, 
1985). These, of course, are age-old truths, but  they are now underpinned by far more solid 
evidence than ever before.  
Unfortunately, as we also know, there is anothe r and less happy side to  the picture. Children 
and adolescents who grow up without their home base providing the necessary support and 
encouragement are likely to be less cheerful; to  find life, especially intimate relationships, 
difficult; and to be vulnerable in conditions of a dversity. In addition, they are likely to have  
-179-

difficulties when they come to marry and have ch ildren of their own. It is fortunate, of course, 
that despite the handicaps some manage to st ruggle through, though often at a much greater 
cost to their emotional life than meets the und iscerning eye. Nor must the fortunate exceptions 
blind us to the rule. Thus, to take an analogy from physiological medicine, the fact that some 
heavy smokers survive is no argument for tobacco.  
That, then, is how I see the state of developm ental psychiatry in 1986 and why I think we can 
claim it has now come of age.  
-180-  
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From J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close
relationships (pp. 25-45). New York: Guilford Press, 1998.
2
Methods of Assessing
Adult Attachment
KIM BARTHOLOMEW
PHILLIP R. SHAVER
In recent years, several streams of research have emerged from Bowlby's
(1988) and Ainsworth's (1982) attachment theory. Originally, the theory
was aimed at explaining child and adult psychopathology in terms of
nonoptimal relationships between children and their caregivers, or "at-
tachment figures." According to attachment theory, the long-term effects
of early experiences with caregivers are due to the persistence of "internal
working models" --cognitive / affective schemas, or representations, of the
self in relation to close relationship partners (Bartholomew, 1990; Shaver,
Collins, & Clark, 1996). Theoretically, these representations influence a
person's expectations, emotions, defenses, and relational behavior in all
close relationships. Although the theory does not assume or require that
internal working models persist without ,::hange across the life span, both
theory and empirical evidence from longitudinal studies have led re-
searchers to suspect that the effects of childhood attachment relationships
extend into adulthood, where they can be seen in the domains of parent-
ing and close peer relationships, including romantic relationships (e.g.,
Bartholomew, 1990, 1993; Main, Kaplan, & Cassidy, 1985; Shaver, Hazan,
& Bradshaw, 1988; Weiss, 1982).
25

26 I MEASUREMENT ISSUES
TWO TRADITIONS OF ADULT
ATTACHMENT RESEARCH
In the 1980s, two distinct programs of research were initiated to investi-
gate patterns of attachment in adulthood. In one line of research, Main
and her colleagues focused on the possibility that adult "states of mind
with respect to attachment" (i.e., adults' current representations of their
childhood relationships with parents) affected parenting behavior, which
in turn influenced the attachment patterns of the parents' young children.
Members of Main's research group interviewed parents about their child-
hood family relationships and then searched for scorable features of the
interview transcripts that could "postdict" their infants: already known
attachment classifications in the Ainsworth Strange Situation (Ainsworth,
Blehar, Waters, & Wall, 1978). In subsequent predictive studies using this
Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985) proce-
dure, the research group confirmed that parents' interview codes were
associated with independent assessments of their infants' attachment
classifications (a connection that has since been replicated many times; see
van IJzendoom, 1995, for a review). Infants classified as "avoidant" in the
Strange Situation had primary caregivers who themselves were dismiss-
ing of attachment-related memories and feelings; infants classified as
"anxious" had primary caregivers who were anxiously preoccupied with
attachment-related issues; and infants classified as "secure" had
caregivers who were "free and autonomous" with respect to attachment.
In subsequent work, a fourth infant pattern, "disorganized," was found
to be associated with caregivers who were "unresolved" with respect to
losses and traumas in their attachment history.
In the second, completely independent line of research, Hazan and
Shaver (1987), who had been studying adolescent and adult loneliness,
followed up Weiss's (1982) idea that chronic loneliness is associated with
insecure attachment. Reasoning that most chronically lonely young adults
were unsuccessfully seeking a secure romantic attachment, and that
orientations to romantic relationships might be an outgrowth of previous
attachment experiences, Hazan and Shaver devised a simple self-report
questionnaire for adults based on Ainsworth's three patterns of childhoOd
attachment: secure, avoidant, and anxious. The measure asked people to
think back across their most important romantic relationships and decide
which of the three types was most self-descriptive. In subsequent studies,
this measure and several variants of it have been related to a host of
theoretically relevant personality ':ariables, behaviors, and experiences in
close relationships (for reviews, see Shaver & Clark, 1994; Shaver &
Hazan, 1993). Although a few studies have correlated this measure with
retrospective reports of childhood experiences with parents, the bulk of
research in this tradition has focused on the influence of attachment
patterns on personal adjustment and adult relationships.

Methods of Asssessing Adult Attachment / 27
These two streams of adult attachment research-<>ne focused on
parenting and the other focused on romantic relationships--derive from
different disciplinary subcultures. Bowlby was primarily a child psychia-
trist, and Ainsworth was a child clinical and developmental psychologist.
Many of the current attachment researchers in the first "subculture" (e.g.,
Bretherton, Cassid~ Crittenden, Kobak, Main, and Waters) were students
of AiI1SwOrth'S. Researchers in this group tend to think psychodynami-
cally;: be interested in clinical problems, prefel interview measures and
behavioral observations over questionnaires, study relatively small
groups of subjects, and focus their attention on parent-child relationships.
Hazan and Shaver were persoriality I social psychologists, and their work
was quickly assimilated by other such psychologists, who tend to think
in tenns of persoriality traits and social interactions, be interested in
normal subject populations, prefer simple questionnaire measures, study
relatively large samples, and focus on adult social relationships, including
friendships, dating relationships, and marriages. Not surprisingly;: the
members of these two research subcultures tend to speak past each other,
or to concentrate their energies on activities within the;-: own subdisci-
pline without paying much attention to activities and developments
within the other subdiscipline.
Because both lines of research are grounded in Bowlby's and
Ainsworth's attachment theory, and both focus on individual differences
and classify people into categories parallel to Ainsworth's infant attach-
ment typology, it was inevitable that some researchers would assume that
the two adult classification systems, Main's and Hazan and Shaver's,
must be highly related. In other words, since both the AAI and Hazan
and Shaver's questionnaire place people into categories roughly desig-
nated as secure, avoidant, and anxious or preoccupied, it is often assumed
that the two assessment procedures are more or less interchangeable.
In 1990, Bartholomew reviewed the adult attachment research in both
traditions and came to the conclusion that the two approaches to assessing
attachment differed in a number of ways. First, she noted that the
dismissing-avoidant individuals identified by the AAI denied experienc-
ing subjective distress and downplayed the importance of attachment
needs, whereas avoidant subjects identified by Hazan and Shaver's self-
report measure reported relatively high levels of subjective distress and
fears of becoming close to others. She argued that two distinct forms of
avoidance were evident, one pattern motivated by a defensive mainte-
nance of self-sufficiency (labeled "dismissing") and the other motivated
by a conscious fear of anticipated rejection by others (labeled "fearful").
Second, she noted that the two approaches fli.:'.lsed on different domains,
one on retrospective descriptions of parent-child relationships and the
other on more recent experiences in adult love relationships, and that the
equivalence of representations in the two domains should not be as-
sumed, but rather was a question for empirical study. Third, she pointed

28 / MEASUREMENT ISSUES
out that the use of interviews and the use of self-reP9rts reflected differing
conceptualizations of adult attadunent. The AAI focuses on dynamics of
internal working models that are revealed indirectly by the way a person
talkS about childhood relationships; the measure is not based on the
assumption that people are conscious of these cynamics. In contrast, the
self-report measure focuses on feelings and behaviors in close relation-
ships of which a person is aware and which the person Can describe fairly
accurately. Building on both traditions, Bartholomew proposed an ex-
panded model of adult attadunent that included two forms of avoidance.
To assess this model, she used a self-reP9rt measure of experiences in close
relationships in general (by revising Hazan and Shaver's measure) as well
as,two interviews, one focusing on childhood experiences (along the lines
of the AAI) and the other focusing on peer relationships, including
friendships and romantic relationships (Bartholomew & Horowitz, 1991).
Problems in Comparing Measures
from the Tw'o Traditions
In recent years, papers have begun to appear (e.g., Borman & Cole, 1993;
Crowell, Treboux, & Waters, 1993) that report comparisons between adult
attachment measures from the two research traditions we have outlined.
Typically;: the authors of such papers conclude that the two kinds of
measures fail to correspond, in which case the authors usually question
the validity of the self-report measure. These kinds of studies are typically
conducted by researchers from the clinical { developmental subculture,
because, with the exception of Bartholomew and her colleagues, re-
searchers in the personality {social subculture have not taken the time to
master the interview techniques. It is easy for interview researchers to add
a simple self-report measure to their studies, but difficult for question-
naire researchers to learn to conduct and code what are essentially
intensive clinical interviews. Thus, comparisons between different kinds
of attachment measures have been made largely by researchers who
concentrate on parent-child relationships and take Ainsworth's Strange
Situation and the AAI as benchmarks.
To the extent that conclusions about attachment measures affect
researchers' understanding of attachment processes or lead them to have
little confidence in particular bodies of research, the question of measure
convergence is important. Some of the authors who have found little
convergence between self-report and interview measures have concluded
that self-report measures are especially prone to measurement error and
unlikely to be related to behavior. They fail to consider studies such as
those by Shaver and Brennan (1992), Feeney and Noller (1991), Kirkpat-
rick and Davis (1994), Kobak and Hazan (1991), Mikulincer and Nachshon
(1991), and Simpson, Rholes, and Nelligan (1992), which show that self-
report measures of adult attachment patterns do relate significantly to the

Methods of Asssessing Adult Attachment I 29
ways in which a person discusses close relationships, to observations of
marital communication, to relationship breakups, to patterns of self-
disclosure, and to seeking and providing social support under stressful
conditions. Within the personality / social research subculture, to consider
the flip side of the coin for a moment, there is a danger of overlooking
discoveries made with interview procedure~ :hat cannot be duplicated
with simple self-report measures. These inciude insights and research
ideas that arIse when an investigator hears what people actually say when
interviewed in depth about important relationships. Many researchers
relying on self-report measures of attachment have also failed to seriously
consider the possibility that there are aspects of attachment patterns that
are inaccessible to conscious awareness and, therefore, cannot be assessed
by self-report methods (cf. Crowell & Treboux, 1995).
Given the significance of the measure convergence issue, it is essen-
tial that comparisons between measures be thoughtful and statistically
appropriate. Most of the .:xisting comparisons involve cross-tabulations
of AAI categories and Hazan-Shaver categories, a strategy which implic-
itly assumes that the two measures are assessing parallel attachment
classifications. Some (e.g., Borman & Cole, 1993) even label the Hazan-
Shaver avoidant category "dismissing" (a term never used by Hazan and
Shaver), as if the designers of the two measures all had dismissing
qualities in mind. This conflation ignores Bartholomew's (1990) distinc-
tion between two kinds of avoidance, which indicates that the AAI
dismissing category and the Hazan-Shaver (fearful) avoidant category are
not the same, Other studies include the "unresolved" AAI category; which
has no match in the self-report measure, and/or a "cannot classify"
interview coding category; which also has no match in the self-report
measure. These differences make it unlikely that the two kinds of mea-
sures will converge strongly.
Some authors who compare attachment measures also overlook or
misinterpret the domain differences between the AAI, which focuses on
adults' characterizations of their childhood relationships with parents,
and the Hazan-Shaver measure, which focuses on experiences in roman-
tic relationships. Although the AAI has sometimes been conceptualized
as assessing generalized attachment representations, the Hazan-Shaver
measure was specifically designed to meaSL:e attachment patterns in the
domain of romantic relationships. Of course, even if the two measures
had been intended to measure precisely the same construct, method
variance would be expected to reduce the degree of "association between
them. Self-report measures focus on conscious, potentially inaccurate
summaries by a person of his or her own experiences and behaviors. The
AAI focuses primarily on the way a person talks about childhood attach-
ment experiences, with the major distinctions having to do with what
might be called defensive style (e.g., denial, repression, compulsive self-
reliance, and dismissal of attachment needs, on the one hand, versus

30 / MEASUREMENT ISSUES
vigilance, sensitization, enmeshment in relationships, and preoccupation
with attachment needs, on the other). These differences in communica-
tional behavior and defensive style are not necessarily noticed or ac-
knowledged by the people who exhibit them. Given all of these differ-
ences, a moderate association, at best, would be expected between the
AAI and Hazan and Shaver's self-report measure.
Also problematic is the fact ;;hat comparers of measures often fail to
conduct power analyses (Cohen, 1988) before performing statistical tests.
Consequentl~ they tend to perform insufficiently powerful tests and then
conclude that two measures are unrelated (i.e., the null hypothesis is
supported) because a test statistic fails to reach conventional levels of
significance. Insufficient power (a reflection of sample size and expected
effect size) is especially disconcerting when investigators are inclined to
accept the null hypothesis, and sufficient power is especially difficult to
attain when categorical variables are under investigation. Researchers
have also failed to consider that unreliability in both measures will always
attenuate the observed degree of correspondence. Single-item measures
are particularly likely to be unreliable. Given the systematic differences
between the AAI and self-report romantic attachment measures, the low
power of the tests used to test the associations between them, and the
relatively low reliability of some attachment measures, it is hardly sur-
prising that previous studies have failed to show convergence.
In the remainder of this chapter we compare various measures of
attachment based on Bartholomew's typology. Because Bartholomew has
created both interview measures of parental and peer attachment and a
self-report measure of peer attachment; similar in many respects to the
Hazan-Shaver measure but including two avoidant categories, it is pos-
sible to compare assessment methods without confounding them with
different conceptual schemes. In addition, continuous prototype ratings
of the four attachment patterns allow for adequate power to test for
moderate associations in relatively small samples. In two separate sam-
ples, the associations between three measures of attachment were as-
sessed-a self-report measure of general orientation to close relationships,
an interview measure focusing on early family relationships, and a second
interview focusing on peer relationships.
BARTHOLOMEW'S TWO-DIMENSIONAL
FOUR-CATEGORY SCHEME
Bartholomew has systematized Bowlby's (1973) conception of internal
working models in a four-category classification scheme (Bartholomew,
1990; Bartholomew & Horowitz, 1991) (see Figure 2.1). Four prototypical
attachment patterns are defined in terms of two dimensions: positivity of
a person's model of self and positivity of a person's model of others. The

Methods of Asssessing Adult Attachment I 31
Positive
Model of Other
Negative
Model of
Self
Negative
FIGURE 2.1. Two-dimensional four-category model of adult attachment.
positivity of the self model indicates the degree to which a person has
internalized a sense of his or her self-worth (versus feeling anxious and
uncertain of the self's lovability). The self model is therefore associated
with the degree of anxiety and dependency on other's approval in close
relationships. The positivity of the other model indicates the degree to
which others are generally expected to be available and supportive. The
other model is therefore associated with the tendency to seek out or avoid
closeness in relationships.
Secure adult attachment is characterized by the combination of a
positive self model and a positive model of others. Secure individuals
have an internalized sense of self-worth and are comfortable with inti-
macy in close relationships. Preoccupied attachment is characterized by a
negative self model and a positive model of others. Preoccupied individu-
als anxiously seek to gain acceptance and validation from others, seeming
to persist in the belief that they could attain safety, or security, if they
could only get others to respond properly toward them. Fearful attach-
ment is characterized by negative self and other models. Fearful individu-
als, like the preoccupied, are highly dependent on others' acceptance and
affirmation; however, because of their negative expectations, they avoid
intimacy to avert the pain of loss or rejection. Dismissing attachment is
characterized by a positive se;:; model and a negative model of others.
Dismissing individuals also avoid closeness because of negative expecta-
tions; however, they maintain a sense of self-worth by defensively deny-
ing the value of close relationships.
As indicated previously; three of these patterns-secure, preoccupied,
and dismissing-are conceptually similar to the correspondin,i?; AAI cate-

32 / MEASUREMENT ISSUES
gories. And three-secure, preoccupied, and fearful-are similar to Hazan
and Shaver's secure, anxious-ambivalent, and avoidant categories.
A Test of Correspondence among Bartholomew's
Attachment Measures
The convergence of different approaches to assessing adult attachment
was tested in two samples. In Sample 1, participants were 69 college
students (see Study 2 in Bartholomew & Horowitz, 1991); in Sample 2,
participants were 134 young adults involved in established roma...ic
relationships (for more information on the sample, see Scharfe &
Bartholomew, 1994). Participants completed three measures: (1) a brief
self-report measure that asked them to rate their degree of fit with each
of the four attachment prototypes (the Relationship Questionnaire), (2) an
interview focusing on close friendships and past and present romantic
relationships (the Peer Attachment Interview), and (3) an interview focus-
ing on representations of childhood experiences in the family (the Family
Attachment Interview). Two independent raters coded each interview for
interviewee's degree of fit to a prototype for each of the four attachment
patterns. Final interview ratings were based on an average of the two
coders' ratings. Thus, each participant received a profile of ratings on the
four attachment patterns. The highest of the four ratings was also used to
define a best fitting categorization for each method.
For each combination of methods, correlations were computed be-
tween the continuous ratings of corresponding attachment patterns (see
Table 2.1). For both samples, each of the associations between correspond-
ing peer and family interview ratings was significant. In addition, the
associations between corresponding ratings '",ere stronger than those
between noncorresponding ratings, and none of the noncorresponding
ratings were significantly positively associated with each other (not
shown in the table), suggesting both convergent and discriminant validity.
Associations between corresponding ratings on the peer interview and
self-report measure were also significant, and the pattern of correlations
again suggested both convergent and discriminant validity. In contrast,
associations between corresponding ratings on the family interview and
self-report measure were weaker and more variable. In both samples,
security and dismissing ratings were positively correlated. However,
corresponding fearful ratings were associated only in Sample 1, and
preoccupied ratings were not significantly correlated in either sample. In
the two other studies \.- ~ are aware of that included the Relationship
Questionnaire and Family Attachment Interview, the obtained associa-
tions between corresponding ratings were stronger. In a sample of assault-
ive men, correlations between self-report and family interview measures
ranged from .22 (for the fearful) to .55 (for the preoccupied) (Saunders,
1992). Similarly, in a sample of women undergoing treatment for breast

Methods of Asssessing Adult Attachment / 33
TABLE 2.1. Correlations between Corresponding Attachment Ratings
across Methods
-~re Fearful Preoccupied Dismissing
", Peer in~~ew and family interviewQ Sample Ib .39- .29- .66- .41-
Sample 2 .37.46.42 .35
Peer inte~ew and self-report measure
.27 .45- .24'
.36- .37- .35-
Sample 1
Sample 2
.36-
.29-
Family intet:View and self-report measure
Sample 1 .25: .35- .19 .33~
Sam£le 2 .23.00 .08 .17
Note. Sex was partialed out of the Sample 2 correlations to avoid bias (see Gonzalez &To Griffin. 1997).
an = 67; bn = 134.
'p < .05; '.p < .01.
cancer, correlations ranged from .22 (for the preoccupied) to .42 (for the
fearful) (Bellg, 1995).
Because of inadequate power, it was not possible to test the corre-
spondence between classifications derived from the three different meth-
ods, but there was sufficient power to compare the secure and insecure
categories across methods. With one exception, the proportion of agree-
ment for the secure-insecure distinction ranged from .63 to .68 and a
significant chi-square indicated that the categorizations across methods
were not independent. However, the proportion of agreement between
the family mterview and self-report measure in Sample 2 was .57, which
is only margi!ially significant (p = .07).
Finall~ factor analyses were performed to examine the convergence
of the three measures. Figures 2.2 and 2.3 show the results of principal
components factor analyses with varimax rotation of the intercorrelations
of the three sets of attachment ratings (with axes rotated to facilitate
interpretation). The two factors accounted for 480;0 of the variance in
Sample 1 and 41% of the variance in Sample 2. As can be seen in the
figures, the three methods exhibit substa..ltial convergence; the three
measures of a particular attachment pattern are always closer to each
other than to measures of different patterns. (See Griffin & Bartholomew,
1994, for similar results based on confirmatory factor analyses of different
methods of assessing the two dimensions underlying Bartholomew's
model.)
The findings indicate a moderate degree of convergence across the
three approaches. As might be expected, the correlational results were
weakest when both the method (interview vs. self-report) and the content
domain (family history vs. current close relationships) differed. The con-

34 I MEASUREMENT ISSUES
FIGURE 2.2. Factor analysis of Relationship Questionnaire, Peer Attachment
Interview, and Family Attachment Interview ratings: Sample 1. P = peer interview;
F = family interview; S = self-report.
vergence was greater when both measures were based on interviews or
when both measures had to do with the peer relationship domain. The
results of the factor analyses also indicate convergence. In sum, when
p~rallel conceptualizations of attachment patterns are used, there is a
moderate degree of convergence between interview and self-report mea-
sures, and across the family and peer domains. This conclusion agrees
with findings obtained by Bellg (1995), O'Hearn and Davis (1997), and
Saunders (1992). But it would be easy to miss the convergence if one
compared different conceptualizations of attachment (such as three vs.
four categories, or systematically differing definitions of avoidance) or
relied on insufficiently powerful statistical tests.
ANCHORING BARTHOLOMEW'S MEASURES
IN THE TWO TRADITIONS OF ADULT
The findings reported in the previous section are relevant to bridging the
gap between the two adult attachment subcultures only to the extent that
Bartholomew's measures are empirically related to the AAI, on the one
side, and Hazan and Shaver's romantic attachment measure, on the other
side.

Methods of Asssessing Adult Attachment / 35
A Comparison of the AAI and Bartholomew's
Interview Coding System
Mardi Horowitz and a group of colleagues at the University of California,
San Francisco, gave us access to clinical interviews with 30 bereaved
women that had been coded, by well-trained coders, using the AAI iind
Bartholomew's scoring systems. The interviews focused on the partici-
pants' relationship with the deceased and their responses to the loss; they
were coded by independent sets of AAI and Bartholomew coders. Both
coding systems contain the secure, preoccupied, and dismissing catego-
ries. The AAI usually includes an "unresolved loss and trauma" (U)
category as well, but in the bereavement study it could not be used
because the interviewees were all mourning a loss that had occurred
within the previous year. As explained earlier, Bartholomew's coding
system includes a fourth, "fearful," category not included in the AM.
A chi-square analysis indicated that the classifications obtained from
the two systems (threeAAI categories and four Bartholomew categories)
were significantly related, x;2(6) = 24.80, P < .001. Perhaps a more appro-
priate test of the association between the two measures is one that leaves
out the seven interviewees who were classified as fearful in Bar-
tholomew's system. When that analysis was performed, the association
was again significant, X;2(4) = 23.93, P < .0001, and the proportion of
agreement was .78. Of seven people judged preoccupied by the AAI

36 / MEASUREMENT ISSUES
coders, all seven were also judged preoccupied by the Bartholomew
coders. Of eight people judged dismissing by the AAI coders, seven were
judged dismissing by the Bartholomew coders. Of eight people judged
secure by the AAI coders, four were judged secure by the Bartholomew
coders, three were judged dismiss~g, and one was judged preoccupied.
All five disagreements involved the secure category and were mainly a
result of the different secure-category base rates for the two sets of coders.
The AAI coders more readily labeled people secure. The seven people
who were coded fearful in Bartholomew's system (and omitted from the
3 x 3 analysis) were distributed as follows in the AAI system: four were
preoccupied, one was dismissing, and two were secure.
As a more powerful test of the association, we conducted analyses of
variance (ANOVAs) in which the AAI categories served as the inde-
pendent variable and the four continuous prototype ratings from
Bartholomew's scoring system served as dependent variables. (See Table
2.2.) The ANaVA for the secure rating was significant, F(2,27) = 5.29,
P < .05, and a follow-up planned comparison indicated that the secure
AAI group differed significantly from both insecure groups, t (27) = 2.96,
P < .01. For the preoccupied rating, F(2,27) = 12.60, P < .0001; the
preoccupied AAI group's rating scale mean was significantly greater than
the secure and dismissing means t(27) = 4.74, P < .001. For the dismissing
rating, F(2,27) = 11.45, P < .001; the dismissing AAI group's rating scale
mean was significantly ~ater than the secure and preoccupied means
t(27) = 4.53, P < .001. For the fearful rating, the ANOVA ~as not signifi-
cant, F(2,27) = 1.12, ns), as could be expected given that the AAI scoring
system does not include a fearful category.
Considering that the interview being coded was not primarily an
attachment interview (i.e., it was not highly sm..lar to either the AAI or
Bartholomew's interviews), that the sample size was small, and thafmany
of the interviewees were still quite upset about their loss, the degree of
correspondence between the two classification systems is impressive. The
results suggest that strong evidence for convergence (to the extent that the
coding systems are parallel) would be obtained from a study of a larger,
more representative sample based on appropriate attachment interviews.~
TABLE 2.2. Means on Bartholomew's Four Prototype Ratings across
AM Categories
AAI categories
Bartholomew Autonomous Enmeshed Dismissing
prototype ratings (n = 10) (n = 11) (n = 9)
Secure 4.;") 2.45 3.11
Preoccupied 3.40 5.36 2.22
Dismissing 3.20 2.18 5.67
Fearful 3.10 4.00 2.67

Methods of Asssessing Adult Attachment / 37
A Comparison of Hazan and Shaver's and
Bartholomew's Self-Report Measures
In a self-report study of 840 college students, Brennan, Shaver, and Tobey
(1991) included both Hazan and Shaver's (1987, 1990) romantic attach-
ment questionnaire and Bartholomew's (Bartholomew & Horowitz, 1991)
relationship questionnaire. Participants placed themselves into one of
Hazan and Shaver's three categories (secure, anxious, and avoidant) and
rated huw self-descriptive each of the three prototypes was. They also
placed themselves into one of Bartholomew's four categories (secure,
preoccupied, fearful, and dismissing) and rated how self-descriptive each
of the four prototypes was.
the two systems (three Hazan-Shaver categories and four Bartholomew
categories) were significantly related, x2(6) = 370.31, P < .001. Of the people
who classified themselves as secure on Bartholomew's measure, 82% were
secure on the Hazan-Shaver measure. Of those who classified themselves
as preoccupied on Bartholomew's measure, 57% were anxious-ambiva-
lent (the conceptually parallel category) on the Hazan-Shaver measure.
Of those who classified themselves as fearful on Bartholomew's measure,
61% called themselves avoidant on the Hazan-Shaver measure. Of those
who classified themselves as dismissing on Bartholomew's measure, 43%
called themselves avoidant on the Hazan-Shaver measure and 45% called
themselves secure. As suggested earlier, there is no category on the
Hazan-Shaver measure that is strongly parallel to dismissing, so most
dismissing subjects are forced to choose fearfuL which acknowledges their
avoidant tendencies, or secure, which emphasizes their autonomy and
self-esteem.
Because participants in the Brennan et al. (1991) study rated all seven
prototypes from the two self-report measures, it was possible to conduct
correlational as well as categorical analyses. The correlations for the
parallel ratings (secure with secure, etc.) were all highly significant and
ranged from .46 (for fearful with avoidant) to .55 (for the two secure
ratings). In each case, these correlations were higher than any of the
correlations among nonparallel ratings. The dismissing rating was not
strongly correlated with any of the Hazan-Shaver ratings, but its correla-
tion with the avoidant rating-the most lvgical quasi-parallel category-
was a highly significant .23. When the seven ratings were submitted to
factor analysis, two clear factors emerged. On the first factor, the two
secure ratings loaded positively (.78 and .79), the avoidant and fearful
ratings loaded negatively (-.77 and -.68), and the other ratings loaded
below .35. On the second factor, the anxious-ambivalent and preoccupied
ratings loaded positively (.84 and .77), the dismissing rating loaded
negatively (-.52), and the other ratings loaded below .20. These factors
confirm the convergence between the two measures, and they correspond

38 / MEASUREMENT ISSUES
clearly to the diagonals of Bartholomew's two-dimensional classification
scheme shown in Figure 2.1.
THE ARRAY OF MEASURES FROM THE AAI TO
HAZAN AND SHAVER'S QUESTIONNAIRE
Our findings indicate that when appropriate comparisons are drawn, one
finds considerable evidence for convergence across various measures of
adult attachment. The convergence is greatest when similar techniques
are used within the same domain-for example, when two self-report
measures of peer attachment are used. The convergence is also substantial
when the same domain is examined with two conceptually parallel
methods--for example, when attachment to peers is measured with
Bartholomew's interview and with self-report measures. The least conver-
gence occurs in exactly the situation that other researchers have been
inclined to study; where an interview measure in the family domain (e.g.,
the AAI) is compared with a self-report measure in the peer or romantic
domain (e.g., the Hazan-Shaver questionnaire). Even in the latter case,
however, there is evidence of modest convergence when conceptually
parallel attachment patterns are assessed in the two domains.
Researchers who have compared AAI classifications with Hazan-
Shaver classifications have generally ignored Bartholomew's discovery
that the "avoidant" categories embodied in these two measures are
fundamentally different. The results discussed in the present chapter
indicate that Bartholomew's fearful category, as assessed by interview, has
nv parallel in the AAI classification system, although the corresponding
dismissing categories converge well. The dismissing category; in turn, has
no clear parallel in the Hazan-Shaver classification system, although that
system's avoidant category converges fairly well with Bartholomew's
fearful category. Thus, direct comparisons between the AAI and the
Hazan-Shaver measure are misleading.
We propose that the different measures of adult attachment-at least
those discussed in this chapter-can be systematically arrayed along a
rough continuum, ranging, let us say; from the left to the right (see Figure
2.4). On the left end is the AAI, an interview procedure that assesses
attachment issues in the family domain and places people into three major
and two secondary categories not organized by any particular dimen-
sional scheme. In the next position is Bartholomew's Family Attachment
Interview, which also assesses attachnlerlt issues in the family domain but
rates people on four attachment prototypes defined in terms of two
dimensions. In the next position to the right would be Bartholomew's Peer
Attachment Interview, which assesses attachment in the peer domain in
a way that is conceptually parallel to her family interview ratings. In the
next position would be her self-report measure, which conceptually par-

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.:g ~ ~'- ,,; § ~ ~ E.gPoQJQJ 'QJQJO> QJ>"'" .~ ~ '" e ~ ,'" '"
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C't C C 'Qj C .~ ~ .goo '0 e~QJQJ'taQJ~~ g~:3 ~ QJQJ~~~-
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39

40 I MEASUREMENT ISSUES
allels her interviews. And in the rightmost position would be Hazan and
Shaver's measure, which places people into three peer/romantic catego-
ries that can be located in Bartholomew's two-dimensional conceptual
space.
Other adult attachment measures can be placed along the same
continuum. For example, Kobak, Cole, Ferenz-Gillies, Fleming, and Gam-
ble (1993) have devised a two-dimensional Q-sort scoring system for the
AAI. Coders characterize a particular interview using a large number of
statements based on the AAI scoring system, and then the Q-sort results
(average~ across coders) are summarized in terms of a secure-insecure
dimension and a deactivating-hyperactivating dimension. These dimen-
sions are very similar conceptually to the diagonals of Figure 2.1 (see also
Shaver & Hazan, 1993), with the secure-insecure dimension being similar
to the secure-fearful diagonal and the deactivating-hyperactivating di-
mension being similar to the dismissing-preoccupied diagonal. Because
the Kobak et al. measure is based on the AAI but is scored in terms of
dimensions similar to Bartholomew's, we would expect it to fall between
those two measures on our proposed continuum.
A second pair of examples are the multi-item questionnaire measures
devised by Collins and Read (1990) and Simpson et al. (1992). These were
created by breaking Hazan and Shaver's three prototypes into 13-18
separate phrases that could be scored as Likert items. When factor
analyzed, the items formed two major dimensions that correlated quite
highly with Bartholomew's two dimensions (Griffin & Bartholomew,
1994). These measures, we suspect, fall along the continuum between
Bartholomew's self-report measure, which is conceptually based on two
dimensions, and the Hazan-Shaver measure from which most of the items
were drawn. Future self-report dimensional mei\sures may better capture
Bartholomew's dismissing style, in which case they may fall somewhere
on the continuum between her peer interview and her simple self-report
measure. (Both of us are currently testing such dimensional measures, so
we have anticipated their location with an additional upward arrow in
Figure 2.4.) A third example is the Close Relationship Interview (CRI;
Crowell, 1990), which was designed for studies of married couples and is
closely related to the AAI in theoretical conception, coding procedures,
and ultimate classifications. Because it was based so closely on the AAI
and is scored categorically rather than dimensionally;: romantic/ marital
relationships, it is also related to self-report attachment scales (e.g., Tre-
boux, 1997). Thus, we have placed it near the center of our hypothetical
continuum and marked it with a third upward arrow in Figure 2.4.
In general, we predict that adult attachment measures that lie near
each other on the continuum will relate to each other more strongly than
those that lie further apart. The AAI and the Hazan-Shaver measures
should be most weakly related because they lie at opposite ends of the
continuum. At the very least, a researcher wanting to detect the underly-

Methods of Asssessing Adult Attachment
 4
ing connection between the constructs assessed by these measures would
need a high degree of statistical power.
THEORETICAL AND
METHODOLOGICAL IMPLJCATIONS
The results -.lggest both (1) that there may be a single representational
system or set of core relational tendencies underlying responses to the
various attachment measures (Griffin & Bartholomew, 1994), and (2) that
an individual's domain-specific attachment patterns can be substantially
different (Collins & Read, 1994). This interpretation of the results is
compatible with the idea, central to attachment theory (e.g., Bowlby;
1988), that adult attachment orientations have their roots in childhood
experiences with important attachment figures. Bowlby wrote about "de-
velopmental pathways" along which children and adults travel, being
moved toward and away from attachment security by events such as the
death of important attachment figures, supportive treatment by a thera-
pist, and the quality of a marital relationship. As a person moves along
these increasingly differentiated pathways, it is quite possible for internal
working models of relationships with parents to diverge from working
models of romantic relationships; the person may feel and act one way in
one kind of relationship and a different way in another.
If a researcher wished to tap the deepest, most general representation
of attachment, it would probably be wise to combine measures to form
latent attachment variables (e.g., Griffin & Bartholomew, 1994). Other-
wise, the choice of measures should be dependent upon the researcher's
conceptualization of attachment. For example, if a researcher wanted to
measure individual differences in the quality of romantic attachments, it
would be wise to use either a highly reliable (probably multi-item mea-
sure) of that specific construct or a latent-variable combination of concep-
tually compatible but methodologically different measures (e.g., a roman-
tic attachment interview and a reliable self-report romantic attachment
questionnaire). In general, except when exploring, or searching for, the
most distant possible connections within the attachment domain. attach-
ment measures should be chosen according tc the domain of interest. It
would not be optimally promising to try to predict, say; the attachment
orientation of a parent's infant or the quality of parent-<:hild interaction
from the parent's attachment classificatiC'" on a measure of romantic
attachment (nevertheless, see Rholes, Simpson, & Blakely, 1995), nor
would it be optimally powerful to predict outcomes of a romantic rela-
tionship from a family attachment interview.
The findings presented in this chapter do not address the differential
predictive or external validity of various measures of attachment. In order
to compare predictive validity; it would be necessary to include multiple

42 I MEASUREMENT ISSUES
methods (such as an interview focusing on childhood relationships and a
self-report measure of romantic attachment) and multiple relevant out-
comes (such as observations of parenting behaviors and marital commu-
nication) in one study. We expect that such studies would indicate
stronger relationships between attachment and outcome variables within
domain than across domain, andno rel~tionship across domain when the
overlapping variance of the attachment measures is controlled for. In
other words, we would expect attachment in the family domain to predict
outcomes in the marital domain only to the extent that the former J-,"ri
developmentally contributed to the formation of romantic attachment
patterns. There is also a continuing need for studies that actually track the
divergence of domain-specific developmental pathways over time.
In conclusion, measures of adult attachment differ in terms of do-
main (family; peer, or romantic relationships), method (interview, Q-sort,
or self-report), dimensionality (categories, prototype ratings, or dimen-
sions), and categorization systems. Despite such differences, the mea-
sures converge to varying degrees, especially when reliability and statis-
tical power are sufficiently high. Each of the currently used measures is
associated with a sizable body of empirical findings inspired by and
compatible with Bowlby and Ainsworth's attachment theory. The differ-
ent measures lie along a continuum of domains, methods, and degree of
dimensionalization. When we step back from the details of specific
measures and measure-specific findings, the results produced by attach-
ment researchers are all compatible with the possibility that various
forms of adult attachment arise from a continuous but branching tree of
attachment experiences, beginning in infancy and developing through-
out the life course.
ACKNOWLEDGMENTS
Preparation of this chapter was supported by a Social Science and Humanities
Research Council of Canada research grant to Kim Bartholomew and a MacArthur
Foundation Grant to Mardi Horowitz. We are grateful to Elaine Scharfe for her
help in the collection and coding of the data.
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Books.

CHAPTER 3
 
ASSESSMENT  OF MENTALIZING
 
Patrick Luyten, Ph.D.
 
Saskia Malcorps, M.Sc.
 
Peter Fonagy, Ph.D., FBA, FMedSci, FAcSS
 
Karin Ensink, Ph.D., M.A. [Clin. Psych.]
 
In clinical practice  and research it is sometimes helpful to consider mentalizing 
as a unitary construct (“ This patient has severe impairments in mentalizing ”), but in most 
cases more detailed assessment and monitori ng of a patient’s mentalizing capacities 
with respect to the different dimensions underlying mentalizing are indicated. Differ­
ent types of psychopathology are characteri stically associated with specific imbal­
ances between the dimensions of mentalizin g; that is, there may be impairments in 
one dimension but not the others (Allen et al. 2008; Luyten and Fonagy 2015). Hence, 
detailed assessment of a patient’s mentalizing capacities along each dimension yields important diagnostic information that can also  be used to tailor a specific treatment 
approach. For instance, although the prog rams of mentalization-based treatment 
(MBT) for patients with borderline personal ity disorder (BPD) and for those with an­
tisocial personality disorder (ASPD) share many features, they also have a number of 
important differences that are related to the specific types of mentalizing impair­
ments that differentiate patients with the two disorders (discussed later in this chap­
ter; see also Chapter 20, “Antisocial Personality Disorder in Community and Prison Settings”). As effective treatment should le ad to a decrease in dissociations between 
mentalizing capacities and thus to a more balanced and flexible use of the different 
dimensions of mentalizing, it is important for therapists to be able to tailor treatment to these specific dissociations or imbalanc es. Hence, the formulation of a so-called 
mentalizing profile —that is, a profile detailing the individual’s mentalizing skills with 
respect to each of the dimensions of mentalizing (Luyten et al. 2012)—is particularly helpful in adapting treatment to the patien t’s needs. This profile also informs thera­
pists about the types of relationships an d associated mentaliz ing impairments that 
37 
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Switch point 38 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
are likely to develop, serving as the first transference tracers —that is, similarities be­
tween the way the patient relates to other peop le in his or her life and to the treating 
clinician (Bateman and Fonagy 2016). 
Mentalizing is typically also heavily depe ndent on context—in particular, attach­
ment contexts (Luyten et al. 2012). With in creasing arousal (often  linked to specific 
types of relationships or interactions), ef fective mentalizing becomes increasingly dif­
ficult (Luyten and Fonagy 2015). This response is in keeping with the biobehavioral 
switch model of the relationship between stress and automatic an d controlled mental­
izing (Figure 3–1). It is therefore imperative to explore the extent to which the patient’s 
mentalizing capacities are context- and rela tionship-specific. Individual differences in 
the use of primary and secondary attachment strategies are key in understanding the 
dynamic relationship between arousal or stress and mentalizing. Thus, the assess­
ment of mentalizing also requires detailed attention to the attachment history of the 
individual. This assessment will also yiel d important informatio n concerning broader 
contextual factors that together with the individual’s attachment history, may have 
influenced his or her capacity for epistemic trust (i.e., the capacity to trust others as a source of knowledge about the social worl d and to consider this knowledge as per­
sonally relevant and generalizable to the se lf; see Chapter 4, “Men talizing, Resilience, 
and Epistemic Trust”) and, thus, mentalizing (Fonagy et al. 2015). 
In this chapter we first discuss the dime nsions underlying mentalizing and how they 
form the basis for a detailed assessment of mentalizing along the different dimensions. Second, we provide an overview of the role of arousal in relation to attachment history and mentalizing, pointing to important indi vidual differences in mentalizing capaci­
ties. We end this chapter by providing deta iled guidelines concerning the assessment of 
mentalizing in routine clinical pr actice and for research purposes. 
Arousal/stress Mentalizing Controlled 
(prefrontal) Automatic 
(posterior cortical and subcortical)
prefronta l) 
Switch point 
FIGURE  3–1. Biobehavioral switch model of the relationship between stress and controlled 
versus automatic mentalizing. 
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39 Assessment of Mentalizing 
DIMENSIONS OF MENTALIZING AND MENTALIZING PROFILES 
As described in Chapter 1 (“Introduction”) , mentalizing is unde rpinned by four di­
mensions, each with its own relatively distin ct neural circuits: 1) automatic–controlled, 
2) internal–external, 3) self–other, and 4)  cognitive–affective (Fonagy and Luyten 2009; 
Luyten et al. 2012). Mentalizing thus is an umbrella concept. Th is has two important 
implications for assessment. First, althou gh mentalizing is sometimes conceptualized 
as a unitary concept, mentaliz ing is in fact all about the balance between the four dimen­
sions underlying mentalizing, and about potential imbalances  between the two poles of 
each dimension. Patients with BPD features, for instance, are typically overly sensitive 
to the emotional states of others at the expense of reflective awareness of their own 
states of mind. They are also easily overwh elmed by the affective states of both them­
selves and others, often have little capacity for cognitive control, and are typically 
highly attuned to external features (e.g., fa cial expressions, posture), which leads them 
to jump to conclusions about internal mental states, resu lting in erroneous and overly 
negative assumptions about what others think and feel about them. Effective mentaliz­ing thus involves a balance between the vari ous systems that are involved in the indi­
vidual’s thinking and feeling about himself or herself and others. As an illustrative 
example, Figure 3–2 represents prototypical  mentalizing profiles of patients with BPD, 
ASPD, and narcissistic personality disorder (NPD). 
A second implication of this multidimensional view is that mentalizing is an over-
arching concept or construct that encompasses related constructs such as empathy, 
mindfulness, and theory of mind (ToM). The different dimensions underlying men­
talizing are again helpful in this context. Empathy and ToM, for instance, involve 
mentalizing with regard to others, whereas mindfulness involves mentalizing about 
the self and concerns basic physical and em otional sensations and experiences in par­
ticular. In terms of the co gnitive–affective dimension, most theory and research on 
empathy and mindfulness have focused on the affective processes involved in each, whereas research on ToM has typically focused on cognitive features involved in 
mentalizing with regard to others (e.g., belief-desire reasoning), although more recent formulations pay more attention to affect ive features involved in ToM. This also 
means that assessment  methods that have been develo ped in research on these re­
lated constructs can be used as proxy measures of different features or components of 
mentalizing, as explained in more detail later in this chapter. 
MENTALIZING, AROUSAL, AND INDIVIDUAL DIFFERENCES 
IN ATTACHMENT 
Arousal typically impedes effective mentalizing. Under increasing arousal, there is a 
switch from controlled mentaliz ing—that is, conscious, refl ective, and verbal consider­
ation of mental states of the self and ot hers—to more automatic mentalizing, which is 
marked by fast and nonreflective processing  of (social) information (Arnsten 1998; 
Mayes 2006) (see Figure 3–1). From an evolut ionary perspective, this switch has a clear 
survival value (Lieberman 2007; Mayes 2006). In response to stress, the fight/flight re­
sponse is best subserved by the swift proce ssing of social information. In the complex 
interpersonal world, however, such automatic processing of social information has 

Typical mentalizing profile for BPD
Typical mentalizing profile for ASPD 
  Ordinary/ 
Average 
Low High Very High 
Very Low 
Internal External Self Other Cognitive Affective 
Typical mentalizing profile for NPD 
Relationship between the poles of the self−other dimension may show 
the reverse pattern in ASPD. 40 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
FIGURE  3–2. Prototypical mentalizing profiles for borderline, narcissistic, and antisocial per­
sonality disorder. 
ASPD=antisocial personality disorder; BPD=borderline personality disorder; NPD=narcissistic personal­
ity disorder. 
many disadvantages, particularly in indivi duals who are characterized by a low thresh­
old for such a switch. 
The biobehavioral switch model depicted in Figure 3–1 proposes that individual 
differences in the use and strength of attachment hyperactivation and deactivation 
strategies in response to stress determine three key parameters in this switch from 
controlled to automatic mentalizing. These pa rameters are as follows: 1) the threshold 
(intercept) at which the switch happens, 2) the strength of the relationship between 
stress and the activation of controlled versus automatic mentalizing (the slope), and 3) the time to recovery from stress (i.e., return to controlled mentalizing). 
Secure attachment  has been related to the capacity to  retain high levels of mentaliz­
ing even in high arousal contexts, and to recover mentalizing relatively rapidly after 
it has been temporarily lost  (Table 3–1). The combination of security of attachment 
and high levels of mentalizing is also ty pically related to “broaden and build” (Fred­
rickson 2001) cycles that rein force feelings of secure attachment, personal agency, and 
mentalizing (“build”), and are associated wi th a genuine interest in and openness to 

41 Assessment of Mentalizing 
others and new social information and contexts (“broaden”) (Mikulincer and Shaver 
2007). Genuine mentalizing thus also fost ers the capacity for epistemic trust and salu­
togenesis , the capacity to benefit from positive features in the environment. Our new­
est formulations link these features (effective mentalizing leading to genuine interest in the mind of others and epistemic trust in knowledge that others transfer) to resil­
ience in the face of adversity (Fonagy et al. 2017a, 2017b; see also Chapter 4). Indeed, 
individuals with these features typically seek out others in times of need (“relation­
ship recruiting”) and have th e capacity to let others “rec alibrate” their mind in adap­
tive ways. 
TABLE 3–1. Attachment strategies, arousal, and mentalizing 
Attachment 
strategy Threshold for switch Strength of automatic response Recovery of controlled mentalizing 
Secure High Moderate Fast 
Hyperactivating Low: hype rresponsivity Strong Slow 
Deactivating Relatively high: 
hyporesponsive, 
but failure under increasing stress Weak, but moderate 
to strong under increasing stress Relatively fast 
Disorganized Incoherent: 
hyperresponsive, but often frantic attempts to downregulate Strong Slow 
Individuals who primarily rely on attachment hyperactivating strategies  (typical for 
anxiously attached individuals, such as those with a preoccupied attachment style) 
also tend to seek out others in times of di stress, yet they typically have the underlying 
belief that others will not be there for them or will eventually reject or abandon them. 
This leads to often desperate efforts to fi nd support and relief, as expressed in de­
manding and claiming behaviors. Attachment hyperactivating strategies have been 
associated with a low threshold for deactiva tion of brain areas involved in controlled 
mentalizing, and thus individuals with these features tend to have a low threshold for 
switching to automatic mental izing (see Table 3–1) (Luyten and Fonagy 2015). More­
over, they tend to be highly sensitive to signs of rejection and abandonment, have an 
increased time to recovery of mentalizing after it has been lost, and experience severe 
lapses in mentalizing. 
Attachment deactivating strategies , which are typically observed in avoidant individ­
uals (e.g., those with fearful-avoidant and dismissive attachment ), are characterized 
by the denial of attachment needs, and often strong assertions of their own autonomy, 
independence, and strength when faced with stress. These individuals are often able 
to keep controlled mentalizing “online” (i.e., active and engaged) for longer and tend to recover quickly from lapses in mentaliz ing (Vrticka et al. 2008; see Table 3–1), 
which may lead clinicians to erroneously attribute genuine mentalizing capacities to 
these individuals. However, mentalizing in these individuals is best described as pseudomentalizing ; particularly in high arousal contexts, their mentalizing tends to be­

42 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
come overly cognitive, without any affective basis. This imbalance in the cognitive– 
affective dimension explains the pretend-mo de character of many of their narratives 
(see Chapter 1): they do not genuinely reflect on what they and/or others feel in a 
given situation, but relate often comple x narratives about what happened to them 
that at first sight seem understandable bu t lack any affective grounding in reality. 
This type of pseudomentalizing is often obse rved in patients with NPD features or in 
those with functional somatic disorders. 
Furthermore, as arousal increases, attach ment deactivating strategies typically 
break down, resulting in the resurgence of defended-against feelings of insecurity and negative self-representations (Mikulincer et al. 2004). It is therefore imperative to 
increase the level of arousal to challenge these deactivating stra tegies when attempt­
ing to assess mentalizing in these individuals. This is typically done, for example, when administering the Adult Attachment In terview (e.g., Fonagy et al. 1996; Levin­
son and Fonagy 2004), which includes demand questions related to affectively highly 
charged issues such as separation and loss. 
Studies have also shown that individuals who primarily rely on attachment deac­
tivating strategies tend to show a diss ociation between subjective and biological 
stress (e.g., blood pressure, skin conductanc e) (Dozier and Kobak 1992; Luyten et al. 
2013). In terms of assessment, paying atte ntion to so-called somatic markers of emo­
tion (Abbass 2015), such as sweating, hand-clenching, or dizziness, is therefore im­
portant. Somatic markers of emotion in the absence of any conscious awareness of 
emotion in these individuals reveal impo rtant discrepancies between an apparently 
composed and coherent narrative that seems to be indicative of genuine mentalizing, 
and the pretend-mode quality of such narratives. Similarly, individuals who rely on 
attachment deactivating strategies often a ppear too calm for the situation (e.g., when 
relating a history of abuse or neglect without showing any signs of distress) or attri­
bute obvious signs of distress  to external factors (e.g., “ I feel suddenly dizzy, but this is 
because I haven’t had breakfast this morning ”) or cannot explain what is happening to 
them (“ I have no idea what is happening to me no w, have never experienced this before, this 
must be coincidence ”)—responses that are indicative of pretend mode and/or teleolog­
ical functioning. Finally, when probed fo r examples illustrating  general statements 
about attachment relationships, these individuals often cannot provide them, or they 
provide examples demonstrating exactly the opposite. For instance, a patient em­
phatically argued that he had always had a good relationship with his son. When 
asked for an example, he recounted how he and his son would frequently get into a fight about the son’s lack of interest in school. 
Finally, individuals with disorganized attachment  tend to use both attachment hy­
peractivating and deactivating strategies wh en confronted with stress, often switch­
ing between the two strategies. This typicall y confuses the clinician, as the patient 
tends to switch from marked  hypomentalizing to hypermen talizing, often in a matter 
of seconds (Bateman and Fonagy 2004) (see Table 3–1). 
Secondary attachment strategies limit br oaden-and-build cycles and inhibit behav­
ioral systems implicated in resilience, such as exploration and affiliation (Insel and 
Young 2001; Mikulincer and Shaver 2007; Neumann 2008). Hence, these strategies limit epistemic trust and salutogenesis, an d manifest themselves in epistemic credu­
lity, epistemic hypervigilance, epistemic freezin g, or epistemic petrification, or as any 
combination of these (see Chapter 4). 

TABLE 3–2.  Consequences of the pressure to externalize alien-self parts for mentalizing 
Examples Markers 
Intrusive pseudomentalizing  The person  “knows” what others are feeling or 
 thinking; this is experienced by others as 
intrusive. 
Destructively inaccurate mentalizing   Mental states are induced either explicitly or 
  implicitly in others (e.g., ranging from simple 
emotional states such as guilt or shame to 
 complex mental states such as victim– 
perpetrator states). 
Disavowal of mentalizing The person re fuses to reflect on mental states. 43 Assessment of Mentalizing 
In fact, the loss of effect ive mentalizing associated with secondary attachment 
strategies leads to the reemergence of more automatic, prementalistic modes of expe­
riencing the subjective reality of both the self and others—that is, psychic equivalence, 
pretend mode,  and teleological mode (Bateman and Fonagy 2016). These nonmentalizing 
modes also are often associated with a te ndency to externalize nonmentalized expe­
riences (i.e., alien-self experiences), partic ularly in individuals with a marked history 
of trauma (see Chapter 5, “Mentalizing and Trauma”). Table 3–2 provides examples 
of the impact of the pressure of alien-self experiences on mentalizing that can be seen 
as special cases of hypoment alizing and hypermentalizing. 
UNSTRUCTURED CLINICAL ASSESSMENT OF MENTALIZING 
The views outlined in this chapter have a number of important implications for the 
assessment of mentalizing in clinical practice. First, the following are required: 1) a 
systematic exploration of mentalizing in di fferent arousal contexts and 2) the use of 
active probing and challenging. Particularly in individuals who rely on attachment 
deactivating strategies, “testing the limits” is required to assess mentalizing capaci­
ties. Gross imbalances in mentalizing capacities across different contexts or relation­
ships are particularly important to note, as  are impairments in mentalizing that are 
related to specific contexts or attachment relationships (e.g., when the individual is 
talking about his or her partner, or abou t partner relationships more generally). 
Second, the assessment of mentalizing in the context of a new attachment relation­
ship with an assessor needs to be explored. Does the patient show an awareness of the 
mental states of the assessor? For instance, the patient who relates a history of abuse 
might appropriately warn the assessor that what  he or she is about to tell is shocking, 
or, by contrast, might relate such a history wi thout any attention to the impact this might 
have on the assessor. Some patients might even assume that the assessor or therapist 
“knows” everything the patient knows (i.e., assuming that all knowledge is shared knowledge); this assumption is typical of many patients with BPD features. For in­
stance, the patient comes into the therapist’ s office and immediately starts complaining 
about a person at work, but without explaini ng who that person is or what has hap­
pened; or the patient begins to tell a very detailed story about how “Jessica” played such 

44 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
an important role when she was a child and teenager, but without explaining who Jes­
sica is. Similarly, is the patient interested in the mind of the assessor ( “What do you 
think?”), and is he or she open to (novel) perspe ctives offered by the assessor? Finally, is 
the patient able to allow the assessor to co -regulate stress and arousal during the assess­
ment interview, particularly “when the going gets tough”? Does this lead to a recovery 
of effective mentalizing or does mentalizing spiral out of control when the assessor at­
tempts to validate or normalize the patient’s experience? 
Finally, assessment of mentalizing involves close attention to individual differences 
in the use of secondary attachment strategies , and the extent to which these differ de­
pending on the type of attachment relationship. 
A comprehensive assessment of mentalizin g should be based on two to three ses­
sions with the patient. The first session coul d start with a detailed review of the pa­
tient’s attachment history, moving from past  to current attachment relationships, and 
exploring to what extent the patient sees any links between his or her attachment his­
tory and presenting problems. As noted earlier, explicit probing using so-called de­mand questions is typically called for.  Examples of such questions include “Do you 
know why your parents/partner acted as they did?” “Do you think what happened to you as 
a child is related to the way you are as an adult?” “How has your relationship with your par­ents changed since childhood?” “In what ways have you changed since childhood?” “How did 
you feel when your parents seemed to prefer your sister over you?”  and “Do you think your 
upbringing is related in any way to your problems now?” 
The second session could focus on areas that were not (or insufficiently) explored 
during the first interview and could also ex plore the patient’s mentalizing skills with 
regard to his or her presenting symptoms. For instance, does the patient see any rela­
tionship between his or her tendency to self-harm and what is happening to him or her in terms of mental states? Does such  probing lead to a loss of mentalizing (“ Why 
do you ask questions like that? I can’t see the point ”), and how extensive are these losses 
of mentalizing? Is the patient able to recover mentalizing when the assessor moves on to another topic? Patients might be completely overwhelmed by such probing and might defensively begin to try to do minate the mind of the assessor (“ Why are you ask­
ing such questions? Do you think it is all my fault then? Do you know what you are suggest­ing, as if I have anything to do with what is happening to me? ”), or may engage in excessive 
mentalizing in an attempt to find some meaningful connection between his or her life 
history and presenting problems (e.g., in patients with obsessive–compulsive or so­
matoform disorders), often using “canned language.” 
In cases where a third assessment session is indicated, the assessor might want to 
revisit certain features of the patient’s life history and gauge the patient’s response to the assessor’s first attempt to meaningfully link the patient’s life history to presenting 
problems. 
From the information gathered through these initial assessment interviews, asses­
sors should ideally consider the following steps in arriving at a comprehensive as­sessment of mentalizing. 
1.	 Make an assessment of the patient’s overall mentalizing  capacities. The assessor 
should first consider the overall level of mentalizing of the patient (see Boxes 3–1 
and 3–2), in a manner similar to the scor ing of the Reflective Functioning Scale on 
the Adult Attachment Interview (Table 3–3). 

TABLE 3–3. Reflective Functioning Scale 
Score Description	 Level 
9 Full or exceptional:  Interviewee’s answers show 
  exceptional sophistication; are surprising, quite 
 complex, or elaborate; and consistently manifest 
reasoning in a causal way using mental states. 
Moderate to high 
reflective functioning 7  Marked:  Numerous statements indicating full 
reflective functioning, which show awareness of 
the nature of mental states and explicit attempts at teasing out mental states underlying behavior. 
5 Definite or ordinary:  Interviewee shows several 
instances of reflective functioning, even if prompted  
by the interviewer ra ther than emerging 
spontaneously from the interviewee. 
Negative to limited 
reflective functioning 3 Questionable or low:  Some evidence of 
consideration of mental states throughout the 
  interview, albeit at a fairly rudimentary level. 
1 Absent but not repudiated:  Reflective functioning is 
totally or almost totally absent. 
−1 Negative:  Interviewee systematically resists taking a 
reflective stance throughout the interview. 45 Assessment of Mentalizing 
2.	 The as sessment of overall mentalizing capacities should be followed by the draw­
ing
 of a mentalizing profile  (see Figure 3–2), by plotting an individual’s mentalizing 
capacities first for each of the different dimensions separately and then making a 
consideration of the compensatory and/or mutually reinforcing relationships be­
tween the various dimensions and poles. No tes should be made concerning 1) dis­
crepancies in mentalizing both within and among the dimensions (see Boxes 3–3 
to 3–6), and 2) how context and specific (t ypes of) relationships may be responsible 
for such discrepancies. Hence, the assess ment of mentalizing includes actively 
probing the patient’s capacity for cont rolled mentalizing and looking for when 
there is a switch to more automatic, bi ased mentalizing; for mentalizing based on 
internal as well as external features of th e self and others; for the patient’s own in­
ternal states and those of others; and for the integration of cognition and affect in 
mentalizing. Assessors should actively increase the arousal in the session (within reason) to “test the limits” of the patient’ s capacity for controll ed mentalizing. For 
instance, the assessor should ask questions that actively probe for mentalizing, such as “ What do you feel now? You just seemed to shiver when you were talking about 
your boss; what does that mean ”? (externally based/self) and “ When he looked at you 
like that, what did you think he thought about you? ” (externally based/other). Con­
trary moves are often useful in this context to shift the perspective from self to other or vice versa: “ You have been talking now about yourself, but how do you think he 
feels about the whole situation? ” Contrary moves may also be particularly useful to 
uncover potential discrepancies in mentalizing, as in patients who are unable to switch from their own perspective to that  of others, or who revert to pseudomen­
talizing, as in patients who seem to invent a “just-so” story on the spot, often to 

46 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
BOX 3–1.   What does good mentalizing look like? 
•	 Security of mental exploration and openness to discovery; internal freedom and interest 
in exploring even painful memories and experiences. 
•	 Acknowledgment of the opaqueness an d tentativeness of mental states. 
•	 Genuine interest in the mental states of the self and others, and their relation. 
•	 Adaptive flexibility in switching from automatic to controlled mentalizing. 
•	 Acknowledgment of the chan geability of mental states, including awareness of the 
developmental perspective (i.e., that the individual’s own attachment history 
influences current ways of relating to self and others). 
•	 Integration of cognitive and affective features of self an d others (“embodied mentalizing”). 
•	 Sense of realistic predictability and controllability of mental states. 
•	 Ability to regulate distress in relation to others. 
•	 Relaxed and flexible, not “s tuck” in one point of view. 
•	 Can be playful, with humor that enga ges rather than hurting or distancing. 
•	 Can solve problems by “give and take” between own and others’ perspectives. 
•	 Describes his or her own expe rience, rather than defining other people’s experience or 
intentions. 
•	 Conveys “ownership” of his or her behavior rather than a sense that it “happens” to him 
or her. 
•	 Open to and curious about other people’s perspectives, and expects to have his or her own views extended by those of others. 
Relational strengths 
•C u r i o s i t y . 
•	 Safe uncertainty. 
•	 Contemplation and reflection. 
•	 Perspective taking (including the recognitio n that others may have different thoughts, 
feelings, and opinions). 
•F o r g i v e n e s s . •	 Impact awareness. 
•	 Nonparanoid attitude. 
Perception of own mental functioning 
•	 Developmental perspective. 
•	 Realistic skepticism. 
•	 Internal conflict awareness. 
•	 Self-inquisitive stance. 
•	 Awareness of the impact of affect. 
•	 Acknowledgment of unconscious and preconscious functioning. 
•	 Belief in changeability. 

47 Assessment of Mentalizing 
BOX 3–1. What does good mentalizing look like? (continued) 
Self-representation 
•	 Rich internal life. 
•	 Autobiographical continuity. 
•	 Advanced explanatory and listening skills. 
General values and attitudes 
•T e n t a t i v e n e s s . 
•	 Humility (moderation). 
•	 Playfulness and humor. 
•F l e x i b i l i t y . •“ G i v e  a n d  t a k e . ” 
•	 Responsibility and accountability. 
BOX 3–2. What does bad mentalizing look like? 
•	 Dominance of unreflective, naive, distorted, automatic assumptions. 
•	 Unjustified certainty about internal mental states of self and/or others. 
•	 Rigid adherence to own perspective or excessively flexible in changing perspectives. 
•	 Overly focused on external or internal features of self and other, or complete neglect of 
one or both (“mind-blindness”). 
•	 Inability to consider both self and other perspectives. 
•	 Emphasis on either cognitive or affective aspe cts of mentalizing (i.e., overly analytical 
versus being overwhelmed by states of mind of self and/or others). 
•	 Excessively sparse or overdetailed mentalizing. 
•	 Focus on external factors (e.g., government, school , colleagues, neighbors). 
•	 Focus on “empty,” purely behavioral person ality descriptors (e.g.,  “tired,” “lazy”) or 
diagnoses. 
•	 Lack of interest in mental states, or defensive attempts to avoid mentalizing by becoming 
aggressive or manipulative, using denial, changing the subject, or otherwise being 
noncooperative (e.g., “I don’t know” ). 
please the assessor. We have often noticed that assessors fail to increase the arousal 
level in the session (e.g., by the use of demand questions and contrary moves); this 
leads to erroneous conclusions concerning the mentalizing capacities of their pa­
tients, ones that either overestimate or underestimate these capacities. 
3.	 Assessing each of the dimensions of mentalizing also leads to a consideration of the different parameters of the biobehavioral switch model  of mentalizing discussed earlier: 
a) the activation gradient of mentalizing (i .e., the proclivity of the individual to men­
talize); b) the switch point between controlled and automatic ment alizing; and c) the 
time to recovery of controlled mentalizin g (see Figure 3–1 and Box 3–6). The influ­
ence of the use of attachment hyperactivat ing and deactivating strategies on these 

48 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
BOX 3–3.   Internally and externally focused mentalizing 
•	 Awareness of internal and external features of self and others, and the relationship 
between the two. 
•	 Sensitivity to external  and internal features of self and others. 
•	 Ability to perceive and to self-correct initial impressions based on external features and 
to let others correct thes e impressions (e.g., “ My first thought seeing his face was that he 
couldn’t be trusted, but I immediately realized that I was prejudiced”; “Something in the way he 
talked bothered me, but I quickly realized that this was because he reminded me of someone I once had a serious disagreement with ”). 
BOX 3–4.   Mentalizing with regard to self and others 
•	 Presence of egocentrism (i.e., to see others in terms of self versus degree of control or 
inhibition of own perspective). 
•	 Liability to emotional contagion (self–other diffusion with rega rd to mental states) versus 
defensive separation from mental states of others. 
•	 Response to contrary moves, particularly flexibility to move between self and other 
perspectives. 
•	 Ability to integrate embodied knowledge wi th more reflective knowledge of self and 
others. 
BOX 3–5.   Cognitive and affective mentalizing 
•	 Tendency to see “mind-reading” as an intellectual, rational game. 
•	 Tendency for either cognitive or affect ive hypermentalizing (pseudomentalizing). 
•	 Tendency to become overwhelmed by affect  when thinking about states of mind. 
•A b i l i t y  f o r mentalized affectivity  and embodied mentalizing (i.e., to integrate cognitive 
knowledge and affective knowledge of the self and others). 
parameters should be assessed, and, again, the assessor should carefully register 
whether these parameters differ across  specific attachment relationships. 
4.	 A detailed assessment of mentalizing capacities also entails an assessment of what 
happens when effective mentalizing breaks down. That is, what are the “preferred” 
nonmentalizing modes that become active in the pati ent, and to what extent do they 
lead to a pressure to externalize nonmentalized states of mind (see Box 3–7)? It is im­portant to note in this context that the nonmentalizing modes are not mutually ex­
clusive. Psychic equivalence often in volves teleological thinking (“ He has never 
liked me, I know for sure because he never answ ers any of my calls; next time I’ll do the 
same when he rings me ”). Nonmentalizing modes may be associated with a rela­
tively mild tendency to externalize nonmentalized (i.e., alien-self) experiences. 
For instance, patients who ha ve a tendency to revert to  the teleological mode may 
try to achieve some control over unmentalized experiences by means of action (e.g., exercising or working excessively) and/or attributing distress purely to ob­jective causes (e.g., a virus or working co nditions). In more extreme cases, there 
may be a constant pressure to externalize alien-self experiences that might lead to 

49 Assessment of Mentalizing 
BOX 3–6.  Automatic and controlled mentalizing in specific contexts and relationships 
•	 Are there global impairments in mentalizin g (e.g., marked automatic mentalizing based 
on distorted assumptions about the self and others) or more partial difficulties? 
•	 Are there marked discrepancies between ment alizing in nonstressful versus stressful 
conditions, or are mentalizing levels approximately equally high or low in both 
conditions? 
•	 What is the optimal stress level for adequate mentalizing? 
•	 Are there differences related to self–other  and context, particularly attachment 
relationships (e.g., gross imbalances betwee n mentalizing about self and others or 
between different attachment figures)? 
•	 How extensive is failure of mentalizing under stress? 
•	 What is the time to recovery (e.g., relatively quick versus slow)? 
•	 Is there the ability to self-correct and be corrected by others, even under high stress 
levels? 
•	 Is there a sense of sufficient and realistic se curity in the relationsh ip to the assessor or 
therapist (e.g., patients may fe el very stressed and/or be co nstantly on their guard, or 
alternatively may show an unrealistic sense of security, as if they have known the therapist 
for years)? 
•	 Are there specific attachment relationship s or contexts that lead to impairments in 
mentalizing? 
BOX 3–7. Nonmentalizing and pseudomentalizing modes 
•	 Pretend mode (i.e., reasoning about mental  states but without any real connection to 
reality). 
•	 Psychic equivalence mode (i.e., concrete understanding)—for example, “You do not love 
me because you didn’t call me ”; “I know you are in love with me, because you smiled at me. ” 
•	 Teleological mode (i.e., internal states of mind are reduced to observable behavior)— for example, “ The only time I feel loved is when you are near me.” 
•	 Pseudomentalizing: mostly self-serving, improbable, and inaccurate. 
•	 Intrusive: the individual “knows what others think.” 
•	 Overactive (hypermentalizing): excessively detailed, decoupled from (affective) 
reality. 
•	 Destructively inaccurate: deni al of others’ internal states  and replacing them with the 
individual’s own constr uction—for example, “ You want to destroy me, I’m sure. Don’t 
deny it. There’s no way you can ever deny this .” 
a tendency to self-harm or harm others, or to attempt to dominate, control, and/ 
or manipulate the mind of others either  unconsciously (as, for instance, in many 
patients with BPD) or consciously (as in patients with ASPD). 
5.	 In an assessment of mentaliz ing, examples of online (i.e., immediate) mentalizing in 
the session—and particularly the extent to which the individual shows evidence of 
the self-correcting function of mentalizing and is able to use the assessor’s presence 
and interventions to co-regulate arousal and recover from mentalizing lapses—are 

50 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
important. These typically provide a more reliable and valid estimate of mentalizing 
than do examples of more offline (i.e., retr ospective) mentalizing, particularly in pa­
tients with high levels of attachment-deactivating strategies. 
6.	 Finally, the assessor should determine to what extent mentalizing impairments are linked to problems with epistemic trus t and salutogenesis. To what extent have 
mentalizing impairments led to a disorder in social communication—that is, an in­
ability to benefit from input from the environment—and in the patient’s capacity to recalibrate his or her mind in  relation to others? Again, evidence of su ch recalibra­
tion and genuine interest in the mind of the assessor should be seen as a positive in­dication with potentially important consequences for prognosis and treatment response. 
STRUCTURED ASSESSMENT OF MENTALIZING 
More structured assessment of mentalizin g (e.g., for research purposes) might be 
thought of in similar ways as the clinical assessment of mental izing. Numerous mea­
sures have been developed that tap into an individual’s overall mentalizing capaci­
ties or more specific areas of mentalizing problems. These measures, which are 
summarized in Table 3–4, include the Refl ective Functioning Scale (Fonagy et al. 
1998), a broad measure of mentalizing that is scored on the Adult Attachment Inter­
view (Hesse 2008) or similar interviews, such as the Child Attachment Interview 
(Shmueli-Goetz et al. 2008; Target et al. 2003), the Object Relations Inventory (Dia­
mond et al. 1991), or transcripts of psyc hotherapy sessions (Karlsson and Kermott 
2006; Szecsödy 2008). The Reflective Functi oning Scale has also been used to assess 
mentalizing with regard to specific issu es or symptoms, such as anxiety symptoms 
(Rudden et al. 2006, 2009), depressive themes (Taubner et al. 2011), trauma (Berthelot 
et al. 2015), and specific attachment figure s or relationships (Diamond et al. 2003). 
More recently, the Reflective Functioning Questionnaire has been developed as a 
broad self-report measure specifically designed to assess severe impairments in men­
talizing, as are typically observed in indi viduals with BPD (Fonagy et al. 2016; Ha et 
al. 2013). Levy et al. (2005) have reported  preliminary evidence for a clinician-rated 
multidimensional Reflective Functioning Sc ale, and several other efforts to develop 
general measures of mentalizing are currently under way. 
Other measures focus on relationship-specific mentalizing, such  as a modification 
of the Reflective Functioning Scale to be scored on the Parent Development Interview 
(Slade 2005; Slade et al. 2007) or on the Working Model of the Child Interview 
(Schechter et al. 2005). The work of Elizabet h Meins and colleagues (Meins et al. 2012), 
who developed a maternal mind-mindedness scale, also deserves a prominent place in this context. This scale taps into a caregiver’s online mentalizing with regard to his 
or her child and can be scored on differen t types of narrative material (Meins and 
Fernyhough 2015). The Parental Reflective Functioning Questionnaire (Luyten et al. 
2017) assesses various dimensions of pare ntal mentalizing. Various experimental 
tasks can be used to assess general or re lationship-specific mentalizing in children 
and adolescents (Sharp and Fonagy 2008). 
There is also a broad range of well-validated measures available to assess different 
dimensions of mentalizing in young people as well as in adults. Table 3–4 provides 
some examples to assist researchers (and cl inicians) in selecting measures that tap into 

TABLE 3–4. Measures assessing the dimensions of mentalizing 
Self–Other Cognitive–Affective Internal–External Automatic–Controlled 
Self Other Cognitive Affective Internal External Automatic Controlled 
Questionnaires
Beliefs about Emotions Sc ale (Rimes and Chalder 2010) X (X) X X X X 
Toronto Alexithymia Question naire (Bagby et al. 1994) X X X X X 
Kentucky Inventory of Mindfu lness—Describe and Act With X X X X (X) X 
Awareness subscales (Baer et al. 2004) 
Mindful Attention Awareness Scale (Brown and Ryan 2003) X X X X (X) X 
Levels of Emotional Awaren ess Scale (Lane et al. 1990) X X X X X X 
Psychological Mindedness Sc ale (Shill and Lumley 2002) X X X X X X 
Interpersonal Reactivity Index—Perspective Taking subscale X X X X X 
(Davis 1983) 
Empathy Quotient (Lawrence et al. 2004) X X X X X (X) X 
Mayer-Salovey-Caruso Emotional Intelligence Test (Salovey and X X X X X X (X) X 
Grewal 2005) 
Reflective Functioning Questionnaire (Fonagy et al. 2016) X X X X X (X) X 
Parental Reflective Functioning Questionnaire (Luyten et al. 2017) X X X X X (X) X 
Mentalizing Stories for Adoles cents (Vrouva and Fonagy 2009) X X X X (X) X 
Basic Empathy Scale (Jolliffe and Farrington 2006) X X X X X X 
Difficulties in Emotion Regulation Scale—Lack of Emotional X X X X X 
Clarity/Awareness subscales (Gratz and Roemer 2004) 
Mentalization Scale (Dimitrijevic et al. 2018) X X X X X 
Mentalization Questionnaire (Hausberg et al. 2012) X X X X X (X) (X) X 51 Assessment of Mentalizing 

TABLE 3–4. Measures assessing the dimensions of mentalizing (continued)
 Questionnaires (continued)
Mentalized Affectivity Scale (Greenberg et al. 2017) X X X X X 
Reflective Functioning Questionnaire for Youths X X X X X (X) X 
(Ha et al. 2013) 
Reflective Functioning Questionnaire for Children (Ensink et al. X X X X X (X) X 
2018a) 
Interviews/narrative coding systems
  Adult Attachment Interview—Re flective Func tioning Scale X X X X X (X) (X) X 
(Fonagy et al. 1998) 
 Parent Development Interview–Reflective Functioning Scale X X X X X (X) (X) X 
(Slade et al. 2004) 
 Working Model of the Child Interview—Reflective Functioning X X X X X (X) (X) X 
Scale (Grienenberger et al. 2005) 
  Pregnancy Interview–Maternal Reflective Functioning Scale X X X X X X (X) X 
(Slade and Patterson 2005) 
 Panic Specific Reflective Functioning Interview—Panic Specific X (X) X X X (X) (X) X 
Reflective Functioning Scale (Rudden et al. 2006) 
Brief Reflective Functioning In terview—Reflective Functioning X X X X X (X) (X) X 
Scale (Rudden et al. 2005;  Rutimann and Meehan 2012) 
Toronto Structured Interview for Alexithymia (Bagby et al. 2006) X X X X (X) X 
Mental States Measure and Grille  de l’élaboration verbale de X X X X X (X) (X) X 
l’affect (Bouchard et al. 2008) 
  Metacognition Assessment Scale (Carcione et al. 2007) X X X X X (X) X 52 Handbook of Mentalizing in Mental Health Practice, Second Edition 

Interviews/narrative coding systems (continued) 
Intentionality Scale (Hill et al. 2007) X X X X (X) (X) X 
Internal State Lexicon (Beeghly and Cicchetti 1994) X X X X X (X) X 
Reflective Functioning Rati ng Scale (Meehan et al. 2009) X X X X X (X) (X) X 
Theory of Mind Assessment  Scale (Bosco et al. 2009) X X X X X (X) X 
Mini Parental Reflective Functi oning Interview (Ensink et al. X X X X X (X) (X) X 
2018a, 2018b) 
Child Attachment Interview—Chil d and Adolescent Reflective X X X X X (X) (X) X 
Functioning Scale (Ensink et al. 2016a) 
Trauma Reflective Function ing Scale (Ens ink et al. 2014a) X X X X X (X) (X) X 
Experimental/observational tasks
Reading the Mind in the Eyes Test (Baron-Cohen et al. 2001) X X X X X 
Reading the Mind in the Vo ice Test (Golan et al. 2007) X X X X X 
Reading the Mind in Films Task (Golan et al. 2008) X X X X X X 
International Affective Picture System (Lang et al. 2008) X X X X X 
NimStim Set of Facial Expres sions (Tottenham et al. 2009) X X X X X 
Face morphs (Bailey et al. 2008) X X X X X (X) X 
Dynamic body expressions (Pichon et al. 2009) X X X X (X) X 
Electromyography of facial mimicry (Sonnby-Borgström and (X) X (X) X X X 
Jönsson 2004) 
Affect labeling (Lieberman et al. 2007) X X X X X 
Movie for the Assessment of Soci al Cognition (Dziobek et al. 2006) X X X X X (X) X 
Trust Task (King-Casas et al. 2008) (X) X X X X X 53 Assessment of Mentalizing 

 Experimental/observational tasks (continued)
Interoceptive sensitivity (Barrett et al. 2004) X X X X X 
Empathy for pain in others (Hein and Singer 2008) (X) X X X X X X 
 Manipulating body consciousness (Brass et al. 2007; X X X X X X X X 
Lenggenhager et al. 2007) 
  Test battery for perception and recognition of facial emotion X X X X (X) X 
expressions (Wilhelm et al. 2014) 
Animated Theory of Mind Invent ory for Children (Beaumont and X X X X X (X) X 
Sofronoff 2008)
Maternal mind-mindedness (Meins and Fernyhough 2015) X X X X X (X) (X) X 
  Maternal mind-mindedness (on free play mother–child X X X X X (X) (X) X 
interaction; Meins et al. 2012) 
Maternal Accuracy Paradigm (Sharp et al. 2006) X X X X (X) (X) X 
Strange Stories Task (Happé 1994; White et al. 2009) X X X X X 
False belief picture sequencing task (Baron-Cohen et al. 1986; X X X X 
Langdon and Coltheart 1999; Langdon et al. 1997) 
Cartoon-based assessment of menta lizing skills (Brüne et al. 2016; X X X X (X) X 
Ghiassi et al. 2010) 
 Faux Pas Test (Baron-Cohen et al. 1999) X X X X (X) X 
 Affect Task for Children (Ensink et al. 2014b) X X X X (X) 
Affective Knowledge Test (Denham 1986) X X X X (X) X X 
Mentalizing about the Self—Interview for Preschoolers X X X X X X 
(Laurent et al. 2018b) 54 Handbook of Mentalizing in Mental Health Practice, Second Edition 

Performance-based measures
Thematic Apperception Test (Murray 1943) (X) X X X X X (X) X 
Projective Imagination Test (Blackshaw et al. 2001) (X) X X X X X (X) X 
Children’s Play Therapy Instrument (Kernberg et al. 1998) X X X X X X X X 
Mirror Paradigm (Ensink et al. 2016b) X X X X X X X 
Squiggle Paradigm (Ensink et al. 2017) X X X X X X X X 
Therapist Mental Activity  Scale (Ensink et al. 2013) X X X X X X X X 
Note. X indicates that the measure captures the relevant pole or dimension of mentalizing; (X) indicates that the measure assesses certain features of the relevant pole or
dimension of mentalizing but mainly captures other poles or dimensions of mentalizing. 55 Assessment of Mentalizing 

56 Handbook of Mentalizing in Mental  Health Practice, Second Edition 
the mentalizing impairments that are typical of  specific patient popu lations. For instance, 
researchers interested in patients with functional somatic problems may want to select 
measures that tap into basic (embodied) mentalizing, rather than assuming that these pa­
tients are characterized by severe impairments in mentalizin g about others. Similarly, re­
searchers of ASPD might want to include measures in their research protocol that tap into cognitive and affective features of mentalizing about self and others. 
A range of clinical research measures fo r assessing mentalizing in therapists and 
parents, children and adoles cents, and mentalizing regarding trauma have been de­
veloped by Ensink and colleagues. To assess mentalizing in clinicians, Ensink et al. 
validated the Therapist Mental Activity Scale and used it to assess the effectiveness of training programs geared to develop therapists’ mentalizin g about complex pa­
tients (Ensink et al. 2013). The Mini Pare ntal Reflective Func tioning Interview was 
validated to assess parental reflective func tioning about infants and children in pedi­
atric practice and predicts parenting behavior and infant attachment (Ensink et al. 
2018b). In addition, the Squiggle Paradigm fa cilitates assessment of parents’ reflective 
stance while engaging their children in a collaborative task and interpreting their 
communication, and is potentially useful for planning interventions with parents 
(Ensink et al. 2017). Furthermor e, in the context of working with patients with histo­
ries of trauma, the Trauma Reflective Functi oning Scale (Ensink et al. 2014a) facilitates 
assessment of reflective functioning rega rding trauma, which has been shown to be 
associated with couple adjust ment and infant attachment. 
Instruments have also been developed to assess mentalizing in young children and 
adolescents. The Child and Adolescent Reflective Functioning Scale (Ensink et al. 2016c) has been developed to assess mentalizing regarding self and others in children 
ages 8–12, which has been shown to be a ssociated with trauma, child psychopathol­
ogy, dissociation, physiological regulation , and parental reflective functioning (En-
sink et al. 2016a). A questionnaire version,  the Reflective Functioning Questionnaire 
for Children (Ensink et al. 2018a), was ad apted to complement the Reflective Func­
tioning Questionnaire for Youths (Ha et al. 2013). In addition, mentalizing about the embodied self can be assessed with the Mirror Paradigm (Ensink et al. 2016b) to iden­
tify child and adolescent mental izing difficulties in this ar ea associated with distress, 
psychopathology, and trauma. Other measures of specific dimensions of mentalizing 
have been validated, including the Affect Task for Children (Ensink et al. 2014b) and Strange Stories Task (Happé 1994). For pr eschoolers, the POKO video-based assess­
ment, as well as puppet interviews, has be en adapted to assess emerging mentalizing 
(Ensink and Achim 2016; Laurent et al. 201 8a, 2018b). Furthermore, mentalizing in 
pretend play can be assessed with the Chil dren’s Play Therapy Instrument, and this 
has been shown to predict child reflective func tioning (Tessier et al. 2016). In parallel, 
mentalizing techniques used in play therapy can be assessed using the schema elab­orated by Muñoz Specht et al. (2016). 
Importantly, tasks that have been developed within social neuroscience approaches 
are increasingly allowing researchers to di sentangle different dimensions of mentaliz­
ing. Contemporary imaging methods are stea dily improving, providing better oppor­
tunities to assess more implicit, automatic mentalizing, particularly as most measures 
of mentalizing developed so far require conscious (and thus explicit and controlled) 
mentalizing as well as considerable cognitive abilities. Indeed, most of the measures 
listed in Table 3–4 require the individual to have some sort of cognitive reflection, con­

57 Assessment of Mentalizing 
trol, and modulation of response. For instan ce, in completing the Reading the Mind in 
the Eyes Test (Baron-Cohen et al. 2001), which purportedly captures emotion recogni­
tion, participants are required to integr ate their cognitive an d affective knowledge 
about emotions. This is also the case for me asures that have been explicitly developed 
to distinguish between aspect s of cognitive and affective mentalizing, such as Baron-
Cohen and Wheelwright’s (2004) measure of cognitive versus affective empathy, and 
measures of cognitive and affective alexithymia (Bermond and Vorst 1998). Some ex­perimental tasks enable a better distinction between cognition and affect in mentalizing 
(and the integration between the two) (Sha may-Tsoory et al. 2009), but more work is 
needed to improve their ecological validity. 
Similarly, there is a growing number of me ntalizing tasks that involve online, “hot” 
mentalizing as opposed to more offline, “c old” self-report measures. The former meth­
ods will undoubtedly play a more prominent role in future research, particularly as these measures may be more ecologically va lid in capturing mentalizing as it typically 
unfolds in real-life situations. 
Hence, a rather daunting task awaits the fi eld, not only to meet the urgent need for 
well-validated, more sophisticated measures  of the different facets of mentalizing, 
but also to facilitate the application of these measures in routine clinical practice. We hope that this chapter will inform and guide such efforts. 
CONCLUSION 
The comprehensive assessment of mentalizing involves an assessment of the individ­ual’s overall mentalizing and of the potential imbalances between different dimen­
sions underlying mentalizing, including whether such imbalances manifest in 
specific contexts and relationships. 
Although an increasing number of well-va lidated measures are available for system­
atically assessing mentalizing, a more clinical approach is often needed to challenge 
“cold” and “offline” mentalizing in the cont ext of a new attachment relationship (i.e., 
with an assessor), to provide a valid estimati on of an individual’s mentalizing capaci­
ties. As mentalizing is a quintessential hu man capacity, another human being—specif­
ically, someone trained in the mentalizing approach—is needed to map the subtleties that are often involved in me ntalizing and the impairments in this capacity. In this con­
text, there is also a pressing need for more observer-rated scales of mentalizing to be de­vised, given the particular combination of strengths and sensitivities of the human mind in understanding others, as well as the many pitfalls involved in this capacity. 
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10.1192/bjp.130.3.201 Access the most recent version at DOI: 1977, 130:201-210.BJP J BowlbyCollege of Psychiatrists, 19 November 1976.version of the Fiftieth Maudsley Lecture, delivered before the Royalpsychopathology in the light of attachment theory. An expanded The making and breaking of affectional bonds. I. Aetiology and
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Brit.3.Psyc/ziat. (i@77),130,201â€”10
TheMaking andBreaking ofAffectional Bonds
I.Aetiology andPsychopathology intheLightofAttachment Theory
Anexpanded versionoftheFiftiethMaudsley Lecture, delivered before
theRoyalCollegeofPsychiatrists, 19November 1976
ByJOHNBOWLBY
Summary. Anaccount isgivenofattachment theoryasawayofconceptualizing
thepropensity ofhumanbeingstomakestrongaffectional bondstoparticular
othersandofexplaining themanyformsofemotional distressandpersonality
disturbance, including anxiety, anger,depression andemotional detachment, to
whichunwilling separation andlossgiverise.Though itincorporates much
psychoanalytic thinking, manyofitsprinciples derivefromethology, cognitive
psychology andcontroltheory.Itconforms totheordinary criteriaofascientffic
discipline.
Certain common patterns ofpersonality development, bothhealthy and
pathological, aredescribed intheseterms,andalsosomeofthecommon
patterns ofparenting thatcontribute tothem.
FromthetimewhenIfirststudiedpsychiatry
attheMaudsley Hospital myinterests have
centred onthecontribution thataperson's
environment makestohispsychological devel
opment. Formanyyearsthiswasaneglected
area,anditisonlynowthatitisreceiving the
attention itdeserves. Thisisnofaultofthat
staunch advocate ofthescientific studyof
mental disorder whoselifeandworkwe
remember today.For,although fromsome
passages inhiswritings itmightbethought
thatHenryMaudsley gavelittleweight to
environmental factors, thisisfarfrombeing
true,asareading ofhisinfluential book,
Responsibil4y inMentalDiseases, firstpublished
almostexactly acentury ago,makesclear.
Indeed, fromtheverystartofhiscareer
Maudsley's approach wasthatofthebiologist
â€”¿aswemightexpectinafarmer's son;andhe
knewthatinpsychiatry, asinallthingsbio
logical, itisnecessary toconsider bothâ€˜¿the
subjectandhisenvironment, themanandhis
circumstances' andthatthisrequires thatweshouldadoptadevelopmental approach.* Thus,
inpreparing thisLecture, whichIfeelmuch
honoured tohavebeeninvitedtogive,Ihave
feltsustained bythebeliefthatitstheme,that
ofsocialandemotional development within
different typesoffamilyenvironment, isin
keeping withallthatHenryMaudsley stoodfor.
Whatforconvenience Iamterming attach
menttheoryisawayofconceptualizing the
propensity ofhuman beingstomakestrong
affectional bondstoparticular othersandof
explaining themanyformsofemotional distress
andpersonality disturbance, including anxiety,
anger,depression andemotional detachment, to
whichunwilling separation andlossgiverise.
Asabodyoftheoryitdealswiththesame
phenomena thathitherto havebeendealtwith
intermsofâ€˜¿dependency need'orofâ€˜¿object
*Thequotation isfromanessaybyMaudsley published
ini86o.Forthisandotherinformation regarding
Maudsley's lifeandworkIamindebted totheaccount
givenbythelateSirAubrey LewisinhisTwenty-Fifth
Maudsley Lecture (Lewis, i@@z).
201

THEMAKING ANDBREAKING OFAFFECTIONAL BONDS. I. 202
relations' orofâ€˜¿symbiosis andindividuation'.
Though itincorporates muchpsychoanalytic
thinking, thetheorydiffersfromtraditional
psychoanalysis inadopting anumber ofprin..
ciplesthatderivefromtherelatively new
disciplines ofethology andcontroltheory; by
sodoingitisenabled todispense withconcepts
ofpsychic energyanddriveandalsotoforge
closelinkswithcognitive psychology. Merits
claimed foritarethatwhilstitsconcepts are
psychological theyarealsocompatible with
thoseofneurophysiology anddevelopmental
biology andthatitconforms totheordinary
criteriaofascientific discipline.
Advocates ofattachment theoryarguethat
manyformsofpsychiatric disturbance canbe
attributed eithertodeviations inthedevelop
mentofattachment behaviour or,morerarely,
tofailureofitsdevelopment; andalsothat
thetheorycastslightonboththeoriginandthe
treatment oftheseconditions. Putbriefly,the
thesisofthislectureisthatifwearetohelp
suchapatient therapeutically itisnecessary
thatweenablehimtoconsider indetailhowhis
present modesofperceiving anddealing with
emotionally significant persons, including the
therapist, maybebeinginfluenced andperhaps
seriously distorted bytheexperiences whichhe
hadwithhisparents duringtheyearsofhis
childhood andadolescence, andsomeofwhich
mayperhaps becontinuing intothepresent.
Thisentailshisreviewing thoseexperiences in
ashonestawayaspossible, areviewwhichthe
therapist caneitherassistorimpede. Inabrief
account itispossible onlytostateprinciples
andtherationale behindthem.Westartwitha
briefsketchofwhatismeantbyattachment
theory.(Forafullerdescription ofthedataon
whichitisbased,theconcepts employed and
thearguments initsfavour,withfullreferences,
seethetwovolumes ofAttachment andLossnow
published, Bowiby, 1969,5973.)
Untilthemid-195os onlyoneexplicitly
formulated viewofthenatureandoriginof
affectional bondswasprevalent, andinthis
mattertherewasagreement between psycho
analysts andlearning theorists. Bondsbetween
individuals develop, itwasheld,because an
individual discovers that,inordertoreduce
@certaindrives,e.g.forfoodininfancy andforsexinadultlife,another human beingis
necessary. Thistypeoftheorypostulates two
kindsofdrive,primary andsecondary; it
categorizes foodandsexasprimary and
â€˜¿dependency' andotherpersonal relationships
assecondary. Although objectrelations theorists
(Balint, Fairbairn, Guntrip, Klein,Winnicott)
havetriedtomodifythisformulation, thecon
ceptsofdependency, oralityandregression have
persisted.
Studiesoftheill-effects onpersonality devel
opment ofdeprivation ofmaternal careledme
toquestion theadequacy ofthetraditional
model.Earlyinthe1950SLorenz's workon
imprinting, whichhadfirstappeared in @
became moregenerally knownandofferedan
alternative approach. Atleastinsomespeciesof
bird,hehadfound,strongbondstoamother
figuredevelop duringtheearlydaysoflife
without anyreference tofoodandsimply
through theyoungbeingexposed toand
becoming familiar withthefigureinquestion.
Arguing thattheempirical dataonthedevelop
mentofahumanchild'stietohismothercan
beunderstood betterintermsofamodel
derived fromethology, Ioutlined atheoryof
attachment inapaperpublished in1958.
Simultaneously andindependently, Harlow
(1958) published theresults ofhisfirststudies of
infantrhesusmonkeys reared ondummy
mothers. Ayoungmonkey, hefound,will
clingtoadummy thatdoesnotfeeditprovided
thedummy issoftandcomfortable toclingto.
Duringthepastfifteenyearstheresultsofa
number ofempirical studiesofhumanchildren
havebeenpublished (e.g.Robertson and
Robertson, 1967â€”72; Heinicke andWest
heimer, 1965;Ainsworth, 1967;Ainsworth,
BellandStayton, 1971,1974;Blurton Jones,
5972), theory hasbeengreatly amplified (e.g.
Ainsworth, 5969;Bowlby, 5969;Bischof, 1975),
andtherelationship ofattachment theoryto
dependency theoryexamined (Maccoby and
Masters, 1970;Gewirtz, 1972).Newformula
tionsregarding pathological anxietyandphobia
havebeenadvanced (Bowlby, @ andalso
regarding mourning anditspsychiatric compli
cations(e.g.Bowlby, 596!;Parkes,1965,1971a,
5972). Parkes (1971b) hasextended thetheory
tocovertherangeofresponses seenwhenever a

JOHNBOWLBY 203
personencounters amajorchange inhislife
situation. Manystudieshavebeenmadeof
comparable behaviour inprimate species(see
reviewbyHinde,1974).
Brieflyput,attachment behaviour iscon
ceivedasanyformofbehaviour thatresultsin
apersonattaining orretaining proximity to
someotherdifferentiated andpreferred indi
vidual, whoisusually conceived asstronger
and/orwiser.Whileespecially evident during
earlychildhood, attachment behaviour isheld
tocharacterize humanbeingsfromthecradle
tothegrave. Itincludes cryingandcalling,
whichelicitcare,following andclinging, and
alsostrongprotestshouldachildbeleftalone
orwithstrangers. Withagethefrequency and
theintensity withwhichsuchbehaviour is
exhibited diminish steadily. Nevertheless, all
theseformsofbehaviour persistasanimportant
partofman'sbehavioural equipment. Inadults
theyareespecially evident whenapersonis
distressed, illorafraid.Theparticular patterns
ofattachment behaviour shownbyanindividual
turnpartlyonhispresentage,sexandcircum
stancesandpartlyontheexperiences hehas
hadwithattachment figuresearlierinhislife.
Asawayofconceptualizing proximity keep
ing,attachment theory, incontrast tode
pendency theory, emphasizes theIbilowing
features:*
(a)Speczf1ci@y. Attachment behaviour isdirec
tedtowards oneorafewspecific individuals,
usuallyinclearorderofpreference.
(b)Duration. Anattachment endures, usually
foralargepartofthelifecycle.Although
during adolescence earlyattachments may
attenuate andbecome supplemented bynew
ones,andinsomecasesarereplaced bythem,
earlyattachments arenoteasilyabandoned and
theycommonly persist.
(c)Engagement ofemotion. Manyofthemost
intense emotions ariseduringtheformation,
themaintenance, thedisruption andthe
renewal ofattachment relationships. Thefor
mationofabondisdescribed asfallinginlove,
*Indescribing thesefeatures Iamdrawing onthe
textofanarticle(Bowlby, 1975)written forVolume VI
oftheAmerican Handbook ofP4yChiafrJ, (@1975byBasic
Books,mc,andamgratefultotheeditorsandpublishers
forpermission todoso.maintaining abondaslovingsomeone, and
losingapartner asgrieving oversomeone.
Similarly, threatoflossarouses anxiety and
actuallossgivesrisetosorrow; whileeachof
thesesituations islikelytoarouseanger.The
unchallenged maintenance ofabondisexperi
encedasasourceofsecurity andtherenewal of
abondasasourceofjoy.Because suchemotions
areusuallyareflection ofthestateofaperson's
affectional bonds,thepsychology andpsycho
pathology ofemotion isfoundtobeinlarge
partthepsychology andpsychopathology of
affectional bonds.
(d)Ontogen,. Inthegreatmajority ofhuman
infantsattachment behaviour toapreferred
figuredevelops duringthefirstninemonthsof
life.Themoreexperience ofsocialinteraction
aninfanthaswithapersonthemorelikelyis
hetobecome attached tothatperson.Forthis
reason, whoever isprincipally mothering a
childbecomes hisprincipal attachment figure.
Attachment behaviour remains readily acti
vateduntilneartheendofthethirdyear;in
healthy development itbecomes gradually less
readilyactivated thereafter.
(e)Learning. Whereas learning todistinguish
thefamiliar fromthestrangeisakeyprocessin
thedevelopment ofattachment, theconven
tionalrewards andpunishments usedby
experimental psychologists playonlyasmall
part.Indeed, anattachment candevelop
despiterepeated punishment fromtheattach
mentfigure.
(f)Organization. Initially attachment beha
viourismediated byresponses organized on
fairlysimplelines.Fromtheendofthefirst
year,itbecomes mediated byincreasingly
sophisticated behavioural systems organized
cybernetically andincorporating representa
tonalmodels oftheenvironment andself.
Thesesystems areactivated bycertaincondi
tionsandterminated byothers.Among acti
vating conditions arestrangeness, hunger,
fatigueandanything frightening. Terminating
conditions include sightorsoundofmother
figureand,especially, happyinteraction with
her.Whenattachment behaviour isstrongly
aroused, termination mayrequire touching or
clinging toherand/orbeingcuddled byher.
Conversely, whenmother-figure ispresent or

204 THEMAKING ANDBREAKING OFAFFECTIONAL BONDS. I.
herwhereabouts well-known, achildceasesto
showattachment behaviour and,instead, ex
ploreshisenvironment.
(g)Biological function. Attachment behaviour
occursintheyoungofalmostallspeciesof
mammal, andinanumber ofspeciesitpersists
throughout adultlife.Although thereare
manydifferences ofdetailbetween species,
maintenance ofproximity byanimmature
animal toapreferred adult,almost always
mother, istherule,whichsuggests thatsuch
behaviour hassurvival value. Elsewhere
(Bowlby, 1969),Ihaveargued thatbyfar
themostlikelyfunction ofattachment behaviour
isprotection, mainlyfrompredators.
Thusattachment behaviour isconceived asa
classofbehaviour distinct fromfeeding beha
viourandsexualbehaviour andofatleastan
equalsignificance inhuman life.Thereis
nothing intrinsically childish orpathological
aboutit.
Itwillbenotedthattheconcept ofattach
mentdiffersgreatlyfromthatofdependence.
Forexample, dependence isnotspecifically
relatedtomaintenance ofproximity, itisnot
directed towards aspecffic individual, itdoes
notimplyanenduring bond,norisitnecessarily
associated withstrongfeeling. Nobiological
function isattributed toit.Furthermore, inthe
concept ofdependence therearevalueimplica
tionstheexactopposite ofthosethattheconcept
ofattachment conveys. Whereas torefertoa
personasdependent tendstobedisparaging,
todescribe himasattached tosomeone canwell
beanexpression ofapproval. Conversely, fora
persontobedetached inhispersonal relations
isusually regarded aslessthanadmirable.
Thedisparaging element intheconcept of
dependence, whichreflectsafailuretorecognize
thevaluethatattachment behaviour hasfor
survival, isheldtobeafatalweakness toits
clinicaluse.
Inwhatfollows, theindividual whoshows
attachment behaviour isusuallyreferred toas
childandtheattachment figureasmother.
Thisisbecause thebehaviour hassofaronly
beencloselystudiedinchildren. Whatissaid,
however, isheldtoapplyalsotoadultsandto
whoever isactingforthemastheirattachmentfigureâ€”often aspouse, sometimes aparent
andmoreoftenthanmightbesupposed achild.
Itwasremarked (under(f)above)that,when
mother ispresent orherwhereabouts well
knownandsheiswillingtotakepartinfriendly
interchange, achildusually ceasestoshow
attachment behaviour and,instead, explores his
environment. Insuchasituation mother can
beregarded asproviding herchildwitha
securebasefromwhichtoexplore andtowhich
hecanreturn,especially shouldhebecometired
orfrightened. Throughout therestofaperson's
lifeheislikelytoshowthesamepattern of
behaviour, moving awayfromthoseheloves
forever-increasing distances andlengthsoftime
yetalwaysmaintaining contact andsooneror
laterreturning. Thebasefromwhichhe
operates islikelytobeeitherhisfamilyof
originorelseanewbasewhichhehascreated
forhimselL Anyone whohasnosuchbaseis
rootless.
Intheaccount givensofartwopatterns of
behaviour otherthanattachment havebeen
referred to,namelyexploration andcare-giving.
Thereisnowamassofevidence tosupport
theviewthatexploratory activity isofgreat
importance initsownright,enabling aperson
orananimaltobuildupacoherent pictureof
environmental features whichmayatanytime
become ofimportance forsurvival. Children
andotheryoungcreatures arenotoriously
curiousandinquiring, whichcommonly leads
themtomoveawayfromtheirattachment
figure.Inthissenseexploratory behaviour is
antithetical toattachment behaviour. Inhealthy
individuals thetwokindsofbehaviour normally
alternate.
Thebehaviour ofparents, andofanyone
elseinacare-giving role,iscomplementary to
attachment behaviour. Therolesofthecare
giverarefirsttobeavailable andresponsive as
andwhenwanted and,secondly, tointervene
judiciously shouldthechildorolderpersonwho
isbeingcaredforbeheading fortrouble. Not
onlyisitakeyrolebutthereissubstantial
evidence thathowitisdischarged byaperson's
parentsdetermines ingreatdegreewhether or
nothegrowsuptobementally healthy. Forthat
reasonandalsobecauseitistherolewefillwhen
weactaspsychotherapists, ourunderstanding of

JOHNBOWLBY 205
itisheldtobeofcentralimportance tothe
practice ofpsychotherapy.
Onefurther pointneedstobemadebefore
weconsider theimplications ofthisschemafor
atheoryofaetiology andpsychopathology and
thenceforthepractice ofpsychotherapy. It
concerns ourunderstanding ofanxiety andof
separation anxiety inparticular.
Acommon assumption thatrunsthrough
mostpsychiatric andpsycho-pathological theory
isthatfearshouldbemanifested onlyinsitua
tionsthataretrulydangerous, andthatfear
showninanyothersituation isneurotic. This
leadstotheconclusion that,because separation
fromanattachment figurecannotberegarded
asatrulydangerous situation, anxiety over
separation fromthatfigureisneurotic. Examina
tionoftheevidence showsthatboththeassump
tionandtheconclusion towhichitleadsare
false.
Whenapproached empirically separation
fromanattachment figureisfoundtobeoneof
aclassofsituations eachofwhichislikelyto
elicitfearbutnoneofwhichcanberegarded
asintrinsically dangerous. Thesesituations
comprise, amongothers,darkness, suddenlarge
changes ofstimulus levelincluding loudnoises,
suddenmovement, strangepeopleandstrange
things.Evidence showsthatanimals ofmany
speciesarealarmed bysuchsituations (Hinde,
1970), andthatthisistrueofhuman children
(Jersild, 1947)andalsoofadults.Furthermore,
fearisespecially likelytobeelicitedwhentwo
ormoreoftheseconditions arepresentsimulta
neously, forexample, hearing aloudnoise
whenaloneinthedark.
Theexplanation ofwhyindividuals shouldso
regularly respond tothesesituations withfear
isheldtobethat,whilenoneofthesituations is
intrinsically dangerous, eachcarrieswithitan
increased riskofdanger. Noise,strangeness,
isolation, andformanyspeciesdarkness, all
theseareconditions statistically associated with
anincreased riskofdanger.Noisemaypresagea
natural disasterâ€”fire, floodorlandslide. Toa
younganimal apredator isstrange, itmoves,
anditoftenstrikesatnight,anditisfarmore
likelytodosowhenthepotential victimis
alone.Because tobehave sopromotes both
survival andbreeding success, thetheoryruns,theyoungofspeciesthathavesurvived, in
cludingman,arefoundtobegenetically biased
sotodevelop thattheyrespond tothepro
pertiesofnoise,strangeness, suddenapproach,
anddarkness bytakingavoiding actionor
running awayâ€”they behaveinfactasthough
dangerwereactually present. Inacomparable
waytheyrespond toisolation byseekingcom
pany.Fearresponses elicitedbysuchnaturally
occurring cluestodangerareapartofman's
basicbehavioural equipment (Bowlby, 1973).
Seeninthislightanxiety overunwilling
separation fromanattachment figureresembles
theanxietythatthegeneralofanexpeditionary
forcefeelswhencommunications withhisbase
arecutorthreatened.
Thisleadstotheconclusion thatanxietyover
anunwilling separation canbeaperfectly
normal andhealthy reaction. Whatmaybe
puzzling iswhysuchanxietyisaroused insome
peopleatsuchveryhighintensity or,conversely,
inothersatsuchlowintensities. Thisbringsus
toquestions ofaetiology andpsychopathology.
Throughout thiscentury debatehasraged
abouttheroleofchildhood experiences inthe
causation ofpsychiatric disturbance. Notonly
havetraditionally minded psychiatrists been
sceptical oftheirrelevance butpsychoanalysts
havebeenatsixesandsevensaboutthem.For
longmostanalysts whohavethought reallife
experience tobeofimportance concentrated
attention onthefirsttwoorthreeyearsoflife
andoncertaintechniques ofbabycareâ€”the
waysaninfantisfedortoilettrainedâ€”and
whether hewitnesses parental intercourse.
Attention tofamilyinteraction andtheparti
cularwayaparenttreatsaparticular childwas
notencouraged. Someextremists, indeed,have
heldthatthesystematic studyofaperson's
experiences withinhisfamilylieoutside the
properinterestofapsychoanalyst.
Nooneengaged inchildpsychiatry, better
termedfamilypsychiatry, canpossibly share
suchaview.Inagreatmajority ofcasesnot
onlyisthereevidence ofdisturbed family
relationships buttheemotional problems ofthe
parents, derived fromtheirownunhappy
childhoods, commonly loomlarge.Thusthe
problem hasalwaysseemedtomenotwhether
tostudyapatient's familyenvironment butto

206 THEMAKING ANDBREAKING OFAFFECTIONAL BONDS. I.
decidewhatfeatures arelikelytoberelevant,
whatmethods ofinquiry arepracticable, and
whattypeoftheorybestfitsthedata.Because
manyothershaveadopted thesameviewa
greatdealofreasonably reliable research has
nowbeendonebyworkers ofmanydisciplines.
Itisfromtheresultsofthisresearch, inter
pretedintermsofattachment theory, thatI
offerthegeneralizations andviewsthatfollow.
Thekeypointofmythesisisthatthereisa
strongcausalrelationship between anindivi
dual'sexperiences withhisparents andhis
latercapacity tomakeaffectional bonds,and
thatcertaincommon variations inthatcapacity,
manifesting themselves inmarital problems
andtroublewithchildren aswellasinneurotic
symptoms andpersonality disorders, canbe
attributed tocertaincommon variations inthe
waysthatparentsperform theirroles.Muchof
theevidence onwhichthethesisrestsisreviewed
inthesecondvolume ofAttachment andLoss
(Chapter i@onwards). Themainvariable to
whichIdrawattention istheextenttowhich
achild'sparents(a)provide himwithasecure
base,and(b)encourage himtoexplore from
it.Intheserolestheperformance ofparents
variesalongseveralparameters ofwhichper
hapsthemostimportant, because itpervades all
relations, istheextenttowhichparentsrecog
nizeandrespectachild'sdesireforasecure
baseandhisneedofit,andshapetheirbeha
viouraccordingly. Thisentails,first,anintuitive
andsympathetic understanding ofachild's
attachment behaviour andawillingness to
meetitandthereby terminate it,and,secondly,
recognition thatoneofthecommonest sources
ofangeristhefrustration ofachild'sdesirefor
loveandcare,andthatanxiety commonly
reflectsuncertainty whether parents willcon
tinuetobeavailable. Complementary in
importance toaparent's respectforachild's
attachment desiresisrespectforhisdesireto
explore andgradually toextendhisrelation
shipsbothwithpeersandwithotheradults.
Research suggests thatinmanyareasof
BritainandtheUnitedStatesrathermorethan
halfthechildpopulation isgrowing upwith
parents whoareproviding theirchildren with
suchconditions. Typically thesechildren grow
uptobesecureandself-reliant, andtobetrusting, co-operative andhelpful towards
others.Inthepsychoanalytic literature sucha
personissaidtohaveastrongego;andhemay
bedescribed asshowing â€˜¿basictrust'(Erikson,
1950), â€˜¿mature dependence' (Fairbairn, 1952)
orashavingâ€˜¿introjected agoodobject'(Klein,
i@8).Intermsofattachment theoryheis
described ashavingbuiltuparepresentational
modelofhimself asbeingbothabletohelp
himselfandasworthyofbeinghelpedshould
difficulties arise.
Bycontrast, manychildren (insomepopula
tionsone-third ormore)growupwithparents
whodonotprovide theseconditions. Notehere
thatthefocusofattention isontheparticular
relationship aparenthaswithaparticular
child,sinceparents donottreateverychild
alikeandmayprovide excellent conditions for
oneandveryadverseonesforanother.
Letusconsider someofthecommoner
deviant patterns ofattachment behaviour, as
shownbyadolescents andadults,withexamples
oftypicalchildhood experiences whichthose
whoshowthemarelikelytohavehadandmay
stillbehaving.
Manyofthosereferred topsychiatrists are
anxious, insecure individuals, usuallydescribed
asover-dependent orimmature. Understress
theyareapttodevelop neurotic symptoms,
depression orphobia. Research showsthemto
havebeenexposed toatleastone,andusually
morethanone,ofcertaintypicalpatterns of
pathogenic parenting, whichinclude
oneorbothparents beingpersistently
unresponsive tothechild's care-eliciting
behaviour and/oractively disparaging and
rejecting;
discontinuities ofparenting, occurring more
orlessfrequently, including periods in
hospital orinstitution;
persistent threatsbyparents nottolovea
child,usedasameansofcontrolling him;
threatsbyparents toabandon thefamily,
usedeitherasamethod ofdisciplining the
childorasawayofcoercing aspouse;
threats byoneparenteithertodesertor
eventokilltheotherorelsetocommit
suicide(eachofthemcommoner thanmight
besupposed);

207 JOHNBOWLBY
inducing achildtofeelguiltybyclaiming
thathisbehaviour isorwillberesponsible
fortheparent's illnessordeath.
Anyoftheseexperiences canleadachild,an
adolescent oranadulttoliveinconstant
anxiety lesthelosehisattachment figureand,
asaresult,tohavealowthreshold formani
festingattachment behaviour. Thecondition is
bestdescribed asoneofanxiousattachment.*
Anadditional setofconditions towhichsome
suchindividuals havebeen,andmaystillbe,
exposed isthatofaparent, usually mother,
exerting pressure onthemtoactasanattach
mentfigureforher,thusinverting thenormal
relationship. Meansofexerting suchpressure
varyfromtheunconscious encouragement ofa
premature senseofresponsibility forothersto
thedeliberate useofthreatsorinduction of
guilt.Individuals treated inthesewaysare
likelytobecome over-conscientious andguilt
riddenaswellasanxiously attached. Amajority
ofcasesofschoolphobiaandagoraphobia arise
probably inthisway.
Allthevariants ofparental behaviour sofar
described arelikelynotonlytoarouseachild's
angeragainst hisparents buttoinhibitits
expression. Theresultismuchpartially un
conscious resentment, whichpersistsintoadult
lifeandisexpressed usuallyinadirection away
fromtheparentsandtowards someone weaker,
e.g.aspouseorachild.Suchapersonislikely
tobesubjectalsotostrongunconscious yearn
ingsforloveandsupport whichmayexpress
themselves insomeaberrant formofcare
eliciting behaviour, forexample, half-hearted
suicideattempts, conversion symptoms, anorexia
nervosa, hypochondria (Henderson, 1974).
Apattern ofattachment behaviour thatis
overtlytheopposite ofanxious attachment is
onedescribed byParkes(i@7@)asthatof
compulsive self-reliance. Sofarfromseekingthe
loveandcareofothersapersonwhoexhibits
thispattern insistsonkeeping astiffupperlip
anddoingeverything forhimselfwhatever the
conditions. Thesepeopletooareapttocrack
understressandtopresentwithpsychosomatic
symptoms ordepression.
â€¢¿Thereisnoevidence whatever forthetraditional
idea,stillwidespread, thatsuchapersonhasbeenover'@
indulged asachildandsohasgrownupâ€˜¿spoilt'.Manysuchpersonshavehadexperiences not
unlikethoseofindividuals whodevelop anxious
attachment; buttheyhavereacted tothem
differently byinhibiting attachment feeling
andbehaviour anddisclaiming, perhaps even
mocking, anydesireforcloserelations with
anyone whomightprovide loveandcare.It
requires nogreatinsighttorealize, however,
thattheyaredeeplydistrustful ofcloserelation
shipsandterrified ofallowing themselves torely
onanyoneelse,insomecasesinordertoavoid
thepainofbeingrejected andinothersto
avoidbeingsubjected topressure tobecome
someone else'scaretaker. Asinthecaseof
anxious attachment, thereislikelytobemuch
underlying resentment which,whenelicited, is
directed againstweakerpersons, andalsoun
expressed yearning forloveandsupport.
Apatternofattachment behaviour relatedto
compulsive self-reliance isthatofcompulsive
care-giving. Apersonshowing itmayengagein
manycloserelationships butalwaysintherole
ofgivingcare,neverthatofreceiving it.Often
theoneselected isalameduckwhomayfora
timewelcome thecarebestowed. Butthe
compulsive care-giver willalsostrivetocare
forthosewhoneither seeknorwelcome it.
Thetypical childhood experience ofsuch
peopleistohaveamother who,duetode
pression orsomeotherdisability, wasunableto
careforthechildbut,instead, welcomed being
caredforandperhaps alsodemanded helpin
caringforyounger siblings. Thus,fromearly
childhood, thepersonwhodevelops inthisway
hasfoundthattheonlyaffectional bondavail
ableisoneinwhichhemustalwaysbethecare
giverandthattheonlycarehecaneverreceive
isthecarehegiveshimself. (Children growing
upininstitutions sometimes develop inthis
way,too.)Hereagain,asinthecaseofthe
compulsively self-reliant, thereismuchlatent
yearning forloveandcareandmuchlatent
angerwiththeparentsfornothavingprovided
it;and,onceagain,muchanxiety andguilt
aboutexpressing suchdesires.Winnicott (1965)
hasdescribed individuals ofthissortashaving
developed aâ€˜¿falseself'andagreesthatitsorigin
istobefoundinthepersonnothavingreceived
â€˜¿goodenough' mothering asachild.Toassist
suchapersontodiscover hisâ€˜¿trueself'entails

208 THEMAKING ANDBREAKING OFAFFECTIONAL BONDS. I.
helping himrecognize andbecome possessed
ofhisyearning forloveandcareandhisanger
atthosewhoearlierfailedtogiveithim.
Eventsthatareespecially liabletoactas
stressors forindividuals whoseattachment and
care-giving behaviour hasdeveloped alongone
orotherofthelinessofardescribed arethe
seriousillnessordeatheitherofanattachment
figureorofsomeone caredfor,orsomeother
formofseparation fromthem.Aserious illness
intensifies anxiety andperhaps guilt.Deathor
separation confirm theperson's worstexpecta
tionsandleadtodespairaswellasanxiety. In
thesepeoplemourning adeathoraseparation
islikelytotakeanatypical course.Inthecase
oftheanxiously attached, mourning islikelyto
becharacterized byunusually intense anger
and/orself-reproach, withdepression, andto
persistformuchlongerthannormal. Inthe
caseofthecompulsively self-reliant, mourning
maybedelayed formonthsoryears.Nonethe
lessstrainandirritability areusuallypresent
andepisodic depressions mayoccur,butoften
solongatimelaterthatthecausalconnection
withthedeathorseparation islosttosight.
Thesepathological formsofmourning are
discussed byParkes(1972).
Notonlyarepeople ofthekindsofar
described likelytobreakdownafteralossor
separation, buttheyarelikelytoencounter
certain typical difficulties whentheyget
married andhavechildren. Inrelation toa
marriage partner, apersonmayexhibitanxious
attachment andmakeconstant demands for
loveandcare;orelseheorshemayexhibit
compulsive caregiving totheotherwithlatent
resentment thatitseemsneitherappreciated nor
reciprocated. Inrelation toachild,also,either
ofthesepatterns maybeexhibited. Inthefirst
casetheparentrequires thechildtobehisor
hercaregiver andinthesecond insistson
providing himwithcareevenwhenitisno
longerappropriate (â€˜smother love').* Distur
â€¢¿Thetermâ€˜¿symbiotic' issometimes usedtodescribe
thesesuffocatingly closerelationships. Thetermisnot
happily chosen, however, sinceinbiology itreferstoa
mutually advantageous partnership between twoorganisms
whereas thefamilyrelationships sotermedareseriously
maladaptive. Todescribe thechildasâ€˜¿overprotected' is
equally misleading sinceitfailstorecognize theinsistent
demands forcarethattheparentisputtingonthechild.bancesofparenting behaviour resultalsofrom
aparentperceiving andtreating hischildas
thoughthechildwereoneofhissiblingswhich
canresult,forexample, inafatherbeing
jealous oftheattentions hiswifegivestheir
child.
Another common formofdisturbance iswhen
aparentperceives hischildasareplicaof
himseli especially ofthoseaspectsofhimself
whichhehasendeavoured tostampout,and
strivesthentostampthemoutinhischildalso.
Intheseeffortsheislikelytouseaversionof
thesamemethods ofdisciplineâ€”perhaps crude
andviolent, perhaps censorious orsarcastic,
perhaps guilt-inducing--to which hehimself
wassubjected asachildandwhichresulted in
hisdeveloping theveryproblems heisnow
striving soinappropriately toprevent orcure
inhischild.Ahusband canalsoperceive and
treathiswifeinthesameway.Similarly, a
wifeandmother canadoptthispattern inher
perception andtreatment ofherhusband or
child.Whenconfronted bydisagreeable and
self-defeating behaviour ofthissortitisuseful
toremember thateachofusisapttodounto
othersaswehavebeendoneby.Thebullying
adultisthebulliedchildgrownbigger.
Whenoneadoptseithertowards oneselfor
towards othersthesameattitudes andformsof
behaviour thatone'sownparentadopted and
maystillbeadopting towards oneselfonecan
besaidtobeidentifying withthatparent.The
processes bywhichsuchattitudes andformsof
behaviour areacquired arepresumably those
ofobservational learning andthusnodifferent
tothosebywhichothercomplex formsof
behaviour, including usefulskills,areac
quired.
Ofthemanyotherpatterns ofdisturbed
familyfunctioning andpersonality development
thatcanbeunderstood intermsofthepatho
logicaldevelopment ofattachment behaviour, a
well-known oneistheemotionally detached
individual whoisincapable ofmaintaining a
stableaffectional bondwithanyone. People
withthisdisability maybelabelled aspsycho
pathicand/orhysterical. Theyareoftendelin
quentandsuicidal. Thetypicalhistoryisone
ofprolonged deprivation ofmaternal care
duringtheearliestyearsoflife,usuallycomm

JOHNBOWLBY 209
binedwithlaterrejection and/orthreatsof
rejection byparentsorfosterparents.*
Toexplainwhyindividuals ofdifferent sorts
shouldcontinue toexhibitthecharacteristics
described longaftertheyhavegrownup,it
seemsnecessary topostulate that,whatever
representational modelsofattachment figures
andofselfanindividual buildsduringhis
childhood andadolescence, thesetendtopersist
relatively unchanged intoandthroughout adult
life.Asaresulthetendstoassimilate anynew
personwithwhomhemayformabond,suchas
spouseorchild,oremployer ortherapist, toan
existing model(eitherofoneorotherparentor
ofself),andoftentocontinue todosodespite
repeated evidence thatthemodelisinappro
priate.Similarly, heexpects tobeperceived
andtreatedbytheminwaysthatwouldbe
appropriate tohisself-model, andtocontinue
withsuchexpectations despite contrary evi
dence.Suchbiassedperceptions andexpecta
tionsleadtovariousmisconceived belief@about
theotherpeople,tofalseexpectations aboutthe
waytheywillbehave andtoinappropriate
actions, intended toforestall theirexpected
behaviour. Thus,totakeasimpleexample, a
manwhoduring childhood wasfrequently
threatened withabandonment caneasilyattri
butesuchintentions tohiswife.Hewillthus
misinterpret thingsshesaysordoesintermsof
suchintent,andthentakewhatever actionhe
thinkswouldbestmeetthesituation hebelieves
toexist.Misunderstanding andconflict must
follow.Inallthisheisasunaware thatheis
beingbiasedbyhispastexperience asheisthat
hispresent beliefsandexpectations aremistaken.
Intraditional theorytheprocesses described
areoftenreferred tointermsofâ€˜¿internalizing a
problem' andthemisattributions andmisper
ceptions ascribed toprojection, introjection or
phantasy. Notonlyaretheresulting statements
apttobeambiguous butthefactthatsuch
misattributions andmisperceptions aredirectly
â€¢¿Sinceallthepsychiatric conditions referred to
represent varying degrees andpatterns ofthesameunder
lyingpsychopathology thereisnomoreprospect of
distinguishing onesharpiy fromanother thanthereisof
distinguishing sharply between different formsoftuber
culousinfection. Inaccounting forthedifferences, genetic
factorsaswellasvariations intheexperiences ofdifferent
individuals arelikelytoberelevant.derived fromprevious real-life experience is
eitheronlyvaguely alluded toorelsetotally
obscured. Byframing theprocesses intermsof
cognitive psychology, Ibelieve, muchgreater
precision becomes possible andhypotheses re
garding thecausative roleofdifferent sortsof
childhood experience, through thepersistence
ofrepresentational modelsofattachment figures
andselfatanunconscious level,canbeformu
latedintestableform.
Itshouldbenotedthatinappropriate but
persistent representational modelsoftenco-exist
withmoreappropriate ones.Forexample, a
husband mayoscillate between believing his
wifetobeloyaltohimandsuspecting herof
planstodesert.Clinical experience suggests
thatthedeepertherelationship andthestronger
theemotions aroused themorelikelyarethe
earlierandlessconscious models tobecome
dominant. Toaccount forsuchmentalfunction
ing,whichistraditionally discussed intermsof
defensive processes, presents achallenge to
cognitive psychologists butisonetowhich
theyarealready addressing themselves (e.g.
Erdelyi, 1974).
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(Received 5August1976)

Attachment Styles and Personality
Disorders: Their Connections to Each Other
and to Parental Divorce, Parental Death,
and Perceptions of Parental Caregiving
Kelly A. Brennan
State University of New York, Stony Brook
Phillip R. Shaver
University of California, Davis
ABSTRACT Attachment theory was explored as a means of understanding
the origins of personality disorders. We investigated whether adult attachment
stylesandpersonalitydisordersshareacommonunderlyingstructure,andhowboth kinds of variables relate to family background factors, including parental
death, parental divorce, and current representations of childhood relationships
with parents. A nonclinical group of 1407 individuals, mostly adolescents andyoung adults, were surveyed about their attachment styles, parental marital
status, parental mortality status, perceptions of treatment by parents in child-
hood, and 13personalitydisorders.Resultsindicatedsubstantialoverlapbetweenattachmentand personality-disordermeasures.Twoofthe personality-disorder
JournalofPersonality 66:5, October1998.
Copyright©1998byBlackwellPublishers,350MainStreet,Malden,MA02148,USA,and108Cowley Road, Oxford,OX4 1JF,UK.Parts of this article were presented at the 101st annual convention of the American
Psychological Association, held August 22, 1993, in Toronto, Ontario, Canada. This
research was supported by grant #2806 from the Hogg Foundation for Mental Health
awardedtothefirstauthor.TheauthorswouldliketothankDrs.KimBartholomew,Keith
Davis, Deborah Jacobvitz, Daniel Klein, K. Daniel O’Leary, and Janet Spence, and ananonymousreviewer, fortheir invaluablecommentsonapreviousdraft.Addresscorre-spondencetoKellyBrennan,DepartmentofPsychology,StateUniversityofNewYork,350 New Campus Drive, Brockport, NY 14420-2914; electronic mail: kbren-
nan@po.brockport.edu

dimensions are related to the two dimensions of the attachment space; that is,
thereisatwo-dimensionalspaceinwhichboththeattachmentpatternsandmost
ofthepersonalitydisorderscanbearrayed.Theonepersonality-disorderfactorthat is unrelated to attachment appears akin to psychopathy. Both personality
disordersandattachmentstyleswereassociatedwithfamily-of-originvariables.
Results are discussed in terms of encouraging further research to test the ideathat insecure attachment and most of the personality disorders share similar
developmental antecedents.
According to the most recent Diagnostic and Statistical Manual of the
AmericanPsychiatricAssociation (APA),personalitydisordersare“en-
duringpattern[s]ofinnerexperienceandbehaviorthatdeviatemarkedly
from the expectations of the individual’s culture, [are] pervasive and
inflexible,[have]anonsetinadolescenceorearlyadulthood,[are]stableover time, and [lead] to distress or impairment” (APA, 1994, p. 629).
Some personality disorders are characterized by patterns of disorderedcognitions(asintheSchizotypalandObsessive-Compulsivedisorders).
Othersarecharacterizedbyproblemswithemotions(asintheHistrionic
andBorderlinepersonalitydisorders).Virtuallyallpersonalitydisorders,
however, are characterized by persistent difficulties in interpersonal
relations,whichisoftentheircentralfeature(Widiger&Frances,1985).
For example, the Schizoid character appears defensively devoid of anyinterest in human interaction,whereasthe Dependent character appears
incapable of functioning without the aid of a close other (Bornstein,
1992; Livesley, Schroeder, & Jackson, 1990). Similarly, the Avoidant
personality disorder is typically characterized by a simultaneous desirefor,and fear of,close relationships(Sheldon&West,1990).
Despite the increasing attention paid to personality disorders since
publication of the third Diagnostic and Statistical Manual of Mental
Disorders (DSM-III-R) (APA, 1987), little is actually known about the
etiologyofthesedisorders.Severalfactorshavebeenimplicated,rangingfrom the genetic to the psychosocial (Benjamin, 1993/1996; Crowell,
Waters,Kring,&Riso,1993;Dahl,1993;Dutton,1994;Heard&Lake,
1986;Laport&Guttman,1996;Livesley,Jang,Jackson,&Vernon,1993;
Mattick&Newman,1991;Norden,Klein,Donaldson,Pepper,&Klein,1995;Risoetal.,1996;Segal,1988).Therehasbeensomediscussionof
possible connections between personality disorders and other well-known
approaches to personality development (Ben-Amos, 1992; Bornstein,
1992; Glickhauf-Hughes & Wells, 1991; Paris, 1993; Vaillant, 1987),including attachment theory (Gacano, Meloy, & Berg, 1992; Heard &836 Brennan and Shaver

Lake, 1986; Sack, Sperling, Fagen, & Foelsch, 1996; Shaver & Clark,
1994;Sheldon&West,1990;Torgersen&Alnaes,1992;VanderKolk,
Perry, & Herman, 1991; West & Keller, 1994; West & Sheldon, 1988;
West & Sheldon-Keller, 1994; Whitely, 1994), but the few empiricalstudies have relatively small sample sizes. The purpose of the present
studywastoinvestigatepossibleconnectionsbetweenpersonalitydisor-ders and adult attachment patterns in a relatively large, nonclinical
sample of young adults. Before describing the study, we will review
relevant literature onattachmenttheory and research.
Literature Review
Researchon attachment theory. Adultromanticlovehasbeen concep-
tualized as an attachment process that is conceptually parallel to most
people’s earliest relationship: infant to mother (Hazan & Shaver, 1987;Shaver & Hazan, 1993). Hazan and Shaver (1987) took advantage of
Bowlby’s (1969/1982,1973,1980)seminalwritingsonattachment the-
ory and Ainsworth’s discovery of three primary attachment types in
infancy(Ainsworth,Blehar,Waters,&Wall,1978)toproposethatthesesame three attachment types—secure, avoidant, and anxious-ambiva-
lent—exist in adulthood and color the ways in which adults experience
romanticloveandbehaveinromanticrelationships.Attachment“style”
therefore refers to characteristic patternsofexperiencingromantic rela-
tionships.HazanandShaver(1987)devisedasimpleself-reportmeasure
of the  three  adult attachment  styles, based on extrapolations  fromAinsworthetal.’s(1978)descriptionsofthethreeprimaryinfantattach-
ment patterns. According to the measure, secures are characterized bycomfort with intimacy and an ability to depend on their  partners;
avoidants are characterized by fear of intimacy coupled with excessive
self-reliance; anxious-ambivalents  are characterized as  emotionally
labile,jealous,“preoccupied”withattachmentissues andwithpartners,
andasdesiringmoreclosenessthantheirpartnersseemwillingtoallow.
Using this measure, Hazan and Shaver (1987) found theoretically
expectable attachment-style differences in how adults experience theirmost important love relationships. People with different attachment
styles also reported characteristically different beliefs about romanticlove, different levels of loneliness, and different patterns of childhood
relationships with parents in ways congruent with attachment research
on parents and young children (Hazan & Shaver, 1987). Hazan andAttachment Styles 837

Shaver’s (1987) simple measure (and later variants) has been shown to
be fairly stable across time periods ranging from eight months to four
years(e.g.,Kirkpatrick&Hazan,1994)andtoberelatedtoawidevariety
of variables, ranging from personality traits, self-esteem, and copingstyles, to relationship functioning and adaptation, to observable social
behavior.(SeeFeeney&Noller,1996,andSimpson&Rholes,inpress,fora summaryofresearchonadult romanticattachment.)
Due to attachment theory’s relevance for the study of personality
structureandorganization(Bowlby,1988;Sroufe&Waters,1977),much
ofadultromanticattachmentresearchhasfocusedonnormalpersonality
functioning (Bartholomew& Horowitz,1991;Carver,1997;Duggan&
Brennan,1994;Mikulinceretal.,1990;Shaver&Brennan,1992;Shaver
et al., 1996). Bowlby (1973) conceived of individual differences inattachment as rooted in relatively stable, internal representations of the
self,importantothers(i.e.,attachmentfigures),andrelationships.Theseinternal representations, orworking models, constructedgradually over
thecourseofinfancyandimmaturity,areconsideredtobefairlyaccurate
reflectionsofactualrelationshipexperiences.Workingmodelsofattach-
ment theoretically account for continuity in attachment styles over the
lifespan.
Following Bowlby (1973), Bartholomew (1990) proposed a fourfold
typology of adult attachment to replace Hazan and Shaver’s threefoldtypology,anddesigned self-report andinterviewassessment techniques
to classify individuals into one of the four categories. Conceptually,secures possess relatively positive models of self and others. Anxious-
ambivalents, whom Bartholomew renamed “preoccupied,” possess a
positive model of others, along with a negative model of themselves.
Notably, Bartholomew distinguishes two types of avoidant attachment.
Fearful avoidants, akin to Hazan and Shaver’s avoidant type, possess
negativemodels ofbothselfandothers; hence theybothdesireandfearintimacy. Dismissing avoidants possess a positive model of the self but
a negative model of others. According to Bartholomew (1990), Hazan
andShaver’savoidanttypeseemedtoovulnerableandlowinself-esteem
compared to Main’s (Main, Kaplan, & Cassidy, 1985) description of“dismissing”adults,whichemergedfromcodedtranscriptsoftheAdult
Attachment Interview (AAI) (George, Kaplan, & Main, 1984/1985/
1996),atechniqueforclassifyingadultparentsofinfants.Bartholomew
and Horowitz (1991) demonstrated that the two kinds of avoidantsdifferedasexpected.Althoughbothkindsofavoidantsidentifiedthemselves838 Brennan and Shaver

as “socially avoidant,” fearful avoidants scored lower in self-esteem
compared to dismissing avoidants. In addition, based on self- and peer
reports, dismissing individuals appeared “cold,” and were described as
“competitive,” “autocratic,” and “introverted.”  Fearful avoidants, incontrast,appeared“submissive,”andweredescribedbythemselvesand
peers as “sub-assertive,” “introverted,”and“exploitable.”
Brennan, Shaver, and Tobey (1991) empirically documented the ex-
pected association between the three- and four-category attachmentmeasuresandfoundacommontwo-dimensionalstructureunderlyingthe
two measures.
1Other researchers (see Griffin & Bartholomew, 1994;
also see Brennan, Clark, & Shaver, 1998), using other measures, have
documentedthesametwo-dimensionalstructure.Therearethreeimpor-
tantimplicationsofthetwomeasures’sharedunderlyingstructure.First,the two dimensions can be used to classify individuals into a three- or
fourfoldtypology,soitdoesnotmattermuchwhichquantitativemeasureisused.Second,thetwo-dimensionalstructureisfurtherevidencethata
simple “good/bad” dimension is not enough to differentiate attachment
styles. This latter point is important in light of personality theorists’
claimsthat“negativeaffectivity”underliesmostself-reportmeasuresof
distress(e.g.,Watson&Clark,1984).Third,afourfold,two-dimensional
typology in adulthood nicely matches what is emerging in the infantliterature (Crittenden, 1988; Main & Solomon, 1990). Following this
logic, Brennan et al. (1991) sought to test whether the fearful avoidant
types, who conceptually possess the “worst of both worlds” in terms of
mental models of self and others, might be the adult versions of the“disoriented”and“disorganized”infantsidentifiedbyCrittenden(1988)
andMainandSolomon(1990).Basedonherresearch,Crittenden(1988)
asserts that this fourth type arises when an infant’s attachment figure is
extremelypreoccupiedorotherwiseunavailable,asinthecaseofmater-naldepression.Asaconsequence,theattachmentfigureisunresponsive
totheinfant’sneeds.Asexpected,fearfulavoidantsweremorelikelythan
1.  As predicted, Bartholomew’s secure and preoccupied types were closely akin to
Hazan and Shaver’s secure and anxious-ambivalent types, respectively. Bartholomew’s
fearful avoidant type was highly associated with Hazan and Shaver’s avoidant type.Bartholomew’s dismissing avoidants classified themselves as either secure or avoidant
on Hazan and Shaver’s measure, indicating some defensiveness on the part of the
dismissing avoidants. A factor-analysis of thesevenscalesrevealed atwo-dimensional,
nearly orthogonalstructureunderlyingboth measures.Attachment Styles 839

the other attachment types to report having grown up with problem-
drinking parents (Brennanet al., 1991).
Several theorists have begun to integrate attachment theory with the
literature on abnormal personality functioning and psychopathology in
infancy and early childhood (Belsky & Nezworski, 1988; Crittenden,
Parridge,&Clauseen,1991).Sroufeandothershaveshownhowattach-mentassessedininfancycanaccountforlaterchildhoodpatternsofego
resilience, affect regulation, and problem solving in the face of stress(Elicker, Englund, & Sroufe, 1992). The same principles thought to
underlie links between attachment and psychopathology in infancy are
being appliedto adults(Shaver&Clark,1994;Shaver&Hazan,1993).
Inadulthood,insecureadultromanticattachmentstyleshavebeenasso-
ciatedwithloneliness(Hazan&Shaver,1987),anxiety,depression,andphysical symptoms(Carnelleyetal.,1994),negativeaffectivity(Simpson,
1990),neuroticism(Shaver&Brennan,1992),lowself-esteem(Brennan& Bosson, in press; Brennan & Morris, 1997; Collins & Read, 1990;
Feeney & Noller, 1990), and maladaptive strategies for coping with
negativeaffect(Brennan&Shaver,1995;Fuendeling,inpress;Mikulincer
et al.,1993).Theseassociations withinsecureattachmentareimportant
in light of the fact that the adult romantic attachment measures do not
refer to orincludeanyphenomenarelevant to individual adaptation.
Researchon attachment andpersonalitydisorders. In the clinical lit-
erature, there is increasing support for conceptualizing personality dis-orders as disorders of attachment (e.g., Heard & Lake, 1986; Shaver &
Clark, 1994; West & Sheldon, 1988; West & Sheldon-Keller, 1994).There is growing empiricalevidence connecting Borderline personality
disorderwithpatternsofinsecureattachmentreflectedinrepresentations
of childhood relationships with parents (Patrick, Hobson, Castle,
Howard, & Maughan, 1994; Sack et al., 1996; Stalker & Davies, 1995;
Westetal.,1994).Patricketal.(1994)assessedinternalrepresentationsof attachment (via the AAI; George et al., 1984/1985/1996) and found
thatindividualsclassifiedasBorderlineevincedthementalorganizationcharacteristic of preoccupied attachment. Stalker and Davies (1995)
found the same pattern in a small, clinical sample of sexually abused
women. West et al. (1994) have discriminated Dependent and Schizoid
personality disorders on the basis of an “enmeshed” (i.e., preoccupied)
versus a “detached” (i.e., dismissing) interpersonal orientation. Similarly,
researchers have observed associations between recollections of insecure840 Brennan and Shaver

attachmentswithoneorbothparentsandtheSelf-Defeatingpersonality
disorder (Williams & Schill,  1993).  Among those  diagnosed with
Avoidant personality disorder, Sheldon and West (1990) reported that
heightened desire for and fear of attachment relationships were morediagnosticofAvoidantpersonalitydisorderthanwerepoorsocialskills.
Sack et al. (1996) compared individuals with a diagnosis of Borderlinewith an unselected group of college students and found evidence of a
number of indicators of attachment-related distress (e.g., fear of loss,
separation protest, compulsive care-seeking, angry withdrawal) as well
asamixtureofgeneralambivalentandavoidanttendenciesinromantic/
sexual attachment relationships. Their pattern of findings indicate that
bothpreoccupationandfearfulavoidancemaybemostcloselyassociatedwiththeBorderlinedisorder,althoughtheydidnotincludeBartholomew
and Horowitz’s (1991)measurein their study.
Todate,however,noonehasempiricallyexaminedlinksbetweenadult
romantic attachment styles and all 11 DSM personality disorders in a
sample large enough to reveal structural connections between the two
domains of interpersonal functioning. It seems likely that personality
disorders and attachment styles overlap. Furthermore, both kinds of
variables may moderate the impact of environmental stresses, such as
major losses, separations, or maltreatment by significant attachmentfigures.Likeinsecureattachmentstyles,personalitydisordersmayfoster
increasingly maladaptive or inflexible patterns of coping. For example,
thosewithBorderlinepersonalitydisorder,likepreoccupiedindividuals,
usuallyexperienceextremesofemotions,amongothersymptoms:Afterexperiencing relationship loss due to death or abandonment,both kinds
ofindividuals arelikely tobedistressedenoughtocontemplatesuicide.
Similarly,thosewithAvoidantpersonalitydisorder,likefearfulavoidant
individuals, appear to desire closeness with others but fear rejection(Bartholomew, 1990; Duggan & Brennan, 1994; Mattick & Newman,
1991). As a consequence, these individuals are likely to avoid the very
socialinteractionthat wouldmitigate theirloneliness.Most troublingisthat both kinds of individuals may counter feelings of depression by
drinking alcohol (Brennan & Shaver, 1995), possibly compoundinginterpersonaldifficultieswithotherproblems(e.g.,drinkinganddriving,illicitdruguse,riskysexualbehavior).Dismissingavoidants,ontheother
hand, who describe themselves as “unsociable” (Duggan & Brennan,1994) and appear to derogate the importance of close relationships, are
likelytobeSchizoid.Thatis,bothdismissingandSchizoidindividualsareAttachment Styles 841

likely to stress self-sufficiency and downplay attachment needs. As men-
tioned, West et al. (1994) reported an association between the Schizoid
diagnosis and the attachment-related dimension of “compulsive self-
reliance.”Thisassociationiswhatonewouldexpectifdismissing(butnotfearful)avoidanceismostcloselyassociatedwiththeschizoidpattern.
The Present Study
The present study had two objectives: First, we sought to explore con-
nections between attachment styles and personality disorders and to
determinewhetherthetwokindsofvariablesshareacommonunderlyingstructure. We predicted thatattachmentstyleswouldbe associatedwith
allof thepersonalitydisorders,using correlationaloranalysis-of-
variance procedures, and share most of their underlying structure. Sec-
ond, we sought to explore the connections between attachment,personalitydisorders,andthreeotherfamily-backgroundfactors:paren-
taldeath,parentaldivorce,andcurrentrepresentationsofearlychildhood
relationships with parents. Previous experience of loss due to parental
divorcehasalreadybeenshowntopredictriskyhealth-relatedbehavior,lower educational attainment, and earlier transition to parenthood (Aro
& Palosaari, 1992), and should similarly affect personality disorders in
adulthood. It is not clear whether parental death should be associated
with anyofthepersonalitydisorders,becauseparentaldeathisafunda-
mentallydifferentkindoflossthanparentaldivorce.Inanycase,fewof
ouryoungadultsubjectswereexpectedtohaveexperiencedthedeathofoneorbothparents.Asnoted,internalrepresentationsofearlychildhood
relationships with parents have been shown to be related to Borderlinepersonalitydisorder(e.g.,Laporte&Guttman,1996;Patricketal.,1994).
Thus,itseemsreasonabletoexpectthatreconstructions(i.e.,memories)
of early childhood relationships with parents should relate to other
personality disorders as well.
To accomplish these objectives, we questioned a large sample of
college-age individuals about their attachment styles, parental marital
status, parental mortality status, perceptions of childhood treatment byparents, and 13 personality disorders: Schizoid, Schizotypal, Paranoid,
Avoidant,Dependent,Obsessive-Compulsive,Passive-Aggressive,Self-Defeating,Histrionic,Narcissistic,Borderline,Antisocial,andSadistic.842 Brennan and Shaver

METHOD
Sample
The sample comprised 1407 introductory psychology students (587 males and
820females)attheUniversityofTexasatAustinwhoparticipatedinexchangefor course credit. Fully 967 (69.1%) classified themselves as Caucasian; 169
(12.1%) as Mexican-American or nonwhite Hispanic; 130 (9.3%) as Asian
American; 69 (4.9%) as African American; 21 (1.5%) as white Hispanics; 21(1.5%)asIndianAsian;5(.4%)asAmericanIndian;and3(.2%)asArabic;22
(1.5%) failed to classify themselves or identified themselves as “other.” Fully
918respondentsreportedthattheirparentswerestillmarried;420reportedthattheir parents were divorced or separated; and 69 reported that one or both of
theirparentsweredeceased.Theintactgroupincludedfourrespondentswhose
parents divorced and then remarried each other, and one respondent whoseparentsnevermarriedbutstayedtogether.Threeindividualsexperiencedparen-
tal divorce followed by the death of a parent, and therefore were omitted from
the divorce/death analyses. Finally, three individuals were adopted and had noknowledgeoftheirbiologicalparents,andsowereexcludedfromthedeathand
divorce analyses. Thus, 417 individuals made up the “divorce” group, and 66
individuals made up the “death” group. Respondent age ranged from 18 to 50(m=18).Forthedivorcegroup,medianagewhenparentsdivorcedwas7;nearly
80% lived with mother post-divorce, and 13% lived with father. Over 80%
reportedthatoneorbothparentsremarriedpost-divorce.Medianageatmother’sfirst remarriage was 9; median age at father’s remarriage was 10. Mothers and
fathers remarried a median number of one time.
Materials
Participantsweregivenapacketofquestionnairesthatbeganwithqueriesaboutdemographicvariablesincludingsex,age,ethnicgroup,parentalmaritalstatus,
and parentalmortalitystatus.
Attachment style. Subjectswereaskedtoclassifythemselvesintoadultroman-
ticattachment-stylecategories(usingBartholomew&Horowitz’s[1991]meth-
odology) and to rate the secure, fearful avoidant, preoccupied, and dismissing
avoidantdescriptionsona7-pointscaletoindicatethedegreetowhicheachonecharacterizedthem.Everyone,regardlessofself-classification,ratedeachofthe
attachment-stylecategories,allowingcorrelationaltestsofassociationsbetween
the attachment-style ratings and other variables. Previous studies indicate thatthe three Hazan and Shaver (1987) attachment-style categories are approxi-
mately 70% stable over testing periods ranging from 2 weeks to 4 years; the
three ratings’ test–retest reliabilities average .60 over the same time periodsAttachment Styles 843

(Brennan & Shaver, 1995; Davis et al., 1994; Kirkpatrick & Davis, 1994;
Kirkpatrick & Hazan, 1994). Given the association between the three- and
four-category measures (Brennan et al., 1991), it is likely that Bartholomew’smeasurewilldemonstrateasimilarlevelofstability(cf.Scharfe&Bartholomew,
1994).Theproportionsofattachment-stylecategoriesweresimilarinoursample
tothosereportedinpreviousresearch(Bartholomew&Horowitz,1991):47.9%secure, 21.0%fearful,15.2% preoccupied, and15.9% dismissing.
Perceptions of childhoodrelationshipswith parents. The Mother-Father-Peer
Scale, developed by Epstein (see Ricks, 1985), consists of dimensions
measuringparticipants’perceivedqualityoftreatmentbymother,father,andpeers while growing up. The following parental dimensions were included:
(1) acceptance versus rejection (e.g., [mother/father] “gave me the feeling
that she liked me as I was; she didn’t feel she had to make me over intosomeone else”);(2)fosteringindependenceversusoverprotectiveness (e.g.,
[mother/father]“encouragedme to do thingsformyself”);and(3)defensive
idealization(e.g.,[mother/father]“hadnotasinglefaultthatIcanthinkof”).Participants were asked first about their mothers, then about their fathers,
for a total of six scales. In the current sample, the three mother scales had
coefficient alphasof.87 (acceptance/rejection), .82 (independence/overpro-tectiveness), and .88 (idealization). The three father scales had coefficient
alphasof.89(acceptance/rejection),.79(independence/overprotectiveness),
and .92 (idealization).
Personality disorders. Students also completed a measure of 13 personality
disorders, the Personality Diagnostic Questionnaire (PDQ-R; Hyler &
Rieder, 1987). The PDQ-R is a revised version of the original PersonalityDiagnostic Questionnaire (Hyler, Rieder, Williams, Spitzer, Hendler, &
Lyons, 1988), which was amended along the lines of the third Diagnostic
andStatisticalManual (DSM-III-R; APA,1987).ThePDQ-Rwas designed
to assess the following 11 DSM-III-R personality disorders: Schizoid, Schizo-
typal, Paranoid, Avoidant, Dependent, Obsessive-Compulsive, Passive-
Aggressive, Histrionic, Narcissistic, Borderline, Antisocial, plus twoothers—fromthe1987DSM-III-RAppendix—Self-DefeatingandSadistic.
The PDQ-R consists of 140 true-false items and takes about 35 minutes to
complete.Itcanbescoredbyanonprofessionaltodetermineanoverallindexof personality disturbance and to determine the existence of each of the
specificpersonalitydisorders listed above.Approximately 30% of thestate-
ments included in the PDQ-R are reverse-scored.
ThePDQ-Rhashightest–retestreliability(Hyler,Skodol,Kellman,Oldham,
& Rosnick, 1990) and is valid for use with both clinical and nonclinical
populations (Hyler et al., 1990; Hyler, Skodol, Oldham, Kellman, & Doidge,844 Brennan and Shaver

1992).2Although the PDQ-R should not be considered a substitute for clinical
interviews,itsresultsagreedwithjudgmentsofeachoftwopsychiatriststothe
sameextentasthetwopsychiatristsagreedwitheachother(Hyleretal.,1992).The PDQ-R has been shown to have high negative predictive power, but lower
positive predictive power (Hyler et al., 1990; Hyler et al., 1992). That is, the
PDQ-R has a relatively low rate of false-negative diagnoses (results indicatingthe absence of a personality disorder when one actually exists) but a relatively
high rate of false-positive diagnoses (results indicating the presence of a per-
sonality disorder when none exists). In the present study of students who werepresumed to be mostly in the normal range on clinical measures, this bias was
considered acceptable, because we were looking for structural similarities
betweenpersonalitydisorderdimensionsandattachment-styledimensions.Wewere not seeking to make categorical clinical diagnoses. Each personality-
disorder scale willbe described briefly below.
The Schizoid scale measures a person’s tendency to retreat from others,
thereby isolating oneself from relationships with family and friends (8 items).
One item on this scale is “Others see me as cold and unemotional.” The
Schizotypal scale describes individuals who have experienced a break fromreality (12 items). These individuals may believe that they are receiving sub-
liminalmessages orthattheycan communicate through ESP. Anexampleis“I
haveanunusualabilitytoknowthatsomethingswillhappenbeforetheyactuallydo.”TheParanoidscaledescribesapersonwhoissuspiciousofothersandfears
persecutionbyothers(7items).Heorsheisafraid ofbeingtrickedorbetrayed
byothers.Asampleitemis“IoftenwonderwhetherthepeopleIknowcanreallybetrusted.”TheAvoidantscaledescribesapersonwhotendstolackself-assurance
and to fear ridicule by or disapproval from others (7 items). Therefore the
Avoidantpersonpreferstominimizecontactwithothers.Anexampleis“Imakefriends with people only when I am sure they like me.”
The Dependent personality disorder scale refers to people who have an
excessiveneedtorelyonothers(9items).Forinstance,theymayagreewithallauthority figures and be overly reliant on relationship partners. One item is “I
want people to like me so much that I volunteer to do things that I’d rather not
do.” The Obsessive-Compulsive scale refers to an excessive focus on rules (9items). This disorder often manifests itself in excessive concern for following
norms in social situations and for following a proper regimen for personal
hygiene, work assignments, and so on. The Obsessive-Compulsive individualseesonlyone properwaytodothingsandbecomeseasilyupsetwhenrulesare
broken.A sample item is “I wastetime trying to make thingstoo perfect.”The
2.  Internalconsistency isnotthebestindicatorofthereliabilityofthesescalesbecause
the scales are essentially heterogeneous lists of items. Test–retest reliability is a betterindicator.Attachment Styles 845

Passive-Aggressivescaledescribesapersonwhousespassivemeanstoaccom-
plish aggressive behaviors (9 items).For instance, rather thandirectlyrefusing
toperformatask,apersonwithPassiveAggressivedisordermightintentionallymake errors (to communicate that he or she did not really want to perform the
task). A sample item is “When I resent doing something I tend to work slowly
or screw things up.”
The Self-Defeating scale assesses the tendency to put oneself down and to
fear success and happiness (11 items). For example, “I find myself more
interestedinpeoplewhotreatmebadlythaninpeoplewhoarenicetome.”TheHistrionic scale assesses a tendency to present oneself as friendly, accommo-
dating, and unselfish, when in reality one is vain and self-serving (10 items).
Thesepeople liketobethecenterofattentionandoftenexaggerateactionsandemotions to attain attention from others. An example item is “I often act very
emotionally when little things go wrong.” The Narcissistic scale assesses the
tendencytowardbeingpompous,egocentric,andself-absorbed(11items).Thissense of personal greatness may be a defensive reaction to internal feelings of
worthlessness. For example, “I often find myself thinking about how great a
person I am,or will be.”
TheBorderlinepersonalitydisorderscaleassessestheextenttowhichpeople
feel out of control of their emotions and behaviors (12 items). They may
experiencemoodswingsandbehaveonimpulse(drinking,shoplifting,orotheracts that often get them into trouble). An example is “My feelings towards
another personcanoftenchangedrastically.” TheAntisocialpersonality disor-
der scale characterizes people who are very focused on personal gain withoutregard for the effects of their behavior on others (12 items). For example, “I
don’t care if other people get hurt so long as I get what I want.” The Sadistic
scale describes a person who is physically and/or emotionally harmful towardother people or animals (8 items). Such a person derives a sense of self-worth
andpowerfromcausingothersharm.Forexample,“Ihaveenjoyedhumiliating
other people.”
RESULTS
Preliminary Analyses
Prevalence rates. Personality disorders were scored categorically
(presence vs. absence of a disorder) as well as on a continuum (i.e., thedegree to which one possesses attributes of a particular disorder).
3The
3.  For the most part, the distributions of responses on the personality-disorder scales
werenotatallskewed.TheskewnessoftheAntisocialandSadisticscales(1.32and1.57,
respectively) were by far the highest (average skew without these two scales was .67),846 Brennan and Shaver

prevalence of various personality-disorder diagnosesrangedfrom 5.2%
(Schizoid) to 42.5% (Paranoid). Most of the subjects had at least one
personality disorder ( N= 1056 of 1407, or 75.0%), consistent with the
PDQ-R’s positive bias (cf.  Moldin, Rice, Erlenmeyer-Kimling, &Squires-Wheeler,1994).Themediannumberofdisorderswas2,withan
average of 2.45. Frequencies and percentages of each disorder in thecurrent sampleare displayedin the first column ofTable 1.
Using the same measure and scoring procedures, two other sets of
researchers have reported similar prevalence rates in late-adolescent sam-
ples (Johnson & Bornstein, 1992; Johnson, Bornstein, & Sherman, 1996;
Maffei et al., 1995). In their random sample of first-year medical students
atauniversityinMilan,Maffeietal.reportedanoverallprevalencerateof
88.7%forall13disorders.Maffei’sprevalenceratesforindividualdisorderswereverysimilartoours,exceptthattheyreportedahigherrateforParanoid
(66.0%) and Schizoid (10.2%), and a lower rate for Borderline (11.7%),Schizotypal(12.1%),Passive-Aggressive(6.6%),andSadistic(2.7%)(Maffei
etal.,1995,p.335).IntwosamplesofAmericanundergraduates,Johnson
andhiscolleagues(Johnson&Bornstein,1992,p.453;Johnsonetal.,1996,
p.81)usedthePDQ-R’sauthors’scoringcriteria(Hyleretal.,1988,1989)
and reported personality-disorder prevalence rates very similar to those
reportedhere.FrequenciesandpercentagesofeachdisorderintheJohnsonet al.(1996) sample (whichis larger thantheJohson& Bornsteinsample)
areshownin the second column ofTable 1.
Such high prevalence rates prompted Johnson and his colleagues to
devisemorestringentscoringalgorithmsforthePDQ-R,resultinginan
overall prevalence rate of 11.3% for 12 of the 13 disorders (Johnson et
al., 1996). Prevalence rates obtained using the more stringent scoring
criteria in both the current sample and the Johnson et al. (1996) sample
are listed in the third and fourth columns of Table 1. Note that in the
currentsampletheoverallprevalenceratedroppedfrom75.0%to14.3%whenJohnsonet al.’smorestringentscoringmethodswereused.None-
theless, we chose not to use Johnson et al.’s (1996) scoring methods,
because these methods appear to rely too heavily on reports of distress.
butnot high enough toviolatethe relatively robustassumptionsofanalysis-of-variance
procedures.Hence,althoughweanalyzedthedataprimarilywiththecontinuousratingsofpersonalitydisorders(followingtheadviceofHyler,Lyons,Rieder,Young,Williams,& Spitzer, 1990), we have provided information about personality-disorder categories
with respecttobasicfrequenciesand associationswithgenderandattachmentstyle.Attachment Styles 847

AccordingtoJohnsonetal.,individualscannotbeclassifiedashavinga
disorderunlesstheyreportatleastsomedistress,acriterionthatmaybe
overlyexclusionary.ApersonwithaSchizoiddisorder,forexample,may
not acknowledge any distress. Note that, using the distress criterion, no
individualswerediagnosedasSchizoidineithersample.Inanycase,wewere interested in the associations between attachment styles and per-
sonalitydisorders,andtheseassociationsgenerallydidnotchangewhenthe more stringentclassification criteria were applied.
4Table 1
Frequency of Disorders (and % of Sample) Using Standard and
More Stringent Scoring Criteria in the Current Sample and
in Johnson et al.’s (1996) Study
Frequencies(Percentages) ofEach
PersonalityDisorder
Standard Scoring More Stringent Scoring
Current Johnson Current Johnson
Sample etal. Sample et al.
Schizoid 73 (5.2%) 17 (4%) 0 (0%) 0 (0%)
Schizotypal 258 (18.4%) 66 (15%) 52 (3.7%) 10 (2.3%)
Paranoid 596 (42.5%) 194 (44%) 38 (2.7%) 12 (2.7%)
Avoidant 245 (17.4%) 75 (17%) 83 (5.9%) 16 (3.6%)Dependent 182 (12.9%) 53 (12%) 56 (4.0%) 4 (.9%)
Obsessive-Compulsive 384 (27.3%) 141 (32%) 52 (3.7%) 9 (2.0%)
Passive-Aggressive 254 (18.1%) 84 (19%) 38 (2.7%) 4 (.9%)
Self-Defeating 102 (7.3%) 35 (8%) 51 (3.6%) 14 (3.2%)Histrionic 431 (30.7%) 150 (34%) 28 (2.0%) 9 (2.0%)
Narcissistic 236 (16.8%) 115 (26%) 13 (.9%) 9 (2.0%)
Borderline 426 (30.5%) 150 (34%) 142 (10.2%) 39 (8.8%)
Antisocial 103 (7.3%) 62 (14%) 0 (0%) 2 (.5%)Sadistic
a 113 (8.1%) — — —
At leastone diagnosisb1056 (75.0%) — 201 (14.3%) 50 (11.3%)
aJohnsonetal.(1996)didnotprovideanyinformationwithregardtotheSadisticscale,
so we could not provide alternative scoring for this scale.bAlso, Johnson et al.did not
providetheoverallprevalencerateobtainedwhenusingstandardscoringmethods.
4.  The association of the Narcissistic personality disorder (present vs. absent) was not
associatedwithattachmentstyle,perhapsbecausethepercentageofindividualswiththis848 Brennan and Shaver

Gender differences. The percentage of males with at least one person-
alitydisorderwas76.8%andthepercentageoffemaleswithatleastone
disorderwas73.8%.Examinationoftheindividualpersonalitydisorders
revealed six statistically reliable gender differences. Males were morelikely to qualify for a diagnosis of Schizotypal ( χ
2[df=1 ,N= 1402] =
4.83,p<.05),Passive-Aggressive( χ2[df=1,N=1405]=8.77, p<.01),
Narcissistic ( χ2[df=1 ,N= 1402] = 17.26, p<.001),Antisocial( χ2[df
=1 ,N= 1403] = 33.72, p< .001), or Sadistic ( χ2[df=1 ,N= 1400] =
26.31,p<.001).Femaleswere more likelytoqualifyforadiagnosis of
Histrionic ( χ2[df=1,N=1403]=5.35, p<.05).
Looked at another way, consistent gender differences emerged on
severalpersonality-disorderscales.Malesscoredhigheronthefollowing
scales:Schizoid(M males=1.47,M females=1.19,t[1254]=4.48, p<.001),
Schizotypal (M males= 2.95, M females= 2.68,t[1202] = 2.70, p< .01),
Passive-Aggressive (M males= 2.97, M females= 2.66,t[1207] = 3.19, p<
.01),Narcissistic(M males=3.18,M females=2.90,t[1170]=3.15, p<.01),
Antisocial (M males= 1.79, M females= .98,t[1027] = 11.03, p< .001),and
Sadistic(M males=1.85,M females=1.30,t[1060]=7.82, p<.001).Females
scored higher on the Dependent (M males= 2.06, M females= 2.32,t[1270]
= 2.65,p< .01) and Histrionic (M males= 2.36, M females= 2.72,t[1288] =
3.85,p<.001)scales.Interestingly,therewerenogenderdifferenceson
theBorderline personalitydisorderscale,althoughthisdisorderisoften
thought to be more characteristic of women than men (e.g., Ekselius et
al.,1996;butsee alsoGolomb,Fava,Abraham,&Rosenbaum,1995).
Intercorrelationsof the scales. Intercorrelationsofthepersonality-dis-
order scales are shown in Table 2. The moderately high correlations
indicate  considerable comorbidity: Individuals  scoring  high on one
personality-disorder scale tend to score high on others as well. As the
sections below explain, however, the correlations are not uniform; and
theirvaryingsizes reflectan underlying structure.
disorder(.9%)wasquitelow.NoonewasclassifiedashavingaSchizoidoranAntisocial
disorder, so these scales could not be associated with attachment style. Lastly, Johnsonetal.(1996)didnotreportscoringcriteriafortheSadisticscale,sowecouldnotusetheiralternativescoring methodswiththisscale.Attachment Styles 849

Table 2
Intercorrelations of 13 Personality Disorders Scales
Scale Name 1 2 3 4 5 6 7 8 9 10 11 12 13
1. Schizoid —
2. Schizotypal .25 —3. Paranoid .12 .54 —4.Avoidant .22 .51 .44 —5. Dependent –.13 .29 .25 .42 —6. Obsessive .08 .40 .36 .37 .27 —7. Passive-Agg. .06 .34 .32 .31 .34 .37 —8. Self-Def. .16 .53 .42 .42 .37 .38 .35 —9. Histrionic –.13 .32 .28 .26 .43 .34 .36 .38 —10. Narcissistic .05 .39 .38 .34 .32 .37 .43 .37 .45 —
11. Borderline .07 .46 .43 .36 .37 .35 .40 .48 .44 .44 —
12.Antisocial .12 .24 .16 .12 .07 .07 .30 .23 .16 .28 .35 —
13. Sadistic .09 .26 .24 .13 .14 .22 .29 .24 .20 .31 .28 .36 —
Note.Becauseofthelarge N(1394–1406,dependingonmissingvalues),allcorrelations larger than.09aresignificantbeyondthe.001level.

Connections Between Attachment Styles and
Personality Disorders
In this section, we will test our first hypothesis, that there would be
associations between attachment styles and personality disorders, and
that the two kinds of variables would share most of their underlying
structure.
Testsusing personality-disorder categories. The association  of cate-
gorical attachment style with the categorical personality-disorder vari-
able (present vs. absent) reached significance ( χ2[df=3 ,N= 1384]
= 148.85, p< .001). Secures were nearly twice as likely not to have a
personality disorder as to have one (75.0% vs. 38.8%). Fearfuls were
aboutfourtimesaslikelytohaveatleastonepersonalitydisorderasnot
(26.0%vs.6.3%).Preoccupiedswereaboutthreetimesaslikelytohavea disorder as not (18.3% vs. 5.7%). Dismissing individuals were nearly
equally distributed across the two categories of “at least one disorder”
and“nodisorders”(16.9%vs.12.9%).Saidanotherway,forindividuals
classifiedassecure,fearful,preoccupied,anddismissing,thepercent-age with at least one disorder was 60.6%, 92.4%, 90.5%, and 79.5%,
respectively.
Foreach personalitydisorder,wecross-tabulatedthepresence versus
absenceofthedisorderwithattachment-stylecategory,andperformeda
chi-square test on each cross-tabulation. The frequency of participantsin each attachment-style categorywith a particular disorder is shownin
Table3,along with the percentagesofthe fourattachment styleswithin
eachdisordercategory.Ineverycase,thedistributionofattachmentstyles
deviated from that of the total sample, as evidenced by the significantchi-square tests. The percentage of secures with eachpersonality disor-
derwaslowerthantheoverallpercentageofsecuresinthetotalsample.
The relative proportion of each insecure group wasusuallygreaterthan
its frequency in the total sample. For example, both kinds of avoidants
were much more likely to earn a diagnosis of Schizoid; fearfuls were
particularly likely to earn a diagnosis of Avoidant personality disorder;preoccupied individuals were particularly likely to earn a diagnosis of
Dependentpersonalitydisorder.
Testsusing personality-disorder dimensions Personality-disorder rat-
ings were then analyzed as a function of attachment-style categoryandAttachment Styles 851

Table 3
Frequency of Disorders Within Each Attachment Group (and % of Each
Attachment Group Within Each Disorder Category)
Frequencies of Each PersonalityDisorder
Secure Fearful Preoccupied Dismissing χ2
Schizoid 6 (8.5%) 29 (40.8%) 3 (4.2%) 33 (46.5%) 88.49
Schizotypal 41 (16.2%) 99 (39.1%) 69 (27.3%) 44 (17.4%) 143.90
Paranoid 174 (29.7%) 199 (34.0%) 107 (18.3%) 106 (18.1%) 162.02
Avoidant 49 (20.3%) 92 (38.2%) 61 (25.3%) 39 (16.2%) 106.90
Dependent 49 (27.4%) 46 (25.7%) 71 (39.7%) 13 (7.3%) 110.97
Obsessive-Compulsive 118 (31.7%) 116 (31.2%) 79 (21.2%) 59 (15.9%) 64.63
Passive-Aggressive 69 (27.8%) 76 (30.6%) 62 (25.0%) 41 (16.5%) 58.07Self-Defeating 13 (12.9%) 41 (40.6%) 36 (35.6%) 11 (10.9%) 79.72Histrionic 172 (40.7%) 102 (24.1%) 101 (23.9%) 48 (11.3%) 47.38
Narcissistic 70 (30.4%) 79 (34.3%) 45 (19.6%) 36 (15.7%) 44.21
Borderline 125 (29.8%) 135 (32.2%) 103 (24.6%) 56 (13.4%) 113.30
Antisocial 24 (23.5%) 33 (32.4%) 19 (18.6%) 26 (25.5%) 27.85Sadistic 26 (23.2%) 33 (29.5%) 27 (24.1%) 26 (23.2%) 30.20
Overall Proportionsa 663 (47.9%) 291 (21.0%) 210 (15.2%) 220 (15.9%) 1407 (100%)
Note.N=1407formosttests.(Insomecases,missingvaluesoneitherattachmentorpersonality-disordermeasuresresultedinminordiscrepancies
between frequency of the total sample with a particular disorder and sum of the frequencies of each of the four attachment groups with the
disorder.)Alltestsweresignificantat p<.001.
aFrequencies(and %s)ofthefourattachment-stylegroupsinthetotalsample.

gender in a 2 × 4 multivariate analysis of variance (MANOVA). The
resultinginteractiontermwasnotsignificant,sothedatawereanalyzed
furtherwithoutrespecttogender.AMANOVAconductedonthepersonality-
disorder ratings as a function of attachment-style category was signifi-cant,Hotelling’s F(df= 39,4022) =20.57, p<.001.Theattachment-
groupmeansforeachofthepersonality-disorderscalesaredisplayedinTable4 along with the univariate Fs and effect sizes( η
2s).
With two exceptions, securely attached participants scored lower on
everypersonality-disorderscalecomparedtoinsecurelyattachedpartici-
pants. Secures scored higher than dismissing individuals on the Depen-
dent scale. Secures did not differ from dismissing individuals on the
Histrionic scale  (both groups scored low). Fearful, dismissing, and
preoccupiedparticipantsgenerallyscoredsimilarly,exceptthatpreoccu-pieds outscored fearfuls on the Histrionic and Dependent scales, but
scored lower than fearfuls on the Paranoid and Schizoid scales. Dis-missings, for the most part, scored intermediately between secures, on
theonehand,andfearfulandpreoccupiedindividuals,ontheother.There
were a few exceptions to this rule: The dismissing group scored lowest
ontheDependentscale.Dismissingindividualsscoredlowerthanfearful
andpreoccupiedindividualsontheHistrionicscale.Dismissingsscored
higherthan fearfulsontheSchizoidscale.Dismissingsscoredsimilarlyto preoccupieds (but lower than fearfuls) on the Paranoid scale. Dis-
missings scored similarly to fearful and preoccupied individuals on the
Antisocial andSadisticscales.
Discriminating among attachment-style categories using personality-
disorder scales. To explore further the association between personality-
disorder scales and attachment styles, a discriminant-function analysis
was conducted using the 13 personality-disorder scales to predict sub-
jects’self-reportedattachment-stylecategory.Table5displaysthecorrela-
tions of the personality-disorder scales with the discriminant functions.Table 6 displays the canonical discriminant functions evaluated at each
attachment-style group’s mean. Function 1 distinguished insecures (es-peciallyfearfuls)fromsecures( χ
2[df=39]=701.44, p<.001).Function
2 distinguished preoccupied and dismissing groups ( χ2[df= 24] =
250.59,p< .001). Function 3 was only marginally significant, weakly
discriminating dismissing and preoccupied from fearful individuals ( χ2
[df=11]=19.55, p<.10).Functions1and2accountedfor66.17%andAttachment Styles 853

Table 4
Mean Personality-Disorder Ratings as a Function of Four Attachment-Style Categories
Personality-Disorders Attachment-StyleCategory
Ratings Secure Fearful Preoccupied Dismissing Univariate Fη2
Schizoid .98a 1.69c 1.04b 1.98c 64.12 .12
Schizotypal 2.05a 3.81c 3.49c 2.98b 89.23 .16
Paranoid 2.50a 4.33c 3.67b 3.45b 95.19 .17
Avoidant 1.34a 2.76c 2.66c 1.98b 78.42 .15
Dependent 1.89b 2.56c 3.56d 1.45a 70.41 .13
Obsessive-Compulsive 3.02a 4.03c 3.99c 3.55b 34.33 .07
Passive-Aggressive 1.35a 2.58c 2.76c 1.83b 78.17 .08
Self-Defeating 2.18a 3.14c 3.38c 2.54b 65.90 .15
Histrionic 2.35a 2.81b 3.42c 2.13a 27.56 .06
Narcissistic 2.61a 3.61c 3.53c 2.91b 38.14 .08
Borderline 2.93a 4.31c 4.32c 3.40b 54.12 .11
Antisocial 1.02a 1.63b 1.43b 1.61b 21.79 .05
Sadistic 1.32a 1.71b 1.72b 1.73b 11.20 .02
Note.dfsrangedfrom3and1372to1380.Alltestsweresignificantat p<.001.Withineachrow,meanswhosesuperscriptsdifferaresignificantly
differentat p<.05.

31.27% of the variance, respectively; Function 3 accounted for the
remainder(2.56%).
The fearful group appeared the most troubled, scoringhighest on the
discriminant function that correlated with personality disorders involvingTable 5
Rotated Correlations Between 13 Personality Disorders Scales and
Three Discriminant Functions Predicting Attachment-Style Category
Personality Disorder Rating Function 1 Function 2 Function 3
Paranoid .72* .03 –.39
Schizotypal .69* .15 –.08
Avoidant .63* .23 –.05
Self-Defeating .61* .38 .20Borderline .51* .29 –.04
Narcissistic .43* .22 –.18
Obsessive-Compulsive .43* .14 .14
Dependent .31 .77* .16
Schizoid .44 –.60* .31
Histrionic .22 .48* .15
Passive-Aggressive .43 .24 .44*
Sadistic .24 –.01 .40*
Antisocial .35 –.08 .36*
Note.N= 1358. Function 1, χ2(39) = 701.44, p< .001; Function 2, χ2(24) = 250.59,
p<.001;Function3, χ2(11)=19.55, p<.10.Asterisksdenoteeachpersonalitydisorders
scale’s highestcorrelation withoneofthethreediscriminantfunctions.
Table 6
Discriminant Functions Evaluated at Attachment-Style
Group Centroids (Means)
Attachment Style Function 1 Function 2 Function 3
Secure –.63 .02 –.03
Fearful .86 –.06 –.16
Preoccupied .45 .80 .15Dismissing .33 –.74 .17Attachment Styles 855

some sort of distortion  of reality  along with negativity  about  others
(Paranoid,Schizotypal,Avoidant,Self-Defeating,Borderline,Narcissis-
tic,andObsessive-Compulsive).Thepreoccupiedanddismissinggroups
appeared to suffer from diametrically opposed personality problems asevidenced by the pattern of scores on the second function, which was
about Dependent and Histrionic versus Schizoid personality charac-teristics. This pattern fits with Bartholomew and Horowitz’s model:
Preoccupiedpersonsappearoverlydependent,whereasDismissingper-
sons appear “counter-dependent.” The third personality-disorder func-
tion,whichappearedakintopsychopathy(Passive-Aggressive,Sadistic,
and Antisocial), accounted for negligible variance among attachment
categories.
Underlyingstructure of the attachment-styleratings. To determine
whether the four attachment-style ratings conformed to the two-dimensional structure postulated by Bartholomew (1990), a principal
componentsanalysiswasconducted.Twoprincipalcomponentsemergedand were rotated, using an oblique procedure. (The same structure
appeared regardless of rotation method.) Factor 1 was defined by the
differencebetweensecureandfearfulattachment(withloadingsof–.88
and .82, respectively). Factor 2 was defined by the difference between
dismissing and preoccupied attachment (with loadings of .82 and –.72,respectively). These results are similar to those obtained by Brennan et
al.(1991).ThefirstattachmentfactorcanbeconceptualizedasInsecurity;theother attachment factor canbe conceptualizedasDefensiveEmotional
Style. The two factors accounted for 72.8% of the variance and were
correlated–.03.(Thatis,theywereessentiallyorthogonal.)
Underlyingstructure of the personality-disorder dimensions. To deter-
minethestructureofthepersonality-disorderscales,aprincipalcompo-
nents analysis was conducted on all 13 personality-disorder scales.
5
Threeprincipalcomponentsemergedandwererotatedusinganobliqueprocedure (again, the same structure appeared regardless of rotationprocedure). The results mirrored those of the discriminant function
5. Principalcomponentsanalyseswerealsoconductedseparatelyformalesandfemales.
Theresultingthree-factorstructureinbothsubsampleswasvirtuallyidenticaltotheoneobtainedwiththetotalsample.Correlationsofeachofthethreetotal-samplefactorswiththethreecorrespondingfactors obtainedwithineachsubsampleallexceeded.99.856 Brennan and Shaver

analysis. Avoidant, Schizotypal, Paranoid, Self-Defeating, Obsessive-
Compulsive, and Borderline personality-disorder scales loaded highly
onthefirstfactor(therespectiveloadingswere.84,.78,.69,.66,.60,and
.44). Schizoid, Histrionic, and Dependent scales loaded highly on thesecond factor (the respective loadings were .79, –.59, –.55). The Anti-
social,  Sadistic,  Passive-Aggressive, and Narcissistic  scales  loadedhighlyonthethirdfactor(therespectiveloadingswere.86,.75,.41,and
.37).(TheBorderline,Passive-Aggressive,andNarcissisticscalesloaded
nearly equally on the first and third factors. Schizoid and Dependent
scales alsoloaded onFactor 1.)
Given the pattern of factor-loadings, it is notsurprising that the three
factors were somewhat intercorrelated: Factors 1 and 2 correlated –.21;
Factors1and3correlated.37;Factors2and3correlated–.12.
6Together
the three factors accounted for 56.3% of the variance. Notice that the
three functions appearstrikingly similar to thosethat emergedfrom thediscriminantfunctionanalysispredictingattachment-categorymember-
6.  Due to the moderate intercorrelations among the disorders scales, we decided to
conduct a second, item-level principal components analysis on the 135 individual
personality-disorderitems.Threeprincipalcomponentsemergedandwererotatedusing
the SPSS oblimin procedure (again, the same structure appeared regardless of rotation
procedure). The first factor, Neuroticism, was composed of items indicative of intensenegative affect, especially anxiety, oversensitivity to criticism or rejection, and otherself-defeating behaviors. The second factor, Psychopathy, derived mainly (95%) fromtheAntisocial, Sadistic, and Borderline scales,and included itemsindicativeofaggres-
sive, self-destructive, or impulsive behaviors. The third factor, Extraversion, was com-
posedofitemsindicativeofsociability,orpreferenceforandeaseofbeingaroundothers.These three factors are similar to Eysenck’s (1970) Neuroticism, Psychoticism, andExtraversion scales.
Whenfourfactorswereselected,Factor2splitintoself-destructive(mainlyBorderline
items) and other-destructive items (mainly Sadistic and Antisocial items). When fivefactorswereselected,thefifthfactorcontainedahandfulofitemsindicativeofendorse-
ment of unusual ideas (e.g., belief in ESP, premonitions, receiving “special messages”
fromothers).Suchafive-factorsolution,althoughinsufficientlystronginthisnonclinicalsample, is reminiscent of other researchers’ findings revealing the presence of the“five-factor model” in assessments of personality disorders (e.g., Wiggins & Pincus,
1994). The results of our item-level analysis (whether 3, 4, or 5 factors were selected)
contrasts with those of other researchers, who found anywhere from 12 to 23 factors
usingthePDQ-R(Hyleretal.,1990;Livesleyetal.,1992)orclinicalinterviews(Ekselius,
Lindstrom,vonKnorring,Bodlund,&Kullgren,1994;Torgersen,Skre,Onstad,Edvardsen,& Kringlen,1993).Attachment Styles 857

ship. The first factor seemed to be a general pathology factor that taps
low sociability, distrust, low self-esteem, and disordered thinking pat-
terns; we therefore named it Generalized Pathology. The second factor
appearedtobeaboutexcessiveself-reliance(vs.dependency);wenamedit Counter-Dependence. The third factor appeared to be about interper-
sonal aggression and callousness; we namedit Psychopathy.
Associations between the attachmentand personality-disorder factors.
A higher-order principal components analysis was conducted on thetwo attachment factors plus the three personality-disorder factors.
Twoprincipalcomponentsemergedandwererotatedusinganoblique
procedure.The first higher-orderfactorwasdefinedbytheInsecurity
attachment factor (with a loading of .83), the Generalized Pathology
personality-disorder factor (with a loading of .82), and the Psycho-
pathy personality-disorder factor (with a loading of .66). The secondfactorcomprisedtheCounter-Dependencepersonality-disorderfactor
(witha loading of.83)andthe DefensiveEmotionalStyleattachmentfactor (with aloading of .82). Together, thetwo factors accountedfor
64.5% of the variance. The two factors correlated –.11; that is, they
were essentially orthogonal.
From these results we can say that the attachment styles and 10 of
the 13 personality disorders(allbutthescales makingupthe Psycho-
pathy factor) are located in a two-dimensional conceptual space
corresponding to Bartholomew’s (1990) attachment-style typology.As mentioned, the first attachment-related factor can be conceptual-
izedasInsecurity;theotherattachment-relatedfactorcanbeconcep-tualized as Defensive Emotional Style. The first personality-disorder
factor, General Pathology, is made up of 6 of the 13 personality-
disorderscalesandissimilartothefirstattachmentfactor.Thesecond
personality-disorder factor, Counter-Dependence, is made up of 3
additional personality-disorder scales (Schizoid, Histrionic, and De-pendent) andissimilartothesecondattachment factor.Fourremaining
personality-disorderscales(Antisocial,Sadistic,Passive-Aggressive,andNarcissistic)formedathirdfactor,Psychopathy,whichwasmod-
estly correlated with the first attachment factor ( r= .28) but not with
the second ( r= .002).
Given that the two kinds of variables share much of their variance, it
seems reasonable to look for common origins. In the next section, we
examine the association of attachment and personality disorders with858 Brennan and Shaver

threefamily-backgroundvariables:parentaldeath,parentaldivorce,and
perceptions ofparentalcaregiving.
Association of Personality Disorders and
Attachment Styles with Family Variables
Inthissection,wetestoursecondhypothesis.Wepredictedthatparental
divorce and negative representations of early relationships with parentswouldberelatedtobothattachmentinsecurityandpersonalitydisorders.
The association of parental death with either attachment insecurity or
personalitydisorderswaslessclear,andourresultsonthatissuewillbeconsideredexploratory.
Parental divorce. The associations of parental marital status (divorced
vs. nondivorced) with both attachment style and personality disorders
were explored. A chi-square test was computed on the cross-tabulation
of attachment-style categoryand (dichotomous) parentalmarital status:
χ
2(df=3 ,N= 1312) = 8.69, p< .05. A series of two-tailed tests of
independent proportionsrevealedthatindividualswithdivorcedparents
were more likely to be fearful ( z= 2.87,p< .01) and less likely to be
secure (z= 1.91,p< .05) than individuals from intact families. Consid-
eringthatsecureandfearfulscalesloadonasingleInsecurityfactor,the
latterresultssuggestthat,onaverage,subjectswhohadexperiencedthedivorce oftheir parents wereless secure (in the attachmentsense).
Personality-disorder ratings were analyzed as a function of parental
marital status and gender in a 2 × 2 MANOVA. The overall interaction
term was significant (Hotelling’s F[df= 13, 1294] = 1.98, p< .05).
Comparedtofemalesfromintactfamilies,femalesfromdivorcedfami-
lies scored higher on the following three personality disorder scales:
Schizotypal (M
intact= 2.55, M divorced= 2.98,t= 3.11,p< .01), Self-
Defeating(M intact=1.78,M divorced=2.19,t=3.25,p<.01),andBorderline
(Mintact= 3.32, M divorced= 3.90,t= 3.96,p< .001). The main effect for
parentalmaritalstatuswasalsosignificant,Hotelling’s F(df=13,1296)
=2.12,p< .05.Comparedtocollege-aged childrenwhoseparents were
stillmarried,thechildrenwithdivorcedparentsscoredsignificantlyhigheron two personality-disorder scales: Paranoid (M
intact= 3.10, M divorced=
3.44,t=3.26,p<.01)andNarcissistic(M intact=2.95,M divorced= 3.14,
t= 2.16,p< .05). (Significant main effects for the Borderline and
Schizotypal scales emerged but were qualified by the interaction ofAttachment Styles 859

genderandparentalmaritalstatus.)Theseresultsshouldbetreatedwith
caution, as parental marital status accounted for less than 1% of the
variance inany particularpersonality-disorder scale.
Thefivehigher-orderfactorsweresimilarlyexaminedasafunctionof
parental divorce. Two of the five factors were associated with parental
divorce:AttachmentInsecurity(M intact=–.06,M divorced=.12,t=3.00,
p<.01)andGeneralizedPathology(M intact=–.05,M divorced=.10,t=2.51,
p<.05)were higher forthose fromdivorced families.
Parental death. The associations of parental mortality status (one or
bothparentsdiedvs.neitherparentdied)withbothattachmentstyleand
personalitydisorderswereexplored.Achi-squaretestwascomputedon
the cross-tabulation of attachment-style category and (dichotomous)
parental mortality status: χ2(df=3 ,N= 1381) = 11.36, p< .01. A
two-tailedtestofindependentproportionsrevealedthatindividualswith
deceasedparentsweremorelikelytobedismissingthanwereindividuals
whose parentswere both stillliving ( z=2.92,p<.01).
A MANOVA conducted on the set of personality disorders as a
function of parental mortality status and participants’ gender was notsignificant.NorwastheMANOVAsignificantwhengenderwasignored,
Hotelling’s F(df=13,1363)=1.25, p=.23.Theabsenceofsignificant
effects might have been due partly to the fact that only a small fraction
ofthesamplehadexperiencedthedeathofoneorbothparents.Still,theeffect ondismissing attachmentwasdiscernible.
These findings were mirroredby those obtained whenexamining
the five higher-order factors as a function of parental mortality.
Scoresonthesecondattachmentfactor, DefensiveEmotionalStyle,
wereelevatedforthosewhohadexperiencedthedeathofoneorbothparents (M
living= –.01, M deceased=. 3 4 ,t= 2.51,p< .05). No other
higher-orderfactorswereassociatedwithparentmortalitystatus.
Perceptionsof childhood relationships withparents. Mean scores on
thescalesmeasuringperceptionsofchildhoodrelationshipswithparents
were analyzedas afunctionofgenderandattachment-stylegroupingin
a 2 × 4 MANOVA. The overall interaction term was not significant, sothe data were analyzed further without respect to gender. A MANOVA
conducted on the mother-father scales as a functionofattachment-style
categorywassignificant,Hotelling’s F(df=18,4046)=8.50, p<.001.860 Brennan and Shaver

(The attachment-group means for each of the six mother-father scales
arelistedinTable7,alongwiththeunivariate Fsandeffectsizes[ η2s].)
As shown in Table 7, all six parent scales differed significantly as a
functionofattachmentstyle.Relativetoinsecuregroups,securesrecalled
more accepting relationships with mothersandfathers. Insecure groups
appearedtoperceivetheirrelationshipswithfathersasequallynegative,but fearful individuals described their mothers as even more rejecting
thandidpreoccupiedanddismissingindividuals(whodidnotdifferfromeach other). Both secure and dismissing individuals recalled parents as
having fostered their independence, relative to fearful and preoccupied
individuals (who did not differ from each other). The fearful group
reported less mother idealization than any other group. Preoccupieds
reported less mother idealization than did secures, and dismissingsscored between the two. Both secures and dismissings reported more
idealistic childhood relationships with fathers than did fearfuls andpreoccupieds(whodidnotdifferfromeachother).Interestingly,despite
dismissing individuals’ perceptions of parental rejection, they did not
differ from secures in degree of idealization of either parent. These
findings partly replicate those found by Carnelley and Janoff-Bulman
(1992), but provide added information about the dismissings. This pat-
ternalsofitswiththeideaintheAAIscoringsystem(Goldwyn&Main,1994) that parental idealization (in combination with evidence that one
orboth parentswere rejecting) is a sign ofdismissingattachment.
7
We then correlated the six parental-perception scales with the 13
personality-disorderscales.(ThesecorrelationsareshowninTable8.)In
general,allthreepositiveparentalfeatureswerecorrelatedsignificantly
negatively,but weakly,with personalitydisorders.
7.  At first glance, it may appear odd that both secures and dismissings report similar
levels of parental idealization. It is problematic to use Epstein’s idealization scale tosingle-handedlyattempttodiscriminatepersonswithpositiveparentalcaregivinghisto-ries (and hence accurately positive descriptions of parents) from persons with negative
parentalcaregivinghistories(andhenceinaccuratelypositive,oridealistic,descriptions
of parents). Logically, scores ontheidealizationscalemustbeevaluatedinconjunctionwithscoresontheacceptancescale.Thatis,secures’idealization,inthecontextoftheirreports of parental acceptance, may accurately reflect a history of positive parenting.Dismissings’idealization,inthecontextoftheirreportsofparentalrejection,isnotatall
consistent with a history of positive parenting. Thus, only the dismissing group’s
idealization is likely to represent “true” idealization (cf. Shaver, Belsky, & Brennan,
1997).Attachment Styles 861

Table 7
Mean Ratings of Perceptions of Childhood Relationships with Parents
as a Function of Four Attachment-Style Categories
Attachment-StyleCategory
Secure Fearful Preoccupied Dismissing Univariate Fη2
Relationship with Mother
Acceptance 4.49c 4.11a 4.29b 4.32b 23.44 .05
Fostered Independence 3.73b 3.47a 3.47a 3.62b 14.65 .03
Idealizationof Mother 3.48c 3.00a 3.25b 3.37bc 16.20 .03
Relationship with Father
Acceptance 4.25b 3.79a 3.84a 3.97a 27.14 .06
Fostered Independence 3.88b 3.61a 3.63a 3.84b 16.76 .04
Idealizationof Father 3.19b 2.72a 2.75a 3.06b 14.30 .03
Note.df=3,1355.Alltestsweresignificantat p<.001. Withineachrow, meanswhosesuperscripts differaresignificantlydifferentat p<.05.

Table 8
Correlations Between Personality-Disorder Ratings and Perceptions of Childhood Relationships with Parents
Perceptions of Childhood Relationshipswith Parents
Mother Scales FatherScales
Personality- Fostered Warm Was the Fostered Warm Was the
Disorder rating independence acceptance idealparent independence acceptance ideal parent
Schizoid –.08 –.17 –.15 –.10 –.19 –.12
Schizotypal –.18 –.24 –.14 –.21 –.23 –.14
Paranoid –.19 –.21 –.12 –.24 –.22 –.13
Avoidant –.23 –.19 –.12 –.19 –.21 –.12
Dependent –.21 –.15 –.07 –.15 –.11 –.04
Obsessive-Compulsive –.22 –.20 –.10 –.22 –.17 –.08
Passive-Aggressive –.22 –.21 –.18 –.18 –.17 –.12
Self-Defeating –.20 –.23 –.14 –.20 –.24 –.12
Histrionic –.13 –.15 –.07 –.14 –.17 –.07
Narcissistic –.20 –.22 –.15 –.19 –.19 –.12
Borderline –.20 –.25 –.20 –.23 –.26 –.17
Antisocial –.10 –.15 –.12 –.09 –.12 –.04
Sadistic –.17 –.16 –.05 –.14 –.11 .00
Note.All correlations larger than .09 are significant at p< .001. Gender was partialed from all correlations, which were computed based on
N=1371to1401.

Finally, we correlated the six parental-perception scales with the five
higher-orderfactorsunderlyingtheattachmentandpersonality-disorder
measures. (These correlations are shown in Table 9.) The use of the
higher-order factors makes it easy to see at a glance which aspects ofattachmentandpersonalitydisordersareassociatedwithrecollectionsof
nonoptimalparentalcaregiving.Maternalandpaternalcaregivingreportswere associatedwiththefirst(Insecurity)attachment factorandwith
the first (Generalized Pathology) and third (Psychopathy) personality-
disorderfactors.DefensiveEmotionalStyle(arisingfromtheattachment
measures)andCounter-Dependence(arisingfromthepersonality-disorder
measures) were weakly associatedwith reports of a parental caregiving
style that emphasized independence, and were also associated with atendencytoidealizefathers.
DISCUSSION
Theprimarypurposeofthisstudywastoexaminepossible associations
between attachment styles and personality disorders. We hypothesized
that attachment style would be associated with all of the personalitydisorders and share most of their underlying structure. Results revealed
that, first, attachment styles are related to personality disorders (in a
sample that is, presumably, mostly within the normal spectrum). Evi-
dence for convergence emerged whether categorical or dimensional
measures ofpersonalitydisorders were used.
Second, information about the underlying common structure of the
twokindsofmeasures wasobtained whenwe conductedadiscriminant
analysis predicting attachment-style categories from all 13 personality
disorders. The set of personality-disorder scales formed a first functionthat appeared to assess generalized pathology (disordered thoughts and
negativeattitudesabout others),andthis functiondiscriminatedsecures
frominsecureswithlowself-esteem,particularlyfearfulindividuals.The
second  personality-disorder function  appeared  to  assess  overdepen-
dency, and distinguished preoccupied from dismissing individuals. The
thirdfunction,whichwasonlymarginallysignificant,appearedtoassessa tendencytowardinterpersonalaggressionandcallousness.
Third, consistent with previous theory (Bartholomew, 1990), attach-
mentpatternsarearrayedinatwo-dimensionalspace.Whenweconcep-tualize the dimensions in terms of relations among the measures, the
dimensionsaresecureversusfearful(ormaximallyinsecure)anddismissing864 Brennan and Shaver

Table 9
Correlations Between Higher-Order Factors and Perceptions of Childhood Relationships with Parents
Higher-order Fostered Warm Was the Fostered Warm Was the
factor independence acceptance idealparent independence acceptance ideal parent
Insecurity –.20*** –.26*** –.20*** –.22*** –.27*** –.18***
Defensive Emot. Style .09** .01 .04 .07* .05 .06*Generalized Pathology –.29*** –.31*** –.19*** –.29*** –.31*** –.18***Counter-Dependence .10*** .03 –.01 .06* .01 –.01Psychopathy –.19*** –.24*** –.16*** –.17*** –.19*** –.08**
Note.Genderwaspartialedfromallcorrelations,whichwerecomputedbasedon N=1344to1401.
*p<.05.** p<.01.*** p<.001.

versus preoccupied. We have named the first attachment-related factor
Insecurity and the second Defensive Emotional Style. These data repli-
catethefindingsofotherresearcherswhohaveuncoveredatwo-dimen-
sional structure underlying attachment measures (e.g., Brennan et al.,1998).
Fourth, our data show that personality disorders are empirically ar-
rayedinathree-dimensionalspace.Thefirstpersonality-disorderfactor,
General Pathology, consisted of six scales assessing thought disordersand troubled interactions with others. The second personality-disorder
factor,Counter-Dependence,consistedoftheSchizoid,Dependent,and
Histrionic scales (the latter two correlated negatively with this factor).
Thethirdpersonality-disorderfactor,Psychopathy,includespersonality-
disorder scales  that tap aggressive behavior (Antisocial, Sadistic,Passive-Aggressive,andNarcissistic).Thesethreefactorsareverysimi-
lar to the three discriminant functions that emerged in the analysis inwhich the personality-disorder scales were used to discriminate attach-
mentstyles.
Fifth, two of the three personality-disorder dimensions appear to
overlapveryclearlywiththeattachmentdimensions.Thefirstpersonality-
disorder factor, General Pathology, coincides well with the first attach-
ment factor, Insecurity. The second personality-disorder factor,
Counter-Dependence,coincideswellwiththesecondattachmentfactor,Defensive Emotional Style. The third personality-disorder factor, Psy-
chopathy, correlates only modestly with the first attachment factor, andnot at all with the second. Thus, mostof the personality-disorder scales
appeartomapontothetwo-dimensionalspacerepresentedbytheattach-
ment measures.
ThepresenceofthePsychopathypersonality-disorderfactorindicates,
however, that some kinds of personality disorders are not so highly
relatedtothetwodimensionsunderlyingtheattachmentmeasures.This
factorincludedtheAntisocial,Sadistic,Passive-Aggressive,andNarcis-sistic scales, which share items related to impulsive, remorseless, de-
structivebehaviors.Psychopathyresearchershaveagreedonatwo-factordefinition of psychopathy: The first factor is impulsive, antisocial, or
criminalbehaviors;thesecondfactorismanipulativeness,deceitfulness,
egocentrism, and lack of empathy for others’ suffering (Hare, 1993).
Sometheoristspointtosocialorenvironmentalconditionsthatgiverise
to psychopathy (Olwens, Block, & Radke-Yarrow, 1986, as cited in866 Brennan and Shaver

Dutton, 1995). Others have demonstrated at least some evidence of
genetic transmission forpsychopathy(Livesleyet al.,1993).
Ourthree higher-orderpersonality-disorderfactorsbearscantresem-
blance to the three DSM-III-R clusters. Two of the scales we included,
Sadisticand Self-Defeating,are not part ofthe threeclusters.We there-
fore removed those two scales to make a cleaner comparison. The firstpersonality-disorderfactor(Avoidant,Schizotypal,Paranoid,Obsessive-
Compulsive)correlatedhighlywithtwoofthethreeClusterAdisorders(Paranoid, Schizoid,Schizotypal).The third personality-disorder factor
(Antisocial,Borderline,Passive-Aggressive,andNarcissistic)correlated
highlywiththreeofthefourClusterBdisorders(Antisocial,Borderline,
Histrionic, Narcissistic). But  the second  personality-disorder factor
(Schizoid,Histrionic,andDependent)correlatedsubstantiallywithonlyone of the disorders in Cluster C (Avoidant, Dependent, Obsessive-
Compulsive, Passive-Aggressive).
Asecondarypurposeofthepresentstudywastoexploreconnections
betweenattachment,personalitydisorders,andthreefamily-backgroundfactors: parental death, parental divorce, and current representations of
early childhood relationships with parents. Both attachment style and
personality disorders are associated with parental divorce, but only
attachment style is associated with parental death (i.e., those with dis-
missive,oremotionallydefensivestyles,moreoftenreportedthelossofone or both parents). Although we cannot know how our participants
wereactuallytreatedinchildhood,attachmentinsecurityandtwoofthethreepersonality-disorderfactorswererelatedtocurrentrepresentations
of childhood relationships with parents. The two personality-disorder
factorsrelatedtoparentaltreatmentweremostcloselyrelatedtoattach-
ment insecurity (Generalized Pathology and Psychopathy), rather than
to the other attachmentdimension,Defensive EmotionalStyle.
Do Attachment Styles and Personality Disorders
Share Common Origins?
Based on our findings, we suggest that patterns of insecure attachment
overlap with patterns of disordered personality, many of which are
moderately related to each other. Thus, it would be parsimonious to
consider the idea that the same environmental conditions that give rise toinsecure attachment also contribute to at least some personality disorders.
Ofcourse,itis likelythatsuchenvironmentalconditionscombinewith,Attachment Styles 867

or interact with, inborn temperaments (e.g., behavioral inhibition). In
addition,cultural variations in the extent towhich particulartraits (e.g.,
independence, eccentricity) are valued are also likely to result in cross-
cultural differences in the expression of personality. Neither option,however, is incompatible with the idea that the quality of one’s early
attachmenttocaregiversaccountsforsomeofthevarianceinabnormal,or maladaptive, personality functioning. In fact, at first glance, it is
astonishing that such connections have been largely overlooked. Such
oversightmaybeduetodiscrepanciesinmethodandchoiceofresearch
subjects in the domains of attachment, onthe onehand,andpersonality
disorders,ontheother.Ainsworth’sandothers’attachmentresearchwas
grounded in orthodox developmental methods: behavioral observationsofyoungchildrenandtheirparents.Incontrast,thestudyofpersonality
disordershastraditionallyreliedontheretrospectivereportsofdisturbed
adultsin therapy.
That the two domains would eventually converge on the same disor-
dered relationship patterns is therefore not surprising and, we think,
would not have surprised John Bowlby. Throughout his career, Bowlby
theorized about the mechanisms likely to account for adolescent and
adult psychopathology (1944, 1973, 1977, 1980, 1988). Particularly
noteworthyisBowlby’sdistinctionbetween“feelingalarmed”and“feel-ing anxious.” Drawing on a military analogy, Bowlby (1973) described
howan army’s safetydepends:
not only on its defending itself against direct attack but also on its
maintainingopencommunicationwithitsbase.Anymilitarycom-
mander whofails to giveasmuchattention tohisbaseandlinesof
communicationastohismainfrontsoonfindshimselfdefeated...
. [A similar situation] holds between an individual and his attach-
ment figure. Each party is autonomous. Given basic trust the ar-
rangement can work well. But any possibility of defection by theattachmentfigurecangiverisetoacuteanxietyintheattached.And
should he be experiencing alarm from another source at the same
time,itis evident that heislikelytofeelthemostintensefear.(pp.
93–94)
Theoretically, environmental threats should provoke withdrawal, fr eez-
ing,orescapebehavior.Inawell-functioninggoal-correctedpartnership
between child and parent, such escape usually entails escaping to an
attachment figure. The failure, however, to establish a well-functioning868 Brennan and Shaver

partnershipwithacaregivermeansthataninfantmaydevelopthechronic
perceptionthat help isunavailable when needed,or,at best,isinconsis-
tentlyavailable.Inotherwords,distressmayresultfromeitherperceived
threats from the environment or perceived lack of support from one’scaregivers.AccordingtoBowlby(1973),thecombinationofboth,expe-
riencedoften enoughthroughoutthecourse ofdevelopment,is likelytoproduce the mostacuteformsof psychopathology.
Itispossibletodelineatethefouradultattachmentpatternsidentified
by Bartholomew (1990) in terms of Bowlby’s distinction between per-
ceived support from attachment figures and perceived threat from the
environment. Secure individuals trust their attachment figures and per-
ceivelittleenvironmentalthreat;asaresult,confidentoftheirattachment
figure’sreliability,securescandefendthemselvesagainstenvironmentalthreats,andhence areable toprocess emotionsinafluidandnondefen-
sive manner and remain the least troubled by personality disorders.Dismissing individuals, chronically lacking support from attachment
figures, may, as a result, habitually deny or dismiss environmental
threats. They may therefore have a higher threshold for experiencing
negativeemotionsorperceivingattachmentneeds,andthusexhibitwhat
Bowlby called compulsive self-reliance. Preoccupied individuals, wary
followingahistoryofinconsistentsupportfromcaregivers,arelikelytohave a lower threshold for perceiving environmental threat. Such a low
threshold for experiencing distress, in combination with mixed percep-
tions of support from caregivers, is likely to contribute to frequent
activationoftheattachmentsystem,withalltheconcomitantdistressandanger such activation provokes. Hence, they are likely to suffer from
compulsive care-seeking,dependency,and Histrionicpersonality disor-
der. Lastly, fearful individuals, who may be the adult versions of disor-
ganized/disoriented infants, appear to be the most troubled in terms ofpersonalitydisorders.Newevidencehasemergedthatdisorganized/dis-
oriented infants experience frightening behavior from attachment fig-
ures; their attachment figures, in turn, are more likely to revealthemselves in the Adult Attachment Interview as “Unresolved” with
respect toloss ortrauma(Lyons-Ruth & Jacobvitz, in press).
Limitations and Directions for Future Research
Oneobviouslimitationofourresearchisitsuseofanonclinicalsample.
To some extent, this limitation turns on whether one accepts a purelyAttachment Styles 869

categorical (vs.dimensional)understandingofpersonalitydisorders.If,
as we do, one assumes that personality disorders can be arrayed on
continua, then our results ought to generalize to clinical populations. It
would be desirable to conduct a similar study in a large enough (i.e.,general population) sample that would allow a credible test of the
categoriesversusdimensionsquestion.If,ontheotherhand,oneassumesthat personality disorders reflect true taxons, then our results may not
generalize well to clinical populations. In particular, our measure of
personality disorders suffers from an overinclusion bias. Examining all
13personalitydisorderstogether,three-fourthsofthesamplehadatleast
one personality disorder. This fact is consistent with the PDQ-R’s posi-
tive bias(cf.Moldinet al., 1994).
The prevalence of individual personality disorders in our sample is
generallyconsistentwithpreviousresearch,butfourscales’prevalences
were higher than is generally found in clinical samples: Paranoid, His-trionic,Borderline,andObsessive-Compulsive.Notethat,whenstandard
scoring methods were used, these four disorders occurred relatively
frequentlyinthetwocollegestudentstudiesbyJohnsonandcolleagues,
and three of the four (i.e., all but Borderline) occurred relatively fre-
quently in the medical student study by Maffei et al. (1995). Why the
higher prevalence rates for these disorders? We draw the same conclu-sionsasdidJohnsonandMaffeiandtheircolleagues.First,oursample’s
higher scores on the Paranoid and Obsessive-Compulsive scales may
reflect high intelligence and work standards in college student popula-
tions. Second, several items on the Borderline and Histrionic scalesappearrelatedtopatternsofthoughts,feelings,andbehaviormoretypical
of adolescence than adulthood. Our young sample (median age = 18)
mayberelativelymoreconcernedthanolderadultswithappearanceand
gossip; may be more moody and impulsive, particularly with regard tobehaviors involving sex, drugs, and alcohol; and may experience en-
hanced difficulties stemming from exploring conflicting beliefs, social
networks, and occupational goals. Not surprisingly, researchers havereportedhigherratesofpersonalitydisordersinadolescentsthaninadults
(Bernsteinetal.,1993;Johnsonetal.,1996;Maier,Lichtermann,Klingler,Heun,& Hallmayer,1992;Swartz,Blazer,George,&Winfield,1990).
A second, related limitation of our research is  its reliance on a
self-administeredmeasureofpersonalitydisorders,whichrequiresafair
degree of insight on the part of respondents. Although the PDQ-R isreliablyassociatedwithclinicians’classifications(49%to58%;Hyleret870 Brennan and Shaver

al.,1990),the overlapis notperfect.WhenJohnsonet al.’s(1996)more
stringent scoring criteria are used, however, prevalence rates of person-
ality disorders assessed with the PDQ-R more closely resemble preva-
lence rates reported for nonclinical samples using structured clinicalinterviews(Maieretal.,1992;Coryell&Zimmerman,1989).Therefore,
it would be desirable to test the associations between attachment stylesandpersonalitydisordersassessedviastructuredclinicalinterviewsand
self-administeredmeasures in the samesample.
Athird limitationofthe current researchis its cross-sectional nature.
Longitudinal research is needed to tease apart causal relations between
attachment and personality disorders, on the one hand, and family
variables, on the other. It is unlikely, however, that even with a longitu-
dinaldesignonecoulddeterminetheontologicalprimacyofattachmentstyles versus personality disorders. Although attachment styles are ob-
servable in the first year of life, only a handful of disorders resemblingadult personality disorders are detectable from behavioral observations
ofyoungchildren.Twoexamplescometomind.First,SeparationAnxi-
etyDisorderinchildhoodappearssimilarinmanyrespectstoDependent
personality disorder in adulthood, and to anxious (or preoccupied) at-
tachmentinbothchildhoodandadulthood.SeparationAnxietyDisorder
is characterized by “excessive anxiety concerning separation from thehome or from those to whom the person is attached . . . beyond what is
expectedfortheindividual’sdevelopmentallevel” (APA,1994,p.110).
Second, childhood disruptive behavior disorders seem similar in many
ways to psychopathy in adulthood and may be associated with the“Disoriented/Disorganized” infant attachment pattern  (Lyons-Ruth,
1996).Twochildhooddisruptivebehaviordisordersareworthmention-
ing.ConductDisorderisa “repetitiveandpersistentpatternofbehavior
in which the basic rights of others or major age-appropriate societalnorms or rules are violated” (APA, 1994, p. 85). This disorder includes
aggression directed toward other people or animals, property damage
(e.g.,fire-setting, window-smashing), theft,deceitfulness,orother seri-ous violations of rules. Oppositional Defiant Disorder, which is often a
precursortoConductDisorder,includes“negativistic,defiant,disobedi-ent, and hostile behavior [directed] toward authority figures” (APA,1994,p.91),butexcludesthemoreseriousaggressionandruleviolations
of Conduct Disorder. Other personality disorders cannot be assessedbehaviorally in very youngchildren,perhaps becausea significant cog-
nitivecomponentisnecessary(e.g.,Paranoid,Obsessive-Compulsive,orAttachment Styles 871

Schizotypalpersonalitydisorders).(SeealsoZeanah,1996,forareview
ofinfant attachmentdisorders.)
Insummary,thereisafairdegreeofoverlapbetweenattachmentstyles
and personalitydisorders, andboth setsofvariablesareassociated with
family variables.Futureresearchshouldfocusonelucidating thedevel-
opmental antecedents of personality disorders to determine which onesare shared by patterns of insecure attachment, and which are separate.
Given the relative lack of understanding of the etiology of personalitydisorders, we hope that clinicians and researchers studying personality
disorders will consider attachment theory as a framework for exploring
possible origins of personality disorders. In addition to investigating
developmental antecedents  of personality disorders, future research
should compare attachment styles and personality disorders in theirabilitytopredictpatternsofintrapersonalprocesses(e.g.,affect-regulation
andcopingwithdistress)aswellasinterpersonalfunctioningovertime.Wehopethatthepresentstudy,connectingattachmentstylesandperson-
alitydisorderswitheachotherandwithfamilyvariables,isausefulfirst
step.
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1 
 
Clinical Diagnostic Interview— Non-patient Version (CDI-NP) 
Drew Westen, PhD 
 
General Principles  
 This interview can be used for clinical or research purposes.1  This interview should be 
conducted as a clinical interv iew, with probing as appropriate based on the interviewer’s 
clinical skill, empathy, and hypothes es that emerge over the course  of the interview.  As in 
clinical interviewing, if the interviewee says  something with an ambiguous meaning, or that 
could lead to important informat ion, the interviewer should ask about it (e.g., “What did you 
mean when you said that your hus band is sometimes ‘off key’?”).  Questions in bold form 
the “skeleton” of the interview, i.e., the “script” around which the interviewer should 
improvise.  They are intended to standardize and syst ematize the interview but not to 
straightjacket the interviewer.  As interviewers get comfortable with the interview, they should 
use the Synopsis  at the end of this manual, which summarizes these questions, to guide 
research interviews. 
 This is largely a narrative-based interview, which requires inferences  based on what subjects 
say, the way they say it, and what they do not  say that seems implicit.  Thus, getting behind 
the “headlines”—the generic, explic it beliefs people s provide—to the “text” or narrative 
beneath it is essential to reliable and valid scoring.  When in doubt,  ask for an example of a 
specific instance.  Always  inquire about idiosyncratic, unc lear, or unusual word choices. 
 If interview questions becom e redundant because the answers are clear from previous 
responses, do not ask them (e.g., do not ask about  depression if interviewee has already told 
of a history of depression).   
 The interviewer should inquire about suicidality or psychosis at any point in the interview if 
the interviewee’s symptoms, na rratives, or presentation s uggest that such questions are 
likely to be relevant (e.g., if the interviewee r eports depression, or if the interviewer has any 
suspicion of suicidality, the interviewer should inquire about su icidal ideation, plans, and past 
suicidal behavior early in the interview).  If at  any point in the interview the person seems 
disorganized, disoriented, manic,  or shows subtle or frank si gns of thought disorder or  
                                                 
1 This interview can be used to assess both Axis  I and Axis II syndromes by applying specific 
instruments to it, although it cannot be used to apply DSM-IV diagnostic algorithms for each 
disorder, which require direct inquiry about the nat ure, length, and duration of hundreds of symptoms 
for disorders that may or may not be clinically relevant.

2
psychosis, the interviewer shoul d immediately assess mental st atus (e.g., orientation to 
person, time, and place; memory; and comprehens ion of proverbs) and current or recent 
drug use, and should directly i nquire about psychotic or mani c symptoms (e.g., delusions, 
hallucinations, paranoia, racing thoughts).  If the in terviewee is psychotic or manic, the rest 
of the interview should be abbreviated, with  a primary focus on questions necessary for 
making an appropriate clin ical disposition.   
 Particularly if the interview is being used for clinical purposes or for assessing Axis I 
symptoms as well as personality functioning, administration of a symptom checklist prior to 
interviewing can be useful to minimize the likelihood of missing symp toms the patient does 
not volunteer during the interview.  The inte rviewer should interject questions about checklist 
responses during initial questi oning about current symptoms or wherever else doing so 
appears appropriate.   
 The interview should take about 2 1/2 hours (or for clinical purposes, three 45-50-minute 
sessions, including feedback to the interviewee at t he end of the last interview).  If it is taking 
longer with a subject, the interviewer should ask for fewer vignettes or less detail as the 
interview proceeds, once s/he has  a good “feel” for the person.  The interviewer should use 
familiarity with the instrument(s) s/he will be applying to the data (e.g., the SWAP-II Q-sort, 
Affect Regulation and Experience Q-sort) to guide clinical inquiry and probing.  
 The interviewer should take notes during t he interview on comments the subject makes of 
relevance to coding the interview or to which s/he wants to return for further inquiry.  If Q-
sorting or making ratings from this interview, be sure to do so within 24 hours after the 
interview , and be sure to review your notes before doing so .  Memory for specific details 
fades remarkably quickly, both from the beginning of the interview to the end, and after 24 
hours, particularly if any other clinical  contact occurs in the interim.  Note: If more than 24 
hours elapses between watching a videotaped interview and scoring it, the scorer needs to 
watch the videotape a second time because the data will not otherwise be valid.

3
Clinical Diagnostic Interview: Probe Questions and Instructions 
1. Could you tell me a little bit about yourself? Like what kind of person you are, what you’re 
like?   
 The goal is to get a sense of who the pers on is, how s/he views him/herself, current adaptive 
functioning, and his/her broader social context.  Note that the goal here is also to help the 
patient feel comfortable with  the interview and interviewer.  
 Are you working right now?  What do you do?  
 Who are the important people in your life?  Elicit descriptions, flesh out details of any 
conflicts with others the per son volunteers, and elicit specific  examples if that is the case 
(e.g., “You said you and your wife are fighting a lot right now about the kids.  Can you give 
me an example of a recent interaction y ou’ve had, where you’ve been fighting about the 
kids?”).  
 
2. Can you tell me about your childhood--what was it like growing up?    
 Probe for specific milestones and significant experiences, including losses, major illnesses, 
family moves, parental discipline, abuse, parent al criminality or poverty where appropriate, 
etc.  Specific initial probe if useful:  Who was in your house and your family when you 
were growing up? 
 3. Can you tell me about your relationship with your mother?   What was (is) she like as a 
person, and what was she like as a parent?  
 If patient asks for clarification, inquire about t he history of the relati onship as both a child and 
an adult.   
 Now I'd like you to describe a specific encounter with your mother, something that 
stands out.  It can be an incident that’s ty pical of your relationship, really meaningful, 
really good, really bad--whatever comes to mind.    
 Probe if subject leaves out any of the following: what led up to the event, what both people 
were thinking and feeling, and the outcome.   If subject has trouble with the task, give these 
probes at the beginning and repeat onc e or twice as necessary.  
 Inquire about one or two more events ; probe incomplete, ambiguous, or incoherent 
narratives.  
 
4. Could you tell me about your re lationship with your father?   What was (is) he like as a 
person, and what was he like as a parent?  Ask for two vignettes .

4
5. Do you have brothers and sisters?  Could y ou tell me a little bit about them and your 
relationships with them?  
 Can you describe a specific encounter with one of your brothers or sisters?  
 Ask for one or two more vignettes; if more than one sibling, ask for an encounter with a 
different sibling than described in the first vignette. 
 Was there anyone else who was really important to you as a child or teenager?  If so, 
probe for  one specific incident.  
 
6.  What was school like for you?  Probe for success or failures, di fficulties, peer rejection or 
neglect, etc.  Ask for specific incidents.  
 
7. What were your friendships like when you were a kid, and what are they like now?  Probe 
friendship history. 
 Who are your closest friends now?  Could you tell me about your relationship with 
one of them--what is it like?  
 Ask for two specific incidents , either with one friend or different  friends if the subject prefers. 
 
8. Can you tell me about your romantic relationships--what have they been like?   
 Get history of adult relationships.  
 Are you currently married or involved with someone?  Alternatively, for young adults or 
populations where formal ma rriage is not the norm, or “Are you with someone now?”  Could 
you tell me about the relationship?  
 Ask for two to three specific encounters in current and past romantic relationships. 
 How is your sex life? Probe for enjoyment, conflicts, and specific dysfunctions.  Probe for 
sexual history , including first sexual experiences.  If the patient describes no problems in 
his/her sex life, ask if thi ngs have always been that way. 
 Are there things that make you uncomfortable sexually, or have led to friction in your 
relationships?   Is there anything about your  sexual attitudes or behavior that other 
people might consider unusual? The interviewer should be certai n that if s/he chooses not 
to ask certain questions about sex this is becaus e of particular cultural constraints, not 
his/her own discomfort in asking the questions. 
 
9. Could you tell me about your work history?

5
 Probe if necessary:  “Do you tend to stay with  jobs for a long time or move around a lot?”  
“Do you sometimes get into conflicts with coworkers or bosses, or leave one job before 
you’ve found another one?”   
 Ask for one or two specific encounters at current or previous jobs. 
 Where appropriate, probe for signs of obse ssionality, passive aggression, or trouble 
committing to an occupation. Probe for the extent to which work is satisfying or a central 
aspect of identity. 
 If a homemaker, get a sense of the extent to which the person feels fulfilled at what s/he is 
doing and any conflicts at home regarding the way s/he fulfills responsibilities. 
 
10. Have you ever been in trouble with the law?   Where appropriate, get complete legal, criminal, 
or violent history, beginning in childhood.    
 Some kids get into things like fighting, hur ting animals, lighting fires, joining gangs, 
or running away from home.  Did you get into any of those kinds of things as a kid?   
 Have you ever hit anybody as an adult—at home, in a bar, at work, or anywhere else?   
 Where appropriate, “Have you ever used a weapon on somebody, or threatened somebody 
with one?” 
 
11. Do you have children?  Can you tell me a little bit about them, and about your 
 Ask for two or three incidents ; if subject has more than one child, solicit information on 
different children. 
 Where appropriate, “How do/did you discipline y our kids?”  Assess for interpersonal violence 
and the motives behind it (e.g., sadism, identif ication with an abusiv e parent, conflict about 
it). 
 If not already clear how the subject deals with dependency issues, “H ow do you feel about 
being taken care of—do you like it? Does it bother you?” “Can you give me an example of a 
time someone took care of you that stands out  in your mind as typical, meaningful, or 
problematic?”   
 
12. Now I'd like you to think of a really difficult, stressful, or upsetting time in the last year or 
two, and tell me about it. It can be an argumen t with someone important to you, a problem at 
work, a financial problem--anythi ng you found really stressful.   
 Probe precisely how the person responded to the experience, incl uding conscious coping 
strategies (e.g., “Are there things you told yourself to try to help you get through it?”).

6
 Now tell me about another incident or si tuation that was difficult, stressful, or 
upsetting in the last year or two.  Use same probes as above.  Do not ask this question if 
you have already heard of several recent event s and have a clear sense of how the subject 
tends to deal with pressure and regulate emotions. 
 How does you body hold up under stress?  Do you often get sick or have headaches, 
stomach problems, backaches, etc.?  How is your health in general?  Probe 
hypochondriasis and somatization.  Ask about eati ng problems or other symptoms if doing so 
seems clinically indicated based on prior material, appearance, etc.  
 
13. Now I’d like to ask you some questions about your emotions and how you deal with them.  
Do not ask questions that are redundant or for wh ich the answer is alr eady clear based on prior 
responses.   
 Have you ever had problems with depression or anxiety?  Like feeling really sad?  
How about nervous or panicky?   
 Have you ever hurt yourself, tried to kill your self, or thought seriously about suicide?  
If so, probe frequency, intensit y, and specific incidents.   
 Do you often feel ashamed, or embarrassed?  
 How about guilty?  
 Do you ever feel overwhelmed by your feelings?  
 Are there times when you try to shut off your feelings entirely, or just feel numb?  
 Have there been times when things were so hard that you sort of disappeared from 
the situation, like you no longer felt like you were in your skin, or were looking at 
yourself from the outside?  Have you ever fe lt like the world was unreal or changing 
when it wasn’t?  
 Has anger ever been a problem for you?  What do you usually do when you get angry? 
(probe specific examples)  
 Probe manic symptoms if appropriate, e.g., “Do you ever get so happy or feel so on top of 
the world that it's unrealistic—lik e you think you can do anything?”  
 Have you ever had trouble with alcohol or drugs?   If unclear, ask if anyone close to 
him/her has complained about his/her drinking or drug use.  Take a complete drug and 
alcohol history where appropriate, beginning with first use of cigarettes, alcohol, and drugs. 
 
14.  Now I’d like to ask you a few questions about the way you think.

7
 Are you a religious or spiritual pe rson?  Can you tell me about that?  Probe religious or 
spiritual beliefs that are particularly meaningful to the person, useful in coping, appear to hold 
together a fragile identity, or  reveal loose thinking.   
 Are you a superstitious person?  Are there things you think or believe that other 
people would find unusual?   
 Do you believe in ESP, or believe that people can read other people’s minds?   
 Do you ever have memories of painful thi ngs that happened to you suddenly come 
back into your mind, or thoughts that just keep coming back that you can’t get out of your mind?  
 Do you ever have strange thoughts or feelings , like sensing that another person is in 
the room when they’re not, or seeing images or hearing voices?   Probe frank psychotic 
thinking or subclinical  thinking disturbances.  
15.  I’d like to finish up by asking you a few questions about how you see yourself.  
 How do you usually feel about yourself?  If the person has a traumatic  history, inquire into 
self-blame and feelings of badness, shamefulness, or self-loathing.  Do your feelings about 
yourself change a lot?  What do you most like and dislike about yourself?  
 If interviewee’s sense of identity or abilit y to find meaning in life is not clear, ask,  “Are there 
times when you feel empty inside, or like y ou’re a different person depending on who you’re 
with?”   
 How do you see your life going in the long run—what do you think it’s going to be 
like?  
 How do you think the things you’ve experienced in your life [give examples] have 
affected you? 
 16. I’ve asked you a lot of questions.  How has this been? Is there anything we haven’t covered that’s really important in understa nding you as a person?  Is there anything else 
you'd like to add, or anything you'd like to ask?  
For both patients and research partici pants, it is useful to provi de feedback to the person about what 
you’ve seen, including both thi ngs s/he is concerned about and hi s/her potential strengths.

8
Synopsis of Clinical Diagnostic Inte rview Questions—Non-patient Version 
 
1. Could you tell me a little bit about yourself? Like what kind of person you are, what you’re like?  A) 
Are you working right now?  What do you do?   B)  Who are the important people in your life?   
2. Can you tell me about your childhood--what was it like growing up?   3. Can you tell me about your relationship with your  mother?  What was (is) she like as a person, 
and what was she like as a parent?  Now I'd like you to describe a specific encounter with your 
mother, something that stands out.  It can be an incident  that’s typical of your relationship, really 
meaningful, really good, really bad—whatever comes to mind. 
4. Could you tell me about your relationship with your father?   5. Do you have brothers and sisters?  Could you te ll me a little bit about them and your relationships 
with them?  Was there anyone else who was really  important to you as a child or teenager?   
6. What was school like for you? 7. What were your friendships like when you were a kid, and what are they like now?  Who are your 
closest friends now?  Could you tell me about your  relationship with one of  them--what is it like? 
8. Can you tell me about your romantic relations hips--what have they been like?  Are you currently 
married or involved with someone?  Could you tell me  about the relationship? How is your sex life?  
Are there things that make you unc omfortable sexually, or have led to friction in your relationships?   
Is there anything about your sexual attitudes or  behavior that other people might consider unusual? 
9. Could you tell me about your work histor y?  What do you do now, and what have you done 
before?   10. Have you ever been in trouble with the law?    A) Some kids get into things like fighting, hurting 
animals, lighting fires, joining gangs, or running away  from home.  Did you get into any of those 
kinds of things as a kid?  B) Have you ever hi t anybody as an adult—at home, in a bar, at work, or 
anywhere else?   11. Do you have children?  Can you tell me a littl e bit about them, and about y our relationships with 
them?  12. Now I'd like you to think of a r eally difficult, stressful, or upsetting time in the last year or two, and 
tell me about it.  How does you body hold up under  stress?  Do you often get sick or have 
headaches, stomach problems, ba ckaches, etc.?  How is your health in general?   
13. Now I’d like to ask you some questions about y our emotions and how you deal with them.  A) 
Have you ever had problems with depression or anx iety?  Like feeling really sad?  How about 
nervous or panicky?  B) Have you ever hurt yoursel f, tried to kill yourself, or thought seriously about 
suicide?  C) Do you often feel as hamed, or embarrassed?  D) How about guilty?  E) Do you ever feel 
overwhelmed by your feelings?  F) Are there times w hen you try to shut off your feelings entirely, or 
just feel numb?  G) Have there been times when th ings were so hard that you sort of disappeared

9
from the situation, like you no longer felt like you were in your skin, or  were looking at yourself from 
the outside?  Have you ever felt like the world was unreal or changing when it wasn’t?  H)  Has 
anger ever been a problem for you?  What do you usually do when you get angry?  I) Have you ever had trouble with alcohol or drugs?   14.  Now I’d like to ask you a few questions about t he way you think.  A) Are you a religious or 
spiritual person?  B) Are you a super stitious person?  Are there things you think or believe that other 
people would find unusual?  Do you believe in ESP,  or believe that people can read other people’s 
minds?  C) Do you ever have memories of pai nful things that happened to you suddenly come back 
into your mind, or thoughts that just keep coming ba ck that you can’t get out of your mind?  D) Do 
you ever have strange thoughts or feelings, like s ensing that another person is in the room when 
they’re not, or seeing images  or hearing voices?    
15.  I’d like to finish up by asking you a few ques tions about how you see yourself.  A) How do you 
usually feel about yourself?  B) Do your feelings  about yourself change a lot?  What do you most like 
and dislike about yourself?  C) How do you see your life going in the long run—what do you think it’s 
going to be like?   D) How do you think the things you’ve experienced in your life have affected you? 
16. I’ve asked you a lot of questions.  How has  this been? Is there anything we haven’t covered 
that’s really important in underst anding you as a person?  Is there any thing else you'd like to add, or 
anything you'd like to ask?

C:\Works\Data\projects\Python\Diagnosis Project\chat_app\knowledge\documents\Granieri Defense Mechanisms.pdf

ORIGINAL RESEARCH
published: 02 November 2017
doi: 10.3389/fpsyg.2017.01926
Frontiers in Psychology | www.frontiersin.org 1 November 2017 | Volume 8 | Article 1926Editedby:
SimonBoag,
MacquarieUniversity,Australia
Reviewedby:
YairNeuman,
Ben-GurionUniversityoftheNegev,
Israel
GiuseppeScimeca,
UniversityofMessina,Italy
WilliamHenryGottdiener,
JohnJayCollegeoftheCityUniversity
ofNewYork,UnitedStates
*Correspondence:
AntonellaGranieri
antonella.granieri@unito.it
Specialtysection:
Thisarticlewassubmittedto
Psychoanalysisand
Neuropsychoanalysis,
asectionofthejournal
FrontiersinPsychology
Received: 13July2017
Accepted: 18October2017
Published: 02November2017
Citation:
GranieriA,LaMarcaL,ManninoG,
GiuntaS,GuglielmucciFand
SchimmentiA(2017)TheRelationship
betweenDefensePatternsand
DSM-5MaladaptivePersonality
Domains.Front.Psychol.8:1926.
doi:10.3389/fpsyg.2017.01926The Relationship between Defense
Patterns and DSM-5 Maladaptive
Personality Domains
AntonellaGranieri1*,LuanaLaMarca2,GiuseppeMannino3,SerenaGiunta3,
FannyGuglielmucci1andAdrianoSchimmenti2
1DepartmentofPsychology,UniversityofTurin,Turin,Italy ,2FacultyofHumanandSocialSciences,KoreUniversityofEnn a,
Enna,Italy,3DepartmentofLaw,LiberaUniversitàMariaSantissimaAssu nta(LUMSA),Palermo,Italy
Aim:Researchhasextensivelyexaminedtherelationshipbetwee ndefensemechanisms
(DM) and personality traits. However, no study to date has ex plored if speciﬁc defenses
(aloneorincombination)areabletopredictdysfunctional variantsofpersonalitydomains,
asconceivedinthealternativeDSM-5modelforpersonality disorders. Thisstudyaimed
toinvestigatetherelationshipbetweenDMsandDSM-5malad aptivepersonalitydomains
among adults.
Materials and Methods: Three hundred and twenty-eight adults aged between 18
and 64 years old completed measures on DMs and maladapive per sonality domains.
RegressionanalyseswereperformedtodeterminewhichDMsp redictedthemaladaptive
personality domains of negative affectivity, detachment, antagonism, disinhibition, and
psychoticism.
Results: Accordingtopsychoanalyticliterature,resultsshowedth atimmaturedefenses
positively predicted maladaptive personality domain scor es, whereas mature defenses
were generally related with better personality functionin g. Moreover, different defense
patterns emerged as signiﬁcant predictors of the maladapti ve personality domains
comprised in the alternative DSM-5 model for personality di sorder.
Discussion: Our ﬁndings support the view that defense patterns represen t core
components of personality and its disorders, and suggest th at an increased use of
immature defenses and a reduced use of mature defenses have a negative impact on
the development of personality.
Keywords: defense mechanisms, defense patterns, personality, psychopatology, diagnosis
INTRODUCTION
As discussed by Sigmund Freud in early papers ( Freud, 1894, 1896 ), the concept
of defense mechanism (DM) was that of a mental operation, usually unconscious,
directed against the expression of drives and impulses. The ori ginal idea was that DMs
serve to control or modulate the expression of unacceptable impu lses, to protect the
individual from being overwhelmed by the anxiety that would r esult from conscious
recognition of these impulses. This conception was subsequent ly expanded to include
the use of defenses as reactions to external sources of stres s as well as to internal forces.

Granieri et al. Defense Patterns and Personality Domains
Contemporary psychoanalytic authors ( Kernberg, 1976, 2005;
Kohut,1977;Bromberg,1998;Cooper,1998;Cramer,2006,200 8;
McWilliams,2011 )highlightthatDMshavethespeciﬁcfunction
to protect the self from anxiety, conﬂict, shame, loss of self -
esteem,orotherunacceptablefeelingsandnegativethought s.
Cramer (2008) has conducted a review of empirical studies,
whichsupportsthesefundamentalpsychoanalyticalassumption s
on DMs. Speciﬁcally, it emerges from her work that DMs have
some operational characteristics. These characteristics c an be
summarized as follows: DMs may be deﬁned as unconscious
mental mechanisms that are directed against both internal d rive
pressures and external pressures, especially those that threa ten
self-esteem or the structure and the integration of the self ; they
develop according to predictable sequences with the maturat ion
ofthechild;theyarepartofnormalpersonalityfunctioning; they
canleadtopsychopathology,ifoneormoreareusedexcessivel y;
theyaredistinguishablefromoneanother.
There are diﬀerent opinions about how many DMs exist
(Freud, 1936; Laughlin, 1979; Vaillant and Vaillant, 1992 ), but
there is some agreement between psychoanalytic theorists on
the idea that defenses are ordered on a continuum, diﬀering in
degree of maturity ( Laughlin, 1979; Vaillant et al., 1986; Perry,
1990;Cramer,1991a;PDMTaskForce,2006;McWilliams,2011 ).
Generally,DMsthatareconsideredmorematureimplyagreater
ability to adapt to reality, so that they can eﬀectively distanc e
threatening feelings without distorting the reality. Exam ples of
these defenses are sublimation, humor, suppression, altruis m.
Diﬀerently,DMsthatareconsideredimmatureorevenprimitive
are characterized by severe alteration of painful mental con tents
and/or radical distortion of external reality. Examples of t hese
DMsareprojection,splitting,actingout,andautisticfantas y.
Severalresearchershavefoundsigniﬁcantsexdiﬀerencesbo th
intheuseofspeciﬁcDMsandinoveralldefensivestylesadopted
by individuals (e.g., Cramer, 1987, 1991a,b, 2006; Vaillant, 1993;
Ptacek et al., 1994; Hibbard and Porcerelli, 1998; Mahalik e t al.,
1998; Watson and Sinha, 1998; Watson, 2002; Petraglia et al. ,
2009; Furnham, 2012 ). Research ﬁndings showed that women
tendtousemoreinternalizingDMs(suchassomatization),wh ile
mentendtousemoreexternalizingdefenses(suchasactingo ut).
This is in line with early theoretical and clinical observat ions
suggestingthatwomenﬁnditmorediﬃculttoexpressaggressi on
outwardly and are more likely to turn it against themselves b y
relying on defenses that modify inner thoughts and feelings . In
contrast,mendependmoreondefensesthatlocateconﬂictint he
external world, and tend to turn against the object ( Freud, 1932;
Deutsch,1944;Erikson,1964 ).
Cramer (2006) has observed that psychological health is
not only related to mature DMs, but especially to the ability
to appropriately use a variety of DMs in diﬀerent contexts.
Severalstudiesshowedthataprincipaloralmostexclusiveus eof
immaturedefenseisariskfactorforthedevelopmentofdiﬀere nt
forms of psychopathology ( Perry and Cooper, 1989; Bloch
et al., 1993; Busch et al., 1995; Spinhoven and Kooiman, 1997;
Lingiardietal.,1999;Bond,2004;BondandPerry,2004;Zan arini
et al., 2009 ). In fact, seminal concepts such as the “rigidity” of
personality or the “character armor” ( Reich, 1933/1979 ) clearly
expresstheideathatmentalhealthisstrictlyrelatedtoemo tional
ﬂexibility.The ﬁeld of personality assessment is widely informed
by studies on DMs ( McWilliams, 2011 ). There is in fact a
vast scientiﬁc literature that explains the organization an d
functioning of the personality in the light of defense patterns
adopted by individuals. From a psychoanalytic perspective
personality styles and organizations are strongly related w ith
speciﬁc defense patterns ( Kernberg, 1984; PDM Task Force,
2006; McWilliams, 2011 ). For example, Kernberg (1984) has
identiﬁed three types of personality organizations that reﬂe ct
the individual’s predominant psychological characteristics and
that are based on the individual’s identity integration, DMs,
and reality testing. The neurotic organization of personali ty
is characterized by identity integration (object constancy ), a
conserved capacity for reality testing and a prevalent use of
mature and neurotic DMs. Borderline personality organizatio n
is characterized by a failure in identity integration(iden tity
diﬀusion), a conserved reality testing when not in condition of
distress, and use of immature DMs. The psychotic organization
of personality is characterized by lack of ego boundaries, lo ss of
realitytesting,anduseofimmatureandprimitiveDMs.
Psychoanalytic considerations are reﬂected in basic resea rch
on personality. There is general agreement that mature defen ses
such as humor, altruism, and sublimation are associated wit h
adaptive functioning ( Vaillant, 1994, 2000; Bond, 2004 ) and are

related to the presence of favorable aspects of personality. In
this context, McCrae and colleagues ( McCrae, 1989; McCrae
and Costa, 1989; Costa et al., 1991 ) examined the relationship
between DMs and the ﬁve-factor model of personality, and they
found that the more mature and adaptive DMs were positively
correlated with the Big-Five domain of extraversion, openne ss,
and agreeableness, whereas neurotic and immature DMs were
positively correlated with higher neuroticism and, to a lesse r
degree, lower conscientiousness. Likewise, several resear ches
have shown by means of diﬀerent personality measures and
diﬀerent methods of assessing DMs that an excessive use of
immature defenses such as splitting, projection, and denial
is related to aﬀective disorders (e.g., depression and anxiet y)
and to less favorable personality characteristics (e.g., ne urotic,
borderline, psychotic, dependent, avoidant, narcissistic, a nd
antisocial traits; see Perry and Cooper, 1989; Berman and
McCann, 1995; Cramer, 1999, 2003; Lingiardi et al., 1999; Si nha
and Watson, 1999; Millon et al., 2004; Bronnec et al., 2005;
Bornstein,2006;Carvalhoetal.,2013;Perryetal.,2013 ).
However, using measures that allow researchers to better
compare and discuss ﬁndings within a shared diagnostic
framework may help clinicians and researchers who are
interested in the relationship between DMs and personality
features to going beyond the diﬀerences among the myriad
measures for assessing personality. In this context, the
Personality Inventory for DSM-5-Brief Form (PID-5-BF;
Krueger et al., 2012 ) assesses ﬁve domains of personality,
according to the alternative DSM-5 model for personality
disorders American Psychiatric Association, 2013 ): negative
aﬀectivity(whichincludespersonalityfeaturessuchasemot ional
lability and hostility), detachment (which includes person ality
features such as intimacy avoidance and suspiciousness),
antagonism (which includes personality features such as
grandiosityandmanipulativeness),disinhibition(whichin cludes
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personality features such as impulsivity and risk taking),
and psychoticism (which includes personality features such
as cognitive perceptual dysregulation, unusual beliefs, and
experiences). These ﬁve domains represent the maladaptive
extremes of the ﬁve-factor model of personality, which has
eﬀectively framed extensive research in the ﬁeld of personalit y
andpsychopathology( WidigerandCosta,2012 ).
To the best of our knowledge, no study to date has used
the PID-5-BF to explore the relationship between DMs and
the maladaptive variants of the ﬁve-factor model of personali ty.
In this respect, our research could bridge a gap in literature ,
and could also highlight potential diﬀerences in the role of
DMs when maladaptive domains of personality, rather than
theircorrespondingadaptivedomains,areconsidered.Moreov er,
empirical research on the relationship between DMs and
personality factors has usually privileged an approach to the
investigation of DMs that was prevalently based on scores on
defense styles (i.e., on combination of similar type of defen ses,
such as suppression, sublimation, humor, and anticipation for
indicating mature DMs), whereas it could be also critical to
explorehowindividualDMsarerelatedwithdiﬀerentpersonalit y
domains.
The aim of the present study was to investigate the
relationship between DMs and PID-5-BF maladaptive
personality domains. In light of previous ﬁndings, we
hypothesized that gender diﬀerences would be observed in
DMs, so that males would use more externalizing DMs (such
as acting-out), whereas women would use more internalizing
DMs (such as somatization). We also hypothesized that an
increased use of immature DMs would predict increased scores
inmaladaptivepersonalitydomains,whereasmatureDMswould
be linked to lower scores in maladaptive personality domains;
however, since psychoanalytic literature has consistently l inked
diﬀerent types and functions of DMs with diﬀerent personality
styles, we also expected that each maladaptive personality
domainwouldberelatedtospeciﬁcDMpatterns.
MATHERIALS AND METHODS
Participants
The study involved 328 adults (113 males, 34.5%; 215 females,
65.5%). Participants ranged in age from 18 to 64 years old ( M=
33.40;SD=13.60).Themeanyearsofeducationwas15.35( SD=
3.55). There were no gender diﬀerences in relation to age [ t(326)
=0.33,p=0.74]oryearsofeducation[ t(326)=−0.18,p=0.86].
Procedures
After ethical permission by the University IRB for psychologica l
research, participants were recruited in three cities of Sici ly
(Italy) through public and electronic advertisements (ﬂier s in
public places and posts in social network pages). People who
contacted the research oﬃce were asked to participate in a
study on the characteristics of personality. Those who agree d to
participate and signed the informed consent were administere d
two measures for the assessment of DMs and maladaptive
personalitydomains.Participantsdidnottakeanycompensati onfor their involvement in the study. At the end of the study, th ey
weredebriefedandthanked.
Measures
The Defense Style Questionnaire-40 (DSQ-40; Andrews et al.,
1993)isaself-reportinstrumentincluding40itemsthatmeasure s
theindividualdefensivefunctioningthrough20DMs(twoite ms
representing each of the 20 DMs). The investigated DMs are
categorized into the three defense styles: mature (8 items),
neurotic (8 items), and immature (24 items). The mature
style embraces four DMs: sublimation, humor, anticipation,
and suppression. The neurotic style includes undoing, pseudo-
altruism, idealization, and reaction formation. The immat ure
style comprises 12 DMs: projection, passive aggression, acting
out,isolation,devaluation,autisticfantasy,denial,di splacement,
dissociation,splitting,rationalization,somatization. Anexample
itemis“Ioftenactimpulsivelywhensomethingisbotheringme”
(related to acting out). In the DSQ-40, participants respond by
a nine-point Likert scale extending from one (strongly disagr ee)
to nine (strongly agree). Scores on single DMs are derived by
calculating the mean of the two items measuring each defense;
scores on defense styles are calculated by averaging the ite ms
loading on each style. Thus, scores range from 1 to 9 for each
DM and style, and elevated scores point out higher utilizatio n
of the target defense/style. The DSQ-40 has been validated i n
many countries, including Italy ( Farma and Cortinovis, 2000 ).
In the present study, reliability coeﬃcients of Cronbach’s a lpha
for mature style, neurotic style, and immature style were,
respectively, α=0.57,α=0.55,and α=0.82.
The Personality Inventory for DSM-5-Brief Form-Adult
(PID-5-BF; Kruegeretal.,2012 )isa25-itemself-ratedpersonality
trait assessment scale for adults aged 18 and older. The pool o f
25 items tap into ﬁve diﬀerent personality domains according t o
thealternativeDSM-5modelforpersonalitydisorders( American
Psychiatric Association, 2013 ). Five maladaptive variants of

personality-trait domains are evaluated: negative aﬀectivi ty,
detachment, antagonism, disinhibition, and psychoticism; ea ch
trait domain includes ﬁve items. Each one of them is rated on
a four-point scale (from 0 =very false oroften false to 3=
very true oroften true ). An example item is “I feel like I act
totally on impulse” (related to the domain of disinhibition). T he
overall measure has a range of scores from 0 to 75, with higher
scores indicating greater overall personality dysfunction . Each
trait domain ranges in score from 0 to 15, with higher scores
suggesting greater dysfunction in the speciﬁc personality tr ait
domain. The PID-5-BF has been validated in many countries,
including Italy ( Fossati et al., 2015 ). In the present study,
Cronbach’s alpha for the PID-5-BF total score was 0.86, where as
Cronbach’s alpha for the PID-5-BF domains ranged from 0.66
(detachment)to0.77(antagonism).
Sociodemographicdatawerealsocollectedbymeansofan ad
hoc-questionnaire.
Statistical Analyses
Statistical analyses included descriptive statistics for all study
variables. Two MANOVAs using gender as factor and age and
years of education as covariates were performed, to examine
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TABLE 1 | Descriptive statistics of defense mechanisms and maladapt ive personality domains.
Full sample Range Skewness Kurtosis Males Females
(N= 328) (N= 113) ( N= 215)
M(SD) M(SD) M(SD)
DSQ mature style 4.82(1.21) 1.13–8.50 −0.007 0.223 4.95(1.27) 4.75(1.17)
DSQ neurotic style 4.36(1.20) 1.25–7.50 0.009 −0.267 4.30(1.26) 4.39(1.17)
DSQ immature style 3.72(1.06) 1.04–6.75 0.289 −0.167 3.71(1.14) 3.73(1.02)
Autistic fantasy 3.43(2.27) 1–9 0.685 −0.594 3.44(2.13) 3.43(2.35)
Acting out 4.47(2.03) 1–9 0.221 −0.673 4.26(1.91) 4.57(2.09)
Anticipation 4.90(1.63) 1–9 0.006 −0.020 4.95(1.68) 4.87(1.60)
Denial 2.66(1.59) 1–9 0.924 0.569 2.72(1.44) 2.62(1.66)
Devaluation 3.79(1.72) 1–9 0.502 0.056 3.68(1.71) 3.85(1. 74)
Displacement 3.35(1.84) 1–9 0.497 −0.367 3.28(2.00) 3.38(1.75)
Dissociation 3.25(1.74) 1–9 0.762 0.296 3.45(1.89) 3.14(1 .65)
Humor 5.59(1.96) 1–9 −0.359 −0.496 5.82(1.91) 5.46(1.97)
Idealization 4.15(2.00) 1–9 0.211 −0.605 3.93(1.94) 4.26(2.00)
Isolation 3.93(2.17) 1–9 0.268 −0.946 4.07(2.07) 3.86(2.23)
Passive aggression 3.85(1.97) 1–9 0.328 −0.654 3.98(2.04) 3.78(1.92)
Projection 2.74(1.62) 1–9 0.096 0.779 2.86(1.78) 2.68(1.5 4)
Pseudo-altruism 4.27(1.85) 1–9 0.214 −0.491 4.25(1.85) 4.28(1.85)
Rationalization 5.15(1.68) 1–9 0.036 −0.442 5.20(1.69) 5.13(1.67)
Reaction formation 4.69(1.76) 1–9 0.274 −0.063 4.70(1.75) 4.69(1.76)
Somatization 3.79(2.11) 1–9 0.448 −0.558 3.31(1.87) 4.05(2.19)
Splitting 4.25(2.26) 1–9 0.303 −0.917 4.30(2.32) 4.22(2.23)
Sublimation 4.45(2.08) 1–9 0.160 −0.699 4.34(1.97) 4.50(2.13)
Suppression 4.34(1.87) 1–9 0.150 −0.528 4.72(1.93) 4.14(1.81)
Undoing 4.33(1.77) 1–9 0.048 −0.476 4.35(1.99) 4.32(1.64)
PID-5-BF total score 22.00(10.52) 0–58 0.318 −0.107 22.33(10.69) 21.83(10.46)
PID-5 -BF negative affectivity 6.91(3.31) 0–15 0.005 −0.638 5.96(3.39) 7.41(3.16)
PID-5-BF detachment 3.97(2.84) 0–13 0.631 −0.135 4.19(2.81) 3.86(2.85)
PID-5-BF antagonism 2.88(2.76) 0–14 1.07 1.13 3.56(3.21) 2. 52(2.42)
PID-5-BF disinhibition 4.41(2.90) 0–15 0.545 −0.068 4.67(2.76) 4.28(2.95)
PID-5-BF psychoticism 3.83(2.97) 0–13 0.594 −0.279 3.95(2.62) 3.77(3.14)
DSQ-40,DefenseStyleQuestionnaire-40;PID-5-BF,Personal ityInventoryforDSM-5-BriefFormAdult.
the eﬀects of sociodemographic variables on maladaptive
personality domains and DMs. Finally, stepwise regression
analyseswereperformedtoexamineifspeciﬁcDMscouldpredict
PID-5-BF total score and its domain scores, controlling for
sociodemographicvariables.
RESULTS
Descriptive Statistics and Group
Differences
In our sample, the defense patterns mean scores were in the
normalrange.ThesameappliedforPID-5-BFscores.Descriptiv e
statistics on the measures used in this study are reported in
Table1forthefullsampleanddiﬀerentiatedbygender.
A MANOVA showed that sociodemographic variables (age,
gender, and years of education) are signiﬁcantly associate d
with DM scores in the sample [intercept: Wilks’ lambda =
0.54,F(5,320)=13.25,p<0.001, partial η2=0.47]. However,multivariate tests showed that only age (partial η2=0.14,
p=0.001) had signiﬁcant main eﬀects in the model. Tests
of between-subject eﬀects showed that sublimation (partial
η2=0.04,p=0.006), humor (partial η2=0.04,p=
0.009), suppression (partial η2=0.03,p=0.029), idealization
(partial η2=0.02,p=0.047), and somatization (partial η2
=0.03,p=0.011) were signiﬁcantly associated with the factor
comprising the sociodemographic variables. The analysis of
the main eﬀects of the model variables on the DMs further
showed that male gender was linked to higher suppression
(partial η2=0.02,p=0.008), while female gender was
linked to higher somatization (partial η2=0.03,p=0.002);
younger age was linked to higher anticipation (partial η2=
0.01,p=0.043), higher autistic fantasy (partial η2=0.02,
p=0.020), and lower sublimation (partial η2=0.03,p=
0.002);higherlevelsofeducationwerelinkedwithhigherh umor
(partial η2=0.03,p=0.004) and higher idealization (partial
η2=0.01,p=0.045).
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TABLE 2 | Stepwise regression analyses predicting PID-5-BF Total sco re.
Predictors B 95.0% Conﬁdence interval for B T p
Lower bound Upper bound
Constant 9.79 6.07 13.52 5.17 0.000
Acting out 0.96 0.44 1.47 3.67 0.000
Autistic fantasy 1.04 0.58 1.49 4.52 0.000
Dissociation 0.64 0.05 1.23 2.12 0.035
Humor −0.63 −1.13 −0.13 −2.48 0.014
Isolation 1.34 0.88 1.79 5.78 0.000
Projection 0.79 0.12 1.45 2.34 0.020
Splitting 0.53 0.06 0.99 2.21 0.028
Suppression −0.88 −1.42 −0.35 −3.25 0.001
Model:F (8,319)=25.00,p <0.001;Durbin-Watson =1.77;R2=0.38
Another MANOVA showed that the eﬀect of
sociodemographic variables (age, gender, years of educatio n)
on maladaptive personality domains was signiﬁcant in the
sample [intercept: Wilks’ lambda =0.73,F(5, 320)=23.36,p<
0.001, partial η2=0.27]. Multivariate tests showed that gender
(partial η2=0.11,p<0.001),age(partial η2=0.08,p<0.001),
and years of education (partial η2=0.03,p=0.048) had all
signiﬁcant main eﬀects in the model. Tests of between-subjec t
eﬀects showed that negative aﬀectivity (partial η2=0.06,p<
0.001), antagonism (partial η2=0.03,p=0.014), disinhibition
(partial η2=0.03,p=0.010),anddetachment(partial η2=0.03,
p=0.024) were signiﬁcantly associated with sociodemographic
variables. In detail, male gender was signiﬁcantly related with
higher antagonism (partial η2=0.03,p=0.001), while female
gender was signiﬁcantly related with higher negative aﬀecti vity
(partial η2=0.04,p<0.001). Higher age was also linked
with lowered negative aﬀectivity (partial η2=0.01,p=0.046)
but higher detachment (partial η2=0.02,p=0.006). Lower
education was linked with higher disinibition (partial η2=0.02,
p=0.009).
Prediction of Maladaptive Personality
Scores
Aseriesofsixstepwiseregressionanalysiswereperformed.T hese
included the 20 DSQ-40 defenses mechanisms and the socio-
demographics characteristics of participants (gender, age, a nd
years of education) as potential predictors, and the PID-5-BF
totalanddomainscoresasdependentvariables.
In detail, a ﬁrst stepwise regression analysis was performed
to examine which DMs best predicted PID-5-BF total scores on
maladaptive personality (see Table2). A signiﬁcant regression
equation was found [ F(8, 319)=25.00,p<0.001], with R2of
0.38. Participants’ predicted PID-5-BF total scores is equal to
9.79 (costant) +0.96 (Acting out) +1.04 (Autistic fantasy) +
0.64 (Dissociation) −0.63 (Humor) +1.34 (Isolation) +0.79
(Projection) +0.53(Splitting) −0.88(Suppression).Participant’s
PID-5-BF total scores increased 0.96 score for greater use o f
actingout,1.04scoreforgreateruseofautisticfantasy,0 .64scoreforgreateruseofdissociation, −0.63scoreforlessuseofhumor,
1.34 score for greater use of isolation, 0.79 score greater u se of
projection,0.53scoreforgreateruseofsplitting,and −0.88score
forlessuseofsuppression.TheseDMsweresigniﬁcantpredictor s
ofPID-5-BFtotalscoresonmaladaptivepersonalitydomains.
A second stepwise regression analysis was calculated to
evaluatewhichDMsbestpredictedPID-5-BFnegativeaﬀectivit y
domain.Asigniﬁcantregressionequationwasfound[ F(10, 317)=
14.51,p<0.001], with R2of 0.31. Participants’ predicted PID-5-
BF negative aﬀectivity is equal to 2.01 (costant) +1.17 (gender),
where gender is coded as 1 for male and 2 for female, +0.30
(Acting out) +0.22 (Displacement) −0.23 (Humor) +0.31
(Isolation) +0.25 (Projection) +0.26 (Pseudo-altruism) +0.25
(Reactionformation), −0.28(Suppression) −0.02(ageinyears).
Participant’s PID-5-BF negative aﬀectivity domain thus
increased 0.30 score for greater use of acting out, 0.22 score
for greater use of displacement, −0.23 score for less use of
humor, 0.31 score for greater use of isolation, 0.25 score for
greater use of projection, 0.26 score for greater use of pseudo-
altruism, 0.25 score for greater use of reaction formation, −0.28
score for less use of suppression; moreover, females showed an
increasedscoreof1.17fornegativeaﬀectivity,andincreas einage
corresponded to a decrease of 0.02 in negative aﬀectivity scor es.
Acting out, displacement, humor, isolation, projection, pseud o-
altruism, reaction-formation, suppression, gender, and age were
allsigniﬁcantpredictorsofPID-5-BFnegativeaﬀectivitydo main
inthemodel(see Table3).
A third stepwise regression analysis was calculated to explor e
which DMs best predicted PID-5-BF detachment domain. A
signiﬁcant regression equation was found [ F(6, 321)=15.47,p
<0.001], with R2of 0.22. Participants’ predicted PID-5-BF
detachment is equal to 1.96 (costant) +0.04 (age in years) +
0.15 (Autistic fantasy) −0.20 (Humor) +0.37 (Isolation) +
0.29(Projection) −0.18(Reactionformation).Participant’sPID-
5-BF detachment personality domain increased 0.15 score for
greater use of autistic fantasy, −0.20 score for less use of humor,
0.37 score for greater use of isolation, 0.29 score for great er use
of projection, −0.18 score for less use of reaction formation;

moreover, increase in age corresponded to an increase of 0.04 in
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TABLE 3 | Stepwise regression analyses predicting PID-5-BF Negative affectivity domain.
Constant 2.01 0.02 3.99 1.99 0.047
Gender 1.17 0.53 1.82 3.56 0.000
Age −0.02 −0.05 0.000 −1.99 0.048
Acting out 0.30 0.14 0.46 3.67 0.000
Displacement 0.22 0.04 0.40 2.40 0.017
Humor −0.23 −0.40 −0.07 −2.77 0.006
Isolation 0.31 0.16 0.47 4.08 0.000
Projection 0.25 0.03 0.46 2.25 0.025
Pseudo-altruism 0.26 0.08 0.43 2.91 0.004
Reaction formation 0.25 0.07 0.44 2.73 0.007
Suppression −0.28 −0.46 −0.11 −3.20 0.001
ModelF (10,317)=14.51,p <0.001;Durbin-Watson =1.80;R2=0.31.
TABLE 4 | Stepwise regression analyses predicting PID-5-BF Detachme nt domain.
Constant 1.96 0.63 3.30 2.90 0.004
Age 0.04 0.01 0.06 3.35 0.001
Autistic fantasy 0.15 0.01 0.28 2.12 0.035
Humor −0.20 −0.34 −0.05 −2.71 0.007
Isolation 0.37 0.24 0.51 5.43 0.000
Projection 0.29 0.10 0.49 2.93 0.004
Reaction formation −0.18 −0.34 −0.02 −2.22 0.027
ModelF (6,321)=15.47,p <0.001;Durbin-Watson =2.02;R2=0.22.
detachmentscores.Autisticfantasy,humor,isolation,pro jection,
reaction formation, and age were all signiﬁcant predictors o f
PID-5-BFdetachmentdomain(see Table4).
Then, a fourth stepwise regression analysis was performed
to evaluate which DMs best predicted PID-5-BF antagonism
domain. A signiﬁcant regression equation was found [ F(8, 319)
=13.13,p<0.001], with R2of 0.25. Participants’ predicted
PID-5-BF antagonism is equal to 1.50 (costant) −0.94 (gender),
where gender is coded as 1 for male and 2 for female, +0.19
(Acting out) +0.28 (Autistic fantasy) +0.22 (Dissociation) −
0.17 (Idealization) +0.20 (Isolation) +0.26 (Pseudo-altruism) −
0.17 (Reaction formation). Participant’s PID-5-BF antagoni sm
personalitydomainincreased0.19scoreforgreateruseofac ting
out, 0.28 score for greater use of autistic fantasy, 0.22 sco re
for greater use of dissociation, −0.17 score for less use of
idealization, 0.20 score for greater use of isolation, 0.26 score
for greater use of pseudo-altruism, −0.17 score for less use of
reaction formation; moreover, males showed an increased sc ore
of1.17forantagonisms.Actingout,autisticfantasy,diss ociation,
idealization, isolation, pseudo-altruism, reaction forma tion, and
gender were all signiﬁcant predictors of PID-5-BF antagonis m
domain(see Table5).
Afterwards, a ﬁfth stepwise regression analysis was calculat ed
to examine which DMs best predicted PID-5-BF disinhibitiondomain. A signiﬁcant regression equation was found [ F(9, 318)
=14.01,p<0.001], with R2of 0.28. Participants’ predicted
PID-5-BF disinhibition is equal to 5.43 (costant) −0.03
(age in years) −0.13 (years of education) +0.42 (Acting
out)−0.44 (Anticipation) +0.25 (Autistic fantasy) −0.29
(Devaluation) +0.25 (Dissociation) +0.20 (Isolation) +
0.18 (Pseudo-altruism). Participant’s PID-5-BF disinhibit ion
personalitydomainincreased0.42scoreforgreateruseofact ing
out,−0.44scoreforlessuseofanticipation,0.25scoreforgreate r
use of autistic fantasy, −0.29 score for less use of devaluation,
0.25 score for greater use of dissociation, 0.20 score for gr eater
use of isolation, 0.18 score for greater use of pseudo-altruism ;
moreover,anincreaseinagecorrespondedtoadecreaseof0.0 3in
disinhibition scores, and an increase in education correspo nded
to a decrease of 0.13 in this domain of personality. All these
acting out, autistic fantasy, devaluation, dissociation, isolation,
pseudo-altruism, age, and years of education were all signiﬁ cant
predictorsofPID-5-BFdisinhibitiondomain(see Table6).
Finally, a stepwise regression analysis was performed to
evaluate which DMs best predicted PID-5-BF psychoticism
domain. A signiﬁcant regression equation was found [ F(2, 325)
=46.316,p<0.001], with R2of 0.22. Participants’ predicted
PID-5-BFpsychoticismisequalto0.93(costant) +0.44(Autistic
fantasy)+0.35 (Isolation). Participant’s PID-5-BF psychoticism
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TABLE 5 | Stepwise regression analyses predicting PID-5-BF Antagoni sm domain.
Constant 1.50 0.06 2.93 2.05 0.041
Gender −0.94 −1.50 −0.38 −3.29 0.001
Acting out 0.19 0.05 0.33 2.71 0.007
Autistic fantasy 0.28 0.15 0.40 4.43 0.000
Dissociation 0.22 0.06 0.38 2.70 0.007
Idealization −0.17 −0.32 −0.03 −2.35 0.020
Isolation 0.20 0.07 0.33 3.05 0.002
Pseudo-altruism 0.26 0.11 0.42 3.36 0.001
Reaction formation −0.17 −0.32 −0.01 −2.10 0.037
ModelF (8,319)=13.13,p <0.001;Durbin-Watson =1.91;R2=0.25.
TABLE 6 | Stepwise regression analyses predicting PID-5-BF disinhib ition domain.
Constant 5.43 3.49 7.37 5.51 0.000
Age −0.03 −0.05 −0.01 −2.60 0.010
Years of education −0.13 −0.22 −0.04 −2.83 0.005
Acting out −0.42 0.28 0.56 5.76 0.000
Anticipation −0.44 −0.62 −0.27 −5.03 0.000
Autistic fantasy 0.25 0.12 0.39 3.80 0.000
Devaluation −0.29 −0.47 −0.11 −3.24 0.001
Dissociation 0.25 0.09 0.42 2.97 0.003
Isolation 0.20 0.07 0.33 2.96 0.003
Pseudo-altruism 0.18 0.03 0.33 2.40 0.017
ModelF (9,318)=14.01,p <0.001;Durbin-Watson =1.92;R2=0.28.
TABLE 7 | Stepwise regression analyses predicting PID-5-BF Psychoti cism
domain.
Predictors B95.0% Conﬁdence interval for B T p
Constant 0.93 0.25 1.60 2.71 0.007
Autistic fantasy 0.44 0.31 0.57 6.73 0.000
Isolation 0.35 0.22 0.49 5.13 0.000
ModelF (2,325)=46.316,p <0.001;Durbin-Watson =1.68;R2=0.22.
personalitydomainincreased0.44scoreforgreateruseofau tistic
fantasy and 0.35 score for greater use of isolation. Both aut istic
fantasy and isolation were signiﬁcant predictors of PID-5-B F
psychoticismdomain(see Table7).
The present study was aimed at exploring the relationship
between DMs and maladaptive personality domains. Most of
participants in this study reported DM scores in the normal
range (Andrews et al., 1993; Farma and Cortinovis, 2000 ),
suggesting a generally adaptive defensive functioning, as i t was
expected for a nonclinical sample of adults. The more prevalentdefenses in the sample were sublimation, humor, anticipation,
suppression, reaction formation, and rationalization. Ther efore,
most participants relied on mature and neurotic defenses. This
general pattern of defensive functioning is characterized b y
generally mature attempts to: (a) reduce a sense of discomfort
or unpleasant aﬀections ﬁnding ironic elements in diﬃcult
situations (as in the case of humor); (b) to turn negative
emotions, impulses or thoughts in more positive and socially
acceptable behaviors (as in the case of sublimation); (c) to d efer
an immediate gratiﬁcation by anticipating and planning the
achievement of future goals (as in the case of anticipation); (d)
and to control, neutralize, or transform disturbing emotion al or
cognitive components (such as suppression, rationalization a nd
reactionformation).
We hypothesized to ﬁnd gender diﬀerences in DMs adopted
by participants. However, the present ﬁndings only partially
supported our hypothesis. Despite previous empirical evidence
(Cramer, 1987, 1991a,b, 2006; Vaillant, 1993; Hibbard and
Porcerelli, 1998 ) suggests that men and women rely on diﬀerent
DMs, we found that males and females adopted similar DMs
to protect themselves from experiencing excessive anxiety an d
psychological distress. In fact, the MANOVA examining the
eﬀect of sociodemographic variables on DM scores did not ﬁnd
a main eﬀect of gender on these scores. However, it should
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be noted that the analysis of between-subject eﬀects showed
a signiﬁcant gender diﬀerence in the use of mature defenses.
Males used the defense of suppression signiﬁcantly more than
females, indicating that in our study it was more likely for
males to consciously and deliberately pushing down thoughts ,
desires, urges, and actions that leads to feelings of anxiet y, in
order to cope with disturbing situations. Moreover, although
previous research ( Petraglia et al., 2009 ) has highlighted that
males use more externalizing defenses than females, who ten d
instead to rely on internalizing defenses, our ﬁndings show ed
that women adopted similar externalizing defenses with respe ct
to men. However, females reported greater use of somatizatio n.
Somatization allows the individuals to unconsciously avoid
painful feelings in their mind and to experience them in form
of physical discomfort and symptoms, and it represents an
internalizing DM par excellence (Freud, 1896 ). In this DM, the
bodyistheplaceinwhichtheinternalconﬂictexpressesitsel f,so
that it becomes the “theater” of cognitively unprocessed fee lings
(McDougall, 1989; Granieri, 2011; Barbasio and Granieri, 20 13;
GranieriandSchimmenti,2014;Barbasioetal.,2015;Giova nnelli
et al., 2016 ). This ﬁnding is in line with the previous research
that observed somatization as far more common in women
(Lipowski, 1988; van Wijk and Kolk, 1997; Hyphantis et al.,
2013a,b). As expected within a theoretical framework informed
by psychoanalytic research on the use of speciﬁc DMs and how
theyreﬂectthedevelopmentallevelofindividuals( Vaillant,1993;
McWilliams,2011 ),ageand,atalesserdegree,yearsofeducation,
alsoassociatedwithhowtheDMswereusedamongparticipants.
Also, as expected in a nonclinical sample, the average scores
of the PID-5-BF total and domain scores were in the normal
range,generallyindicatingagoodoverallpersonalityfunc tioning
for the majority of the participants ( Krueger et al., 2012; Fossati
et al., 2013, 2015, 2017; Gervasi et al., 2017 ). However, we
found signiﬁcant gender diﬀerences with respect to the PID-
5-BF maladaptive personality domains. Speciﬁcally, we found
that women showed higher scores on negative aﬀectivity than
males.Thisﬁndingisinlinewithresearchusingothermeasu res,
in which it is commonly observed a higher prevalence of
depression,anxiety,andneuroticismamongwomen( Parkerand
Brotchie, 2010; Van de Velde et al., 2010; Weisberg et al., 20 11;
Lehmann et al., 2013; Langvik et al., 2016 ). In contrast, males
displayed higher scores on antagonism than females. This res ult
is consistent with many studies, including South et al.’s (2016)
study, in which a clear evidence for higher antagonism among
malesemerged.
Stepwise regression analyses generally provided support for
the hypothesis that immature defenses would predict higher
scoresonmaladaptivepersonalitydomains.Thisgeneralﬁndi ng
is perfectly in line with theoretical models, highlighting th at
defensestylecanberegardedasanenduringaspectofpersonal ity,
in which its mature components facilitate good adjustment an d
mental health, while its neurotic and immature components
promote psychopathology ( Kernberg, 1967, 1970, 1975, 1984;
Vaillant, 1977; McWilliams, 2011 ). In fact, the regression model
predicting PID-5-BF total scores included an increased used of
immature (acting out, autistic fantasy, isolation, dissoc iation,
projection, and splitting) as positive predictors, whereas mat uredefenses (humor and suppression) were negative predictors of
PID-5-BFscoresinthemodel.So,immatureandmaturedefense s
played an opposite role in our study, with mature defenses
reducing maladaptive personality traits, and immature defen ses
increasing them. Therefore, our ﬁnding supports other resear ch
in showing that an increased use of immature defenses and a
reduced use of mature defenses have a negative impact on the
developmentofpersonality.
For what concerns negative aﬀectivity, our study showed
that this maladaptive personality domain was related to femal e
gender and younger age, but it was also predicted by an
increased use of reaction formation, pseudo-altruism, isola tion,
displacement, projection, and acting out, along with a reduced
use of humor and suppression. According to the alternative
DSM-5 model for personality disorders, negative aﬀectivity
is characterized by personality facets such as anxiousness,
emotional lability, hostility, perseveration, lack of rest ricted
aﬀectivity, separation insecurity, and submissiveness ( Krueger
et al., 2012 ). Several studies (for a review, see Al-Dajani
et al., 2016 ) had shown positive associations between negative
aﬀectivity and avoidant, schizotypal, borderline, and obsess ive-
compulsive personality disorders. In this sense, it is not
surprising that reaction formation, pseudo-altruism, isolat ion,
displacement, and projection were signiﬁcant predictor of

this maladaptive domain of personality. Reaction formation
can be often observed in avoidant and obsessive-compulsive
personalities ( Fairbairn, 1954; Shapiro, 1965; Gabbard and
Newman, 2005; McWilliams, 2011 ) as a pathognomic defense
against negative and unacceptable emotions, feelings, thoug hts
(such as anger, sense of dependence). It allows to deny
ambivalence, to control and to transform disturbing emotion al
or cognitive components into the opposite polarity to make it
less threatening. So, it can be hypothesized that an increase d use
ofreactionformationwasrelatedtothetendencyofparticipa nts
withincreasednegativeaﬀectivitytodenyfeelingsofdepend ence
and to try showing greater autonomy; moreover, they may
strive to acquire full control over anger by showing them
obedient and obsequious. In this context, pseudo-altruism wa s
another signiﬁcant and positive predictor of negative aﬀectivi ty.
An intriguing hypothesis could be that displaying apparently
altruistic and prosocial attitudes might represents an attem pt to
obtain approval and support from others in people displaying
high levels of negative aﬀectivity. Isolation may add to this
picture, as it allows individual to manage anxiety and other
painful mental states by separating the aﬀective features of an
experience or idea from its cognitive dimension. Furthermor e,
displacement and projection of impulses, emotions, worries,
behaviors, and inner aspects of the self may help people high
in negative aﬀectivity to defend themselves from overwhelmin g
feelings that are unconsciounsly perceived as potentially
disorganizing. In this context as discussed by several scho lars
(e.g.,Kernberg,1967,1975;Andrulonis,1991;Gunderson,2001 ),
acting out represents a central DM in borderline personality,
indicating a tendency to an immediate discharge of feelings or
impulses for the inability to endure them and to reﬂect on the
painful circumstances that determined them. In addition, th e
reduced use of humor and conscious suppression may further
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reinforce the presence of negative feelings and the diﬃculty to
dealwiththem.
Regression analyses further showed that older age, higher
levels of autistic fantasy, isolation, and projection and lo wer
levels of humor and reaction formation predicted detachment
scores. The personality domain of detachment seems to be
associated with avoidant, obsessive-compulsive, and schiz otypal
personalitydisorders(see Al-Dajanietal.,2016 ),anditexpresses
personality facets such as anhedonia, depressivity, intimac y
avoidance, suspiciousness, withdrawal. In this sense, it is not
surprising that autistic fantasy was a signiﬁcant predictor o f
thismaladaptivedomainofpersonality.Psychoanalyticlite rature
(e.g.,Guntrip, 1952, 1961; Fairbairn, 1954; Eigen, 1973 ) suggests
that autistic fantasy represents the pathognomic defense of t he
schizoid personality organization against a conﬂict betwee n the
desire to get in touch with others and the fear of being engulf ed
and overwhelmed by others, which often leads these individu als
tosocialwithdrawal.Thus,autisticfantasymayhelppeoplehi gh
in detachment to defend themselves from other people who
could be perceived as overly controlling and invading. In thi s
context, the reduced use of reaction formation could indica te a
lower tendency of these individuals to deny ambivalence. Th e
role of isolation in predicting detachment among participants
is in line with the psychoanalytic literature, which suggest s
that isolation is among the organizing defenses of obsessiv e-
compulsive individuals ( Fenichel, 1928 ). It is recognized that
these people overestimate mental and cognitive activity and
avoid emotionally charged situations for fear of losing con trol
and being vulnerable ( Shapiro, 1965 ). Also, projection emerged
as signiﬁcant predictor of detachment. Projection concerns a
wronglyattributionofone’sownunrecognizedimpulses,feel ings
and thoughts to others, so that the individual can avoid to de al
with internal experiences that could make him or her too feel
excessively vulnerable. From a psychodynamic point of view,
it is possible to hypothesize that increased scores on isolati on
and projection may help people high in detachment to defend
themselves from unconscious feelings of shame and inadequa cy.
These feelings are likely related to their substantial lack of
relatedness( SchimmentiandCaretti,2016 ),andthereduceduse
ofhumormightfurtherincrease,inaviciouscircle,theint ensity
ofsuchunconsciousfeelings.
Together with male gender, a combination of higher levels
of isolation, dissociation, autistic fantasy, pseudo-altr uism, and
actingout,andlowerlevelsofidealizationandreactionfo rmation
predicted antagonism scores. Antagonism includes personali ty
facets such as attention seeking, callousness, deceitfuln ess,
grandiosity, manipulativeness ( Krueger et al., 2012 ), and it was
foundtobeassociatedwithantisocialandnarcissisticpers onality
disorders( Al-Dajanietal.,2016 ).Accordingto Kernberg(1975) ,
a grandiose self is present in these personalities, which can
be conceptualized as a defense against investment in others
and dependence on others. The “pseudo-self-suﬃciency” may
allow individuals with increased antagonism traits to deny
any need for care and love, and to defensively exclude from
consciousness disturbing feelings such as anger and resent ment
toward a needed but frustrating or rejecting ﬁgure, which mi ght
explain the role of isolation and dissociation in predicting t heantagonism domain scores. Autistic fantasy also resulted as a
signiﬁcant predictor in the regression model, suggesting th e
general tendency of individuals with antagonistic traits t o do
not engage emotionally with other people. Also, acting out
emerged as a signiﬁcant predictor in the regression model,
indicating the tendency of people with high antagonism to act
in potentially aggressive and destructive ways toward other s and
even themselves. These considerations might also explain the
increaseduseofpseudo-altruisminpeoplewithhigherscoreson
antagonism: an intriguing hypothesis could be that some people
high in antagonism show a facade of altruistic and prosocial
attitude, as they are apparently oriented toward others’ well-
being;however,itispossiblethatthisfacadehidesaverydiﬀe rent
attitude, so that desires for power are enacted by unconsciou sly
forcing other people to feel submissive and obliged toward the
antagonistic individual. In line with this interpretation, i t is not
surprising that people high in antagonism display decreased use
of idealization. This highlights their lower investment in values
andcapabilitiesofothers.Inaddition,thereduceduseofrea ction
formation could indicate a lower tendency of these individu als
to feel guilt and to repair potential damage that they inﬂicted t o
others.
Regressionanalysesshowedthatyoungerageandlowerlevels
ofeducationpredicteddisinhibitionscores.Thisdomainin cludes

others.
speciﬁc personality facets such as distractibility, impulsivity ,
irresponsibility, lack of rigid perfectionism, and risk takin g
(Krueger et al., 2012 ) and it was found to be associated with
antisocial and borderline personality disorders ( Al-Dajani et al.,
2016). The ﬁndings on the role of socio-demographic variables
inantagonismareconsistentwithempiricalresearchandclin ical
interpretations (e.g., Arnsten and Casey, 2011; Charnigo et al.,
2013; Klimstra et al., 2014 ) suggesting that a tendency to act
impulsively is related to younger age, when the pre-frontal
cortex is not totally mature and behavioral and mental state s
are not fully integrated into a consistent sense of self, and to
lower education that reduce the possibility to use symbols and
wordstoresolvetheinternalconﬂicts( Schimmenti,2016 ).Along
with the role of sociodemographic variables, higher levels o f
acting out, dissociation, isolation, autistic fantasy, an d pseudo-
altruism, and lower levels of devaluation and anticipation, were
found as signiﬁcant predictors of disinhibition scores in the
sample.Thepredictorsinthismodelﬁtverywellwith Kernberg’s
(1975)earlydescriptionsofnarcissistic,borderline,andantisocia l
personalities. Speciﬁcally, acting out is considered one of th e
most representative modalities of the borderline functioni ng.
So, it is plausible that people with high levels of disinhibition
may act impulsively due to their diﬃculty integrating interna l
representations,reﬂectingonexperience,andverbalizingf eelings
when they face stress and disturbing emotions ( Clarkin et al.,
2007). Indeed, Freud (1901, 1914) had earlier speciﬁed that
acting out was a repetitive impulsive behavior acted upon
by the individual for a diﬃculty in communicating. Also,
dissociation emerged as signiﬁcant predictor, suggesting t he
possible lack of the sense of continuity in the areas of
identity, memory, conscience, or perception among participant s
with high disinhibition. This defensive mechanism may allow
to keep the illusion of psychological control when in front
Frontiers in Psychology | www.frontiersin.org 9 November 2017 | Volume 8 | Article 1926

of overwhelming mental states, such as hopelessness, hatred
feelings, and loss of control. In this respect, psychoanalyti c
literature (e.g., Bromberg, 1998; Schimmenti, 2016; Schimmenti
and Caretti, 2016 ) suggests that dissociation may paradoxically
protect the individuals from a fragmentation of the self thro ugh
multiple disconnections in the self. Likewise, isolation re sulted
as a signiﬁcant predictor in our sample, consistent with the
tendency of people with high disinhibition to exclude painful
feelings (such as anxiety, shame, guilt) associated with spe ciﬁc
events or memories from consciousness. Moreover, autistic
fantasy resulted as a signiﬁcant predictor of disinhibition
scores. This might result from the tendency of people with
high disinhibition to do not engage emotionally with others ,
preferring to focus on their personal wishes and needs, and
to act on the basis of such internal experiences. Moreover,
surprisingly and somewhat counterintuitively, higher leve ls of
pseudo-altruism and lower levels of devaluation added to the
predictive model of disinhibition. Increased use of pseudo-
altruism could suggest that altruistic behaviors in people hig h
in disinhibition may serve to generate intense, albeit vola tile,
relationships that may help these individuals to satisfy perso nal
needs. Likewise, a reduced use of devaluation could indicat e a
tendency to value others as they can support the disinhibited
individual and provide help to him or her when needed. Finally ,
it is not surprising that the reduced use of anticipation was
found as a signiﬁcant predictor in the predictive model of
antagonism. People who are impulsive, irresponsible, and prone
to risky behaviors usually display considerable inability t o delay
gratiﬁcationandtoanticipateandplantheachievementoffut ure
goals(e.g., WhitesideandLynam,2001 ).
Higher levels of isolation and autistic fantasy predicted
psychoticism scores. This domain includes personality facet s
such as eccentricity, cognitive perceptual dysregulation, u nusual
beliefs and experiences ( Krueger et al., 2012 ), and it was found
to be associated with borderline and schizotypal personality
disorders ( Al-Dajani et al., 2016 ). This pattern of defense may
reﬂect the diﬃculty of people who report high psychoticism
to eﬀectively deal with emotional conﬂicts ( Schimmenti et al.,
2017),whichmightleadthemtocompartmentalizetheemotionalaspects of the experience. This condition may imply a tendency
toexcludethepainfulfeelingsfromtheircorrespondentcogn itive
representations (as expressed by increased isolation), and t o be
absorbed in excessive fantasies as an unconscious strategy to
avoid such painful feelings (as expressed by increased autist ic
fantasy).
In conclusion, our study supports the general hypothesis
that maladaptive personality traits are modulated by dominan t
defense patterns. However, as with every research our study
comes with a number of limitations. The study involved only
adult volunteers from an Italian isle, which strongly limit s the
generalizability of our results. Studies on community-dwell ing
individuals from diﬀerent cultures and studies with clinical
samples are greatly needed to develop this line of research, an d
eﬀorts directed toward longitudinal research could also oﬀer
valuable contribution to better understand the role of DMs in
normal and abnormal personality. Also, although the measures
used in this study have displayed adequate psychometric
properties in worldwide research, it is to be acknowledged
that we collected the information by means of self-report
measures,whicharesusceptibleofsocialdesirabilityandc ultural
bias.
However, our cross-sectional ﬁndings support the
psychoanalytic consideration that a correct identiﬁcation of
defense patterns is critical for personality assessment, and
may be particularly informative for psychotherapy work with
individuals who display high levels in one or more maladaptive
personalitydomains.
AUTHOR CONTRIBUTIONS
AS designed the study. LL, SG, and GM were responsible for
data collection. SG, GM, and FG conducted literature searche s,
and provided summaries of previous studies. LL, FG, and AS
conductedthestatisticalanalysis.LLandAGwrotetheﬁrst draft
of the article. AS and AG contributed with relevant theoreti cal
andclinicalinputsandwereresponsibleforsubsequentcolla tion
of inputs and redrafting. All authors critically revised the
manuscriptandapproveditsﬁnalversion.
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Attachment ‐style differences in
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Laura K. Guerrero a
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Attachment-Style Differences in Intimacy and
Involvement: A Test of the Four-Category Model
Laura K. Guerrero
This study tested the hypothesis that individuals with different attachment styles vary in the
degree to which they display intimacy and nonverbal involvement to their romantic partners.
Eighty dyads currently involved in enduring romantic relationships participated in an
observational study, with one partner from each dyad representing one of Bartholomew's
(1990) four attachment styles. A team of coders viewed videotapes of the dyads' conversations
and rated the degree of intimacy and involvement exhibited. Preoccupieds and Secures
surpassed Dismissives and Fearful Avoidants on measures of trust/receptivity, gaze, facial
pleasantness, vocal pleasantness, general interest, and attentiveness. Preoccupieds engaged in
more in-depth conversation than Dismissives. Fearful Avoidants sat farthest from their
partners and displayed the least fluency and longest response latencies. Finally, Preoccupieds
and Fearful Avoidants were the most vocally anxious. These findings, which provide
preliminary behavioral validation of Bartholomew's four-category model of attachment, are
interpreted in light of the dimensions underlying attachment styles and the principle that
communication reinforces mental models of self and others. Key words: Attachment
Style, Intimacy, Involvement
Attachment Theory (AT) provides a rich theoretical framework for the study of
interpersonal interaction in close relationships. Among the many themes
embraced by researchers studying relational communication, some of the most
widely studied include approach versus avoidance orientations (e.g., Andersen,
1985; Burgoon, Stern, & Dillman, 1995; Markus-Kaplan & Kaplan, 1984), dialectical
tension between autonomy and connectedness (e.g., Baxter, 1988; 1990; Markus-
Kaplan & Kaplan, 1984); commitment (e.g.Johnson, 1991; Kelley, 1983; Rusbult &
Buunk, 1993); and needs for privacy and space (Altman, Vinsel, & Brown, 1981;
Burgoon, 1982; Burgoon, Parrott, et al., 1989; Petronio, 1991). AT encompasses
these relational themes, supplies an explanatory framework for how individuals
develop and maintain relationship orientations, and focuses on: (a) the process of
forming an attachment and becoming close to others; (b) the mental working models
that guide this process; and (c) the resultant attachment styles that individuals
develop to maintain the type of relationship they desire. An attachment style is
manifest in social interaction and includes one's own communication, the way the
person processes and interprets others' behavior, and the way he or she reacts to
others' behavior (Bartholomew, 1990; Scher & Mayseless, 1994).
A primary dimension underlying attachment styles is intimacy/avoidance. Accord-
ing to AT, those having positive models of others display communication styles
reflecting intimacy, whereas those having negative models of others exhibit commu-
nication styles reflecting avoidance and detachment. AT also predicts that attach-
ment styles reinforce the mental models or images people have of themselves and
others (Bartholomew, 1993). Bartholomew (1993) notes that interaction patterns
Laura Guerrero is Assistant Professor of Communication at Arizona State University. This study is part of a
Ph.D. dissertation completed in the Department of Communication at the University of Arizona. The author
thanks her dissertation advisor, Judee Burgoon, fir her guidance and insight during all phases of this project
and Dan Canary for his helpful comments on an earlier draft of this paper. This research was partially funded
by an Army Research Office ASSERT Grant (#30235-RT-AAS). A version of this paper was presented at the
1995 meeting of the Speech Communication Association in San Antonio, TX.
COMMUNICATION MONOGRAPHS, Volume 63, December 1996
Downloaded by [Central Michigan University] at 09:15 21 December 2014

270 COMMUNICATION MONOGRAPHS
may "set into action self-fulfilling interpersonal patterns" (pp. 54-55). Similarly,
Collins and Read (1994) argue that individuals adopt interaction styles that "create
social environments," which, in turn, perpetuate expected outcomes and reinforce
mental models (p. 80).
Despite the central role of interpersonal communication in AT, research on
attachment in romantic relationships traditionally has been concerned with emo-
tional outcomes and relationship quality indicators, such as anxiety, commitment,
emotional dependency, loneliness, relational satisfaction, and attitudes about love
and romance (e.g., Carnelley &Janoff-Bulman, 1992; Collins & Read, 1990; Feeney
& Noller, 1990, 1991; Hazan & Shaver, 1987, 1990; Kirkpatrick & Davis, 1994;
Kobak & Hazan, 1991; Levy & Davis, 1988; Senchak & Leonard, 1992; Simpson,
1990). These findings show that those with positive models of self and others have
realistic relational expectations and are generally satisfied with their relationships.
Recently, researchers have begun paying increased attention to communication
patterns characterizing attachment styles and examining behavioral as well as
perceptual differences among the styles. Attachment-style differences have been
found for several communication variables, including: conflict management style
(Levy & Davis, 1988; Pistole, 1989), maintenance behaviors (Simon & Baxter, 1993),
openness and self-disclosure (Collins & Read, 1990; Feeney & Noller, 1991; Miku-
lincer & Nachshon, 1991), problem-solving (Kobak, Cole, Ferenz-Gillies, Fleming,
& Gamble, 1993; Kobak & Hazan, 1991), and support-seeking and support-giving
behavior (Simpson, Rholes, & Nelligan, 1992). Feeney, Noller, and Callan (1994)
propose that attachment-style differences in communication may partially, but
nonetheless substantially, account for attachment-style differences in relational
satisfaction.
According to Bartholomew's (1990) four-category model, attachment-style differ-
ences in communication should reflect the mental models people have of themselves
and others. Those who view relationships and relational partners negatively should
engage in less behavior reflecting intimacy than those with positive views of
relationships. In addition, those who have negative models of themselves should
display communication reflecting less confidence and more anxiety than those who
view themselves positively. Despite these straightforward predictions, no previous
study has used behavioral data to test these hypotheses. This study provides a formal
test of Bartholomew's model by using observational data to corroborate self-report
findings on attachment-style differences in behavior reflecting intimacy and involve-
ment. Nonverbal messages, because they are often spontaneous, convey emotion,
and tend to leak anxiety and discomfort, are especially likely to be relevant to
attachment styles, and, thus, were the primary focus of this study.
The Four-Category Model of Attachment
Bartholomew (1990) extended previous work on attachment styles (see Ains-
worth, Blehar, Waters, & Wall, 1978; Hazan & Shaver, 1987; Main, 1981; Main &
Goldwyn, 1988) by positing a four-category model of attachment based on mental
models of self and others. Mental models can be thought of as generalized schemata
or internal representations of both oneself and potential relational partners. These
models reflect an individual's past experiences in close relationships (Bowlby, 1973;
Bretherton, 1990; Collins & Read, 1994) and fall along a positive-negative con-
tinuum. A positive self model is "an internalized sense of self-worth that is not

Positive Model
of Others
Negative Model
of OthersATTACHMENT AND INTIMACY 271
Positive Model Negative Model
of Self of Self
Secures
* comfortable with intimacy
* confident and self-sufficient
* holds positive expectations
about relationships
Dismissives
* uncomfortable with intimacy
* compulsively self-reliant
* views relationships as
nonessentialPreoccupieds
* craves excessive intimacy
* lacks confidence
* looks to relationships to
fulfill dependency needs
Fearful Avoidants
* fears intimacy
* would like closer relation-
ships but fears rejection
FIGURE 1.
BARTHOLOMEW'S (1990) FOUR-CATEGORY ATTACHMENT STYLE SYSTEM
dependent on ongoing external validation" (Bartholomew, 1993, p. 40). Individuals
with positive self models view themselves as self-sufficient, secure, and lovable.
Conversely, those with negative self-models see themselves as dependent, insecure,
and unworthy of love and affection. Positive models of others reflect expectations
concerning how supportive, receptive, and accepting others are and how rewarding
it is to participate with others in intimate relationships. Individuals with positive
mental models of others see relationships as worthwhile and possess approach
orientations toward intimacy, whereas individuals with negative mental models of
others see relationships as relatively unrewarding and have avoidant orientations
toward intimacy.
Bartholomew (1990) crossed the self-model dimension with the other-model
dimension to form four quadrants representing distinct attachment styles (see Figure
1). Two of the four styles, Preoccupied and Fearful Avoidant, reflect low levels of
self-sufficiency and high needs for external self-validation (Bartholomew, 1993).
Similarly, two of the four styles, Dismissive and Fearful Avoidant, reflect negative
perceptions of relationships and relational partners. Given the prominence of these
two dimensions (i.e., models of self and others) in AT, most of the predictions in the
present study compare styles representing positive versus negative models of self or
others. Continuous measures of attachment-style dimensions are also provided as
supplementary analyses. These include measures of the two primary dimensions, as
well as measures associated with preoccupation, fearful avoidance, and dismissive-
ness. I describe the four specific attachment styles in more detail below.

272 COMMUNICATION MONOGRAPHS
The secure style
Secures are likely to have high levels of self-esteem and a capacity for intimate and
satisfying personal relationships. They are comfortable depending on others and
letting others depend upon them (Hazan & Shaver, 1987). Their communication
should reflect a positive view of others and lead to a generally friendly, affiliative
style of social interaction. Moreover, they are likely to be flexible and show an ability
to adapt to various situations and relational partners (Bartholomew, 1993). Bartho-
lomew (1990) describes Secures as the least likely of the four styles to encounter
"serious interpersonal problems" (p. 163).
The preoccupied style
Preoccupieds are likely to be highly affiliative but less flexible than their secure
counterparts. Bartholomew (1990) argues that Preoccupieds possess low levels of
self-esteem and are overly dependent on their relational partners. This dependence
stems from a strong need to gain the approval of others and bolster esteem. Without
a close relationship, Preoccupieds report feeling lost, unloved, and unable to cope.
They are likely "to reach out to others in an attempt to fulfill dependency needs"
(Bartholomew, 1990, p. 165), to cling to relationships once they are established, and
to resist partner attempts to de-escalate or terminate their close relationships. These
strong needs for affiliation and external validation lead to affiliative and overin-
volved communication styles (Feeney & Noller, 1991).
The fearful avoidant style
Fearful Avoidants must contend with incompatible feelings and desires. They seek
external validation and relational intimacy but distrust others and fear rejection
(Bartholomew, 1990). These opposing tensions stem from the negative models they
have of themselves and others. They view themselves as unlovable and see others as
unaccepting. Ironically, by refusing to take risks and make themselves vulnerable to
others, they undermine their chances for building the kind of trusting, intimate
relationship that would allay their fears. Fearful Avoidants' communication styles
should reflect a pervasive tendency to avoid social situations as a result of high
anxiety and fear of rejection. Even when they do become involved in relationships,
they are likely to be reticent and passive and to avoid communicating intimacy or
conveying emotion.
The dismissive style
Whereas Fearful Avoidants desire close attachments but avoid them, Dismissives
neither desire nor fear close attachments. Instead, Dismissives are unmotivatedwhen
it comes to initiating or maintaining intimate relationships (Bartholomew, 1990).
Bartholomew (1990) suggests that Dismissives maintain a model of self as so
self-sufficient that relationships are unnecessary. Their self-sufficiency also works as a
barrier to protect them from any negative feelings that might result from activation
of the attachment system. Dismissives often focus their attention on work, hobbies,
self-improvement, or other activities that do not involve relationships (Bartho-
lomew, 1990; Feeney, Noller, & Hanrahan, 1994). Their communicative behavior is
likely to be characterized by intimacy avoidance and low levels of disclosure. In
contrast to Fearful Avoidants, they are unlikely to display passivity or anxiety.

ATTACHMENT AND INTIMACY 273
It is easy to see how these styles might contribute to the reinforcement effect
discussed in AT. For example, if Dismissives engage in distancing behaviors and
learn to become self-sufficient and content without close relationships, they reinforce
their positive image of self and their relatively negative images of others. Fearful
Avoidants, paradoxically, withdraw and avoid taking risks-a pattern that keeps
them isolated, precludes their developing and refining social skills, and prevents
them from finding the security and intimacy they desire. Preoccupieds, who are
typically overinvolved and try to escalate relationships quickly, are likely to encoun-
ter resistance by their partners, which reinforces the notion that others do not care
for them as much as they would like. Finally, Secures engage in the most flexible and
socially appropriate communication patterns. Secures' communication should elicit
positive reactions from their partners. These positive reactions reinforce Secures'
positive attitudes toward self and others.
Attachment-Style Differences in Intimacy
and Nonverbal Involvement
Relational Messages of Intimacy
If Bartholomew's (1990) four-category model is valid, and if communication
differences are indeed partially responsible for the reinforcement effect noted above,
individuals with different attachment styles should vary in their behavioral displays
of intimacy and nonverbal involvement. Three relational messages that reflect
intimacy (see Burgoon & Hale, 1984, 1987)-depth, immediacy/affection, and recep-
tivity/trust-are particularly likely to differ as a function of attachment style. Because
Fearful Avoidants and Dismissives have negative expectations of others (as rejecting
or nonessential, respectively) and are uncomfortable with intimacy, their self-
disclosure tends to be inhibited (Bartholomew & Horowitz, 1991; Bartholomew &
Scharfe, 1993; Mikulincer & Nachshon, 1991). Conversely, both Preoccupieds and
Secures tend to be self-disclosive, but Preoccupieds may be even more so (Bartho-
lomew & Horowitz, 1991 ; Mikulincer & Nachshon, 1991).
Messages of immediacy/affection and receptivity/trust may also differ as a func-
tion of attachment style. Bartholomew (1990) contended that because of the negative
perceptions they hold of others and because of dieir discomfort with physical
closeness, Fearful Avoidants and Dismissives are likely to engage in less affiliative
behavior than are Secures and Preoccupieds. Fearful Avoidants are likely to avoid
intimacy to minimize rejection, whereas Dismissives are likely to avoid intimacy to
maximize autonomy. Preoccupieds and Secures, on the other hand, are likely to
exhibit affiliative behaviors because of their propensity to seek and maintain
intimacy. Those with positive mental models of others may also appear to be more
receptive and trusting (Hazan & Shaver, 1987). Indeed, one of the features that
distinguishes Fearful Avoidants and Dismissives from Secures is the former groups
hesitancy to trust others (Bartholomew, 1990; Feeney, Noller, & Hanrahan, 1994;
Hazan & Shaver, 1987). In light of these theoretical considerations, Hypothesis 1
provides a formal test of the connection between mental models of others and
behavioral displays of intimacy:
HI: Preoccupieds and Secures convey stronger relational messages of (a) depth, (b) immediacy/
affection, and (c) receptivity/trust than Fearful Avoidants and Dismissives.

274 COMMUNICATION MONOGRAPHS
Involvement and Positive Affect
Mental models are also likely to be related to a number of behaviors that show
nonverbal involvement. Involvement cues signal attention and demonstrate that a
conversation interests the interactant. The degree of nonverbal involvement an
individual displays can be thought of as falling along an engagement-detachment (or
approach-avoidance) continuum.
Involvement is communicated by behaviors reflecting immediacy, expressive-
ness, smooth interaction management, altercentrism, and moderately low social
anxiety (Burgoon, 1994; Burgoon, & Newton, 1991; Coker & Burgoon, 1987;
Spitzberg & Hecht, 1984). Nonverbal immediacy cues signal psychological and/or
physical closeness (Andersen, 1985) and are distinct from the other involvement
cues in their focus on proxemics. Mehrabian (1969) and Patterson (1983) classified
gaze, direct body orientation, forward leans, close proxemic distancing, and touch as
immediacy behaviors. Nonverbal expressiveness refers to the level of animation and
dynamism one communicates (Cappella, 1983; Coker & Burgoon, 1987; Spitzberg
& Hecht, 1984). Vocal, facial, and gestural animation indicate a high level of
expressiveness (Burgoon & Newton, 1991). Short response latencies, greater fluency,
and a high degree of coordination in body movements indicate smooth interaction
management. Altercentrism refers to the degree to which an individual focuses on the
conversational partner. Coker and Burgoon (1987) suggested thatkinesic, proxemic,
and vocalic patterns combine to create perceptions of alertness, attention, focus, and
interest, all of which are relevant to altercentrism. Social anxiety is the tension or
arousal that individuals feel during social interaction. Moderately low levels of social
anxiety that convey excitement, attention, and the absence of nervousness are
associated with involvement (Coker & Burgoon, 1987).
Burgoon (1994) argued that positive affect is a sixth component that is relevant to
involvement. When involvement behaviors are accompanied by positive affect cues
(e.g., smiling and/or a warm voice), intimacy and affiliation are likely conveyed. In
contrast, if involvement behaviors are combined with negative affect cues, hostility is
the likely message.
Available evidence suggests that Secures and Preoccupieds display greater imme-
diacy, positive affect, expressiveness, and altercentrism as a result of their affiliative
interaction styles and approach orientations. They report being more comfortable
with closeness (Feeney, Noller, & Hanrahan, 1994) and more sociable (Bartholomew
& Horowitz, 1991) than Fearful Avoidants or Dismissives. Secures and Preoccupieds
also report using more touch and closer proxemic distancing (Kunce & Shaver,
1994) and being more socially and emotionally expressive (Guerrero, 1996) than
Fearful Avoidants and Dismissives, but these findings have yet to be corroborated
with behavioral data. Nevertheless, the findings suggest that positive models of
others lead Secures and Preoccupieds to be more expressive, trusting, other-
directed, and affiliative than Fearful Avoidants and Dismissives. Those with positive
models of others also find social interaction more interesting and enjoyable than do
those holding negative models of others (Bartholomew & Horowitz, 1991).
Research findings from studies of children support these characterizations. Chil-
dren with avoidant attachment styles are less empathetic, less expressive, less
friendly, and less likely to display positive affect when communicating with others
than are children with other attachment styles (Erickson, Sroufe, & Egeland, 1985;
Lieberman, 1977; Matas, Arend, & Sroufe, 1978; Sroufe, 1983; Waters, Wippman, &

ATTACHMENT AND INTIMACY 275
Sroufe, 1979). Hypothesis 2 predicts similar patterns for adults in romantic relation-
ships:
H2: Preoccupieds and Secures display greater (a) immediacy, (b) positive affect, (c) expressive-
ness, and (d) altercentrism than do Dismissives and Fearful Avoidants.
Social anxiety is also likely to differ as a function of attachment style. Both Fearful
Avoidants and Preoccupieds worry that their partners will not approve of or accept
them. Fearful Avoidants worry about being rejected; Preoccupieds worry that their
partners do not care for them enough and may eventually leave them. These worries
may manifest themselves in the degree of social anxiety evident in interactions. In
contrast, Secures and Dismissives should be more comfortable and less anxious
when interacting with others. Thus:
H3: Fearful Avoidants and Preoccupieds convey greater social anxiety than Secures and Dismiss-
îves.
Fearful Avoidants are likely to withdraw and experience nervousness about their
conversational performances, which could lead to nonfluent oral utterances and
uncoordinated interaction management. Both Fearful Avoidants and Dismissives
are likely to be less socially skilled than Secures and Preoccupieds, in that they have
often missed the opportunity to practice and hone communication skills (Bartho-
lomew, 1993; Guerrero, 1996). Fearful Avoidants and Dismissives tend to have few
peer and romantic relationships and are apt to report low sociability in comparison
to those having other attachment styles (Bartholomew, 1993). However, the lack of
communication experience is most likely to impair Fearful Avoidants' management
of interaction since they also have high levels of social anxiety and negative self
models. In other words, Fearful Avoidants may be doubly disadvantaged as a
consequence of the combination of low social skill and high anxiety. Self-report data
support this conclusion. Guerrero (1996), for example, found fear of intimacy to
associate with a lack of verbal communication skill and oversensitivity to criticism. In
light of this evidence, it follows that:
H4: Fearful Avoidants display less fluency than Secures, Dismissives, and Preoccupieds.
Method
Screening Procedures
Dyads consisting of romantic partners were recruited from a multi-section corpo-
rate communication course at a large southwestern university. The majority were
advanced business majors. Students considering themselves to be in an on-going
romantic relationship received a packet containing an envelope, two pretests
assessing attachment style and relationship type, and a cover letter containing the
following instructions: "Both you and your dating/marital partner will need to
complete a questionnaire. You and your romantic partner should complete the
questions independently. After you complete your questionnaire, place it in the
envelope provided. When your partner completes her/his questionnaire, have
her/him place it in the envelope and then seal it. This way, neither of you will see the
other's answers." Students returned these envelopes to their instructors, who for-
warded them to the experimenter. This procedure resulted in the acquisition of 262
completed sets of preliminary data.

276 COMMUNICATION MONOGRAPHS
Two criteria underlay the screening of dyads for participation in this study. First,
those whose members classified themselves as "casually dating" were eliminated.
The goal was to select dyads in continuing romantic relationships because attach-
ment theorists claim that interaction differences are likely to be highlighted in such
relationships (Bartholomew, 1990; Bowlby, 1977). The second criterion was degree
and clarity of attachment style. All individuals who completed the pretest checked
which of Bartholomew and Horowitz's (1991) four short descriptions of attachment
style best characterized them. Individuals also indicated on seven-point scales, with
the anchors "very unlike me" and "very like me," how well each of these descrip-
tions fit them. Those individuals who fit each attachment style most clearly and
cleanly were invited to participate in the study.1 The attachment styles of these
individuals' partners did not vary systematically. In addition, it is important to note
that when partner attachment style was entered into the analyses, no significant main
or interaction effects attributable to partner style emerged. As a result, only the
attachment style of one partner is utilized as an independent variable in this study. It
is not surprising that there were no effects for partner style, given that the attachment
styles of die participants chosen for study were much stronger tfian the attachment
styles of their partners. Finally, gender was balanced so that ten of the twenty
individuals selected to represent each attachment style were female.
As a result of the screening procedure, 80 romantic dyads were invited for
participation. However, members (two Fearful Avoidants and one Dismissive) of
three different dyads declined to be videotaped after arriving at the laboratory and
reading consent forms. They were excused from participating and were replaced
with new dyads. Of die 80 dyads videotaped, 14 involved marital partners, seven
were engaged, and the remainder were seriously dating. The average age of die
participants was 22.3 (range = 18 to 39 years), and die average lengdi of the
relationships was 2.9 years (range = 4 months to 11.5 years). Students received extra
credit in exchange for their participation.
Procedure
Upon arrival at the research laboratory, a comfortable apartment-like setting,
participants were told that the experiment was being conducted to determine how
diose in different types of romantic relationships discuss relational issues. The
partner who represented one of die four attachment styles (hereafter called the
participant) was seated on die left side of a sofa and the odier partner (hereafter called
the partner) was seated on die right side. Both individuals then read and signed
consent forms.
Dyads were told diat diey would be engaging in two separate videotaped
diree-minute interactions, die first of which provided die data for diis study.2 Each
dyad received a list of four personal topics diat have been found to be discussed
frequendy by romantic partners: future of the relationship, family, friends, and
relational feelings (Guerrero, in press). They had a few minutes to examine the list
and decide which topic to discuss first. The topics, dyadic partners were told, should
be diought of as "starting points" to prompt conversation. The conversation,
however, was not limited to diese topics. Researchers (e.g., Guerrero, in press;
Levenson & Gottman, 1985; Segrin, 1993) have successfully used similar methods of

ATTACHMENT AND INTIMACY 277
inducing conversation to study emotional and nonverbal communication. More-
over, the format used in this study provides some level of control while also allowing
participants to go beyond the topic. After couples decided on their first topic, they
attached small lavaliere microphones and waited for the researcher to exit to an
adjoining room and to knock on the one-way mirror to signal the start of the first
interaction. Following the first interaction, participants separately completed ques-
tionnaires concerning jealousy and social skills. These questionnaires were part of
companion studies, as were data from the second videotaped interaction. Following
the second interaction, dyads were debriefed and thanked.
Attachment-Style Pretest
Categorical descriptions. Participants indicated which of Bartholomew and Horow-
itz's (1991) four attachment styles best characterized them. Each description was a
short paragraph. For example, the description of fearful avoidance read: "I am
somewhat uncomfortable getting close to others. I want emotionally close relation-
ships, but I find it difficult to trust others completely, or to depend on them. I
sometimes worry that I will be hurt if I allow myself to become too close to others."
These categorical descriptions served as the primary operationalization of attach-
ment in this study.
Continuous measures. Several researchers argue that categorical descriptions are too
simplistic to capture fully the differences in attachment styles (e.g., Collins & Read,
1990; Feeney, Noller, & Hanrahan, 1994; Fuller & Fincham, 1995; Griffin &
Bartholomew, 1994; Guerrero, 1994). Thus, before reading the four descriptions of
the attachment styles and marking the style that they felt best characterizes their
personality, participants completed a series of items related to attachment style.
Principal components analysis revealed five factors: General Avoidance, Lack of
Confidence, Preoccupation, Fearful Avoidance, and Relationships as Secondary,
which accounted for 57.2 percent of the variance (see Table I).3
Validation of categorical descriptions. Planned contrasts validated the single-
paragraph descriptions of attachment styles. As expected, Dismissives and Fearful
Avoidants scored higher on General Avoidance than Preoccupieds and Secures,
presumably because of their negative models of others. Fearful Avoidants and
Preoccupieds scored higher on Lack of Confidence than Dismissives and Secures,
which most likely is a function of their negative models of self. Focused contrasts also
revealed Preoccupieds, Fearful Avoidants, and Dismissives to report the highest
scores on Preoccupation, Fearful Avoidance, and Relationships as Secondary,
respectively. Details connected to these tests can be found in Guerrero and Burgoon
(1996).
Coded Relational Messages and Behaviors
Relational messages and nonverbal involvement behaviors were coded by 14
undergraduate students who were currently or previously enrolled in an advanced
course in nonverbal communication. Pairs of coders were trained to rate one to three
behaviors at a time. After several hours of training, coders worked independently.
They coded each minute of the interaction separately to maximize coder attention
and to check for possible time effects. Almost all the relational messages and
behaviors were coded from videotapes. The exceptions were gaze, smiling, and

278 COMMUNICATION MONOGRAPHS
TABLE 1
ITEMS AND INTERITEM RELIABILITIES FOR SCALES MEASURING ATTACHMENT-STYLE DIMENSIONS
General Avoidance (a = .87)
1. I find it easy to trust others (recoded)
2. I feel uncomfortable when people get close to me
3. I feel uneasy getting close to others
4. I prefer to keep to myself
5. I worry about people getting close to me
6. I tend to avoid getting close to others
7. I find it relatively easy to get close to others (recoded)
Lack of Confidence (a = .83)
1. I sometimes worry that I do not really fit in with other people
2. I sometimes worry that I do not measure up to other people
3. I am confident that other people will like and respect me (recoded)
4. I worry that others will reject me
5. I am confident that others will accept me (recoded)
Preoccupation (a = .81)
1. Intimate relationships are the most central part of my life
2. I feel a very strong need to have close relationships
3. Sometimes others seem reluctant to get as close to me as I would like
4. I worry a lot about the well-being of my relationships
5. I worry that others do not care about me as much as I care about them
6. I wonder how I would cope without someone to love me
7. I rarely worry about what relational partners think of me (recoded)
8. I sometimes worry that relational partners will leave me
Fearful Avoidance (a = .78)
1. I would like to trust others, but I have a hard time doing so
2. I worry about getting hurt if I allow myself to get too close to others
3. I would like to depend on others, but it makes me nervous to do so
4. I would like to have closer relationships, but getting close makes me uneasy
5. I worry that I might get hurt if I get too close to others
Relationships as Secondary (a = .84)
1. Achieving things is more important to me than building relationships
2. If something needs to be done, I prefer to rely on myself rather than others
3. I put more time and energy into my relationships than I put into other activities (recoded)
4. Maintaining good relationships is always my top priority (recoded).
5. Pleasing myself is more important to me than getting along with others
facial pleasantness, which were coded from behind the one-way mirror as the actual
interaction took place. The more microscopic nature of these behaviors made them
hard to discern on videotape. For all measures, interitem reliabilities were estimated
by Cronbach's alpha statistic, and interrater reliabilities were estimated by means of
Ebel's intraclass correlation. The two coders' ratings were averaged before entering
data into the analyses. For depth, three coders' ratings were averaged. The third
coder was added to boost interrater reliability, which was initially somewhat low.4
Relational messages. Relational message themes were assessed on three subdimen-
sions of Burgoon and Hales's (1987) Relational Communication Scale: (1) a five-item
measure of immediacy/affection (e.g., the target was "intensely involved in the conver-
sation," interitem a = .91, interrater r\ = .80); (2) a five-item measure of depth (e.g.,
the target "tried to move the conversation to a deeper level," a = .85, r\ = .78); and
(3) a six-item measure of receptivity/trust (e.g., the target "seemed willing to listen to
her/his partner," a = .89, »j = .76). In all cases, items were in a seven-point Likert
format.
Nonverbal involvement behaviors. Behaviors reflecting all six dimensions relevant to
involvement were also coded. All items came from work by Coker and Burgoon

ATTACHMENT AND INTIMACY 279
(1987) or Guerrero (in press). Ratings were made on seven-point scales. Frequency
counts were converted to interval measures by means of square root transformations
(see Snedecor & Cochran, 1969).
Five measures of immediacy were coded: Touch, gaze, direct body orientation,
forward lean, and close proxemic distancing. Touch was assessed in terms of
frequency counts of discrete touches that the target initiated or reciprocated (ri = .96).
Gaze was rated on-line on three scales bounded by: unsteady/steady gaze; no
gaze/constant gaze; never gazing/always gazing (a = .92; r\ — .64). Degree of for-
ward lean was measured in terms of two items for gauging whether the participant
leaned forward toward the partner (a = .91; T\ = .97). Body orientation was origi-
nally measured with two items; however, low reliability (a = .38) resulted in
retention of only the side-to-side/face-to-face measure as an indicator of body
orientation (r\ = .91). Proxemic distancing was assessed by examining the amount of
space between the participants' bodies and faces (a = .92; jj = .94).
Expressiveness was assessed in respect to kinesic animation and vocal expressive-
ness. Kinesic animation involved three items relating to the degree of facial, gestural,
and overall kinesic expressiveness the target displayed (a = .87; r\ = .87). Coders
rated vocal expressiveness in terms of the extent to which targets were vocally
animated and exhibited vocal variety in terms of tempo and pitch (a = .94; n = .76).
Interaction management was measured by coding fluency and response latencies.
Fluency entailed two items: nonfluent/fiuent and choppy/smooth (a = .89; ri = .61).
Coders used a one-item scale (long/short) to gauge the length of response latencies
in = -48).
Altercentrism was measured by assessing attentiveness (inattentive/attentive, dis-
tracted/focused, and unalert/alert; a = .81; r\ = .57) and general interest/involve-
ment (uninvolved/involved and bored/interested; a = .86; r\ = .70).
The level of social anxiety was assessed on measures of: general composure
(anxious/calm, still/restless, and uncomposed/composed; a = .85; rj = .79); body
relaxation (tense/relaxed and rigid/loose; a = .87; r\ — .70); and vocal anxiety
(tense/relaxed and anxious/calm; a = .94; r\ = .82). In addition, random movement
was determined by coding the frequency (infrequent/frequent) of (1) trunk/limb
movement; (2) rocking and twisting; and (3) nervous movements (a = .92; r\ = .72),
and adaptors were established by simple frequency counts [r\ = .76).
Finally, positive affect involved four measures: Smiling (never smiling/always
smiling and smiled a little/smiled a lot; a = .96; r\ = .82); facial pleasantness
(unpleasant/pleasant and conveyed negative affect/positive affect; a = .91; ri = .75);
vocal pleasantness (unpleasant/pleasant, cold/warm, and unfriendly/friendly;
a = .89; n = .80), and relaxed laughter ("hardly any" to "a lot"; rx = .91).
It is important to note that although interitem reliabilities were sufficient across all
variables, interrater reliability was less than optimal (rç < .70) for gaze, fluency,
response latencies, and attentiveness. Despite these low interrater reliabilities (which
are likely to attenuate findings), significant results emerged for each of these
variables. It is also noteworthy that interrater reliabilities in the .60 range are fairly
common for fluency, response latencies, and other vocalic cues (see Baesler &
Burgoon, 1987 for a discussion of these issues).
Results
The hypotheses were tested by means of planned contrasts associated with 4
(attachment style) X 3 (one-minute time segments) mixed-model MANOVAs or

280 COMMUNICATION MONOGRAPHS
ANOVAs. Attachment style was a between-subjects factor, and time was a within-
subjects factor. Multivariate contrasts were constructed if: (a) dependent measures
were related conceptually; (b) the intercorrelations among dependent measures
were significant; and (c) Bartlett's test of sphericity was significant. The time factor
was included to determine whether those with different attachment styles conveyed
more or less intimacy over time and whether time interacted with attachment styles.
Results for the time effects showed that depth, vocal animation, and vocal interest
increased after the first minute of the interaction, which indicated that conversations
became more involving after an initial settling-in period. Time effects also surfaced
for postural congruence and body coordination, which suggested a pull toward
behavioral similarity over time.5 Only one time by attachment style interaction
surfaced (for adaptors). This interaction is discussed in conjunction with other results
relevant to H3.
Supplementary correlations among the dimensions underlying attachment styles-
General Avoidance, Lack of Confidence, Fearful Avoidance, Preoccupation, and
Relationships as Secondary-and intimacy/involvement behaviors were also exam-
ined. For each relational message or behavior, ratings were averaged across the three
time periods and then correlated with each of the attachment-style dimensions. The
resultant correlations were then examined to determine what properties underlying
attachment styles best accounted for attachment-style differences in communication.
Because the hypotheses imply directional associations between attachment-style
dimensions and communication variables, one-tailed significance levels are reported
for the correlations.
Hypothesis 1': Relational Messages of Intimacy
Hypothesis 1, which predicted that Preoccupieds and Secures convey more (a)
depth, (b) immediacy/affection, and (c) trust/receptivity than Fearful Avoidants and
Dismissives, was tested by means of a multivariate contrast (coefficients set at 1 for
Preoccupieds and Secures and —1 for Fearful and Dismissives) within a larger
MANOVA. Bartlett's test of sphericity (12.16, p < .05, average r = .27) suggested
that it was appropriate to treat the three intimacy measures as a composite depen-
dent variable. The multivariate contrast was significant, i*(3, 74) = 3.83, p < .05,
Wilks' A = .85, and provided support for HI. Accompanying univariate contrasts
revealed a significant effect for attachment style on trust/receptivity, /(76) = 3.11,
p < .01, T|2 = .11, and depth, <76) = 1.76, p < .05, T|2 = .04 (see Table 2), but not on
immediacy/affection, t{76) = 1.43, p > .05. However, the means connected to depth
did not conform to HI because Fearful Avoidants' score were slightly higher than
Secures' scores. Thus, an omnibus F-test, F{3, 76) = 3.52, p < .01, partial T|2 = .12,
followed with a TukeyB range test [p < .05) was performed for depth. The range test
showed that Dismissives displayed significantly less depth than Preoccupieds. Taken
together, these results provide partial support for HI: Preoccupieds and Secures
displayed more trust/receptivity than Dismissives and Fearful Avoidants. In addi-
tion, one of the avoidant styles-Dismissives—engaged in more depth than one of the
affiliative styles—Preoccupieds.
Supplementary analyses indicated that both General Avoidance and Fearful
Avoidance were negatively correlated with immediacy/affection; Preoccupation
positively correlated with depth; and Relationships as Secondary negatively corre-
lated with depth and trust/receptivity (see Table 3). Although effect sizes were small,
these analyses suggest that the dimensions underlying attachment style have some

ATTACHMENT AND INTIMACY 281
TABLE 2
MEANS AND (STANDARD DEVIATIONS) ASSOCIATED WITH PLANNED CONTRASTS COMPARING ATTACHMENT
STYLES ON RELATIONAL MESSAGES AND NONVERBAL INVOLVEMENT BEHAVIORS
Global Intimacy Messages
Immediacy/Affection
Depth"1
Trust/Receptivitya
ifiiTiicuiu uy
Proxemic Distancing6
Forward Lean
Body Orientation
Gazea
Touch Frequency
Positive Affect
Facial Pleasantness"
Vocal Pleasantness*
Smiling
Relaxed Laughter
JZtXJJTcii IV CllCàS
Kinesic Animation
Vocal Animation
Altercentrism
General Interest"
Attentivenessa
tJUCllil AllXieVy
Random Movement0
Vocal Anxiety0
Adaptors
General Composure
Bodily Relaxation
Interaction Management
Fluency*1
Short Response Latencies'5Dismissives
4.59 (1.04)
4.71 (.40)
4.00 (.80)
4.94 (.74)
3.99(1.35)
3.19(2.22)
4.76 (.89)
1.35 (2.82)
4.42 (.79)
4.33 (1.14)
3.38 (1.27)
2.80 (1.22)
2.80 (.62)
3.83 (1.39)
4.56 (.98)
4.82 (.94)
3.19(1.04)
4.30(1.07)
1.60(1.16)
4.09 (.96)
4.01 (.85)
4.60 (.80)
4.38 (.70)Fearful
Avoidants
4.75 (.97)
5.07 (.49)
4.01 (.74)
4.14 (1.47)
3.66 (1.21)
4.14 (2.01)
4.84 (.81)
.70(1.78)
4.29 (.76)
3.48 (1.23)
2.61 (1.05)
2.80 (.91)
4.21 (.99)
4.69 (.84)
4.90 (.96)
2.84 (.62)
4.82 (1.05)
1.28 (1.31)
4.30 (.96)
4.43 (.92)
4.27 (.63)
4.03 (.67)Secures
5.02 (.90)
4.97 (.50)
4.25 (1.02)
4.58 (1.06)
4.14(1.08)
3.53 (2.13)
5.10 (.90)
.30 (.73)
4.63 (.90)
4.69 (.88)
3.58(1.31)
2.55(1.15)
2.88 (1.04)
4.07 (.98)
4.83 (.92)
5.24 (.81)
3.30 (1.07)
3.62 (.97)
1.22 {.55)
4.45(1.11)
4.28 (.67)
4.53 (.91)
4.43 (.72)Preoccupieds
4.89 (1.09)
5.18 (.50)
4.71 (1.09)
5.23 (.70)
4.26 (.76)
3.93 (2.02)
5.16 (.94)
.55 (1.05)
4.67 (.89)
4.76 (.93)
3.30 (1.26)
2.48 (1.01)
2.83 (1.00)
3.97 (.89)
5.08 (.87)
5.30 (.94)
2.69 (.64)
4.46 (.92)
1.09 (.79)
4.67 (.71)
4.00 (.63)
4.58 (.65)
4.27 (.52)
Note. Significant tests are marked as follows:
"Contrast compared Dismissives and Fearful Avoidants to Secures and Preoccupieds.
••Contrast compared Fearful Avoidants to the other three groups.
cContrast compared Secures and Dismissives to Preoccupieds and Fearful Avoidants.
••Multiple Comparison Test showed Dismissives and Preoccupieds to differ from one another.
eMultiple Comparison Test showed Fearful Avoidants to differ from the other three groups.
effect on immediacy/affection even though the contrast reported above was nonsig-
nificant. These correlations also suggest that attachment style differences in trust/
receptivity depend most on differences in how "secondary" individuals judge their
relationships to be. Attachment-style differences in depth, in contrast, may depend
most on how preoccupied one is with relationships.
Hypothesis 2: Immediacy, Positive Affect, Expressiveness, and Altercentrism
Hypothesis 2 predicted that Secures and Preoccupieds display greater (a) imme-
diacy, (b) positive affect, (c) expressiveness, and (d) altercentrism than do Dismiss-
ives or Fearful Avoidants. Thus, contrast coefficients were set at 1 for Secures and
Preoccupieds and —1 for Fearful Avoidants and Dismissives. Results for this
hypothesis are reported separately for each of the four involvement dimensions.
H2a: Immediacy. Distance and lean were analyzed as a composite dependent
measure (Bartlett's test of sphericity = 6.06, p < .05, r = .28). The multivariate

282 COMMUNICATION MONOGRAPHS
TABLE 3
SIGNIFICANT SUPPLEMENTARY CORRELATIONS BETWEEN ATTACHMENT-STYLE DIMENSIONS AND
INTIMACY/INVOLVEMENT MEASURES
General Avoidance Fearful Avoidance
Immediacy/Affection = -.26** Immediacy/Affection = -.28**
Forward Lean = —.25*
Gaze = -.35**
Facial Pleasantness = —.22*
Attentiveness = -.22*
Preoccupation
Depth = .28**
Relaxed Laughter = -.20*Close Proxemic Distancing = -.19*
Direct Body Orientation = .22*
Gaze = -.19*
Relaxed Laughter = -.21*
Random Movement = —.22*
Vocal Anxiety = .33**
Lack of Confidence
Forward Lean = —.19*
Random Movement = —.35**Relationships as Secondary
Trust/Receptivity = -.24*
Depth = -.23*
Direct Body Orientation = -.22*
Gaze = -.22*
Facial Pleasantness = —.19*
Vocal Pleasantness = -.22*
General Interest = -.20*
Attentiveness = —.19*
Random Movement = -.22* Vocal Anxiety = .47***
Vocal Anxiety = .31** Response Latencies = —.18*
Note. All/»values are one-tailed: */> < .05, **/> < .01, ***/> < .001.
contrast was not significant, F{2, 75) = 1.94, p >.O5, nor were the accompanying
univariate contrasts, distance t{76) = 1.61, p > .05; leans t{76) = 1.56, p > .05.
However, the omnibus MANOVA showed a significant multivariate main effect for
attachment style, F[6, 150) = 2.27, p < .05, Wilks' A = .84. A TukeyB multiple
comparison test (p < .05) indicated that Fearful Avoidants sat furthest from their
partners.
As a result of low intercorrelations, separate univariate contrasts were constructed
for gaze, body orientation, and touch. The results indicated that, as hypothesized,
Secures and Preoccupieds displayed more gaze than Dismissives and Fearful
Avoidants, <76) = 1.83, p < .05, -n2 = .04. Contrasts for body orientation, <76) =
.13, p > .05, and touch t{76) = -.48, p > .05, were nonsignificant.6 Thus, H2a was
only confirmed for one immediacy behavior, gaze.
Supplementary correlations revealed that General Avoidance associated nega-
tively with gaze and lean; Fearful Avoidance related negatively to gaze and close
proxemic distancing, but positively with direct body orientation; Relationships as
Secondary correlated negatively with gaze and direct body orientation; and Lack of
Confidence correlated negatively with lean (see Table 3). It is noteworthy that all
three avoidance-related dimensions were negatively associated with the use of gaze
and contributed to the significant contrast effect reported above. Furthermore, the
finding that direct body orientation was positively related to Fearful Avoidance, but
inversely related to Relationships as Secondary, may explain why the contrast for
body orientation was nonsignificant: Different types of avoidance appear to be
differentially related to direct body orientation. These supplementary analyses lend
limited support to H2a.
HZb: Positive affect. Smiling, facial pleasantness, vocal pleasantness, and relaxed
laughter were analyzed as a composite dependent variable (Bartlett's test of spheric-
ity = 151.94, p < .001, average r = .61). The multivariate contrast supported H2b,
F{4, 73) = 3.20, p < .05, Wilks' A = .85. Univariate contrasts revealed significant
effects for facial pleasantness, t{76) = 1.69, p < .05, T)2 = .04, and vocal pleasantness,
*(76) = 1.91, p < .05, T)2 = .05, but not for smiling, *(76) = .06, p > .05, or relaxed
laughter, f(76) = .16, p > .05 (see Table 2). Thus, Secures and Preoccupieds
exhibited more facial and vocal pleasantness than Dismissives or Fearful Avoidants.

ATTACHMENT AND INTIMACY 283
Supplementary correlations indicated that General Avoidance was inversely
related to facial pleasantness. Fearful Avoidance showed a negative relationship to
relaxed laughter. In addition, those who viewed relationships as secondary were less
facially and vocally pleasant, whereas those who were preoccupied with their
relationships exhibited less relaxed laughter (see Table 3). Consistent with H2b, the
correlations show that all three avoidance dimensions were inversely related to at
least one behavior reflecting positive affect. However, contrary to H2b, preoccupa-
tion may lead to less relaxed laughter, possibly because preoccupation contains an
element of social anxiety.
H2c: Expressiveness. Kinesic and vocal animation were analyzed together (BarÜett's
test of sphericity = 20.16, p < .001, average r = .87). The multivariate contrast was
nonsignificant, F[2, 75) = .06, p > .05, as were both univariate contrasts: kinesic
animation t{76) = .31, p > .05; vocal animation t{76) = .00, p > .05. Supplementary
correlations between expressiveness measures and attachment-style dimensions
were also nonsignificant. H2c was not supported.
H2d: Altercentrism. General interest and attentiveness were analyzed as a compos-
ite dependent measure (Bartlett's test of sphericity = 70.51, p< .001, average r= .40).
The multivariate contrast was significant, F[2, 75) = 2.68, p < .05, Wilks' A = .93, as
were both accompanying univariate contrasts: general interest, t(76) = 1.91, p< .05,
if = .05, and attentiveness, t{76) = 2.28, p < .05, -n2 = .06. Thus, H2d was
supported: Secures and Preoccupieds conveyed more general interest and were
more attentive to their partners than were Dismissives or Fearful Avoidants.
Supplementary correlations also indicated that avoidant orientations toward
relationships are inversely related to altercentrism. General interest showed an
inverse association with Relationships as Secondary, and attentiveness showed
inverse associations with both General Avoidance and Relationships as Secondary
(see Table 3).
Hypothesis 3: Social Anxiety
Hypothesis 3 predicted that Fearful Avoidants and Preoccupieds convey greater
social anxiety than Secures and Dismissives. Five dependent variables were used to
measure social anxiety/composure: Random movement, vocal anxiety, adaptors,
bodily relaxation, and overall composure. Because none of these measures showed
consistent correlations with one another across the three time segments, each was
analyzed separately.
For random movement, the planned contrast comparing Fearful Avoidants and
Preoccupieds to Secures and Dismissives was significant, t{76) = —3.22, p < .01,
T|2 = .12. However, means were in the opposite direction of the prediction. Fearful
Avoidants and Preoccupieds displayed less random movement than Secures and
Dismissives. For vocal anxiety, the contrast was also significant, t{76) = 3.42,/>< .01,
T|2 = .13, but in this case means were in the hypothesized direction. When adaptors
were analyzed, the planned contrast was not significant, t{76) = 1.28, p > .05, but a
Style by Time interaction surfaced, F{6, 152) = 2.50, p < .05, T\2 = .09. The means
revealed that the number of adaptors used by Dismissives followed a curvilinear
pattern, Fearful Avoidants increased their use of adaptors over time, and Secures and
Preoccupieds decreased their use of adaptors over time (see Table 4). Contrasts for

284 COMMUNICATION MONOGRAPHS
TABLE 4
CELL MEANS AND (STANDARD DEVIATIONS) FOR THE ATTACHMENT STYLE X TIME INTERACTION
ON ADAPTORS
Time 1 Time 2 Time 3
Dismissives 1.43 (1.32) 1.91 (1.33) 1.39 (.82)
Fearful Avoidants .95 (.92) 1.24(1.07) 1.66(1.59)
Secures 1.34 (.90) 1.28 (.86) 1.04(76)
Preoccupieds 1.21 (.95) 1.10 (.81) .96 (.61)
Note. Adaptor scores represent frequency counts. Before conducting the analysis, these counts were converted
using a square root transformation. Actual counts are presented here for ease of interpretation.
general composure, t[76) = 1.03, p > .05, and bodily relaxation, £(76) = .40, p > .05,
were not significant.
Supplementary correlations produced similar findings. Random movement was
negatively associated with Fearful Avoidance, Lack of Confidence, and Preoccupa-
tion. The opposite was true for vocal anxiety, which was positively associated with
Fearful Avoidance, Lack of Confidence, and Preoccupation (see Table 3). Thus, the
dimensions related to negative self-models are associated with less random move-
ment and more vocal anxiety. Effect sizes for these associations ranged from small to
moderate. Because both random movement and vocal anxiety (which were related
to attachment styles in opposite ways) are likely to factor into assessments of general
composure, it is not surprising that there were no significant findings for the general
composure measure.
Hypothesis 4: Interaction Management
Hypothesis 4 predicted that Fearful Avoidants display less fluency than Secures,
Dismissives, and Preoccupieds. Fluency and response latency length were analyzed
together (Bartlett's test of sphericity = 24.52, p < .001, r = .53), with coefficients set
at —3 for Fearful Avoidants and 1 for the other groups. Response latency length
represented how short a participant's response time was when turn-taking shifted.
Results from the multivariate contrast support H4, F[2, 75) = 3.05, p = .05, Wilks'
A = .92. Both univariate contrasts also supported the hypothesis: fluency t{76) =
1.78, p < .05, Ti2 = .04; and response latency length t{76) = 2.41, p < .01, T)2 = .07.
Fearful Avoidants were less fluent and exhibited greater response latency than the
other three groups.
Supplementary correlations revealed only one significant association between
attachment-style dimensions and interaction management: Lack of confidence was
inversely related to the shortness of response latencies (see Table 3). Taken together,
the analyses provide support for H4.
The overall goal of this study was to investigate attachment-style differences in
communication reflecting intimacy and affiliation. The hypotheses received mixed
support. Individuals with positive views of relationships (i.e., Preoccupieds and
Secures) conveyed more trust/receptivity, gaze, facial pleasantness, vocal pleasant-
ness, general interest, and attentiveness. However, other expected differences (e.g.,
lean, relaxed laughter, expressiveness) did not emerge. Individuals with negative
views of themselves displayed more vocal anxiety (as predicted) and less random

ATTACHMENT AND INTIMACY 285
movement (which is the reverse of the prediction). The other three social anxiety
measures did not vary as predicted. As expected, Fearful Avoidants were the least
fluent. In all, over a third of the behaviors conformed to predictions. However, many
of the behaviors that revealed nonsignificant findings in the contrast tests did exhibit
small but significant correlations with attachment-style dimensions. Thus, when
examined as a total package, the results suggest that attachment styles, and the
dimensions underlying them, contribute to subtle differences in communication and
behavior.
These differences surfaced during a short conversation in a semi-public context,
which make it likely that attachment-style differences in communication are even
more pronounced during longer conversations in more intimate settings. Indeed,
some research (e.g., Simpson et al., 1992) suggests that attachment-style differences
in behavior are most likely to emerge during extended and stressful interaction. In
extended interaction there is more opportunity to exhibit greater involvement and
depth. In stressful situations, behavior indicative of stress, uncertainty, and depen-
dency is more likely.
This study's finding that some nonverbal behaviors vary as a function of attach-
ment style in a relatively nonstressful interaction is important. Even subtle attachment-
style differences in communication may promote or reinforce the self- and other-
perceptions that undergird attachment styles. For example, the larger distances that
Fearful Avoidants put between themselves and their partners may help shield them
from becoming too involved. If Fearful Avoidants perceive that such protective
devices keep them from being hurt or becoming uncomfortable, using these devices
may reinforce the notion that it is important to maintain distance despite desiring
intimate relationships.
This study also demonstrates the utility of examining both attachment-style
dimensions and categories. Many of the contrasts pitted the two attachment styles
characterized by approach orientations (Secures and Preoccupieds) against those
with avoidant orientations (Dismissives and Fearful Avoidants). The contrasts on
social anxiety cues compared the two styles with positive self models (Secures and
Dismissives) to those with negative self models (Fearful Avoidants and Preoccu-
pieds). The results from these contrasts, as well as the supplementary correlations,
indicate that several intimacy-related behaviors associate with the two primary
attachment-style dimensions: approach/avoidance and high/low need for external
validation. The dimensions of fearful avoidance and preoccupation also associated
with various relational messages and behaviors. In some cases, effect sizes for the
supplementary correlations were larger than those connected with mean difference
tests, indicating that utilizing dimensions as predictors may yield more precise
information than using categorical descriptions alone.
Approach versus Avoidance Orientations
Intimacy avoidance, which is a defining feature of Dismissive and Fearful Avoid-
ant attachment styles, was negatively associated with a number of nonverbal cues
related to immediacy, altercentrism, and positive affect. Gaze, general interest, and
attentiveness were all lower for Dismissives and Fearful Avoidants than for Preoccu-
pieds and Secures. For Dismissives, these findings may stem from their general lack
of interest in intimate conversation. Couples were instructed to converse on topics
related to their relationship and their social networks. Consequently, Dismissives,

286 COMMUNICATION MONOGRAPHS
who tend to have less invested in their relationships, were less likely to be involved.
This explanation is bolstered by the correlations showing that depth, gaze, attentive-
ness, and general interest all decreased the more relationships were viewed as
secondary. In addition,' those reporting high levels of General Avoidance (discom-
fort with closeness) and Fearful Avoidance tended to display less gaze. For Fearful
Avoidants, low levels of attention and interest may stem from passivity or from the
hesitancy to become too involved with others. Anxiety levels may also cause Fearful
Avoidants to become distracted. Previous research has revealed that nervous
individuals sometimes avert their gaze (Burgoon, Buller, & Woodall, 1989).
Gaze, general interest, and attentiveness also relate to the level of receptivity one
displays. Contrasts showed that Dismissives and Fearful Avoidants convey less
trust/receptivity than Preoccupieds and Secures. This result is not surprising,
inasmuch as one of the chief components underlying negative models of others is
distrust (Bartholomew, 1990, 1993; Feeney, Noller, & Hanrahan, 1994; Hazan &
Shaver, 1987). Dismissives often feel that they cannot trust or rely on others to
complete tasks or solve problems as well as they can on their own. Further,
Dismissives' high levels of self-sufficiency may lead them to "dismiss" others' ideas
rather than show receptivity. Indeed, this study indicated that those who considered
relationships to be secondary to achievement tended to display less overall trust/
receptivity than those who considered relationships to be more central. Fearful
Avoidants, in contrast, have often been hurt by others in the past and, as a result, are
hesitant to trust again.
Both Avoidant types also showed less facial and vocal pleasantness. Since these
findings were obtained from both on-line measures (facial pleasantness) and coding
from videotapes (vocal pleasantness), these results appear to have substantial
validity. Avoidants may convey less pleasantness because they: (a) enjoy interacting
less, (b) feel less comfortable with closeness, and/or (c) are less sociable (Bartho-
lomew & Horowitz, 1991; Feeney, Noller, & Hanrahan, 1994). In addition, Dismiss-
ives may not be concerned with impression management and may, therefore,
exhibit more negative affect. Fearful Avoidants may exude negative affect associated
with anxiety and worry, despite their efforts to manage their impressions and secure
approval.
Past research has shown that nonverbal cues associated with pleasantness and
positive affect convey receptivity/trust and immediacy/affection (Burgoon & New-
ton, 1991; Gutsell & Andersen, 1980; Harrigan & Rosenthal, 1983; Ho & Mitchell,
1982; Patterson, Jordan, Hogan, & Frerker, 1981). Correlations reported here
showed that individuals who reported General Avoidance and/or Fearful Avoid-
ance conveyed less immediacy/affection. Taken together, these findings indicate
that the avoidance orientations held by Dismissives and Fearful Avoidants may lead
to communication styles that convey less attentiveness, trust, and affection. The
opposite is also true: The approach orientations held by Preoccupieds and Secures
may be manifest in communication characterized by altercentrism and trust/
receptivity and, thereby, reflect positive views of relationships.
Interestingly, if the partners of Dismissives and Fearful Avoidants match their
lower levels of attentiveness, interest, and positive affect, reinforcement of negative
models of others is likely to take place. Such a situation allows Avoidants to justify
their perceptions of interaction as nonrewarding. Moreover, not being actively
engaged in conversation in and of itself is likely to reinforce avoidance orientations

ATTACHMENT AND INTIMACY 287
and negative models of others. Avoidant individuals may sometimes "shut down"
conversations before giving them a chance and unwittingly reinforce the perception
that interacting with others is uninteresting and nonrewarding.
Need for External Validation
The results indicated that negative models of self, which are defined by the need
for external validation and lack of confidence, may be associated with a variety of
anxiety-related behaviors. Hypothesis 3 predicted that Fearful Avoidants and Preoc-
cupieds engage in more random movement than Dismissives and Secures. The data
failed to support this hypothesis, as the means were in the opposite direction. Thus,
the following interpretations of the finding that Fearful Avoidants and Preoccupieds
used less random movement than Dismissives and Secures must be regarded as
tentative. Random movement included trunk and limb movement, rocking, twist-
ing, and fidgeting. At first glance, it may appear to be counterintuitive that those with
negative self models engaged in less of these behaviors than the two types possessing
positive self models. After all, Siegman (1985) noted that: "It is widely assumed that
anxiety is associated with an increase in fidgeting and motor activity" (p. 48), though
there are few studies supporting this claim. Studies that have investigated the
relationship between random movement and anxiety have yielded inconsistent
results, but it is possible that trait anxiety may lead to less, rather than more, random
movement (see Burgoon, Buller, et al., 1989). Thus, these two insecure types might
react to their anxiety by feeling inhibited and remaining relatively still. They may be
acutely aware of their anxiety and seek to control any movements that might betray
their nervousness. This is especially true since Fearful Avoidants and Preoccupieds
actively seek the approval of their partners. Thus, they are likely to manage their
impressions.
This explanation is especially plausible, in that Fearful Avoidants and Preoccu-
pieds were found to be more vocally anxious than Dismissives and Secures. Research-
ers studying mixed messages, such as those involving deception, have demonstrated
that the voice is a fairly leaky nonverbal channel, particularly when compared to
facial cues (Bugental, Henker, & Whalen, 1976; DePaulo, Zuckerman, & Rosenthal,
1980; Ekman & Friesen, 1974; Zuckerman, Amidon, Bishop, & Pomerantz, 1982;
Zuckerman, DePaulo, & Rosenthal, 1981). Burgoon, Buller, et al. (1989) explained
this rather consistent finding by noting that because there is a strong, automatic link
between affect and vocalic cues, encoders may find it difficult to control vocal
anxiety.
Together, the findings for random movement and vocal anxiety present a portrait
of Fearful Avoidants and Preoccupieds as exercising some control over their anxiety
(in terms of body movement) but leaking their nervousness vocally. Correlations
supported the idea that the dimensions related to negative self models were partially
responsible for this finding. The more lack of confidence, fearful avoidance, and
preoccupation individuals reported, the more likely they were to inhibit random
movement and sound vocally anxious. It is also noteworthy that of these three
attachment measures, Lack of Confidence, which is the dimension separating
Fearful Avoidants and Preoccupieds from Dismissives and Secures, accounted for
the most variance in both random movement and vocal anxiety. Those reporting
low levels of confidence also showed a tendency to exhibit longer response latencies.
Since short response latencies have been associated with general composure and

288 COMMUNICATION MONOGRAPHS
relaxation, and long response latencies often indicate control, thoughtfulness, or
reticence (Burgoon, Buller, et al., 1989; Burgoon & Newton, 1991), this finding fits
the general pattern of insecurity leading to controlled body movements accompa-
nied by vocal leakage (in the form of vocal anxiety and longer response latencies).
Interestingly, those who scored highly on Fearful Avoidance and Preoccupation
also tended to exhibit less relaxed laughter. Coders rating relaxed laughter were told
to disregard nervous laughter (which is often a release for anxiety) when making
their judgments. They often commented in the margins of the coding sheet that
laughter occurred, but it sounded like "nervous" rather than "relaxed" laughter and,
therefore, was ignored. As a vocal behavior, laughter is likely to reveal affective
states. Therefore, it is not surprising that the dimensions representing the two styles
with negative self models-fearful avoidance and preoccupation-associated nega-
tively with relaxed laughter. It would be informative to examine whether attachment-
style differences in nervous laughter also exist.
The attachment style by time interaction on adaptors is curious. This interaction
showed that Fearful Avoidants increased their use of adaptors, whereas both Secures
and Preoccupieds decreased their use of adaptors over time. Perhaps Fearful Avoid-
ants are less able to control nervous movements as interaction unfolds. At the
beginning of an interaction, Fearful Avoidants may be more cognizant of their
behavior and may try harder to control nervous displays. Conversely, Secures and
Preoccupieds, who enjoy interacting with others, may feel less need to control their
nervous gestures and become more comfortable as the conversation progresses.
Dismissives exhibited the most curious and counterintuitive pattern: Adaptors were
most prevalent during the second time segment. This finding may be anomalous;
however, Dismissives could feel the least comfortable when the conversation first
becomes involving and demands their attention.
Fearful A voidance
The results also suggest that there may be nonverbal behaviors unique to the
dimension of fearful avoidance. In particular, Fearful Avoidants displayed the least
fluency and the longest response latencies of any of the attachment style groups.
Mean scores also indicate that Fearful Avoidants were most vocally anxious,
followed by Preoccupieds. It may be that Fearful Avoidants, as a result of the
combination of negative models of both self and other, are the most anxious when
communicating. This assertion is supported by anecdotal data: Two of the three
individuals who refused to participate in the study upon learning they would be
videotaped were Fearful Avoidants. In each case, there were visual signs of anxiety.
These potential participants became still and stared at the consent form until the
experimenter approached and asked if they wanted to be excused. Fearful avoid-
ance may be associated with general anxiety about communicating, particularly
when performances are public. This conclusion is consistent with research showing
that those who fear intimacy perceive themselves to have difficulty expressing
themselves verbally, managing interactions, and assuming leadership roles (Guer-
rero, 1996).
Fluency and response latencies are intricately related to both anxiety and interac-
tion management. Researchers have shown that induced anxiety often leads to more
nonfiuencies and nervous vocalizations (Siegman, 1987). Fluency and response
latencies are also crucial to smooth interaction management. Choppy speech and

ATTACHMENT AND INTIMACY 289
long or inappropriate response latencies can lead to interruptions and awkward
turn-taking. Thus, Fearful Avoidants may be doubly disadvantaged when it comes to
these behaviors. Their high anxiety levels, combined with their avoidance orienta-
tions and lack of social skill, may lead to more hesitancy and less smooth interaction.
Fearful Avoidants also spaced themselves furthest away from their partners,
perhaps as a result of both discomfort with closeness and reticence. Additionally,
fearful avoidance was positively associated with direct body orientation, whereas
relationships as secondary was negatively associated with direct body orientation.
Thus, it appears that the dimensions unique to each of the avoidant styles relate to
body orientation in opposite ways. Fearful Avoidants may orient themselves toward
their partners because of their need for external validation and their desire for close
relationships. Yet, because Fearful Avoidants tend to feel less comfortable with
closeness than the other styles (Feeney, Noller, & Hanrahan, 1994), they may space
themselves farther away from their partners as a protective device. Dismissives, in
contrast, may use more indirect body orientation due to the detachment and
disinterest they often feel.
Individuals scoring high on Preoccupation tended to engage in in-depth conversa-
tion. The association between Preoccupation and depth (or openness) has been
found by other researchers (Bartholomew & Horowitz, 1991; Bartholomew &
Scharfe, 1993; Feeney & Noller, 1990; Feeney, Noller, & Callan, 1994; Mikulincer &
Nachshon, 1991). In this study, preoccupation associated positively with depth, and
Preoccupieds were found to engage in more in-depth conversation than were
Dismissives. Presumably, the increased depth displayed by those who are preoccu-
pied with their relationships stems from needs to approach others, escalate intimacy,
and control the conversational floor. Similarly, the limited depth displayed by
Dismissives is likely related to the perception that they are self sufficient and intimate
relationships are nonessential.
Summary
This study focused on determining whether there are attachment-style differences
in communication reflecting intimacy and affection. The findings revealed a number
of significant attachment-style differences in relational/nonverbal communication.
Fearful Avoidants and Dismissives conveyed less trust/receptivity, gaze, facial
pleasantness, vocal pleasantness, interest, and attentiveness than Preoccupieds and
Secures, which suggests that individuals with avoidant attachments do indeed
communicatively reveal their detachment. In addition, Preoccupieds engaged in
more in-depth conversation than Dismissives, even within the short three-minute
time frame. These findings provide preliminary validation of Bartholomew's (1990)
predictions concerning attachment styles and affiliativeness. Those with negative
models of self (Fearful Avoidants and Preoccupieds) displayed less random move-
ment and more vocal anxiety than those with positive models of self, providing some
behavioral validation for attachment theorists' (e.g., Bartholomew, 1990, 1993;
Feeney, Noller, & Hanrahan, 1994) claim that social anxiety and needs for external
validation differentiate attachment styles. The study also yielded findings unique to
single dimensions underlying attachment styles. For example, preoccupation was
related to depth, whereas fearful avoidance was related to less fluency and longer

290 COMMUNICATION MONOGRAPHS
response latencies. In general, the study provided reasonably strong support for the
general hypothesis that mental models of self and others translate into observable
differences in social interaction styles. These findings add to the growing body of
literature on attachment styles and communication.
Endnotes
1 The following systematic procedure was used to choose the participants in this study. First, 11 individuals
who did not rate themselves as a "5" or higher on any of the four attachment style descriptions were eliminated.
Next, those individuals who rated the style they marked as fitting them best and a second style as fitting them
equally well (e.g., marked a "6" under both the Preoccupied and Fearful Avoidant descriptions) were
eliminated. About 15 percent of those completing the pretest marked themselves as fitting two categories
equally well. Next, individuals with the most extreme scores on the 7-point scales were placed into categories
on the basis of gender (female, male) and attachment style (Dismissive, Fearful Avoidant, Preoccupied, Secure)
so that these eight cells contained 10 cases each. If two members of a dyad had equally extreme scores, the
individual who fit the more difficult-to-fill category was selected as the representative. Thus, although both
members of the dyad were asked to participate, dyads were placed into categories based upon only one
partner's attachment style.
2 It is important to note that the three-minute time segment used here is considerably shorter than the time
segments used by Levenson and Gottman (1985), Segrin (1993), and Guerrero (in press) who used fifteen-,
eight-, and six-minute conversations, respectively. The length of the conversations in the present study was
somewhat constrained by the overall design, which included comparisons between the first and second
three-minute conversations. The second three-minute conversation included a partner manipulation of
positivity or negativity (for results connected to this manipulation, see Guerrero & Burgoon, 1996). For ethical
reasons, it was important not to let the second conversation run longer than three minutes in the negativity
condition. For methodological reasons, it was important for the first and second conversations to be the same
length. It is likely that a longer interaction time would have produced more variation in involvement. Despite
this, several significant findings emerge in the present study, which suggests that attachment-style differences in
communication surface even in relatively short interactions.
3 Factor loadings can be obtained from the author.
4 A third coder was also added to assess gaze, fluency, and response latencies. However, the addition did not
improve interrater reliability. Therefore, the original two-coder ratings were retained.
5 Results for these time effects can be obtained from the author. Time was included as a factor in the analyses
since the F-ratios connected to the time main effects were often greater than one. Thus, time was left in the
analysis and allowed to pull out some of the significant variance. With the exception of adaptors, time effects
were irrelevant to the hypotheses and, thus, are not reported in detail here.
6 To correct for the problem of empty cells, touch was averaged across the three pre-manipulation time
segments and analyzed with only a planned contrast (rather than within a 4 × 3 ANOVA).
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C:\Works\Data\projects\Python\Diagnosis Project\chat_app\knowledge\documents\Handbook of Diagnosis and Treatment of DSM-5.pdf

1
DIAGNOSIS AND TREATMENT
OF PERSONALITY DISORDERSTODAY
The ﬁrst chapter of the ﬁrst edition of Handbook of Diagnosis and Treatment of
DSM-IV Personality Disorders (Sperry, 1995a) likened the paradigm shift occurring
with the personality disorders beginning the early 1990s to the paradigm shiftthat already had occurred with the depressive disorders. Until the mid-1970s,many clinicians felt relatively ineffective in treating depressive disorders, and untilthe early 1990s this same sentiment was shared by many clinicians about treatingpersonality disorders. I insisted that such a paradigm shift involving the personalitydisorders would require a major change in the way clinicians conceptualize, assess,and treat these disorders. I predicted that while such a change in attitude andpractice patterns might be resisted by some, most clinicians would respond to thechallenge. Such a shift would mean relinquishing the then prevailing view thatthe personality disorders were essentially “untreatable” conditions. With sometrepidation, I ended the chapter with a quote conveying the sentiment thatclinicians might even come to consider that personality-disordered patients would“become our most welcome clients in the new century, clients who are deeplytroubled, but whom we can help with conﬁdence” ( Clinical Psychiatry News , 1991,
p. 26).
Some 20 years and two editions later, much has changed in clinician attitudes
and practice patterns. Indeed, the paradigm has shifted. While not every clinicianbelieves that they can help every personality-disordered individual “withconﬁdence,” there is, nevertheless, an increasing consensus among clinicians thatmany patients can be helped with current treatment interventions, even thosemeeting DSM-5 criteria for Borderline Personality Disorder.
This chapter provides an introduction and overview to the diagnosis and
treatment of the personality disorders. It begins with a description of changes inDSM-5, emphasizing those involving the personality disorders, particularly the

“Alternative DSM-5 Model of Personality Disorders” and the Levels of Personality
Functioning Scale. Following this is a brief description and illustration of thePsychodynamic Diagnostic Manual, another alternative way of conceptualizingpersonality disorders. The main part of this chapter details several exciting,cutting-edge trends—in both diagnosis and treatment—that are further effectingthis paradigm shift. Prior to detailing these trends, the chapter begins by explainingthe nature of the paradigm shift underway in the diagnosis and treatment of thepersonality disorders. Finally, the chapter concludes with an overview of thestructure of Chapters 3 –12.
DSM-5 and the Personality Disorders
The DSM diagnostic system has undergone some major changes since the second
edition of this book was published in 2003. Most of these changes have involvedadding or removing diagnoses and criteria. However, there are also some majorchanges in the structure of the DSM-5 ( American Psychiatric Association, 2013 ),
and these are brieﬂy noted here.
DSM-5: General Changes
The most obvious change in DSM-5 is the return to a single-axis diagnosis, asit was in DSM-I and DSM-II. The multiaxial (5-axes) system was introduced inDSM-III and continued through DSM-IV-TR. Of particular relevance for thepersonality disorders were Axis II and Axis V. Axis II was added for the codingof personality disorders, while Axis V was added for coding the individual’s currentlevel of functioning and impairment on the Global Assessment of FunctioningScale. There were several reasons for eliminating the multiaxial system. Amongthese was an unexpected drawback to adding Axis II. Although it was not theintent of earlier editions of DSM, the opportunity to specify a diagnosis of a person -
ality disorder became problematic for many clinicians. Out of concern that thediagnosis of a personality disorder would stigmatize an individual, some cliniciansrefused to specify an Axis II diagnosis when it was present. This was complicatedby the mistaken notion among therapists and third party payers that person-ality disorders were untreatable. As a result, some individuals who were diagnosedwith personality disorders encountered problems securing treatment. Today,however, individuals who met the criteria for a personality disorder diagnosis maynow ﬁnd it easier to navigate mental health treatment, since they are less likelyto be viewed as having a diagnosis that is more difﬁcult to treat than of otherdisorders.
By eliminating Axis V, the Global Assessment of Functioning (GAF) score is
gone. GAF was the numeric measure used by clinicians to rate an individual’ssocial, occupational, and psychological functioning and well-being. It is a sub -
jective measure of the degree of adaptivity (well-being) or maladaptivity (impaired2Diagnosis and Treatment of DSM-5 Personality Disorders

functioning) an individual demonstrates in dealing with various problems-in-living.
In place of this largely unreliable measure of functioning and impairment, DSM-5 encourages the use of the World Health Organization DisabilityAssessment Schedule 2.0 (WHODAS 2.0). Nevertheless, GAF continues to beused by some clinicians. It provides a continuum (1–lowest, to 100–highest) onwhich to rate overall functioning and well-being. Clinicians can also utilize theLevel of Psychological Functioning Scale (LPFS), which is described below.
DSM-5 Section on Personality Disorders
While there were a number of signiﬁcant changes in many diagnoses in DSM-5, there were very few changes involving the personality disorders. Retained inDSM-5 was the earlier DSM deﬁnition of a personality disorder as an “enduringpattern of inner experience and behaviors that deviates markedly from theexpectations of the individual’ s culture, is pervasive and inﬂexible . . . is stableover time, and leads to distress or impairment” (American Psychiatric Association,2013, p. 645). While DSM-IV-TR diagnostic criteria have been retained, therehas been some updating of descriptions of the various disorders. However, thereis one notable change. The diagnosis of Personality Disorder Not OtherwiseSpeciﬁed (NOS) has been replaced with Other Speciﬁed Personality Disorder(301.89) and Unspeciﬁed Personality Disorder (301.9).
Despite the efforts of the DSM-5 Personality Disorders Work Group to effect
major change, the 10 “ofﬁcial” personality disorder diagnoses remain unchangedfrom DSM-IV-TR. The Work Group proposed that a “dimensional” modelreplace the existing “categorical” model due to its numerous and signiﬁcant prob -
lems. However, that proposal was ultimately rejected by the Board of Directorsof the American Psychiatric Association. Instead, it was relegated to “Section III:Emerging Measures and Models” of the DSM-5 manual. The new dimensionalmodel developed by the Work Group is referred to as the “Alternative DSM-5Model for Personality Disorders,” in contrast to the DSM-IV-TR Model ofPersonality Disorders, also known as the categorical model.
Categorical Model of Personality Disorders
So why replace the categorical model? Three major concerns with the DSM-IV-TR Personality Disorder model involve comorbidity, heterogeneity, and theconstruct of personality.
The concern about comorbidity is that individuals can simultaneously meet
criteria for more than one disorder. For instance, it was estimated that the modalnumber of personality disorder diagnoses possible for an individual who meetscriteria for at least one DSM personality disorder is 3–4 diagnoses (Gunderson,1996). Arguably, this is problematic for case conceptualization and planning tailoredinterventions: if there are 3 diagnoses, which one should be the initial focus ofPersonality Disorders Today  3

treatment, and why? The Alternative DSM-5 Personality Disorder model solves
this problem through the diagnosis of Personality Disorder-Trait Speciﬁed (PD-TS). If the client is not a good match to a speciﬁc DSM-5 Personality Disorder(e.g., Narcissistic Personality Disorder), the clinician records PD-TS and detailsthe client’s clinically important personality features. For example, a client mayhave features of Narcissistic, Histrionic, Antisocial, and Borderline PersonalityDisorder. Instead of recording all four diagnoses, the clinician can record PD-TS and note the mix of grandiose, attention-seeking, antagonistic, and emotionallability.
The other concern involves heterogeneity. The premise of the DSM-IV-TR
Personality Disorder model was that articulating speciﬁc personality disordercategories would facilitate accurate diagnoses. Unfortunately, individuals’personality and psychopathological features seldom ﬁt such a categorical model.For example, individuals meeting DSM-IV-TR criteria for Borderline PersonalityDisorder are a highly heterogeneous group. In fact, there are six distinctivesubgroups of clients who met these criteria and these subgroups differed markedlywith regard to therapeutic concerns such as past suicide attempts, antisocialbehavior, and self-injury (Wright et al., 2013). The Alternative DSM-5 PersonalityDisorder model greatly reduces this heterogeneity problem, because relevantheterogeneity is speciﬁed as part of the diagnostic process. For example, a clientmay meet the general Borderline Personality Disorder proﬁle but also presentswith other clinically signiﬁcant personality features, such as unusual beliefs andexperiences. In this case, the diagnosis of Borderline Personality Disorder can begiven, while also recording the unusual beliefs and experiences.
The third concern is with the very nature of categorical diagnosis. As a
categorical model it is expected to accurately determine whether an individualhas or does not have a personality disorder. In many respects, such a model isnot well suited for diagnosing personality disorders since personality is a con -
tinuous, multi-faceted dimension. To illustrate, consider the trait of grandiosity,a characteristic trait of the Narcissistic Personality Disorder. On a continuum fromhealthy self-esteem to self-centered entitlement, where does a clinician distinguishbetween health and disorder with regard to this trait? Utilizing a categorical modelwith a continuous dimension like grandiosity is akin to trying to force a roundpeg into a square hole.
Given these concerns, it is not surprising that many clinicians did not ﬁnd the
DSM-IV-TR Personality Disorder model to be very clinically useful. As a resultthey often deferred making meaningful personality description in clients’ charts.Many also viewed DSM-IV-TR Personality Disorders as highly stigmatizedconditions, leading to further reluctance to characterize personality disorderfeatures accurately in clinical practice.
Presumably, the Alternative Model can solve these problems. A survey of 337
psychiatrists and psychologists found the Alternative Model to be considerablymore useful than the DSM-IV-TR Personality Disorders model (Morey, Skodol,4Diagnosis and Treatment of DSM-5 Personality Disorders

& Oldham, 2014). As clinicians become more familiar with the Alternative Model,
clients are likely to receive more accurate assessments and diagnoses, which canlead to improved clinical care.
Alternative DSM-5 Model for Personality Disorders
So what is this alternative model? Recognizing the many limitations of thecategorical model of DSM-IV, the DSM-5 Personality Disorders Work Groupproposed a dimensional model to replace the categorical model. That dimensionalmodel has two primary criteria: personality functioning and pathologicalpersonality traits ( American Psychiatric Association, 2013 ).
Personality Functioning . Four elements of personality functioning are
identiﬁed. There are two indicators of self-functioning: Identity and Self-direction.There are also two indicators of interpersonal functioning: Empathy and Intimacy.Impairment in these four elements of personality functioning is rated along acontinuum from 0 to 4. Assessment of such impairment can be accomplishedwith the Levels of Personality Functioning Scale , which is provided below.
Pathological Personality Traits . Five broad trait domains are speciﬁed in
a dimensional or continuous fashion. These traits are derived from the Five-FactorModel of Personality and Personality Psychopathology ( American Psychiatric
Association, 2013, p. 773 ). These trait domains contain 25 speciﬁc personality trait
facets. These domains and facets can be assessed with several psychometric tests.They are: Negative Affectivity vs. Emotional Stability; Detachment vs.Extraversion; Antagonism vs. Agreeableness; Disinhibition vs. Conscientiousness;and Psychoticism vs. Lucidity. In the Alternative Model, only six speciﬁcpersonality disorders are listed, compared to the current 10. These are AntisocialPersonality Disorder, Avoidant Personality Disorder, Borderline PersonalityDisorder, Narcissistic Personality Disorder, Obsessive-Compulsive PersonalityDisorder, and Schizotypal Personality Disorder. Due to lack of research evidenceto support their inclusion, the remaining four are not included: DependentPersonality Disorder, Histrionic Personality Disorder, Paranoid PersonalityDisorder, and Schizoid Personality Disorder.
With this dimensional method, it is now possible to diagnose a personality
disorder based on traits. The designation: “Personality Disorder—Trait Speciﬁed”is used. Another useful feature of the Alternative Model is that it can be used toassess personality functioning and traits, irrespective of whether or not a personalitydisorder is present. This increases the clinical utility of the Alternative Model,because it assists clinicians to identify clients’ strengths in addition to deﬁcits.
This model is expected to become the “ofﬁcial” diagnostic approach for
personality disorders at some point in the future. In the meantime, clinicians maywish to familiarize themselves with it. They can also choose to use the dimensional
model now.Personality Disorders Today  5

Levels of Personality Functioning Scale
Besides assessing client functioning with the World Health Organization Disability
Assessment Schedule 2.0 (WHODAS 2.0), clinicians can also utilize the Level ofPsychological Functioning Scale (LPFS). This scale is included on pages 775–778
in Section III of DSM-5 ( American Psychiatric Association, 2013 ). The LPFS is 
an objective measure for quickly and accurately determining the presence of apersonality disorder. It assesses the four components of personality functioningin the Alternative DSM-5 Personality Disorders model: identity, self-direction,empathy, and intimacy (Bender, Morey, & Skodol, 2011). Impairment in thesefour elements of personality functioning is rated along a continuum of ﬁve levelsof functioning and impairment where 0 = little to no impairment; 1 = someimpairment; 2 = moderate impairment; 3 = severe impairment; and 4 = extremeim pairment. Moderate or greater impairment is required for diagnosis of a
personality disorder. Table 1.1  summarizes these levels of functioning and
impairment.
Psychodynamic Diagnostic Manual
This section brieﬂy describes another clinically valuable alternative to DSM-5
which an increasing number of clinicians utilize in planning and implementingtreatment with personality-disordered individuals. The Psychodynamic Diagnostic
Manual (PDM) (PDM Task Force, 2006) is a diagnostic framework that
characterizes individuals in terms of both their psychodynamics as well as theiremotional, cognitive, and social functioning. The purpose of the PDM is tocomplement the Diagnostic and Statistical Manual of Mental Disorders (DSM) with
psychodynamically based descriptions of patterns of personality, global functioning,and symptom formation. It also emphasizes motivational factors that commonlyunderlie the emergence of particular personality disorders and symptom disorders(depressive disorders) and the ways individuals with these disorders are likely toexperience them. While the DSM provides a behavioral description and diagnosticcriteria of a speciﬁc disorder, the PDM identiﬁes the inﬂuences and causes or
etiology that underlies that disorder. The PDM attempts to explain how and why
those inﬂuences are emerging in the present and causing symptoms, and the roleof early environment, developmental factors, current stressors, and internalpsychological factors. In short, unlike the DSM, the PDM provides a moreindividualized, dimensional, and motivationally based understanding as well as a
therapeutic strategy for working with such individuals.
The PDM was published in 2006 as a collaborative effort of ﬁve psychoanalytic
organizations. It was authored by a task force consisting of Stanley Greenspan,Nancy McWilliams, Robert Wallenstein, and an interdisciplinary group of 37other task force members and consultants. Despite the considerable clinical value
of the PDM, it seems unlikely that the PDM will replace the DSM. There are6Diagnosis and Treatment of DSM-5 Personality Disorders
f Level of
Psychological Functioning Scale (LPFS).
determining the presence of a
personality disorder. 
identity, self-direction,
empathy, and intimacy Impairment 
f ﬁve levels
Moderate or greater impairment is required for diagnosis of a
personality disorder.
 While the DSM provides a behavioral description and diagnostic
r criteria o f a speciﬁc disorder, the PDM i dentiﬁes the inﬂuences an d causes o r
etiology that underlies that disorder. The PDM attempts to exp lain how an d why
those in ﬂuences are emerging in t he present an d causing symptoms, an d the role
of early environment, developmenta l factors, current stressors, an d interna l
psychological factors.

Personality Disorders Today  7
TABLE 1.1 Levels of Personality Functioning
0. No Impairment. 
These individuals functionally optimally in all spheres of life. They have a well-
integrated sense of self and of the world. They experience a mostly positive and
appropriately regulated emotional life. They are goal-directed and possess thecapacity to function productively in society. They easily empathize with others,and can form mutually reciprocating and satisfying relationships.
1. Mild Impairment. 
These individuals have a relatively intact sense of self and of the world and a
lessened clarity about boundaries in the face of strong emotions or mental distress.They may be overly goal-directed or goal-inhibited, or have somewhat unrealisticpersonal standards. They tend to have some difﬁculty appreciating andunderstanding others’ perspectives, and may not consistently be aware of the effect
of their behavior on others. Although they can form intimate and reciprocal
relationships, they may be somewhat limited in their ability to respect and tocooperate with others.
2. Moderate Impairment. 
These individuals have a compromised sense of self and of the world, along withsome difﬁculty maintaining boundaries. Their self-appraisal tends to be inﬂated or
deﬂated, and can experience difﬁculty in emotional regulation. Threats to self-
esteem may engender strong emotions such as rage and shame. Goals are moreoften a means of gaining external approval than self-generated, and thus may lackcoherence and stability. Their capacity for empathy is somewhat limited. Whilethey can form relationships, they are superﬁcial and not always reciprocal. They
cooperate with others primarily for personal gain.
3. Severe Impairment. 
These individuals have an impoverished sense of self. Their self-appraisal rangesfrom self-loathing to self-aggrandizing. They have considerable difﬁculty inemotional regulation. They have a weak sense of autonomy, and may experience alack of identity, or emptiness. Boundaries are poorly deﬁned or rigid. They have
difﬁculty establishing and achieving personal goals. Their ability to reﬂect upon and
understand their inner experiences is quite limited, and their capacity for empathyis limited. Their relationships are unstable and are viewed as means of meeting theirneeds. Cooperative efforts are often disrupted due to the perception of slights fromothers.
4. Extreme Impairment. 
These individuals have a greatly impoverished, disorganized, weak, ineffective,and/or conﬂicted sense of self. They have a propensity to negative and signiﬁcantly
dysregulated emotions. Their capacity for empathy is signiﬁcantly limited, and theycannot consider alternative perspectives, or are threatened by different perspectives.They lack the capacity for adaptive and cooperative interpersonal functioning and
social behavior.0. No Impairment. 
3. Severe Impairment.
4. Extreme Impairment. Goals are more
often a means of gaining external approval than self-generated,may be overly goal-directed or goal-inhibited,intact sense of self and of the world a well-
integrated sense of self and of the world. experience a mostly positive and
appropriately regulated emotional life.
capacity for empathy is somewhat limited.
cooperate with others primarily for personal gain.Their self-appraisal tends to be inﬂated or
deﬂated,
impoverished sense of self.
from self-loathing to self-aggrandizing. considerable difﬁculty in
emotional regulation.
lack of identity, or emptiness.
Their ability to reﬂect upon and
understand their inner ex periences is quite limited, and their ca pacity for em pathy
is limited. relationships are unstable 
have a greatly impoverished, disorganized, weak, ineffective,
and/or conﬂicted sense of self. signiﬁcantly
dysregulated emotions. Their capacity for empathy is signiﬁcantly limited, and they
cannot consider alternative perspectives, or are threatened by different perspectives.some difﬁculty appreciating and
understanding others’ perspectives,

many reasons for this, not the least of which is that it does not yet have the
established reliability necessary to warrant its widespread adoption. Overall, thePDM complements DSM by providing a valuable framework for planning andimplementing clinical treatment.
While DSM-5 describes 10 personality disorders, the PDM describes several
additional personality disorders that are common in clinical practice but may nothave the research base that is required of those described in DSM-5. Among theseare the Depressive Personality Disorder, the Anxious Personality Disorder, theDissociative Personality Disorder, the Sadistic and Sadomasochistic PersonalityDisorder, and the Passive-Aggressive Personality Disorder. Following is an illus -
tration of how the PDM conceptualizes a relatively common clinical presen tation
that no longer appears in the recent versions of the DSM: the Passive-AggressivePersonality Disorder .
Passive-Aggressive Personality Disorder
PDM conceptualizes the passive-aggressive pattern as a variant of Dependent
Personality Disorder. Typically, individuals with this disorder deﬁne themselvesin reference to others, but with a negative valence, e.g., “I’m the wife of thatSOB.” Like those with paranoid personalities, these individuals preemptively attackin anticipation of being attacked by others, but they do so indirectly. Like thosewith masochistic personalities, they expect mistreatment, but they ﬁght back, butcunningly. While they have core narcissistic concerns, they tend to be more inter -
personally engaged than those with narcissistic personalities. Their central pre -
occupation is getting revenge while tolerating mistreatment of others, and theirmain affects are anger, resentment, and pleasure in hostile enactments. Their mainways of defending themselves are projection of negativity onto others, denial,externalization, and rationalization. Their self-view is that feeling worthwhilerequires sabotaging the achievements of others. Related to this, their view of theworld and others is that everyone wants them to conform to their rules.
Because they are predisposed to oppose others’ agendas, they ﬁnd it difﬁcult
to conceive of and to pursue their own personal and professional goals. Accord -
ingly, one of the main tasks of therapy is to increase their sense of identity andtheir capacity to accept themselves as active rather than just passive respondersand reactors. Not surprisingly, it can be therapeutically challenging to connectwith those who reach out with aggression or respond aggressively to others’ effortsto relate to them.
The therapist needs a sense of humor as counterpoise to the feelings of
irritation and impatience the patient is likely to evoke. Negative feelingsemerge quickly in treatment, and power struggles are a risk to avoid.Sometimes stunningly naïve about the hostility they exude, passive-aggressive patients need help naming their negative feelings and8Diagnosis and Treatment of DSM-5 Personality Disorders

differentiating verbal from behavioral expressions of anger. To avoid feeding
into their oppositionalism, therapists should not seem to be overinvestedin their progress. Instead, clinicians need to take their provocations andinconsistencies in stride, keeping the therapy focused on the price the patientpays for passive-aggressive acts.
(PDM Task Force, 2006, p. 53)
Trends in the Diagnosis of Personality Disorders
This section describes a number of cutting-edge clinical and research trends thatare and will continue to impact the assessment and diagnosis of personalitydisorders. These include: attachment styles, temperament, culture, emotional abuseand neglect, and functional impairment.
Attachment Styles and Personality Disorders
Attachment refers to the emotional bond that develops between child and parentor caregiver and subsequently inﬂuences the child’s capacity to form matureintimate relationships in adulthood. It is an inborn system of the brain thatinﬂuences and organizes motivational, emotional, and memory processes thatinvolve caregivers. The impact of the process of attachment on developmentcannot be underestimated since the “patterning and organization of attachmentrelationships during infancy is associated with characteristic processes of emotionalregulation, social relatedness, access to autobiographical memory, and thedevelopment of self-reﬂection and narrative” (Siegel, 1999, p. 67).
Attachment researchers insist that early life relational deﬁcits lead to both
neurophysiological brain deﬁcits as well as psychological deﬁcits (Siegel, 1999).A sensitive and responsive parent helps grow the connections in the orbitofrontalcortex of the infant’s brain by communicating—or “collaborating”—with the baby,via eye contact, facial expression, gestures, tone of voice, and so on. The gurgling,smiling infant is picked up and “answered” by the parent with a smiling and joyfulexpression and words. Or, the baby cries in pain or frustration and the parentsoothes and consoles it, or calms down the overexcited child at bedtime. Theseroutine and continuous interactions serve to stimulate the growth of synapses inthe orbitofrontal cortex of the brain which enable children to modulate theirfrustration, rage, and fear, and to respond ﬂexibly to others. Research indicatesthat securely attached children develop neural pathways for resilience. Even whentheir parents are upset or impatient, their brain’s wiring “knows” from experiencethat they won’t be abandoned and will reconnect after the storm has passed.Unfortunately, children with insecure attachment styles do not experience suchreciprocal parental attention, and consequently they tend to be more vulnerableto emotional assaults, i.e., they are less able to modulate rage and aggressive affects,calm and soothe their anxieties and sadness, as well as tolerate high levels of pleasurePersonality Disorders Today  9

and excitement (Ainsworth et al., 1978). Needless to say, they are also less likely
to correctly interpret others’ social cues because of deﬁcits in their orbitofrontalcortex which further complicates interpersonal relationships.
Types of Attachment Styles
Distinct patterns or styles of attachment in early life tend to persist into adulthood(Bartholomew & Horowitz, 1991; Hazen & Shaver, 1987; Main & Solomon,1990). Reﬂecting Bowlby’s (1973) concept of working models of self and others,Bartholomew (1990) developed a four-category system of adult attachment thatorganizes a person’s working models along two dimensions: (1) the distinctionbetween self and others; and (2) valence—positive vs. negative evaluation. Basedon these dimensions, Bartholomew derived four prototypical styles of adultattachment: The four attachment styles are: secure (positive view of self and
others), preoccupied (negative view of self and others), dismissing (positive
view of self, negative view of others), and fearful (negative view of self and others).
Subsequently, based on clinical experience, an additional style, the
disorganized (ﬂuctuating positive and negative views of self and others) style
was added (Main, Goldwyn, & Hesse, 1998; Main & Solomon, 1990).
Accordingly, personality disorders can be viewed as the outcome of insecure
working models that have become self-conﬁrmatory. These working models ofself and other have become relatively inﬂexible and closed to new information,and as a result the individual experiences signiﬁcant distress in social, occupational,and relational functioning. It is possible to characterize the various personalitydisorders in terms of this dimensional model of self and others. It should be notedthat Bartholomew (1990) does not assume that “all individuals are expected toexhibit a single attachment style” (p. 162). Instead, these attachment styles areconceptual prototypes and, thus, it is more appropriate to view adult attachmentin a multidimensional way, with individuals exhibiting one or more style typesas predominant . Accordingly, the DSM-IV personality disorders can be
categorized in the following adult attachment style designations (Lyddon &Sherry, 2001).
Preoccupied attachment style . The preoccupied attachment dimension is
characterized by a sense of personal unworthiness and a positive evaluation ofothers. These individuals tend to be very externally oriented in their self-deﬁnitions. Personality disorders that seem to exemplify this adult attachment styleinclude the Dependent, Obsessive-Compulsive, and Histrionic personalitydisorders.
Fearful attachment style . Individuals with a fearful attachment style exhibit
a sense of personal unworthiness combined with an expectation that other peoplewill be rejecting and untrustworthy. They trust neither their own internalcognitions or feelings nor others’ intentions. While they believe themselves tobe special and different from others, they guard against threats and unexpected10 Diagnosis and Treatment of DSM-5 Personality Disorders
these attachment styles are
conceptual prototypes and, thus, it is more a ppropriate to view a dult attac hment
in a mu ltidimensiona l way, with individuals exhibiting one or more st yle types
as predominant .d Distinct patterns or st yles of attachment in ear ly life tend to persist into a dulthood
(Bartholomew & Horowitz, 1991; Hazen & Shaver, 1987; Main & Solomon,
1990). Re ﬂecting Bow lby’s (1973) conce pt of working models of self and others,
Bartholomew (1990) developed a four-cate gory system o f adult attac hment t hat
organizes a person’s wor king models along two dimensions: (1) t he distinctio n
between se lf and others; an d (2) va lence— positive vs. ne gative eva luation. Base d
on these dimensions, Bart holomew derived four prototypical styles of adult
attachment: T he four attac hment st yles are: secure(positive view o f self and
others), preoccupied (negative view o f self and others),dismissin g(positiv e
view o f self, negative view o f others), an d fearful (negative view o f self and others).
Subsequently, based on c linical experience, an a dditiona l style, the
disorganized (ﬂuctuatin g positive an d negative views o f self and others) st yle
was added (Main, Go ldwyn, & Hesse, 1998; Main & So lomon, 1990).
Dependent, Obsessive-Compulsive, and Histrionic personality
disorders.It should be noted
that Bart holomew (1990) does not assume t hat “all individuals are ex pected to
exhibit a single attachment style” (p. 162). Instead, 
Fearful attachment st yle. Preoccupie d attachment st yle.

circumstances, since they cannot trust that others will protect them. The
personality disorder most characteristic of such a fearful adult attachment style isthe Paranoid Personality Disorder.
Dismissing attachment style . Individuals with a dismissing attachment style
are characterized by a sense of self that is worthy and positive, as well as a lowand negative evaluation of others which typically manifests as mistrust of others.Because they believe they are emotionally self-sufﬁcient while others areemotionally unresponsive, they dismiss the need for friendship and contact withothers. The personality disorder most characteristic of such a preoccupied andfearful adult attachment style is the Schizoid Personality Disorder.
Preoccupied-fearful attachment style . Individuals with a self-view that is
negative and an other-view that vacillates between positive and negative exhibita composite preoccupied and fearful style of attachment. Their avoidance is basedon the desire to be liked and accepted by others, while at the same time fearingrejection and abandonment. The personality disorder most characteristic of sucha preoccupied and fearful adult attachment style is the Avoidant PersonalityDisorder.
Fearful-dismissing attachment style . Individuals with a view of others that
is negative and a self-view that vacillates between positive and negative exhibita composite fearful-dismissing style of attachment. They tend to view themselvesas special and entitled, but are also mindful of their need for others, who canpotentially hurt them. Accordingly, they use others to meet their needs whilebeing wary and dismissive of them. Personality disorders that are characterizedby such a fearful-dismissing adult attachment style are the Antisocial, Narcissistic,and Schizotypal personality disorders.
Disorganized attachment style . Individuals with vacillating views of both
self and others exhibit the disorganized attachment style: “Disorganized attachmentdevelops from repeated experiences in which the caregiver appears frightened orfrightening to the child” (Siegel, 1999, p. 117). This style is associated withdissociative symptomatology, which increases their proneness to posttraumaticstress disorder. The Borderline Personality Disorder is characterized by unstablepersonality structure that seems to shift among the various insecure attachmentstyles, creating a disorganized proﬁle.
Temperament and Personality Disorders
Like attachment, temperament is a construct that appears to have both researchand clinical utility. Temperament refers to “the characteristic phenomena of anindividual’s emotional nature, including his susceptibility to emotional stimula-tion, his customary strengths and speed of response, the quality of his prevailingmoods, and the peculiarities and ﬂuctuation and intensity of moods; thesephenomena being regarded as dependent on constitutional makeup and thereforelargely hereditary in origin” (Allport, 1937, p. 54). Although proposed over 60Personality Disorders Today  11
Paranoid Personality Disorder.
Schizoid Personality Disorder.
Avoidant Personality
Disorder.
Antisocial, Narcissistic,
and Schizotypa l persona lity disorders.
Borderline Personality Disorder 
that seems to shift among the various insecure attachment
styles, creating a disorganized proﬁle.an other-view that vacillates between positive and negative 
a self-view that vacillates between positive and negative a self-view that is
negative 
a view of others that
is negative Fearful-dismissing attachment st yle. Preoccupied- fearful attachment st yle.Dismissing attac hment st yle. 
Disorganize d attachment sty le.

years ago, Allport’s deﬁnition is remarkably consistent with many contem porary
formulations of the construct. Reﬂecting the clinician’s view that tempera ment
and attachment styles are related, temperament is viewed as “a ﬁlter of personalitythrough which information is processed, attachments evolve, and emotions areexperienced and expressed” (Graybar & Boutilier, 2002, p. 156).
While clinicians seem convinced that temperament inﬂuence attachment—
and vice versa—researchers are still trying to clarify the exact nature of therelationship between the two constructs. This is largely because both constructsrepresent different origins and different research agendas. While temperamentrepresents a biological determinant of personality (nature), attachment stylerepresents an environmental determinant of personality (nurture). As in othernature-nurture discussions, the relationship is seldom “either-or” but usually “both-and.” Currently, the research consensus seems to be that attachment andtemperament are modestly related and that “both will inﬂuence the formation and
expression of personality and self-concept as these are assembled during earlychildhood” (Vaughn & Bost, 1999, p. 221).
Temperamental traits and patterns are evident from birth. For instance, while
some infants are quite sensitive to light and loud sounds, others are not; whilesome are calm and placid, others are very active or very fussy. Three maintemperament pattern styles have been observed in infants: easy(usually predictable
and in a good mood), slow to warm (more likely to be resistant to attention and
moody), and difﬁcult (typically unpredictable and with irritable moods) (Thomas
& Chess, 1977). A child’s temperament tends to be reﬂected in adult patterns.For example, optimism and consistency of effort are more common in adults whohave easy temperaments, while negativity and suspiciousness are associated withthe “difﬁcult” temperament, and passivity and overdependency with the “slowto warm up” temperament. Several other temperament traits or descriptors havebeen identiﬁed in adults, including: impulsivity, irritability, hypersensitivity tostimulation, reactivity, emotional lability, inhibition, reﬂectivity, mood con stric -
tion, hypervigilance, and intensity.
Before 1980, personality disorders were typically conceptualized in “character
language,” such as the oral character or obsessive character. Although there wasa biological tradition in the study of personality that emphasized temperament,the psychological tradition that emphasized character was in vogue for most ofthe 20th century. Descriptions of personality disorders in DSM-I and DSM-IIreﬂected this emphasis on character and psychodynamics. Within the psycho -
analytic community, character reﬂected speciﬁc defense mechanisms. Accordingly,from a character perspective, the obsessive-compulsive personality would becharacterized by the defenses of isolation of affect, intellectualization, and ration -
alization.
Currently, personality disorders are conceptualized in a broader perspective
that include both character andtemperament (Cloninger, 2004; Stone, 1993).
Character refers to the learned, psychosocial inﬂuences on personality. Character12 Diagnosis and Treatment of DSM-5 Personality Disorders

forms largely because of the socialization process, particularly regarding
cooperativeness, and the mirroring process that promotes the development of self-concept and a sense of purpose in life (i.e., self-transcendence and self-responsibility).
Temperament refers to the innate, genetic, and constitutional inﬂuences 
on personality. Whereas character and schema reﬂect the psychological dimen-
sion of personality, temperament or trait (or style, as it is used synonymously inthis book) reﬂects the biological dimension of personality. Cloninger (2004)
contends that temperament has four biological dimensions (novelty-seeking,
harm-avoidance, reward-dependence, and persistence), whereas character has threequantiﬁable dimensions (self-directedness or self-responsibility, cooperativeness,and self-transcendence). Other researchers would describe impulsivity and
aggressivity as additional dimensions of temperament (Costello, 1996). Another
widely known temperament-based model is the Five Factor Model with its traitdimensions of neuroticism, extraversion, openness, agreeableness, and conscien -
tiousness (Costa & McCrae, 1990). Section III of the DSM-5 provides a dimen -
sional approach to the personality disorders that is based on these and other models.It consists of ﬁve temperament domains: negative affectivity, detachment,antagonism, disinhibition, and psychoticism (American Psychiatric Assocition,
2013). Accordingly, from a temperament perspective, the obsessive-compulsive
personality would be characterized by inhibited emotional expression, behavioralinhibition, cognitive rigidity, and overconscientiousness.
Temperament and character can be assessed by interviews and self-report instru -
ments. The relevance of distinguishing character and temperament for treatmentplanning is signiﬁcant. Whereas insight-oriented psychotherapy might be focusedon the character dimensions, psychotherapy can have little or no impact on tem -
pera ment dimensions. However, the addition of focused skill training may
sufﬁciently regulate or modulate temperament or style features such as emotionaldysregulation, impulsivity, and distress intolerance.
Attachment, Temperament, Culture, and Personality
Disorders
As already indicated, research strongly suggests that insecure attachment inﬂuences
the development of personality disorders (Brennan & Shaver, 1998). But whatabout the inﬂuence of temperament and culture on the development of personalityand personality disorders? Brennan and Shaver (1998) believe that the same
environmental conditions that contribute to the development of insecure attach -
ments, and subsequently personality disorders, also interact with an individual’stemperament: “In addition, cultural variations in the extent to which particulartraits (e.g. independence, eccentricity) are sxpressed are also likely to result incross-cultural differences in the expression of personality” (p. 868).Personality Disorders Today  13

Unfortunately, there is currently little research on the cultural aspects of
personality disorders to offer speciﬁc guidelines for clinical practice (Mulder, 2012).Nevertheless, DSM-5 does offer some general guidelines regarding diagnosis. Itstates that personality disorders “should not be confused with problems associatedwith acculturation following immigration or with the expression of habits,customs, or religious and political values professed by the individual’s culture oforigin. It is useful for the clinician, especially when evaluating someone from adifferent background, to obtain additional information from informants who arefamiliar with the person’s cultural background” (American Psychiatric Association,2013, p. 648).
Trends in the Treatment of Personality Disorders
In comparison to the previous approach of utilizing conventional psychotherapyin the treatment of personality disorders, treatment methods today tend to beconsiderably more focused and structured, with the clinician taking a more activerole. Many of these treatment approaches and intervention strategies are theory-based and have been researched in clinical trials in comparison with othertreatment approaches and modalities. These include the Cognitive BehaviorTherapies, Dialectical Behavior Therapy, Cognitive Behavior Analysis System of Psychotherapy, Pattern-Focused Psychotherapy, Mindfulness, Schema Ther-apy, Structured Treatment Interventions, Transference Focused Psychotherapy,Mentalization-Based Treatment, and Developmental Therapy. A useful frame -
work for understanding the recent trends in treatment comes from the neuro -
sciences, and it begins this discussion.
Neurosciences and the Treatment Processes
One of the outcomes of recent neuroscience investigations regarding the treatmentof personality disorders is the conceptualization of treatment as either “top-down”or “bottom-up” strategies. This conceptualization is useful in understanding effortsto normalize the expression of overmodulated maladaptive personality traits withvarious psychotropic and behavioral interventions (Fawcett, 2002). “ Top-down ”
refers to treatment efforts that are primarily focused on cortical structures andneural tracts (top) which also can inﬂuence subcortical circuits, particularly in thelimbic system (down). Similarly, “ bottom-up ” refers to the treatment efforts that
are largely focused on limbic circuits which also can produce changes in corticalcircuits. Of particular promise are recent efforts to normalize the expression ofunder- and overmodulated maladaptive personality traits with psychotropic andbehavioral interventions. For example, top-down treatment strategies typicallyutilize psychotherapies and behavioral interventions, i.e., cognitive behaviortherapy, to enhance cortical inﬂuences on limbic circuits. The goal is to undonegative learning, particularly maladaptive schemas, and to increase the modulating14 Diagnosis and Treatment of DSM-5 Personality Disorders

or normalizing effects of emotional responses. Bottom-up treatment strategies
typically involve the use of psychotropic medication in order to modulate harmfulpersonality traits and emotional states by normalizing the activity of limbicstructures. Besides medications, it appears that skill-training interventions functionas bottom-up treatments.
Cognitive Behavior Therapies
Since the mid-1980s, Behavior Therapy, Cognitive Therapy, and CBT have beenthe treatment of choice for the psychosocial treatment of the personality disorders.While research did not consistently support the efﬁcacy of these traditionalapproaches, it has for newer, more focused approaches such as Dialectic BehaviorTherapy (DBT), Cognitive Behavior Analysis System of Psychotherapy (CBASP),and Mindfulness-Based Cognitive Therapy (MBCT). Interestingly, DBT,CBASP, and MBCT constitute what is being called the “third wave” of behaviortherapy (Hayes, Follette, & Linehan, 2004).
The ﬁrst wave refers to traditional behavior therapy, which endeavors to replace
problematic behaviors with constructive ones through counterconditioning andreinforcement. Cognitive therapy is the second wave of behavior therapy. It worksto modify problem behaviors by changing the thoughts that cause and perpetuatethem. In the third wave, treatment tends to be more experiential and indirectand utilizes techniques such as mindfulness, dialectics, acceptance, values, andspirituality. More speciﬁcally, third wave approaches are characterized by “lettinggo of the attempts at problem solving, and instead standing back to see what it
feels like to see the problems through the lens of non-reactivity, and to bring akindly awareness to the difﬁculty” (Segal, Williams, Teasdale, & Williams, 2004,
p. 55). Unlike the ﬁrst and second wave, third wave approaches emphasize second-
order change, i.e., basic change in structure and/or function, and are based on
contextual assumptions, including the primacy of the therapeutic relationship.
These approaches appear to be particularly germane to treating personality
disorders.
Dialectical Behavior Therapy
Originally developed for the treatment of borderline personality disorder (Linehan,1993a), Dialectical Behavior Therapy (DBT) has been modiﬁed and extended
for use with other personality disorders, as well as Axis I or symptom disorderssuch as mood disorders, anxiety disorders, eating disorders, and substance usedisorders (Lynch & Cuper, 2012; Marra, 2005). DBT is an outgrowth of behaviortherapy but is less cognitive than traditional CBT, since DBT assumes thatcognitions, per se, are less important than affect regulation. Accordingly, DBTplaces more emphasis on emotion regulation rather than maladaptive thoughtprocesses. While it recognizes that cognitions are a factor in behavior, they arePersonality Disorders Today  15

not a necessary mediating factor. Rather, cognitions are more likely to serve to
make sense of behavior and emotional events after the fact (Marra, 2005).
Theory . There are numerous similarities between DBT and traditional CBT,
particularly cognitive therapy. Both require a collaborative stance between clientand therapist. Both utilize learning principles, analyze triggers and environmentalprompts, explore schemas and emotions, and utilize modeling, homework, andimagery. Furthermore, both recognize the importance of empathic responding.
There are a number of differences between cognitive therapy and DBT in the
treatment of personality disorders. Essentially, cognitive therapy posits that thesame techniques used in eliciting and evaluating automatic thoughts duringdepression or anxiety disorders are used in treating personality disorders (Beck,Davis, & Freeman, 2015). While cognitive therapy contends that dysfunctionalfeelings and behaviors are due to schemas that produce consistently biasedjudgments and a tendency to make cognitive errors through attributional bias,DBT focuses instead on how schemas are initially formed. Accordingly, therapistsutilizing DBT explore schemas and the underlying dialectic conﬂicts that producedthem rather than performing “collaborative experiments” to prove their limitedusefulness. Rather than utilizing cognitive restructuring, the DBT therapistattempts to connect belief systems to underlying affect and need, and then toassist clients to reinterpret their belief systems based upon greater awareness oftheir feelings and needs.
Instead of utilizing “guided discovery” to dispute and revise maladaptive beliefs,
DBT analyzes both the affective and cognitive inference processes to determinehow the schema was formed in the ﬁrst place. This involves identifyingdeprivational emotional states in early development that could have producedﬁxation or perseveration and attentional constriction that could serve as protectionfrom threatening internal or external cues, as well as broadly examining the effectsof negative reinforcement through emotional escape and avoidance strategies orinadequate psychological coping skills that could have been rewarded throughthe partial reinforcement effect (Marra, 2005, p. 141).
Finally, DBT differs from the cognitive therapy of personality disorders by
adopting a nonpejorative interpretation of pathology. Instead, the DBT therapistsees behavior and strategy as operant behavior. Like others, the personality-disordered client is attempting to avoid harm and seek pleasure but has difﬁcultysuccessfully obtaining the desired outcome due to the emotional vulnerability.Nevertheless, the DBT therapist assumes that inadequate compromises betweencompeting and contradictory needs and desires form the basis of their personalitystructure and helps them achieve their needs in a non-pejorative way.
Treatment . Linehan (1993a, 2015) speciﬁed four primary modes of treatment
in DBT: individual therapy; skills training in a group, telephone contact, andtherapist consultation (Linehan, 1993a, 2015). Whilst keeping within the overallmodel, group therapy and other modes of treatment may be added at thediscretion of the therapist, providing the targets for that mode are clear and16 Diagnosis and Treatment of DSM-5 Personality Disorders

prioritized. The individual therapist is the primary therapist and the main work
of therapy is carried out in the individual therapy sessions. Between sessions theclient should be offered telephone contact with the therapist, including out-of-hours telephone contact, although the therapist has the right to set clear limitson such contact. The purpose of telephone contact is not psychotherapy but ratherto give help and support to clients to ﬁnd ways of avoiding self-injury as well asfor relationship repair where the client feels that she has damaged her relationshipwith her therapist and wants to put this right before the next session. To avoidreinforcing self-injury, calls after the client has injured herself are not acceptableand, after ensuring her immediate safety, no further calls are allowed for the next24 hours. DBT therapists are encouraged to participate regularly in therapistconsultation groups. These groups provide both emotional support for therapistsdealing with difﬁcult clients, as well as for ongoing training in DBT methods.
Skills training is usually carried out in a group context, ideally by someone
other than the individual therapist. In the skills training groups, clients are taughtskills considered relevant to the particular problems of personality-disorderedindividuals. There are four groups of skills: core mindfulness skills, interpersonaleffectiveness skills, emotion modulation skills, and distress tolerance skills (Linehan,2015).
Stages of treatment . Following an initial period of pre-treatment involving
assessment, commitment and orientation to therapy, DBT consists of four stagesof treatment (Linehan, 2015). Stage 1 focuses on “severe behavioral dyscontrol.”The goal of this stage is to increase behavioral control and it targets suicidalbehaviors, self-harm, and severe therapy interfering like substance abuse. Stage 2focuses on “quiet desperation,” with the goal of increasing emotional experiencingin those dealing with issues like posttraumatic stress and other residual disordersnot addressed in Stage 1. Stage 3 focuses on “problems of living.” The goal ofthis stage is to work through concerns of ordinary happiness and unhappiness.Stage 4 focuses on “incompleteness,” where the work is on increasing thecapacity for joy, freedom, and spiritual fulﬁllment. The targeted behaviors of eachstage are brought under control before moving on to the next phase. Therapyat each stage is focused on the speciﬁc targets for that stage, which are arrangedin a deﬁnite hierarchy of relative importance.
Core strategies . The core strategies in DBT are “validation” and “problem
solving.” Attempts to facilitate change are surrounded by interventions thatvalidate clients’ behavior and responses in relation to the clients’ current lifesituation and that demonstrate an understanding of their difﬁculties and suffering.Problem solving focuses on the establishment of necessary skills. Other treatmentmodalities include contingency management, cognitive-therapy exposure-basedtherapies, and medication.
Practicing DBT . The provision of DBT therapy is easier to accomplish in
an inpatient, partial hospitalization or residential treatment setting rather than inoutpatient practice. The reason is that, as described by Linehan (1993a), DBT isPersonality Disorders Today  17

best implemented with a treatment team in which one therapist provides
psychosocial skill training, another provides individual therapy, others can providea consultation function, and the therapists have access to a therapist consultationgroup for support. Recently, Marra (2005) has offered suggestions for adaptingDBT treatment in private practice settings. While he recommends that skillstraining be provided by another therapist, he offers guidelines when that is notpossible. Nevertheless, he encourages any private practice clinician who anticipatesutilizing DBT to have access to a psychotherapy consultant if involvement in atherapist consultation group is not possible.
Research support . Finally, empirical support exists for the effectiveness of
DBT. Several randomized controlled trials that evaluate the overall effectivenessof a comprehensive DBT treatment have been published (Linehan et al., 1991,2002, 2006). When evaluated against treatment-as-usual control conditions, DBTwas superior. While most of this research focused on borderline personalitydisorders in females, some studies modiﬁed DBT for use in other populationsand in various settings. These include studies with adolescents and adults ininpatient and forensic settings with various disorders, including binge eatingdisorder, bulimia, anorexia nervosa, chronic depression, and other personalitydisorders. However, there is very little research on the use of DBT with malesor minorities (Lynch & Cuper, 2012).
Cognitive Behavior Analysis System of Psychotherapy
Cognitive Behavior Analysis System of Psychotherapy (CBASP) is a form of CBTthat was developed by McCullough (2000) and further elaborated (McCullough,Schramm & Penberthy, 2015). Basic to this approach is a situational analysis whichcombines behavioral, cognitive, and interpersonal methods to help clients focuson the consequences of their behavior and to use problem solving for resolvingboth personal and interpersonal difﬁculties. CBASP was initially targeted for thetreatment of clients with chronic depression. A national, multisite study launchedCBASP as an effective treatment. Clients who met criteria for chronic unipolardepression, usually meeting criteria for both major depressive disorder anddysthymic disorder, were randomly assigned to one of three treatment groups:medication only (nefazodone with the, trade name of Serzone), psychotherapy(CBASP) only, or a combination of medication and CBASP. While clients in allthree treatment conditions improved signiﬁcantly, those receiving the combinedtreatment improved the most. Over the 12-week study period, 55 percent of themedication-only group reported a positive response, and 52 percent of theCBASP-only group experienced a treatment response, whereas 85 percent of thosewho took both medication and received CBASP had a positive response totreatment (Keller et al., 2000).
Theory . A basic assumption of CBASP is that clients can learn to analyze
speciﬁc life situations and then manage daily stressors on their own. The basic18 Diagnosis and Treatment of DSM-5 Personality Disorders

premise of CBASP is simple and straightforward: a therapist assists clients to
discover why they did not obtain a desired outcome by evaluating theirproblematic thoughts and behaviors. In short, therapists assist clients indetermining which thoughts and behaviors have gotten in the way of achievingwhat they wanted. Since there is often a mismatch between what a client wantsand what actually occurs in the client’s life, the CBASP approach can be utilizedwith a variety of distressing problems and presentations ranging from childbehavior problems and couples conﬂict to anxiety disorders and personalitydisorders, including Borderline Personality Disorder (Driscoll, Cukrowicz,Reardon, & Joiner, 2004). Interestingly, McCullough (2002) noted his reserva -
tions to utilizing CBASP with adults with severe Borderline Personality Disorder,particularly those with comorbid chronic depression.
Treatment . The overall goal of CBASP treatment is to identify the
discrepancy between what clients want to happen in a particular situation andwhat has happened or is actually happening. By examining their speciﬁc circum -
stances, clients gradually discover problematic themes and patterns in their livesas well as ways in which they can achieve what is desired.
There are two phases in CBASP treatment: elicitation and remediation. The
elicitation phase consists of six steps, which are framed by speciﬁc questions: Howwould you describe the situation? How did you interpret the situation?Speciﬁcally, what did you do and what did you say? What did you want to getout of the situation, i.e., what was your desired outcome?
What was the actual outcome of this situation? And, ﬁnally: Did you get what
you wanted?
During the remediation phase, behaviors and interpretations or cognitions are
targeted for change and revised so that the client’s new behaviors and cognitionswill contribute and result in the desired outcome. First, each of the client’sinterpretations of the situation is assessed to determine whether it helped orhindered the achievement of the desired outcome. Next, each of the client’sbehaviors is similarly analyzed to determine whether or not it helped or hinderedin the attainment of the desired outcome (Driscoll et al., 2004).
A modiﬁed version of this approach (Sperry, 2006b, 2014) is particularly useful
in working with personality-disordered individuals, particularly those who areassessed as low in learning from experiences. Such individuals have not hadsufﬁcient experience in learning from their mistakes because they, too, often engagein emotional thinking rather than in consequential thinking. This modiﬁedintervention strategy works by increasing consequential thinking. It focuses theindividual’s attention on the link between how their negative or self-defeatingthoughts and behaviors result in the negative consequence (actual outcome) theyend up with instead of the desired outcome that they really want. The strategyincludes nine steps, which begin with a cognitive and a behavioral analysis andproceed to process their interpretations and behaviors in terms of their desiredoutcome or consequence.Personality Disorders Today  19

Pattern-Focused Psychotherapy
Pattern-Focused Psychotherapy was developed by Len Sperry (Sperry, in press).
It is derived from Biopsychosocial Therapy which emphasizes pattern identiﬁca-
tion and pattern change (Sperry, 1998, 2000, 2006b), Cognitive Behavioral AnalysisSystem of Psychotherapy (CBASP) (McCullough, 2000), and Motivational
Interviewing (MI) (Miller & Rollnick, 2002). Both CBASP and MI are identiﬁed
as empirically supported treatments by the Society of Clinical Psychology
(Division 12) of the American Psychological Association.
Theory . Pattern is the predicable, consistent, and self-perpetuating style and
manner in which individuals think, feel, act, cope, and defend themselves (Sperry,2006b; Sperry, Brill, Howard, & Grissom, 1996). Patterns can be maladaptive oradaptive. Maladaptive patterns tend to be inﬂexible, ineffective, and inappropriate,and cause symptoms, impairment in personal and relational functioning, andchronic dissatisfaction (Sperry, 2010). If such a pattern is sufﬁciently distressingor impairing, it can be diagnosed as a personality disorder. In contrast, an adaptivepattern reﬂects a personality style that is ﬂexible, appropriate, and effective, andis reﬂective of personal and interpersonal competence (Sperry & Sperry, 2012).
Pattern-Focused Psychotherapy is based on four premises. The ﬁrst is that
individuals unwittingly develop a self-perpetuating, maladaptive pattern offunctioning and relating to others. Subsequently, this pattern underlies the client’s
presenting issues. The second premise is that pattern change is an essential
component of evidence-based practice. The third is that effective treatmentinvolves a change process in which the client and practitioner collaborate to identifythe maladaptive pattern, break it, and replace it with a more adaptive pattern. Atleast two outcomes result from this change process: resolution of the client’spresenting issue and increased well-being (Sperry & Sperry, 2012). The fourthpremise is that replacing non-productive thinking and behaviors with more
productive ones is likely to effectively and quickly lead to therapeutic change
that might otherwise occur with directly restructuring cognitions or modifying
behavior.
Practice . Pattern-Focused Psychotherapy begins with establishing a collab -
orative relationship and educating the client in the basic premises of this approach.Central to the assessment and case conceptualization process is the identiﬁcationof the maladaptive pattern, and then planning treatment that focuses on patternchange. Other key factors considered in planning treatment are level of readinessfor change, severity, skill deﬁcits, and strengths and protective factors.
A basic therapeutic strategy in the change process is to analyze problematic
situations reported by clients in terms of their maladaptive pattern. Clients areﬁrst asked to describe the situation and their resulting interpretations (thoughts)and behaviors. Then, they are queried about their expected outcome in contrastto the actual one that resulted. As therapy begins, clients inevitably report thatthey did not achieve their expected outcome. They are then asked about their20 Diagnosis and Treatment of DSM-5 Personality Disorders

interpretation and if each helped or hurt them in getting what they expected. If
not, they are asked what alternative interpretations would have helped themachieve. Their reported behaviors are analyzed as to whether they helped or hurtin achieving their expected outcome. If not, the focus is on identifying alternativebehavior which could achieve that end. Finally, the client’s level of importance of
changing the maladaptive pattern and level of conﬁdence in doing so are assessed
and therapeutically processed. Not surprisingly, a marker of therapeutic changeis that clients increasingly achieve their expected outcome as a result of shifting
to a more adaptive pattern.
In short, this therapeutic strategy focuses on identifying and changing a mal -
adaptive pattern to a more adaptive one primarily by replacing the nonproductive
interpretations and behaviors that underlie the maladaptive pattern. Other
modalities, including cognitive restructuring, behavioral activation, exposure, skills
training, reframing, interpretation, etc., might also be employed as adjunctivetreatments.
Mindfulness
Mindfulness is a form of awareness in which an individual can focus on thoughts,feelings, and experiences in the present moment with an attitude of acceptanceand without analysis or judgment. The practice of mindfulness can diffuse
negativity, aggression, and compulsivity without suppressing emotions or
indulging them (Marlatt & Kristeller, 1999). While mindfulness derives from theBuddhist tradition, it has recently been incorporated into medicine and
psychotherapy. Since it is associated with developing an awareness of alternativeperspectives and reducing habitual response patterns, mindfulness has beenproposed as a common factor across various therapeutic systems (Martin, 1997).
Linehan (2015) describes the application of mindfulness techniques as a way of
integrating acceptance into psychotherapy, emphasizing its association with
intentional rather than automatic information processing as well as the nonjudging,nonevaluative nature of mindfulness attention. Not surprisingly, mindfulness is
included in Linehan’s dialectical behavior therapy of borderline personality
disorder. Recently, mindfulness approaches have been incorporated in severalcognitive and cognitive behavioral treatment interventions, including depression(Segal, Williams & Teasdale, 2002; Teasdale et al., 2000), substance abuse(Marlatt, 1994), Borderline Personality Disorder (Linehan, 1994), panic disorder(Kabat-Zinn et al., 1992), binge eating (Kristeller & Hallet, 1999), generalizedanxiety disorder (Roemer & Orsillo, 2002), and obsessive compulsive disorder(Schwartz & Begley, 2002). There is mounting research evidence that mindfulness
is effective in these disorders as well as medical conditions such as stroke andTourette’s syndrome (Schwartz & Begley, 2002). The extent to which mindfulness
has become the core strategy in Teasdale’s approach to depression and otherPersonality Disorders Today  21

disorders is reﬂected in the name of his approach: “mindfulness-based cognitive
therapy “(Teasdale et al., 2000). It is also interesting to note that Young’s SchemaTherapy (Young, Klosko, & Weishaar, 2003) has incorporated mindfulness as akey strategy in the treatment of personality disorders.
Schema Therapy
Schema Therapy is an elaboration of cognitive therapy that has been developedby Young (1990, 1999; Young et al., 2003) speciﬁcally for personality disorders,and other difﬁcult individual and couples problems. It integrates elements ofAdlerian psychology, behavior therapy, object relations, and Gestalt therapy intoa systematic approach to treatment. Recently, it has incorporated mindfulness forclients sensitive to the spiritual dimension.
The most basic concept in Schema Therapy is an Early Maladaptive Schema.
Schemas are deﬁned as broad, pervasive themes regarding one’s view of self andof others that were developed during childhood and elaborated throughout one’s
lifetime. They are enduring and self-defeating patterns that typically begin early
in life—although they can also form in adulthood, cause negative/dysfunc tional
thoughts and feelings, and interfere with accomplishing goals and meetings one’sneeds. These schemas are perpetuated behaviorally through the coping styles ofschema maintenance, schema avoidance, and schema compensation (Young,1999).
Young (1999; Young et al., 2003) has identiﬁed 18 schemas. They develop
in childhood from an interplay between the child’s innate temperament and the
child’s ongoing damaging experiences with parents, siblings, or peers, and becausethey begin early in life, schemas become familiar and thus comfortable. We distortour view of the events in our lives in order to maintain the validity of our schemas,
which may remain dormant until they are activated by situations relevant to thatparticular schema.
These schemas are arranged into ﬁve broad developmental categories of
schemas called schema domains. Each of these domains represents an important
component of a child’s core needs. Schemas interfere with the child’s attemptsto get the core needs met within each domain.
Table 1.2  provides a capsule description of these schemas and domains.
Schema Therapy involves identifying maladaptive schemas, deciding on the
appropriate level of change, and planning interventions to effect this level or degreeof change. Differing levels of schema change are noted: schema reconstruction,schema modiﬁcation, interpretation and schema camouﬂage. Schema reconstruc -
tion—i.e., maladaptive replacing the schema with a more functional one—is themost extensive level of transformation and often involves long-term treatment,
whereas schema camouﬂage is the least extensive and may be a more appropriate
goal in shorter-term treatment (Young, 1999; Young et al., 2003).22 Diagnosis and Treatment of DSM-5 Personality Disorders

Personality Disorders Today  23
TABLE 1.2 Maladaptive Schemas and Schema Domains
Disconnection and Rejection
•Abandonment/Instability: The belief that signiﬁcant others will not or cannot
provide reliable and stable support.
•Mistrust/Abuse : The belief that others will abuse, humiliate, cheat, lie,
manipulate, or take advantage.
•Emotional Deprivation : The belief that one’s desire for emotional support will
not be met by others.
•Defectiveness/Shame : The belief that one is defective, bad, unwanted, or inferior
in important respects.
•Social Isolation/Alienation: The belief that one is alienated, different from
others, or not part of any group.
Impaired Autonomy and Performance
•Dependence/Incompetence: The belief that one is unable to competently meet
everyday responsibilities without considerable help from others.
•Vulnerability to Harm or Illness: The exaggerated fear that imminent
catastrophe will strike at any time and that one will be unable to prevent it.
•Enmeshment/Undeveloped Self : The belief that one must be emotionally close
with others at the expense of full individuation or normal social development.
•Failure: The belief that one will inevitably fail or is fundamentally inadequate in
achieving one’s goals.
Impaired Limits
•Entitlement/Grandiosity : The belief that one is superior to others and not bound
by the rules and norms that govern normal social interaction.
•Insufﬁcient Self-Control/Self-Discipline : The belief that one is incapable of
self-control and frustration tolerance.
Other-Directedness
•Subjugation: The belief that one’s desires, needs, and feelings must be suppressed
in order to meet the needs of others and avoid retaliation or criticism.
•Self-Sacriﬁce: The belief that one must meet the needs of others at the expense of
one’s own gratiﬁcation.
•Approval-Seeking/Recognition-Seeking : The belief that one must constantly
seek to belong and be accepted at the expense of developing a true sense of self.
Overvigilance and Inhibition
•Negativity/Pessimism: A pervasive, lifelong focus on the negative aspects of life
while minimizing the positive and optimistic aspects.
•Emotional inhibition: The excessive inhibition of spontaneous action, feeling, or
communication—usually to avoid disapproval by others, feelings of shame, or losingcontrol of one’s impulses.
•Unrelenting Standards/Hypercriticalness: The belief that striving to meet
unrealistically high standards of performance is essential to be accepted and to avoid
criticism.
•Punitiveness. The belief that others should be harshly punished for making errors.

Structured Treatment Interventions
Unlike schemas which reﬂect the psychological dimension of personality,
temperament—i.e., the innate, genetic, and constitutional aspect of personality—
reﬂects its biological dimension. Temperament plays an important role in the
regulation and dysregulation of an individual’s affective, behavioral, and cognitivestyles (Sperry & Sperry, 2016). While research shows that medication canmodulate or normalize dysregulated behaviors, a similar modulating effect has
also been noted for social skills training (Lieberman, DeRisi, & Mueser, 1989).
Thus, it appears that social skills training is a relatively potent bottom-up treatmentstrategy for normalizing such limbic system mediated behaviors as impulsivity,
aggressivity, and mood lability, to name a few. Sperry (2015) contends that
personality-disordered individuals typically exhibit signiﬁcant skill deﬁcits, andthat structured skill training interventions are useful and necessary in successful
treatment of moderate to severe personality disorders. Skill deﬁcits can be reversed
by the acquisition of requisite skills in individual and group sessions throughpractice via modeling, coaching, role-playing, and graded task assignment. Sixteenstruc tured intervention strategies for modifying a personality-disordered
individual’s affective, behavioral, and cognitive temperament styles are describedand illustrated in Cognitive Behavior Therapy of DSM-5 Personality Disorders, Third
Edition (Sperry & Sperry, 2016). Table 1.3  lists these interventions.
Transference-Focused Psychotherapy
Transference Focused Psychotherapy (TFP) was developed by Otto Kernberg,
MD and associates (Clarkin, Yeomans, & Kernberg, 2015) for the treatment of
personality disorder, but initially for Borderline Personality Disorder. It is a highlystructured, manualized, evidence-based treatment approach.
TFP emerged in response to the failure of psychoanalysis to treat personality
disorders. While psychoanalysis beneﬁted some individuals, it was not helpful forthose with severe personality disorders. In fact, many with personality disordersappeared to worsen with psychoanalysis. Instead of concluding that the treat-ment method itself might be the cause, many concluded that personality disorderswere untreatable. The developers of TFP challenged this belief and went on tomodify and tailor the traditional psychoanalytic methods to severe personalitydisorders.
TFP is based on object relations theory, which contends that infants form
internal representations of themselves (“self”) and others (“objects”). Typically,these “objects” are early caregivers. These early self-object representations areconnected to each other through a dominant affect. In early stages of infantdevelopment, it is posited that positively toned, self-object representations developseparately from negative-toned representations. According to Kernberg, healthy24 Diagnosis and Treatment of DSM-5 Personality Disorders

adult personality development requires these split-off, positively and negatively
toned object representations to become integrated into a single, cohesive whole.On the other hand, when good and bad representations remain split off andseparate, a disintegrated personality organization, or personality disorder, is likelyto result.
Once formed, these object relationship pairs (dyads) serve as a map or template
by which later relationships can be understood and enacted. Such internalizedobject relations are thought to later play out in the individual’s life in importantrelationships. To the extent that an individual has an accurate map or template,a healthy and accurate understanding of future relationships is available. Incontrast, when the individual has an inaccurate, “split-off,” and polarized mapor template, interpersonal problems result. This also applies to the relationshipwith a therapist. Accordingly, the therapist is able to identify the nature of theproblem and its repair.
In transference-focused psychotherapy (TFP) the relationship that forms
between the therapist and patient is the mechanism of change. This means thatthe therapeutic relationship itself provides the means to identify and then correctthe problematic personality structure. The goal is to provide patients with acorrected template of relationships. This correction becomes possible through theprocess of “transference,” which occurs because the patient draws upon the faultyrelationship template formed during childhood. As transference occurs duringtherapy sessions, the therapist uses this experience as a framework for identifying,understanding, and updating these internal representations or templates. As TFPtherapists recognize this transference, they assist patients to understand and tomodify these internal representations.Personality Disorders Today  25
TABLE 1.3 Structured Treatment Interventions
1. Anger Management Training
2. Anxiety Management Training
3. Assertiveness Training
4. Distress Tolerance Training5. Emotional Regulation Training6. Empathy Training7. Impulse Control Training
8. Interpersonal Skills Training
9. Limit Setting
10. Mindfulness Training11. Problem-Solving Training12. Radical Openness Skills Training
13. Self-Management Training
14. Sensitivity Reduction Training15. Symptom Management Training
16. Thought Stopping

The primary goal of TFP is to assist patients in achieving a corrective emotional
experience by means of the therapeutic relationship. The therapist seeks to createan empathic and soothing relational climate that enables patients to directlyexperience painful, contradictory, and ambivalent feelings toward the therapist.In this safe and comforting setting, patients learn to confront and tolerate thedisturbing feelings that emerge when the chaotic and split-off, self-objectrepresentations are activated. This ability to tolerate these highly uncomfortablefeelings was not possible as an infant or child. The purpose of this process is toassist the patient to integrate split-off representations of self-and-other into acohesive whole. The ultimate goal of TFP is identity integration.
TFP differs from the traditional psychoanalytic treatment, in several ways. For
one, there is a very speciﬁc agenda and therapy contract. The contract addressesthe boundaries of the treatment, such as frequency and duration of sessions, phonecalls, and procedures when crises arise. The therapist is not simply a passive listener,but instead takes on a very active role in the therapy, asking pointed, clarifyingquestions, and challenging self-destructive or other negative behaviors. Ofparticular note is that the focus of treatment is on here-and-now, relationalproblems. Such a focus helps patients make connections between their presentrelationship with the therapist, and the current problems they experience withother relationships in their life. Furthermore, patients are expected to develop ameaningful and productive life outside of therapy by ﬁnding a job, engaging involunteer work, or continuing in school. Typically, therapy sessions are 45 minuteslong and meet twice weekly. When indicated, group treatment or involvementin a 12-step program may be recommended.
Mentalization-Based Treatment
Mentalization-Based Treatment (MBT) was developed by Anthony Bateman andPeter Fonagy (Bateman & Fonagy, 2007, 2009) for the treatment of personalitydisorders, particularly for Borderline Personality Disorder. MBT is primarily basedon attachment theory, wherein the basic premise is that infants have an inbornneed to seek closeness with their caregiver. When distressed, an infant’s attachmentbehaviors (e.g., smiling, clinging, crying) are activated in an order to elicit theresponse of soothing from a caregiver. How the caregivers respond greatly inﬂu -
ences the development of the child’s basic sense of security. Over time, childrendevelop an internal working model of relationships based on their inter actions with
caregivers, and this model inﬂuences other important relationships later in life.
To the extent caregivers respond appropriately in soothing and comforting
the child, a secure attachment is formed. As a result of secure attachments, childrenlearn to self-soothe and self-regulate their emotions as they model their caregiver’scomforting responses. To the extent the caregivers fail to respond appropriately,an insecure attachment is formed, and the child is less likely to engage in self-soothing and self-regulating behaviors.26 Diagnosis and Treatment of DSM-5 Personality Disorders

Mentalization is the ability to reﬂect upon, and to understand, one’s own state
of mind. It is the insightful understanding of what and why one is feeling. Mental -
ization develops by means of the caregiver’s empathic and insightful response toa child’s distress. It is learned through the experience of a secure attachment.
Mentalization is a critical coping skill necessary for effective emotional
regulation. For all practical purposes, mentalizing is like hitting the “pause” button.For example, the experience of a powerful negative feeling is usually coupledwith an intense urge to act or respond. The ability to tolerate brieﬂy that power -
ful feeling, and to reﬂect on it, can effectively deter one from acting on that intenseurge. Since the deﬁning characteristic of a personality disorder is relationaldifﬁculties, personality-disordered individuals typically have deﬁcits in this criticalskill. A basic premise of MBT is that mentalization must be learned to correctrelational difﬁculties. Accordingly, a basic goal of MBT therapy is to increase thecapacity for mentalization, a necessary skill.
Typically, this is how MBT therapy works. It begins with the development
of a warm and empathic therapeutic alliance which provides the context forlearning this skill of mentalization. Then, the therapist actively encourages thepatient to reﬂect upon current relational interactions. This includes interactionswithin therapy sessions. The mind of the patient becomes the focus of treatmentin that patients come to know and understand what their minds are thinking.They also learn to identify and label the feelings associated with what they arethinking. They learn to evaluate errors and misjudgments in themselves and othersthat have led to negative consequences. Usually, sessions for individuals arescheduled on a weekly basis, as are group sessions in which group members learnfrom one another.
Developmental Therapy
As increasing numbers of individuals seek or demand that psychotherapy helpthem to improve personal, relational, or professional performance—in other words,to become more fully functioning—therapists and focused therapies will rise tothe occasion. The developmental focus in psychotherapy that began to emergein the 1960s and 1970s (Blocher, 1974; Shostrum, 1976), and was subsequentlyeclipsed, is now being retrieved (Blocher, 2000; Cortright, 1997; Sperry, 2002).Such a developmentally focused approach conceptualizes an individual’s needsand concerns on a continuum ranging from pathological states to growth states.
The developmental perspective is particularly compatible with the treatment
of personality disorders, in that it conceptualizes problem-oriented and growth-oriented needs and views in dimensional rather than in categorical terms, i.e., ona continuum from the low to high level of functioning: disordered, adequate,and optimal functioning (Sperry, 2002). Such a developmental-dimensionalperspective is superior to the current DSM-5 categorical distinction betweenpathological functioning vs. normal functioning or optimal functioning. WhilePersonality Disorders Today  27

28 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 1.4 Developmental Levels of Personality: Optimal, Adequate, and Disordered
OBSESSIVE
Optimal Conscientious but spontaneous individuals who balance personal
integrity with generosity, hopefulness, and kindness.
Adequate Less perfectionism and rigidity in tasks and relationships, with
some degree of emotional involvement.
Disordered Perfectionism and feeling avoidance that interferes with task
completion and relationships; overly rigid thinking and attitudes;
pessimistic and stingy.
HISTRIONIC
Optimal Having found the love they seek within themselves, they are
altruistic and giving without expecting reciprocity.
Adequate While fun-loving and often impulsive, they can delay
gratiﬁcation and be emotionally appropriate much of the time.
Disordered Uncomfortable in situations in which they are not the center of
attention.
NARCISSISTIC
Optimal Energetic and self-assured without expecting special treatment or
privilege.
Adequate Conﬁdent, yet emotionally vulnerable, they favor special
treatment or privilege.
Disordered Manifest a grandiose sense of self-importance and demand special
AVOIDANT
Optimal While sensitive to interpersonal cues and possessing a keen
intuition about others, they are nonetheless respectful and
compassionate toward others.
Adequate Maintain a reserved demeanor around others, because they are
sensitive and concerned about others’ opinion of them.
Disordered Avoid social and work-related activities that involve signiﬁcant
interpersonal contact because of fear of criticism, disapproval, or
rejection.
SCHIZOID
Optimal Deeply grounded in themselves, they are emotionally connected
to the world.
Adequate Reasonably comfortable being around others, provided there are
limited demands for intimacy or emotional connectedness.
Disordered Neither desire nor enjoy close relationships.

Personality Disorders Today  29
TABLE 1.4 continued
DEPENDENT
Optimal May seek out the opinions and advice of others when making
major decisions, but the decisions they make are ultimately their
own.
Adequate Have the capacity to be responsible and make decisions, but still
seek out and rely on others for help and advice.
Disordered Need others to assume responsibility for most major areas of
their life.
ANTISOCIAL
Optimal Have the gift of gab and easily befriend others, although they
may not offer much depth to these relationships.
Adequate Earn respect by acting honorably and with compassion, by 
using power constructively and by promoting worthwhilecauses.
Disordered Exhibit aggressive, impulsive, self-serving, and irresponsible
behavior.
BORDERLINE
Optimal Sensitive, introspective, and impressionable individuals who are
very comfortable with their feelings and inner impulses.
Adequate They quickly and easily engage in relationships and are
sometimes hurt and rejected in the process.
Disordered Display frantic efforts to avoid real or imagined rejection and
SCHIZOTYPAL
Optimal Possess the unique capacity to view situations and life differently
so as to beneﬁt others.
Adequate Immersed in the unique and unusual, irrespective of whether it
has any socially redeeming value.
Disordered Exhibit odd, eccentric, or peculiar behavior, thinking, and
speech.
PARANOID
Optimal Highly observant and discerning, they can defend themselves
without losing control or becoming aggressive.
Adequate Thin-skinned, they are rather sensitive to and hurt by 
Disordered Suspicious, without sufﬁcient basis, that others are exploiting,
harming, or deceiving them.

it is true that third party payers may not easily be convinced that it is immediately
in their best interest to reimburse for therapy that focuses on optimal functioning,such a developmental-dimensional conceptualization can serve to not only guidetherapists’ decisions for optimizing treatment but also to guide outcomes researchon the cost-effectiveness of such treatment. A brief overview of these three levelsof functioning for each of the 10 personality disorders is presented in  Table 1.4 .
A protocol for conducting developmental therapy focused on increasing
optimal functioning is described by Sperry (2002). Other developmentalapproaches for fostering optimal functioning have been described by Cortright(1997) and Blocher (2000).
Medication Strategies
Traditionally, the use of medication in the treatment of personality disorders wasviewed as limited. Medication tended to be utilized only for a concurrent clinicaldisorder such as Bipolar Disorder or a target symptom like insomnia. This viewis rapidly changing. Today, a growing number of psychopharmacologists believethat psychopharmacological treatment can and should be directed to basicdimensions that underlie the personality. Psychopharmacological research ontreatment of selected personality disorders has grown rapidly in the past few years(Reich, 2002; Sperry, 2003). Until recently, medication treatment of personality-disordered individuals has been largely empirical, that is, largely trial and error.The reason is that there are still no speciﬁc drug treatments for DSM-5 personalitydisorders except for Avoidant and Borderline Personality disorders (Black,Zanarini, Romine, Shaw, Allen, & Schulz, 2014; Silk & Feurino, 2012).
Combined Treatment
There is growing consensus, among all segments of the mental health community,that effective treatment of the personality disorders involves combining treatmentmodalities and integrating treatment approaches (Sperry, 2006a). In manytreatment centers, this means individual therapy is combined with group therapyor psychoeducation groups, and it may include medication or other modalities.Combining medication with individual and group modalities tends to increaseeffectiveness. Such efforts to integrate various approaches, as well as to combinetreatment modalities, would have been considered heretical just a few years ago.Now, integrating and combining treatments is an emerging consensus that reﬂectsthe immensity of the “paradigm shift” that is occurring (Beitman, 2003; Sperry,2003).
Structure of Subsequent Chapters
Each chapter is divided into ﬁve major sections: overview, description, caseconceptualization, assessment, and treatment. The overview section provides a30 Diagnosis and Treatment of DSM-5 Personality Disorders

brief historical sketch of the disorder including its evolution in DSM. It also reports
an incidence/prevalence data on the disorder.
The section on Description provides an extensive discussion of the particular
personality disorder in biopsychosocial terms. Emphasized are aspects of temper -
ament such as cognitive style, affective style, behavioral style, and interpersonalstyle. To assist the clinician in both establishing whether the presentation is oneof disorder or style, and what the proﬁle of successful treatment of the disorderwould look like, descriptions, characteristic features, and case examples of boththe personality style and disorder are provided. Included are DSM-5 descriptions,prototypic descriptions, and prevalence data. Case conceptualizations can bethought of in terms of diagnostic, clinical, cultural, and treatment formulations(Sperry, Gudeman, Blackwell, and Faulkner, 1992; Sperry & Sperry, 2012). Thissection represents a diagnostic formulation of the disorder.
The next section contains ﬁve different case conceptualizations of the dis-
order. The ﬁve dominant clinical formulations are psychodynamic, the biosocial—represented largely by Millon (1981, 1990; Millon & Everly, 1985); the cognitive-behavioral in which the cognitive is represented largely by Beck and Freeman(1990) and the behavioral which is represented by Turkat (1990); the inter -
personal—described by Benjamin (1993); and the integrative or biopsychosocial—described by Sperry (1990, 2010a, 2015).
The section on Assessment describes typical interview behavior manifested by
the personality-disordered patient and the ease or difﬁculty of establishing rapport.It also describes characteristic response patterns common for this personalitydisorder on such psychological tests as the MMPI-I, the MCMI-II, which is basedon Millon’s (1981, 1990) biosocial formulation and research data; and twocommon projective tests, the Rorschach and the Therapeutic Apperception Test(TAT). Since psychological testing can be particularly useful in clarifying adimen sional characterization of the patient’s personality, i.e. where more than
one personality disorder or clusters of traits are present, this section may be clinicallyrelevant to psychologists and others who utilize psychological assessment. Thefollowing section on case conceptualization can be quite useful in understandingthe origins of these disorders.
Three general approaches most commonly utilized in the individual Treat-
ment of the disorder are detailed. They are the psychodynamic, the cognitive-behavioral, and the interpersonal approaches. The psychodynamic approachusually includes a description of the ways the traditional analytic method has beenmodiﬁed for this disorder in terms of expressive-supportive terms. The cognitivetherapy of personality disorder approach of Beck, Davis, and Freeman (2015) ishighlighted, and complemented with the research-based behavioral approach ofTurkat (1990) and others. Furthermore, Benjamin’s (1993, 2007) protocol forinterpersonal treatment is presented.
Other modalities of treatment relevant to the disorder are explored, along with
relevant research on theory indications and efﬁcacy. A unique feature of this bookPersonality Disorders Today  31

is the discussion of group, marital and family, and psychopharmacology modalities
for each disorder. The group treatment modality can be either homogeneous orheterogeneous, and structured and time-limited, or less structured and ongoing.Heterogeneous refers to the composition group being diverse in terms of32 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 1.5 Chapter Format
I. Overview and Background
II. Description
1. Deﬁning Characteristics
a. Style vs. Disorder
b. Triggering Event
c. Behavioral Style
d. Interpersonal Stylee. Cognitive Stylef. Affective Styleg. Attachment Style
h. Optimal Diagnostic Criterion
2. Prototypic Description
3. DSM-5 Description4. Prevalence
III. Case Conceptualization
1. Psychodynamic
2. Biosocial3. Cognitive-Behavioral4. Interpersonal
5. Integrative
IV. Assessment
1. Interview Behavior and Rapport
2. Psychological Testing Data
a. MMPI-2
b. MCMI-IVc. TAT/Rorschach
V. Treatment Approaches and Interventions
1. Treatment Considerations
2. Individual Psychotherapy
a. Psychodynamic Approaches
b. Cognitive-Behavioral Approaches
c. Interpersonal Approaches
3. Group Therapy
4. Marital and Family Therapy5. Medication
6. Combined/Integrative Approaches

functioning. Homogeneous refers to the group composition being similar in terms
of personality types and level of functioning (Frances, Clarkin, & Perry, 1984).Homogeneous groups lend themselves to being structured, and time-limited.Finally, speciﬁc suggestions for combining modalities and integrating or blendingtreatment approaches, round out this section and the book.
Chapters 3  to 12 follow the same general format or chapter outline as noted
in Table 1.5 .
Deﬁning Characteristics of Personality Disorders
A key to providing effective treatment of the personality disorders is an in-depth
understanding of how and why personality disorder pathology develops as wellhow it is experienced by the both personality-disordered individual and relatedothers. Although the narrative of each chapter—in the Description section—provides a detailed description of a given personality disorder, a table providinga capsule summary of these deﬁning characteristics is included in each chapter. Its
purpose is to facilitate both initial learning about the disorder and to serve as asubsequent reference source. Table 1.6  lists these characteristics. This is followed
by a brief description of each these 12 characteristics.
Triggering event(s) . The characteristic and predictable situations, circum -
stances, or other stimuli that initiate a characteristic maladaptive response—in familyor intimate relations, in social situations, or in work settings (Othmer & Othmer,2002)—are reﬂected in the individual’s behavioral, interpersonal, cognitive, andaffective styles. Triggering events can be intrapersonal, such as failing an exam,or interpersonal, for instance a narcissistic injury.
Behavioral style . The characteristic way in which an individual reacts
personally to a triggering event. Examples include: self-centeredness, impatience,defensiveness, arrogance, etc.Personality Disorders Today  33
TABLE 1.6 Deﬁning Characteristics of a Personality Disorder
• Triggering Event(s)
• Behavioral Style• Interpersonal Style
• Cognitive Style• Affective Style• Temperament• Attachment Style• Parental Injunction• Self-Other Schema• Maladaptive Core Schemas
• Optimal Diagnostic Criterion

Interpersonal style . The characteristic way in which an individual relates to
others. Examples include: exploitive, disdainful, socially facile without empathy,pleasing, clinging, blaming, condescending, etc.
Cognitive style . The characteristic way in which an individual perceives and
thinks about a problem and then conceives and implements a solution. Examples
of such styles include analytic, methodical, global or thematic, cautious, careless,
etc.
Affective style . The characteristic way in which an individual responds with
various types and intensities of affects. Examples of such styles include anger, rage,
elation, and mood lability.
Temperament . An inborn, characteristic response pattern reﬂecting an
individual’s energy level, emotional makeup, intensity, and tempo of response
which serve as “a ﬁlter of personality through which information is processed,
attachments evolve, and emotions are experienced and expressed” (Graybar &Boutilier, 2002, p. 156). Examples of such styles include: inhibited, impulsive,reﬂective, and aggressive.
Attachment style . The pattern of adult relating reﬂecting the emotional bond
between parent and infant which inﬂuences affect regulation, psychologicalresilience, access to autobiographical memory, and the development of self-reﬂection and narrative. Styles are either secure or insecure (Ainsworth et al.,1978; Erdman & Caffery, 2003). Examples of insecure styles noted in personality-disordered individuals include preoccupied, fearful, dismissing, and disorganizedstyles.
Parental injunction . An expressed or implied parental expectation for what
a child should be or how they should act. Examples of such injunctions are: “Youcan’t do it by yourself,” “You must be better to be worthwhile,” “Never make
mistakes.”
Self-other schema . This schema involves self-view and view of others. An
individual’s self-view or personal conception of self includes a self-evaluation of
abilities, personal worth, potential, and goals. Examples of such self-convictions
include: “I am defective,” “I need the attention of others to feel important andworthwhile,” “I am special and entitled” (Sperry, 2015). 
An individual’s evaluative conception of others includes beliefs about human
nature, the world, and other people. Examples of such convictions include: “life
is a struggle,” “people can’t be trusted,” “other are here to take care of me” (Sperry,2015).
Maladaptive core schemas . Schemas are enduring and self-defeating patterns
regarding one’s view of self and of the world and others that are developed duringchildhood and elaborated throughout one’s lifetime. They cause negative thoughtsand feelings, and interfere with accomplishing goals and meetings one’s needs
(Young et al., 2003). Examples of such schemas include: defectiveness, social
isolation, approval-seeking, self-sacriﬁce.34 Diagnosis and Treatment of DSM-5 Personality Disorders

Optimal diagnostic criterion . It’s believed that if clinicians can remember
one key criterion for each personality disorder, they “could then test for thepresence or absence of that criterion and quickly diagnose the personality disorder”(Allnutt & Links, 1996, p. 22). An optimal criterion is derived from threecharacteristics: its protypicality, i.e., having a high correlation with the sum ofall criteria for that disorder; an apt behavioral description; and a high positivepredictive value, i.e., the probability the individual has the criteria of the targetdisorder. Data on protypicality and predictive value were derived from researchwith the Structured Interview for Diagnosing Personality—Revised (Allnutt & Links,
1996)
Concluding Note
At the outset of this new millennium, clinicians are considerably more conﬁdentand effective in working with personality-disordered individuals than at any timein the history of psychiatry and the mental health sciences. Whereas 20 years agomany, if not most, clinicians believed these disorders to be untreatable, nowclinicians can point to both clinical experience and research evidence that indicatethat personality-disordered individuals, including those with BorderlinePersonality Disorder, can be helped to increase their functioning and well-being.As chronicled in the ﬁrst edition of this book, the emerging shift in the treatmentparadigm of the personality disorders is now fully underway and promises to be
as exciting and far-ranging as was the earlier paradigm shift in diagnosing and
treating the depressive disorders.
This chapter has previewed a number of cutting-edge developments involving
the conceptualization, assessment and diagnosis, and treatment of the DSM-5personality disorders. Many of these developments in diagnosis and treatment areincorporated in subsequent chapters. My hope is that this revised edition willfurther foster an attitude of conﬁdence and a measure of competence in clinicianswhen working with personality-disordered individuals.Personality Disorders Today  35

2
CASE CONCEPTUALIZATION 
AND THE EFFECTIVE TREATMENT OF PERSONALITY DISORDERS
In this age of accountability, effective clinical practice presumes that clinicians
will conduct a focused clinical assessment and develop a compelling case con -
ceptualization based on it. The case conceptualization then becomes the basis formaking informed clinical decisions about treatment tailored to the individual’scircumstances and level of functioning. In other words, the case conceptualizationis central to achieving effective treatment outcomes with difﬁcult-to-treatindividuals, particularly those with personality disorders.
This chapter describes the clinical value of an integrative case conceptualization.
It deﬁnes and describes case conceptualization and its components and elements,making the case for the centrality of the case conceptualization as the bridge thatlinks assessment with treatment, and particularly in informing treatment goals andinterventions. It is argued that effective case conceptualizations are those withhigh levels of explanatory power and predictive power, and which focus onreplacing maladaptive patterns with more adaptive ones. Examples of caseconceptualizations for three of the most common personality disorders in clinicalpractice today are presented. Case material illustrates the discussion, beginningwith the interactive cases in the next section.
Clinical Illustrations
This is an interactive section which aims to involve you directly in the learningprocess. It begins with this question: How do you make clinical decisions inworking with personality-disordered individuals? Read the following two cases
and consider how you would approach them in terms of assessment, case
conceptualization, and interventions.

Case of Kiera
Kiera is a 33-year-old, never-married female who was ﬁrst diagnosed with
Borderline Personality Disorder after some 20 years of psychotherapy and drug
treatment. During this time she experienced mood instability, unstable relation -
ships, and life-threatening behaviors which led to several hospitalizations andongoing outpatient therapy. She began full-scale Dialectical Behavior Therapy(DBT) approximately two years ago, which consisted of individual DBT therapy,
phone consultations with her therapist during times in which she experienced
crises, and group psychoeducation.
The following developmental history was elicited. As a child she describes
herself as overly sensitive and emotionally dysregulated. Reportedly, her childhood
was marked by demanding, critical, and emotionally distant parents. Her parentsdivorced when she was about 4 years old, presumably because of her father’s
alcoholism. Her mother is described as “invalidating,” meaning that she denied,
disregarded, and erratically responded to Kiera’s concerns and experiences. Kierawas also blamed for not meeting her mother’s high expectations and standardsfor achievement and propriety. Over the years, she has been involved in several
intense, short-term relationships as well as many jobs, all of short duration.
She also reports a history of sexual abuse, initially by a babysitter at age 6,
which may be related to her hypersexuality throughout her adolescence and earlyadulthood. Her ﬁrst suicide attempt was at age 12, leading to the ﬁrst of manyhospitalizations. Since then she has engaged in various self-harming behaviors,including wrist-cutting. She began substance use at age 14 which escalated untilher early 20s. Reportedly, she has been sober for 10 years with ongoing AA and
NA involvement. Kiera describes being involved in “every form of therapy” with
several therapists for nearly 20 years for moodiness, substance abuse, and self-harmful behavior before beginning individual and group DBT.
What other pertinent information might you need to complete your
assessment? What is your case conceptualization, diagnosis, and intervention plan?We’ll return to the case of Kiera and these questions near the end of this chapter.
Case of Aimee
Aimee is a 30-year-old single mother of two boys, aged 12 and 11. She’scurrently employed as a limousine driver and attends graduate school part-time.Her stated reason for seeking therapy was to learn to deal with anger and
resentment toward her mother. She describes herself as passive and hides her angerand resentment, but she displays these feelings “by beating myself up, runningmyself ragged,” which means she continually focuses on meeting the needs of
others and not relaxing nor enjoying life. Aimee is very careful and circumspect
in talking with her mother, fearful she will hurt her mother’s feelings. Essentially,Case Conceptualization and Effective Treatment 37

Aimee was abandoned by her mother as a child, and raised by her maternal
grandmother. She indicated that she was, and is, very close to her grandmother,and remains much closer to her father.
She also reported that her ex-husband had been verbally and physically abusive
to her and that he is being released from prison soon. In anticipation of his release,she worries for her safety and that of her children. Aimee reports that she remainsvery close to her father but quite emotionally distant from her mother. On theintake form she stated, “I have very angry feelings about her.” No current medicalproblems are reported, although she does report having somewhat severe head -
aches, anxiety, depression, trouble with sleeping, and bad dreams. Psychologicaltesting reveals a high need to please and being a victim .She reports that her greatest
worry is being alone. While Aimee had been involved in therapy previously, sheindicated that, while she understood her situation better, no positive changesoccurred.
What other pertinent information might you need to complete your assess -
ment? What is your case conceptualization, diagnosis, and intervention plan? We’llreturn to the case of Aimee and these questions near the end of this chapter.
Case Conceptualization
While the term “case conceptualization” is relatively new, clinicians andresearchers have used “case formulation” for more than 50 years (Tarrier, 2006).Common to most case conceptualization models, including the analytic,constructivist, interpersonal, psychodynamic, cognitive behavioral, and systemicapproaches, is the element of “pattern.” This is not to suggest that all approachesto case conceptualization are the same. However, while there are elements thatare unique in every approach, there are also some elements, such as pattern, thatare common among nearly all approaches (Eells, 2007, 2010). The remainder ofthis chapter describes an integrative approach to case conceptualization thatemphasizes common elements and can incorporate unique elements as well(Sperry & Sperry, 2012).
Case Conceptualization: Deﬁnition and Components
A case conceptualization is a way of summarizing diverse information in a brief,coherent manner for the purpose of better understanding and treating of theindividual. Furthermore, a case conceptualization consists of four components:the diagnostic formulation, clinical formulation, cultural formulation, andtreatment formulation (Sperry, 2010; Sperry & Sperry, 2012).
Diagnostic Formulation . A diagnostic formulation is a descriptive statement
about the nature and severity of the individual’s psychiatric presentation. Thediagnostic formulation aids the clinician in reaching three sets of diagnosticconclusions: whether the patient’s presentation is primarily psychotic, character -38 Diagnosis and Treatment of DSM-5 Personality Disorders

ological, or neurotic; whether the individual’s presentation is primarily organic
or psychogenic in etiology; and whether the individual’s presentation is so acuteand severe that it requires immediate intervention. In short, diagnosticformulations are descriptive, phenomenological, and cross-sectional in nature. Theyanswer the “What happened?” question. For all practical purposes the diagnosticformulation lends itself to being speciﬁed with DSM-5 criteria.
Clinical Formulation . A clinical formulation, on the other hand, is more
explanatory and longitudinal in nature, and attempts to offer a rationale for thedevelopment and maintenance of symptoms and dysfunctional life patterns.Clinical formulations answer the “Why did it happen?” question. Just as varioustheories of human behavior exist, so also do various types of clinical formulations:psychoanalytic, Adlerian, cognitive, behavioral, biological, family systems,biopsychosocial, or some combination. In this book, Cognitive Behavioral caseconceptualizations are emphasized.
Cultural Formulation . A cultural formulation is a systematic review and
explanation of cultural factors and dynamics that are operative in the presentingproblems. It answers the “What role does culture play?” question. More speciﬁc -
ally, it describes the client’s cultural identity and level of acculturation. It providesa cultural explanation of the client’s condition, as well as the impact of culturalfactors on the client’s personality and level of functioning. Furthermore, itaddresses cultural elements that may impact the relationship between the individualand the therapist, and whether cultural or culturally sensitive interventions areindicated.
Treatment Formulation . A treatment formulation follows from the
diagnostic, clinical, and cultural formulations and serves as an explicit blueprintgoverning treatment interventions. Rather than answering the “What happened?”or “Why did it happen?” questions, the treatment formulation addresses the “Whatcan be done about it, and how?” question.
The most useful and comprehensive case conceptualizations are integrative ones
that encompass all four components: diagnostic, clinical, cultural, and treatmentformulations (Sperry & Carlson, 2014; Sperry & Sperry, 2012). The format ofthe following chapters of this book will highlight integrative conceptual-izations. The diagnostic formulation will emphasize DSM-5 criteria; the clinicalformu lation will emphasize Cognitive Behavioral explanations; while the treat-
ment formula tion will suggest Cognitive Behavioral treatment goals and methods.
Basic Premises and Elements
In the opinion of many clinicians and researchers, case conceptualization is one
of the most challenging clinical competencies to master (Eells, 2010; Sperry &Sperry, 2012). The perceived difﬁculty in developing an effective case conceptual -
ization may be one reason why many therapists neither develop nor use caseconceptualizations, or they lack conﬁdence in their ability to conceptualize cases.Case Conceptualization and Effective Treatment 39

My experience is that both experienced therapists and trainees can easily and
conﬁdently begin to master this competency in as little as two to three hours offormal training. The training approach involves learning an integrated model ofcase conceptualization based on common and distinctive elements, and whichemphasizes the element of pattern, i.e., maladaptive pattern. Two basic premisesunderlie this integrative model.
Maladaptive Pattern . The ﬁrst premise is that individuals unwittingly
develop a self-perpetuating, maladaptive pattern of functioning and relating toothers. Inevitably, this pattern underlies the individual’s presenting issues. Effectivetreatment always involves a change process in which the client and therapistcollaborate to identify this pattern, break it, and replace it with a more adaptivepattern. At least two outcomes result from this change process: increased well-being and resolution of the client’s presenting issue.
Pattern Recognition and Change . The second premise is that pattern
recognition and pattern change is at the heart of the case conceptualization process.Pattern is the predictable, consistent, and self-perpetuating style and manner inwhich individuals think, feel, act, cope, and defend themselves (Sperry, 2005;Sperry et al., 1996). Pattern change involves three processes: (1) identify the mal -
adaptive pattern, (2) relinquish the maladaptive pattern and replace it with a moreadaptive pattern, and (3) maintain the adaptive pattern (Beitman & Yue, 1999).
Case Conceptualization: Elements
The integrative case conceptualization described in this chapter comprises 17elements, which are identiﬁed in Table 2.1  (Sperry & Sperry, 2012). Identifying
these elements is considered essential in conceptualizing cases involving individualswho meet the criteria for one or more personality disorders (Sperry & Sperry,2016).
Case Conceptualization: Strengths and Protective Factors
This integrative case conceptualization model accounts for strengths and protectivefactors as well as deﬁcits, and risk factors (Sperry, 2014). The inﬂuence of clientstrengths and protective factors—speciﬁed as one aspect of predisposition—is ofconsiderable clinical value in a case conceptualization, because it both “balances”strengths and protective factors with deﬁcits and risk factors, and provides a tangiblebasis for estimating prognosis.
Case Conceptualization: Full-Scale vs. Concise Case
Conceptualizations
Full-scale case conceptualizations include all or most of these 17 elements. As such,
a full-scale case conceptualization represents all four formulations: diagnostic,40 Diagnosis and Treatment of DSM-5 Personality Disorders

Case Conceptualization and Effective Treatment 41
TABLE 2.1 Elements of an Integrative Case Conceptualization
Presentation presenting problem and characteristic response to
precipitants
Precipitant triggers that activates the pattern resulting in presenting
problem
Pattern: maladaptive inﬂexible, ineffective manner of perceiving, thinking,
acting
Predisposition factors fostering adaptive or maladaptive functioning,
including protective factors , strengths, and risks 
factors
Perpetuants triggers that activate one’s pattern, resulting in
presentation
Cultural identity sense of belonging to a particular ethnic group
Culture: acculturation level of adaptation to the dominant culture; stress-
and acculturative stress rooted acculturation including psychosocial difﬁculties
Cultural explanation beliefs regarding cause of distress, condition, or
impairment
Culture vs. personality operative mix of cultural and personality dynamics
Treatment pattern ﬂexible, effective manner of perceiving, thinking, 
acting
Treatment goals stated short- and long-term outcomes of treatment
Treatment focus central therapeutic emphasis providing directionality to
treatment that is keyed to the adaptive pattern
Treatment strategy action plan and vehicle for achieving a more adaptive
pattern
Treatment interventions speciﬁc change techniques and tactics related to the
treatment strategy for achieving treatment goals andpattern change
Treatment obstacles predictable challenges in the treatment process anticipated
from the maladaptive pattern
Treatment—cultural incorporation of cultural intervention, culturally sensitive
therapy or interventions when indicated
Treatment prognosis prediction of the likely course, duration, and outcome 
of a mental health condition with or without 
treatment

clinical, cultural, and treatment formulations. In contrast, a concise case
conceptualization includes fewer elements. At a minimum, a concise case concep -
tualization should include presentation, precipitant, pattern, treatment goal(s), andtreatment intervention(s). To the extent that a concise case con ceptual ization 
is clinically useful, it must provide a reasonably compelling explanation for anindividual’s behavior and level of functioning. Because of its explanatory power,a case conceptualization, no matter how brief, cannot be considered merely a casesummary.
Case Conceptualizations: Explanatory, Tailoring, and
Predictive Power
A clinically useful case conceptualization has three characteristics. First, it provides
a high level of explanatory power , which means that the case conceptualization
provides a compelling explanation for the presenting problem that answers thequestion of why the individual acted the way he or she did. Second, it providesa high level of tailoring power , which refers to the selection of treatment inter -
ventions that are the “best ﬁt” to the individual’s style and functional proﬁle, andextent of symptom severity, level of functioning, and whether it is an internalizingor externalizing disorder. The selected interventions must also match thepresenting problem and the clinical, diagnostic, and cultural formulations and havea high likelihood of being successful for effecting change. Third, a clinically usefulcase conceptualization also provides a high level of predictive power —the
anticipation of both the most likely obstacles and facilitators to treatment success(Sperry & Sperry, 2012). All three are essential for effectively and competentlyplanning and guiding the treatment process.
Case Conceptualization: Case Example
The process of constructing an integrative case conceptualization is illustrated here. Following background information, there is an integrative assessmentsection that identiﬁes key information. This is followed by a table summarizingthe 17 elements from the diagnostic, clinical, cultural, and treatment formulationsfor the case. Then, a full-scale case conceptualization statement is provided thatintegrates this information in a coherent narrative. The ﬁrst paragraph reports thediagnostic and clinical formulation, the second paragraph reports the culturalformulation, and the third reports the treatment formulation. A concise caseconceptualization statement is also provided.
Case of Geri
Geri is a 35-year-old, African-American female who works as an administrativeassistant. She is single, lives alone, and was referred by her company’s human42 Diagnosis and Treatment of DSM-5 Personality Disorders

resources director for evaluation and treatment following three weeks of
depression and social isolation. Her absence from work prompted the referral.Geri’s symptoms began soon after her supervisor told her that she was beingconsidered for a promotion. As a child, she reports isolating and avoiding otherswhen she was criticized and teased by family members and peers. She is highlyacculturated, and believes that her depression is a result of work stress and a“chemical imbalance” in her brain.
Integrative Assessment
Besides diagnostic assessment information, the following biopsychosocialinformation was elicited. Her family history suggests a biological vulnerability todepression. Geri recalls her parents talking about her maternal aunt beingprescribed antidepressants. Besides moderate obesity, she reports reasonably goodhealth. She denies the use of medication, alcohol, or recreational drugs. Herdevelopmental and social history reveals demanding, critical, and emotionallydistant parents who reportedly provided her little emotional support and favoredher younger brother. In addition, she was regularly teased and criticized by herpeers in the neighborhood and at school. There is a lifelong history of socialisolation, rejection sensitivity, and avoidance of others, instead of ﬁghting backingor neutralizing the criticism and teasing of others. She reports no best friends asa child and only one coworker with whom she feels comfortable being around.Besides a paternal aunt, she has limited contact with her family. It is noteworthythat, despite the experience of being a college graduate and working for severalyears in an ofﬁce setting, she continues to have signiﬁcant skill deﬁcit in assertivecommunications, friendship skills, and problem-solving skills. Furthermore, shelacks conﬁdence in being around others whom she cannot fully trust. She meetscriteria for Major Depressive Disorder, Single Episode and for AvoidantPersonality Disorder with Obsessive-Compulsive traits. Table 2.2  summarizes the
elements of an integrative case conceptualization in the case of Geri (Sperry &Sperry, 2012).
Full-Scale Case Conceptualization
Geri’s increased social isolation and depressive symptoms ( presentation ) seem to
be her reaction to the news of an impending job transfer and promotion, givenher history of avoiding situations in which she might be criticized, rejected, andfeel unsafe ( precipitant ). Throughout her life, she found it safer to avoid others
when possible and conditionally relate to them at other times; as a result she lackskey social skills and has a limited social network ( pattern ). This is a mild-to-
moderate internalizing pattern designated as “moderate impairment” on theLevels of Personality Functioning Scale (LPFS) .Her reaction and pattern can be
understood in light of demanding, critical, and emotionally unavailable parents,Case Conceptualization and Effective Treatment 43

44 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 2.2 Integrative Conceptualization Elements: Case of Geri
Presentation increased social isolation and depressive symptoms
Precipitant talk of job promotion and transfer out of her close-knit
work group
Pattern: maladaptive avoid and disconnect from others when feeling unsafe
Predisposition Biological —family history of depression
Psychological —shy, avoidant, non-assertive; rejection
sensitive
Social —current: avoids critical and demanding people;
past: demanding, critical, emotionally, unavailable parents;teasing, taunting, critical peers
Protective factors/strengths —one trustworthy friend;
strong religious convictions against suicide; likely to
qualify for a return-to-work accommodation (ADA) 
re: psychiatric disability
Perpetuants maintained by her shyness, living alone, and generalized
social isolation
Cultural identity middle-class African American with limited ethnic ties
Acculturation and highly acculturated; no obvious acculturative stress
acculturative stress
Cultural explanation sadness results from job stress and chemical brain
imbalance
Culture vs. personality personality dynamics are signiﬁcantly operative
Treatment pattern connect with others while feeling safer
Treatment goals reduce depressive symptoms; increase socialization; return
to work
Treatment focus troublesome situations triggered or exacerbated by
vulnerabilities
Treatment strategy target social vulnerabilities and foster adaptive functioning;
medication; support; replacement; skill training
Treatment medication evaluation/ monitoring; supportive and 
interventions cognitive-behavioral interventions; psychoeducation
group; collaborate work supervisor
Treatment obstacles “test” practitioners; likely to resist group therapy;
overdependence on clinicians; difﬁculty with termination
Treatment—cultural gender may be an issue, so consider assigning supportive
female clinicians
Treatment prognosis good, if increased social connections, skills, and returns to
work

strong parental injunctions against making personal and family disclosure to
others, and the teasing and criticism of peers. Her family history of depressionmay biologically predispose her to sadness and social isolation, as did theunderdevelopment of relational skills ( predisposition ). This pattern is maintained
by her shyness, the fact that she lives alone, her limited social skills, and that sheﬁnds it safer to socially isolate ( perpetuants ).
She identiﬁes herself as a middle-class African American but has little interest
and no involvement with the African-American community ( cultural identity ).
She is highly acculturated, as are her parents, and there is no obvious acculturativestress ( culture: acculturation ). She believes that her depression is the result of stress
at work and a “chemical imbalance” in her brain ( cultural explanation ). There
are no obvious cultural factors that are operative. Instead, it appears that Geri’spersonality dynamics are signiﬁcantly operative in her current clinical presentation(culture vs. personality ).
The challenge for Geri is to function more effectively and feel safer in relating
to others ( treatment pattern ). The goals of treatment include reducing depressive
symptoms, increasing interpersonal and friendship skills, returning to work, andincreasing her social network ( treatment goals ). Treatment that is focused on
interpersonal relatedness will keep the treatment goals in the forefront of therapy(treatment focus ). The basic strategy for treatment is to target her vulnerabilities
while fostering a more adaptive pattern and functioning. Speciﬁc treatmentstrategies include medication, support, replacement, and skill training ( treatment
strategy). Initially, reducing her depressive symptoms will be addressed with
medication, support, and behavioral activation in an effort to sufﬁciently energizeher to accomplish daily routines and responsibilities. Next, cognitive and behaviorreplacement interventions will target her rejection sensitivity and isolation fromothers. Then, social skills training in a group therapy setting will emphasize assertivecommunication, trust, and friendship skill. It is very likely that Geri will be eli-gible for a work accommodation under the American for Disabilities Act (ADA).Presumably, she can return to the safety of her former work setting with apromotion and/or raise. Accordingly, this treatment goal can be facilitated by thetherapist consulting with her work supervisor and human resources director aboutsuch an accommodation. Treatment will be sequenced with medication manage -
ment by her physician (in consultation with the clinic’s psychiatrist), in additionto supportive and cognitive behavioral interventions beginning immediately inan individual treatment format which will prepare her to transition into a grouptreatment mode ( treatment interventions ). Some obstacles and challenges to
treatment can be anticipated. Given her avoidant personality structure, ambivalentresistance is likely. It can be anticipated that she would have difﬁculty discussingpersonal matters with practitioners, and that she would “test” and provoke prac -
titioners into criticizing her for changing or canceling appointments at the lastminute, being late, and that she might procrastinate, avoid feelings, and otherwise“test” the practitioner’s trustability. Once trust in the practitioner is achieved, sheCase Conceptualization and Effective Treatment 45

is likely to cling to the practitioner and treatment and thus termination may be
difﬁcult unless her social support system outside therapy is increased. Furthermore,her pattern of avoidance is likely to make entry into and continuation in grouptherapy and support groups difﬁcult. Therefore, indi vidual sessions can serve as a
transition into group, including having some contact with the group practitioner,who will presumably be accepting and nonjudg mental. This should increase Geri’s
feeling safe and making self-disclosure in a group setting less difﬁcult. Transferenceenactment is another consideration. Given the extent of parental and peercriticism and teasing, it is anticipated that any perceived impatience and verbal ornonverbal indications of criticalness by the practitioner will activate thistransference. Finally, because of her tendency to cling to others whom she trusts,increasing her capacity to feel more conﬁdent in functioning with greaterindependence and increasing time between the last four or ﬁve sessions can reduceher ambivalence about termination ( treatment obstacles ).
Concise Case Conceptualization
Geri’s increased social isolation and depressive symptoms seem to be her reaction
to the news of an impending job transfer and promotion. Throughout her life,she found it safer to avoid others when possible and conditionally relate to themat other times. This is mild-to-moderate internalizing pattern of “moderateimpairment” on the Levels of Personality Functioning Scale. Her pattern can be
understand in light of demanding, critical, and emotionally unavailable parents,strong parental injunctions against making personal and family disclosure toothers, the teasing and criticism of peers, and schemas of defectiveness and socialisolation. As a result she lacks key social skills and has a limited social network.Her family history of depression may biologically predispose her to sadness andsocial isolation, as did the underdevelopment of relational skills. This pattern ismaintained by her shyness, the fact that she lives alone, her limited social skills,and that she ﬁnds it safer to socially isolate. A more adaptive pattern is for herfeeling safe and connecting with others who are trustworthy. Initial treatmentgoals were to reduce her depressive symptoms and return to work. A longer-term goal is to increase social connections, which would reﬂect a more adaptivepattern.
Clinical Illustrations—Continued
Case of Kiera—Continued
When this case was ﬁrst presented, you were asked some questions: What else
would you need to complete your assessment? What is your case conceptual -
ization, diagnosis, and intervention plan? Here is the way I answered thesequestions.46 Diagnosis and Treatment of DSM-5 Personality Disorders

Additional Assessment Information . Despite several risk factors that
seemed to fuel her distress and self-mutilation, there have also been someprotective factors. These include the validation and ﬁnancial and emotional supportof Raymond, her mother’s ex-boyfriend, and a consistent and supportive workenvironment during the course of DBT therapy, both of which appear to havebeen signiﬁcant factors in her recovery. Kiera’s description of her relational patternas a cycle of accusing, arguing, crying, and further accusation was quite useful inframing the case conceptualization.
Diagnosis . Her DSM-5 diagnoses were Borderline Personality Disorder, Other
Speciﬁed Depressive Disorder, and Substance Related Disorders, in sustainedemission. On the Levels of Personality Functioning Scale (American Psychiatric
Association, 2013), her impairment was assessed as 3—severe impairment—which would be equivalent to 43 on the Global Assessment of Functioning (GAF)
scale.
Case Conceptualization . The following case conceptualization is offered.
Kiera presented with mood instability, unstable relationships, and life-threateningbehaviors, which were her reaction to feeling victimized or jealous or inanticipation of being abandoned. Her relationship difﬁculties involve the cycleof accusing, arguing, crying, and then more accusing. This reﬂects a maladaptivepattern of driving others away with unrealistic demands for closeness. It is a strongexternalizing pattern designated as “severe impairment” on the Level of Personality
Functioning Scale . The origins of this pattern include her oversensitivity to distress
and emotional dysregulation, her demanding, critical, and emotionally distantparents, and particularly her mother’s “invalidating” response to her. She viewsherself as helpless and vulnerable and views others as dangerous and uncaring.When under increased stress, she is most likely to experience feelings of abandon -
ment. She is particularly sensitive and ﬁnds it very difﬁcult to tolerate such negativeemotional states. She is also biologically vulnerable to substance abuse, distressintolerance, and impulsivity. Dialectical Behavior Therapy with group skillstraining in mindfulness, emotion regulation, distress tolerance, and interpersonaleffectiveness are interventions that, together with individual DBT therapy andtele phone consultation, are aimed at decreasing her distress intolerance and
increas ing her sense of self-control, emotional balance, and resilience.
Intervention Plan . The dynamics of this case strongly suggest that full-scale
DBT is the treatment of choice. This would include twice-weekly individualtherapy, telephone consultation, and group psychoeducation. Four speciﬁc goalswere established to focus treatment. They were: (1) decrease her suicidal and self-harming behaviors and achieve safety; (2) work through her emotional andtraumatic experiences and learn to survive them; (3) work through problems ofdaily living and maintain gainful employment; and (4) increase her capacity forexperiencing a fulﬁlling life and sustaining relationships. These treatment goalsdirectly reﬂect a more adaptive pattern of more effectively relating to otherswithout self-harm.Case Conceptualization and Effective Treatment 47

Clinical Outcome . Despite few, if any, reported treatment gains in her
previous 20 years of therapy, Kiera did respond positively to a full course of DBTand continuing care. An intensive course of twice-weekly individual and groupDBT were effective in ending to her distress, mood instability, unstablerelationships, and life-threatening behaviors. After one year she was in remissionof her personality disorder, and over the next two years she increasingly beganto experience a more fulﬁlling life.
Kiera’s story is an actual case, reported in Kiera Van Gelder’s autobiography,
The Buddha and the Borderline: A Memoir (Van Gelder, 2010). This engaging book
provides readers a ﬁrsthand account of the development of the BorderlinePersonality Disorder and her response to a full course of DBT.
Case of Aimee—Continued
When this case was ﬁrst presented, you were asked some questions: What elsewould you need to complete your assessment? What is your case concep -
tualization, diagnosis, and intervention plan? Here is the way I answered thosequestions.
Additional Assessment Information . There were some key strengths and
protective factors. Among these were the fact that she bonded to a caringmaternal grandmother, who effectively raised her when her own abusive motherwas absent for long periods of time. Although it was quite difﬁcult, Aimee wasable to leave her abusive husband knowing that her father would protect herfrom him. She is also articulate, hard-working, and perfectionistic. She also hasnotable skill deﬁcits in assertiveness and self-empowerment.
Diagnosis . Her DSM-5 diagnoses were Dependent Personality Disorder,
Obsessive-Compulsive Personality traits, and Other Speciﬁed Depressive Disorder. On the Levels of Personality Functioning Scale (American Psychiatric
Association, 2013), her impairment was assessed as 2—moderate impairment—which would be equivalent to 59 on the Global Assessment of Functioning (GAF)
scale.
Aimee presented with depression, fatigue, insomnia, anger at her mother, andworries about her children and ex-husband, which were her reactions to theincreased demands to care for others and the anticipation of her ex-husband’srelease from prison. Her maladaptive pattern involves focusing on meeting others’needs in a perfectionistic and overly conscientious manner while ignoring herown needs. Doing so allowed her to feel needed and worthwhile. This is a mildto moderate internalizing pattern designated as “moderate impairment” on theLevel of Personality Functioning Scale. The origins of this pattern include an
upbringing in which her parents were self-centered, highly critical, and overlydemanding while emotionally absent; as well as skill deﬁcits in assertivecommunication and self-care. It also included maladaptive beliefs about herself48 Diagnosis and Treatment of DSM-5 Personality Disorders

as being nice but deﬁcient, and a view of the world as demanding, critical, and
conditional. Initially, treatment was focused on decreasing symptoms ofdepression, fatigue, and insomnia. The longer-term goal was to balance meetingthe needs of others and her own needs in a reasonably conscientious manner,which was a more adaptive and life-giving pattern.
Intervention Plan . Three goals were speciﬁed as the focus of six planned
treatment sessions. They were: (1) decrease her presenting symptoms; (2) increaseher sense of empowerment; (3) take better care of herself. These treatment goalsdirectly reﬂect a more adaptive pattern of caring for others and also caring forherself. In the process of achieving these goals she effectively dismantled hermaladaptive behavior. Several intervention strategies were seamlessly combinedto achieve this new pattern and four treatment goals.
Clinical Outcome . This planned six-session treatment was provided by Dr.
Jon Carlson and is available as a DVD in the American Psychological Association’s“Psychotherapy Over Time” series (Carlson, 2006). In the last session, treatmentgains are discussed and Aimee indicates that she achieved all her speciﬁedtreatment goals. In a subsequent interview seven years after therapy was com -
pleted, Aimee reﬂects on the impact of this time-limited therapy. She indicatesthat she not only maintained the treatment gains but also extended these gainsto other areas of her life (Sperry & Carlson, 2014).
Like the case of Kiera, the case of Aimee is also an actual case, and is reported
in detail in How Master Therapists Work: Effecting Change from the First to the Last
Session and Beyond (Sperry & Carlson, 2014). Besides additional case history the
book contains session transcriptions, and commentaries on each therapy session.
Commentary on the Cases
It may be useful to step back and reﬂect on the successful outcomes of these twocases.
Like many individuals presenting for psychological treatment with personality
disorder diagnoses, both Kiera and Aimee experienced considerable early child -
hood abuse and neglect.
Both also had troubling symptoms and skill deﬁcits. However, both also had
notable protective factors and strengths that were not only recognized but also“incorporated” as therapeutic adjuncts to the treatment process by those therapistswho were most effective. For Kiera the support and validation of Raymond, andsupportive coworkers, appear to have been important and, presumably, necessaryfactors in her recovery. Similarly, having the experience of being raised by a caringgrandmother and then later leaving her abusive marriage were obvious strengthsand protective factors for Aimee.
The focused nature of the therapeutic interventions was obvious in both cases.
These case conceptualization-informed interventions were effective, whereasprevious therapeutic efforts for both Kiera and Aimee had not been effective. Case Conceptualization and Effective Treatment 49

In the case of Aimee, a focused form of talk therapy along with some skill training
(assertive communication) was a good “ﬁt” for her, largely because her cognitive,emotional, and behavioral styles—i.e., temperament—were reasonably wellmodu lated. In the case of Kiera, however, her cognitive, emotional, and behav -
ioral styles were so overly modulated that 20 years of talk therapy had little effect.It was not until Kiera developed sufﬁcient DBT skill mastery in emotionalregulation, distress tolerance, mindfulness, and interpersonal effectiveness that shewas able to proﬁt from focused psychotherapy.
When clinicians inform their therapy with case conceptualizations that have
high levels of explanatory power and predictive power, and they recognize and“incorporate” strengths and predictive factors, positive therapeutic outcomes arelikely. Of course, clinician expertise is also a factor. While not every clinicianwould be able to complete therapy with Aimee in only six sessions, it would notbe unreasonable for most therapists—including interns—to have similar resultsin 20 sessions. This assumes that they followed the case conceptualization’s focuson replacing Aimee’s maladaptive pattern with a more adaptive pattern, as Dr.Carlson did with Aimee.
Competency in working effectively with individuals diagnosed with personalitydisorders is increasingly expected of psychotherapists today, and competency incase conceptualization is perhaps the most important competency for effectiveclinical outcomes. This chapter has highlighted the value of an integrative caseconceptualization that effectively links assessment with treatment and informstreatment goals and interventions. Case conceptualizations with high levels ofexplanatory power, tailoring power, and predictive power are ones that focus onreplacing maladaptive patterns with more adaptive ones. Case conceptualizationsfor three of the most common personality disorders in clinical practice today—Avoidant, Borderline, and Dependent personality disorders—were presented. Casematerial on two actual cases illustrated key points.50 Diagnosis and Treatment of DSM-5 Personality Disorders

3
ANTISOCIAL PERSONALITY 
DISORDER
Individuals with antisocial personalities commonly present with assaultiveness,
impulsivity, hedonism, promiscuity, unreliability, and drug and alcohol abuse.Criminality may be involved. These individuals fail at work, change jobs fre -
quently, tend to receive dishonorable discharges from the military, are abusingparents and neglectful spouses, have difﬁculty maintaining intimate relationships,and may be convicted and spend time in prison. This disorder is similar but differentfrom the psychopathic personality disorder, which is also known as psychopathy,and sociopathy (Hare, Neumann, & Widiger, 2012).
This chapter describes a framework for the assessment and effective treatment
of this disorder. It includes sections on diagnosis, psychological assessment, caseconceptualization, and treatment interventions. It begins with background
information on the disorder as well as a DSM-5 description and a prototypic
description of this disorder. The section on case conceptualization provides ﬁvecommon clinical formulations of this disorder: psychodynamic, biosocial,
cognitive-behavioral, interpersonal, and an integrative conceptualization of this
disorder. Several treatment approaches, modalities, and intervention strategies arealso described. These include individual psychotherapy, group therapy, maritaland family therapy, medication, and integrative and combined treatment.
Description of the Antisocial Personality Disorder
Antisocial Personality Disorder can be recognized by the following descriptorsand characteristics: styles vs. disorders, triggering event, behavioral styles, inter -
personal styles, cognitive styles, affective styles, attachment style, and optimalcriterion.

52 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 3.1 Comparison of Antisocial Personality Style and Disorder
Personality Style Personality Disorder
Prefer freelancer living, and live well Unable to sustain consistent work 
by their talents, ingenuity, and wits. behavior.
Tend to live by their own internal code Fail to conform to social norms with
of values and not much inﬂuenced by regard to lawful behavior, performingsocial norms, yet live within the law. acts that are grounds for arrest.
As adolescents were usually high- Irritable and aggressive as indicated by
spirited hellraisers and mischief makers. physical ﬁghts or assaults.
Can be responsible and meet ﬁnancial Irresponsible and fail to meet ﬁnancial
obligations. obligations.
Tend to be wanderlusts, but are able Fail to plan ahead, or act impulsively.
to make plans and commitments
Reasonably truthful, albeit gifted in using Have little regard for the truth, and lie,
words and making friends. use aliases, or “con” others for personal
proﬁt.
Tend to be courageous, physically bold, Reckless regarding their own and 
and tough; will stand up to those who others’ personal safety, as indicated by take advantage of them. driving while intoxicated or recurrent
speeding.
Tend not to worry too much about others, If a parent or guardian lacks the ability 
expecting others to be responsible for to function as a responsible parent.themselves.
Have strong libido and, while may desire Have never sustained a totally 
several partners, can remain monogamous. monogamous relationship for extended
periods of time.
Tend to live in the present and seldom Lack remorse and feel justiﬁed in 
experience much guilt. having hurt, mistreated, or stolen from
another.Style vs. Disorder . The antisocial personalities can be thought of as spanning
a continuum from healthy to pathological, wherein the antisocial personality styleis on the healthy end, and the Antisocial Personality Disorder is on the pathologicalend. Table 3.1  compares and contrasts the antisocial personality style and disorder.
The following two cases further illustrate differences between the Antisocial
Personality Disorder (Juan G.) and the antisocial personality style (Gordon J.).

Because individuals with Antisocial Personality Disorder, Psychopathic
Personality Disorder, and Sociopathic Personality Disorder can engage in criminalbehavior, some clinicians use the three terms interchangeably. Because researchindicates some notable differences in behavior and in etiology, others prefer todifferentiate psychopathy and sociopathy (Hare et al., 2012; Walsh & Wu, 2008).Antisocial Personality Disorder 53
CASE STUDY: ANTISOCIAL PERSONALITY DISORDER 
Juan G. is a 28-year-old Cuban male who presented late in the evening to
the emergency room at a community hospital complaining of a headache.
His description of the pain was vague and contradictory. At one point hesaid the pain had been present for three days, while at another point it was
“many years.” He indicated that the pain led to violent behavior and
described how, during a headache episode, he had brutally assaulted a medicwhile he was in the Air Force. He gave a long history of arrests for assault,burglary, and drug dealing. Neurological and mental status examinations were
within normal limits, except for some mild agitation. He insisted that only
Darvon—a narcotic—would relieve his headache pain. The patient resisteda plan for further diagnostic tests or a follow-up clinic appointment, sayingunless he was treated immediately, “something really bad could happen.”
CASE STUDY: ANTISOCIAL PERSONALITY STYLE
Gordon J. is the 38-year-old president of a rapidly expanding manufacturingcompany. He has taken over the small business that his uncle had foundedafter the Second World War and Gordon had greatly increased production,added new product lines and formed a marketing and sales group, which
he personally supervised in the nine years he had run the company. Prior to
taking over the company, Gordon had become the youngest member of themillion-dollar club for selling real estate for the ﬁrm that he had worked forfor just three years. His father had died in a freak skiing accident when Gordon
was 11, but that didn’t seem to stop him from pursuing his fascination with
scuba diving and hang-gliding. Gordon was invited to join the YoungPresident’s Organization (YPO) in his region soon after turning his uncle’scorporation into a highly proﬁtable enterprise. He was quite popular in the
group given his magnetic personality, visionary outlook, and captivating
stories of his various exploits. He had been married for nearly ﬁve years beforedivorcing. Since then he has not remarried, but has maintained ongoingrelationships with two women.

Psychopathic Personality Disorder
Psychopathic personality disorder—also referred to as psychopathy—is a mental
disorder characterized by amoral behavior, extreme self-centeredness, andinterpersonal deﬁcits, such as grandiosity, arrogance, and deceitfulness, and globallack of empathy. Affective deﬁcits such as lack of guilt and remorse are also noted.According to the Psychodynamic Diagnostic Manual (PDM) (PDM Task Force, 2006),
this disorder is diagnosable by the following criteria: individuals exhibit highthreshold for emotional stimulation and aggressiveness; they are preoccupied withmanipulating others; their basic emotions tend to be rage and envy; their viewof themselves is that they are omnipotent, in that they believe that they can makeanything happen and control everything; and their view of others is that everyoneis selﬁsh, manipulative, or dishonorable.
Furthermore, their basic way of defending themselves is by attempting to
control everything around them. Psychopaths are not common in corporate settingsand may engage in and elude criminal prosecution by cleverly exploiting loopholesin regulations (Babiak & Hare, 2007).
The diagnosis of Psychopathic Personality Disorder has not appeared in the
DSM since the ﬁrst edition; however, it reappears as a speciﬁer: “withpsychopathic features” for Antisocial Personality Disorder in the “Alternative DSM-5 Model for Personality Disorders” (American Psychiatric Association, 2013).
Sociopathic Personality Disorder
Sociopathic personality—also known as sociopathy—is a mental disordercharacterized by amoral and criminal behavior and a diminished sense of moralresponsibility. Individuals with this disorder tend to spontaneously act out ininappropriate ways without thinking through the consequences. They may benervous, easily agitated, and quick to display anger. They will lie, manipulate,and hurt others, but will often avoid doing so to the select few individuals theycare about. Most often they are able to form attachments and loyalties to others.This means that they are likely to experience guilt and remorse when shouldthey end hurt someone they care about. While they are capable of committingheinous crimes, they are unlikely to commit crimes against family or friends. Unlikethe psychopathic personality, which research suggests has more genetic loading,the sociopathic personality appears to be more inﬂuenced by environmental factorssuch as poverty, exposure to violence, and overly permissive or neglectfulparenting (Stout, 2005). The Sociopathic Personality Disorder only appeared inDSM-II.
Triggering Event . The typical situation, circumstance, or event that most
likely triggers or activates the characteristic maladaptive response of the Anti-social Personality Disorder (Othmer & Othmer, 2002), as noted in behavioral,interpersonal, cognitive, and affective styles, is “social standards and rules.”54 Diagnosis and Treatment of DSM-5 Personality Disorders
tend to spontaneously act out in
inappropriate ways without thinking through the consequences. 
lie, manipulate,
and hurt others, will often avoid doing so to the select few individuals they
care about. able to form attachments and loyalties to others.
d are likely to experience guilt and remorse when should
they end hurt someone they care about.
 unlikely to commit crimes against family or friends. amoral behavior, extreme self-centeredness, and
interpersona l deﬁcits, suc h as gran diosity, arrogance, an d deceitfulness, an d global
lack of empathy. A  lack of guilt and remorse 
high
threshold for emotional stimulation and aggressiveness;
manipulating rage and envy;
 omnipotent, 
d control everything;  that everyone
is selﬁsh, manipulative, or dishonorable.

Behavioral Style . The behavioral style of antisocial personalities is charac -
terized by impulsivity, irritability, and aggressiveness. They are likely to beirresponsible in honoring work commitments and ﬁnancial obligations. Rule-breaking is typical. Antisocial personality-disordered individuals are also notedfor their impulsive anger, deceitfulness, and cunning. They tend to be forcefulindividuals who regularly engage in risk-seeking and thrill-seeking behavior.
Interpersonal Style . Their interpersonal style is characterized by antagonism
and reckless disregard of others’ needs and safety. They tend to be highlycompetitive and distrustful of others and often poor losers. Their relationshipsmay at times appear to be “slick” as well as calculating. These behaviors can charac -
terize the successful businessperson, politician, lawyer, medical professional, aswell as the criminal. They tend to develop superﬁcial relationships that involvefew, if any, lasting emotional ties or commitments. Furthermore, they tend tobe callous toward the pain and suffering of others.
Cognitive Style . The cognitive style of the antisocial personality is described
as impulsive and cognitively inﬂexible as well as externally oriented. They tendto be keenly aware of social cues and may be quite adept at “reading” peopleand situations. Because they are contemptuous of authority, rules, and social norms,they easily rationalize their own behavior. Impulsivity, irritability, and aggressivitypredispose them to argumentation and even assaultive action. Recent researchindicates that there tends to be signiﬁcant neuropsychological impairment inindividuals diagnosed with this disorder. In particular, there is likely to beimpairment in executive functioning tasks of planning ability and set shifting (Dolan& Park, 2002).
Affective Style . Their emotional or affective style is characterized as shallow
and superﬁcial. They avoid “softer” emotions such as warmth and intimacy,because they regard these as signs of weakness. Guilt is seldom, if ever,experienced. They are unable to tolerate boredom, depression, or frustration andsubsequently are sensation-seekers. Finally, they may show little guilt, shame, orremorse over their own deviant actions.
Attachment Style . Individuals with a view of others that is negative and a
self-view that vacillates between positive and negative exhibit a composite fearful-dismissing style of attachment. They tend to view themselves as special and entitled,but are also mindful of their need for others, who can potentially hurt them.Accordingly, they use others to meet their needs while being wary and dismissiveof them. The fearful-dismissing attachment style is associated with the AntisocialPersonality Disorder.
Optimal Diagnostic Criterion . Of all the diagnostic criteria for the
Antisocial Personality Disorder, one has been found to be the most useful indiagnosing this disorder. The belief is that, by beginning with this criterion, theclinician can test for the presence or absence of the criterion and more quicklydiagnose the personality disorder (Allnutt & Links, 1996). The optimal criterionfor this disorder is criminal, aggressive, impulsive, irresponsible behavior.Antisocial Personality Disorder 55
impulsivity, irritability, and aggressiveness.
irresponsible 
competitive and distrustful reckless disregard of others’ needs and safety.
poor losers.
 “slick” as well as calculating. 
businessperson, politician, lawyer, medical professional, as
well as the criminal. tend to develop superﬁcial relationships that involve
few, if any, lasting emotional ties or commitments. 
callous toward the pain and suffering of others.
impulsive and cognitively inﬂexible 
keenly aware of social cues and may be quite adept at “reading” people
and situations. B
avoid “softer” emotions such as warmth and intimacy,
because they regard these as signs of weakness. Guilt is seldom, if ever,
experienced. unable to tolerate boredom, depression, or frustration and
subsequently are sensation-seekers. r w little guilt, shame, or
remorse 
h a view of others that is negative and a
self-view that vacillates between positive and negative  fearful-
dismissing  view themselves as special and entitled,

DSM-5 Description
Individuals with this personality disorder are characterized by an unremitting
pattern of disregarding and violating the rights of others. They disrespect and
disregard laws and social norms, and regularly engage in acts that are grounds for
arrest. These individuals lie, are deceitful, and will take advantage of others forpleasure or for personal proﬁt. They are impulsive and fail to plan ahead. Theyare also irritable and aggressive, which results in physical ﬁghts or assaults. It is
not surprising that these individuals disregard the safety of others as well as
themselves. Their irresponsibility is demonstrated by their failure to engage inconsistent work behavior and failure to meet ﬁnancial obligations. Furthermore,
their lack of remorse is shown by their indifference in having hurt, mistreated,
or stolen from others (American Psychiatric Association, 2013).
The “Alternative DSM-5 Model for Personality Disorders” provides another
description of this disorder (American Psychiatric Association, 2013). It is
described as a failure to conform to legal and ethical norms, along with deceitful -
ness, manipulativeness and risk-taking. Characteristic difﬁculties are noted inidentify, self-direction, empathy, and intimacy, as well as impulsivity and irre -
sponsibility.
Prototypic Presentation
A prototype is a brief description that captures the essence of how a particulardisorder commonly presents. Prototypic descriptions are useful and convenientand clinicians commonly rely on them rather than lists of behavioral criteria orcore beliefs (Westen, 2012). Here is a common prototypic description of theAntisocial Personality Disorder: These individuals displayed symptoms of ConductDisorder from early childhood, engaged in delinquent behavior as adolescents,and turned into selﬁsh, manipulative, and ruthless adults. Their primary interest
in others is what they can get from them. They manipulate, lie, cheat, and steal
and have no remorse or empathy for the harm they inﬂict on others. They arereckless, impulsive, and engage in criminal behavior. This disorder is common
among criminals and is a predictor of violence. Fortunately, by middle age these
individuals can outgrow this pattern.
Prevalence
Prevalence of this disorder has been estimated at between 0.2 and 3.3 percent in
the general population. However, it is greater than 70 percent in males with alcoholand substance use disorders in clinics, prison, and other forensic settings (AmericanPsychiatric Association, 2013).56 Diagnosis and Treatment of DSM-5 Personality Disorders
r lie, are deceitful, and will take advantage of others for
pleasure or for personal proﬁt.

Conceptualizations of the Antisocial Personality Disorder
Psychodynamic Case Conceptualizations
Psychoanalytic writers describe the antisocial personality as similar to the
narcissistic personality. While both form a pathological grandiose self, the antisocialindividual’s self is based on an aggressive introject, called the “stranger self-object”(Meloy, 1988). This self-object reﬂects an experience of the parent as a strangerwho cannot be trusted and who harbors bad will toward the infant. Notsurprisingly, this threatening internalized object derives from experiences ofparental neglect or cruelty. Combined with an absence of a loving maternal objectis a lack of basic trust and a ﬁxation in the separation-individuation process sothat object constancy does not occur. Since the mother is experienced as a strangeror predator, the infant’s emotional attachment to her is derailed, leading to adetachment from all relationships and affective experiences, as well as sadisticattempts to bond with others through destructive and controlling behaviors.
As a result the antisocial individuals do not perceive others as separate
individuals. Hence, they cannot develop the capacity for guilt and depressive
anxieties based on how their actions hurt others. A corollary is that they are
incapable of true depression. Kernberg (1984) notes that these antisocial individualsare similarly stunted in superego development, except for sadistic superego
precursors manifest by cruel and sadistic behaviors. Higher functioning antisocial
individuals are noted to have some development of consciousness withcircumscribed areas—called superego lacunae—where their superego does notseem to function. Furthermore, antisocial individuals show little interest inrationalizing or morally justifying behavior, or adherence to a value system otherthan the exploitive, aggressive exercise of power (Kernberg, 1984; Meloy, 1988).
Biosocial Case Conceptualization
There is mounting evidence that biological factors inﬂuence the development ofthe antisocial personality. Low levels of the neurotransmitter serotonin have beennoted in individuals prone to aggressive and impulsive behavior. Meloy (1988)suggests that antisocial individuals often have histories of childhood abuse orneglect. They are likely to have had a difﬁcult infant temperament (Thomas &Chess, 1977), meaning they were difﬁcult to soothe and comfort, which mayhave interfered with the normal attachment process, further increasing theprobability of childhood abuse or neglect. Millon and Everly (1985) suggest thatlow thresholds for limbic system stimulation are likely in antisocial individuals.Meloy (1988) adds that antisocial individuals have been found to be autonomicallyhyperactive, possibly because of their inability to learn from experience, and thusmanifest less anticipatory anxiety to deter them from ill-advised behavior.Antisocial Personality Disorder 57

Environmental factors such as parental hostility, deﬁcient parental role
modeling, and reinforcement of vindictive behavior appear to interact with thesebiological predisposing factors. Parental hostility may result from the child’sdisruptiveness with the parents, from the perception that these children are ill-tempered, or because these children are used as a scapegoat for the parents’ orfamily’s frustration. They often have had little or no parental guidance or theabsence of an authority ﬁgure in the home. Without such an authority ﬁgure tomodel, and feeling abandoned or rejected, these children often become streetwiseand hardened to the world around them. Out of these experiences they learnthat “the end justiﬁes the means,” “it’s a dog-eat-dog world,” and “you’ve gotto be strong and crafty to survive.” Not surprisingly, this deﬁant behavior is metwith social disapproval, which further reinforces their self-reliance and hardenedoutlook. As a result they learn not to trust others and, anticipating that othersintend to exploit or humiliate them, they strike out at others with vindictivebehaviors.
This personality pattern is self-perpetuated through consistent perceptual
distortion, a demeaning attitude toward affection and cooperation, and antag -
onistic and vindictive behavior that breeds antagonism in return. Further, thispattern is perpetuated by their fear of being used and forced into an inferior,dominated position (Millon & Everly, 1985).
Cognitive-Behavioral Case Conceptualizations
According to Beck (2015), the behavior of individuals with this disorder ispersistently irresponsible. They hold various core, conditional, and instrumentalbeliefs. Their core beliefs are that they must look out for themselves and be aggressive
so as not to be victimized by others. They also believe they are entitled to breakrules. They believe that their thoughts and feelings are always accurate, and thattheir choices are always right and good. In addition, they believe that feelings
make facts which means they are in the right because they feel right about their
actions. Their conditional belief is that if they don’t manipulate, exploit, or attach
others, they will never get what they deserve. Their instrumental belief is to get
others before they get you, and take what you need since you deserve it.Underlying these various beliefs are their beliefs about self and the world (Mitchell,
Tafrate, & Freeman, 2015).
These individuals tend to view themselves as strong, clever, self-sufﬁcient, and
invulnerable. They tend to view others as either weak and vulnerable, or stupidand exploitable. Accordingly, they have two strategies: they will openly attack,
defraud, and victimize others; or they will more subtly “con,” deceive, andmanipulate them (Beck, 2015). Furthermore, they are likely to dismiss unsolicited
counsel from others as irrelevant to their purposes. Finally, they tend to be present-
oriented, with absolutely no concern for future outcomes.58 Diagnosis and Treatment of DSM-5 Personality Disorders
 view themselves as strong, clever, self-sufﬁcient, and
invulnerable.y must look out for themselves and be aggressive
so as not to be victimized by others. k entitled to break
rules.
are always right and good.

From a more behavioral perspective, Turkat (1990) describes three subtypes
of this disorder: the clear sociopath—meaning the individual clearly and obviouslymeets DSM-5 criteria; the clever sociopath—wherein this individual feignspsychological symptoms usually to avoid legal responsibility for their actions; andthe hurting sociopath—who meets the DSM criteria but is sincerely and genuinelydistressed. For all three types, the core behavioral deﬁcits are in managingimpulses and anger. Of the three, only the hurting sociopath is consideredamenable to behavior therapy.
Interpersonal Case Conceptualization
For Benjamin (2003a), persons with Antisocial Personality Disorders typically havedevelopmental histories of harsh, neglectful parenting. The adult consequence ofthis is that the antisocial individual neglects and is insensitive to others’ needs, orexploits others. This unpredictable pattern of parenting tends to result inundermodulated parental control and blaming. The result is that, as an adult, theantisocial individual ﬁercely protects their autonomy. Furthermore, this patternof inept parental caring can be internalized by the antisocial individual as substanceabuse, criminal behavior, or parental dereliction of duty. The antisocial-to-be islikely to “take over” parental responsibilities, since no one else did. As aconsequence of this inappropriate parental role-taking, the antisocial individualis likely to continue controlling others as an end in itself, without emotionallybonding with those being controlled. In short, a sustained pattern of inappropriateand unmodulated desire for control of others is prominent. There is also a strongneed for independence, and for resisting being controlled by others, who aretypically held in contempt. Unbridled aggressivity is frequently utilized to sustaincontrol and independence. Finally, antisocial-disordered individuals may presentfriendly and sociable, albeit somewhat detached, since they have little regard forothers.
Integrative Case Conceptualization
The following integrative formulation provides a biopsychosocial explanation for how this personality is likely to have developed and how it is maintained.Biologically, antisocial personalities manifested “difﬁcult child” temperaments(Thomas & Chess, 1977). As such their patterns were unpredictable, tended towithdraw from situations, showed high intensity and had a fairly low, discontentedmood. This ill-tempered infantile pattern has been described by Millon (1981)as resulting, in part, from a low threshold for limbic stimulation and a decreasein inhibitory centers of the central nervous system. Their body types tend to beendomorphic (lean) and mesomorphic (muscular) (Millon, 1981).
Psychologically, these individuals have a unique view of themselves, others,
and the world. They tend to view themselves with some variant of the themeAntisocial Personality Disorder 59
f harsh, neglectful parenting. 
exploits others.
parental control and blaming.

“I am cunning and entitled to get whatever I want.” In other words, they see
themselves as strong, competitive, energetic, and tough. Their view of life andthe world is variant of the theme “Life is devious and hostile, and rules keep mefrom fulﬁlling my needs.” Not surprisingly their life’s goal has a variant of thetheme “Therefore, I’ll bend or break these rules because my needs come ﬁrst,and I’ll defend against efforts to be controlled or degraded by others.” Actingout and rationalization are common defense mechanisms used by the antisocialpersonality.
Socially, predictable parenting styles and environmental factors can be noted
for this disorder. Typically, the parenting style is characterized by hostility anddeﬁcient parental modeling. Or, the parents might have provided such good60 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 3.2 Characteristics of Antisocial Personality Disorder
Triggering Event(s) Social standards and rules
Behavioral Style Self-reliant, cunning, and forceful
Risk-taking and thrill-seekingGlib and shallow
Interpersonal Style Deceitful
Irritable and aggressiveReckless disregard for othersLacks empathy
Distrustful of others
Cognitive Style Impulsive
Externally oriented and realistic
Affective Style Avoids “softer” emotions which connote weakness
Shows little guilt, remorse, or shame
Temperament Ill-tempered infantile pattern and an aggressive, 
impulsive adult pattern
Attachment Style Fearful and dismissing
Parental Injunction “The end justiﬁes the means”Self-View “I’m cunning and I’m entitled to get what I want.”World-View “Life is devious and hostile and rules keep me from
fulﬁlling my needs. Therefore, I’ll bend or break thembecause my needs come ﬁrst and I’ll defend any efforts tobe controlled or degraded.”
Maladaptive Schemas Mistrust/abuse; entitlement; insufﬁcient self-control;
defectiveness; emotional deprivation; abandonment; social
isolation
Optimal Diagnostic Criminal, aggressive, impulsive, irresponsible behavior
Criterion“Life is devious and hostile, and rules keep me
from fulﬁlling my needs.”

modeling that the child could not, or refused to, live up to high parental
standards. The parental injunction is that “The end justiﬁes the means.” Thus,vindictive behavior is modeled and reinforced. The family structure tends to bedisorganized and disengaged. The antisocial pattern is conﬁrmed, reinforced, andperpetuated by the following individual and systems factors: the need to bepowerful and the fear of being abused and humiliated leads to a denial of “softer”emotions plus uncooperativeness. This, along with the tendency to provoke others,leads to further reinforcement of antisocial beliefs and behaviors (Sperry, 2015;Sperry & Mosak, 1996).
Table 3.2  summarizes the characteristics of this disorder.
Assessment of Antisocial Personality Disorder
Several sources of information are useful in establishing a diagnosis and treatment
plan for personality disorders. Observation, collateral information, and psycho -
logical testing are important adjuncts to the patient’s self-report in the clinicalinterview. This section brieﬂy describes some characteristic observations that theclinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e. MMPI-2 and MCMI-IV) and projective tests (i.e.Rorschach and TAT) are also described.
Interview Behavior and Rapport
Interviewing an individual with Antisocial Personality Disorder can be particularlychallenging. While it is easy to communicate with them as long as the clinicianplays along, they become angry and critical when the clinician resists theirmanipulations. It is very difﬁcult to have them focus on their impulsivity, irre -
spon sibility, or the negative consequences of their actions. Such lack of genuine -
ness and sincerity limits rapport. Nevertheless, these individuals crave attention,and the clinician can stimulate discussion by encouraging them to display theiraccomplishment (Ackley, Mack, Beyer, & Erdberg, 2011). By avoiding a judg -
mental or accusatory tone, the clinician may be able to encourage cooperationand explore the negative consequences of their actions. When they are unwillingto cooperate, answer questions, or adopt a complaining or hostile posture, theclinician does well to display indifference or initiate termination of the interview.Both of these strategies may quickly reverse their behavior. However, while theyare seldom remorseful about their deceit and mistreatment of others, they can bemade to realize that things are going poorly for them and they are ruining theirlives. The clinician can establish rapport and review their difﬁculties free ofdistortions and lies by showing empathy for the consequences of their behaviorand failures. Only when they perceive the clinician as a non-punitive ally whowill support their constructive goals and shows understanding of their inability toAntisocial Personality Disorder 61

follow social forms, can they begin to form a therapeutic alliance (Othmer &
Othmer, 2002).
Psychological Testing Data
The Minnesota Multiphase Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-IV), the Rorschach Psychodiagnostic Test, and theThematic Apperception Test (TAT) can be useful in diagnosing AntisocialPersonality Disorder, as well as the antisocial personality style or trait (Groth-Marnat, 2009).
On the MMPI-2, the 4–9/9–4 (Psychopathic Deviant-Hypomania) proﬁle is
considered the classic proﬁle of the Antisocial Personality Disorder. While the 9represents the activator energizer of acting-out behavior, the 4 represents thecognitive component of the psychopathy (Graham, 2012). Two patterns ofantisocial personality or psychopathology have been noted (Megargee and Bohn,1979). The primary psychopath is easily provoked to violence, and thus a spikeon scale 4 (Psychopathic Deviant), with elevators on 6 (Paranoid) and 8(Schizophprenia), is likely. The 4–9/9–4 proﬁle is more suggestive of secondarypsychopathy as is the 2–4/4–2 (Depression-Psychopathic Deviant) proﬁle (Meyer,1995).
On the MCMI-IV elevations on scale 5 (Narcissistic) and 6 A (Antisocial) are
most likely (Millon, Millon, Grossman, Boice, & Sinsabaugh, 2015). Becausealcohol and drug abuse are common in antisocial individuals, elevations in B(Alcohol use disorder) and/or T (Drug use disorder) are expected. Since Antisocialindividuals are usually not highly distressed, elevations on A (Generalized anxietydisorder), D (Dysthymia disorder) and H (Somatic symptom disorder) are notcommon (Choca & Denburg, 1997).
Projective techniques can be very helpful in assessing the antisocial patient’s
object relations and superego development. Although these individuals are morelikely to deceive a clinician during a clinical interview by simulating guilt orremorse, they are less likely to do so with ambiguous stimuli such as Rorschachblots, where there are no “correct” answers (Gabbard, 2000).
On the Rorschach, antisocial individuals tend to produce only a low to average
number of responses, and they even reject cards that they could clearly handlecognitively. There is often a delayed reaction to the color cards, but then theymay respond with C (Pure Color) responses in a fairly primitive and impulsivemanner. They tend to give a high number of A (Animal) and P (Popular) responses,and a low number of M (Human Movement) and W (Whole) response. Anabsence of shading (Y, YF, and FY) and a low Form plus (F+%) response iscommon (Wagner & Wagner, 1981).
On the TAT, their stories tend to be juvenile and sophomoric. And, while
the protagonist may be caught in a negative act, there is usually no mention ofthe consequences of the negative act (Bellak, 1997).62 Diagnosis and Treatment of DSM-5 Personality Disorders

Treatment Approaches and Interventions
Treatment Considerations
This diagnosis is reserved for individuals with a history of disregarding and violating
the rights of others since the age of 15. The differential diagnosis for AntisocialPersonality Disorder includes other personality disorders, such as the NarcissisticPersonality Disorder, the Paranoid Personality Disorder, and the BorderlinePersonality Disorder, where it tends to be misdiagnosed in females. The mostcommon symptom disorders associated with it are Substance Use Disorders, BipolarDisorder, Delusional Disorders, and Factitious Disorders.
In terms of treatment goals, these individuals are usually not interested in
presenting for treatment or are resistant to treatment if they are forced by thecourts, employers, or other agencies. This is probably because they appear to sufferlittle or no personal distress, see little wrong with their behavior or attitudes, andconsent to treatment only if it is in their best interest, such as when it mightimprove their chances when seeking parole or probation (Hare et al., 2012).
Individual therapy, in and of itself, has proved to be remarkably ineffective
with these individuals. This is particularly the case when therapy is insight-orientedor focuses on developing empathy, conscience, or interpersonal skills. However,special residential treatment programs have shown some promise (Harris & Rice,2006). If the antisocial personality is able to engage in psychotherapy, a clear signof progress is noted with the appearance of depressive features (Sperry, 2015).
Individual Psychotherapy
Hatchett (2015) recently conducted an in-depth literature review regardingtreatment options for Antisocial Personality Disorder. While he concluded thatthere does seem to be some beneﬁt to psychosocial interventions to remediateantisociality and reduce criminal recidivism, the picture is muddy and complex.Research has not yet identiﬁed any interventions that clearly meet the standardfor treatment efﬁcacy in his analysis. Because of this, he concludes that there isno basis to support the clinical utility for any psychosocial intervention for thetreatment of this disorder. However, this doubt is not universally held. This sectionreviews the psychodynamic, cognitive-behavioral, and interpersonal approachesof individual psychotherapy with Antisocial Personality-Disordered individuals.
Psychodynamic Psychotherapy Approach
There is relatively little literature on successful treatment outcomes of individualdynamic psychotherapy with Antisocial Personality-Disordered individuals. In fact,there is widespread pessimism that dynamic psychotherapy can change theantisocial pattern (Valliant & Perry, 1985). A number of explanations have beenAntisocial Personality Disorder 63

offered for this seeming failure. These explanations involve both patient selection
and therapeutic stance and interventions.
Gabbard (1990) indicates that the clinician’s task at the outset of treatment is
to determine which patients are “worth” the time, energy, and money requiredby a long-term therapy process with an uncertain outcome. Meloy (1988) hasidentiﬁed ﬁve contraindications for psychotherapy with antisocial patients. Theyare: a history of sadistic, violent behavior toward others; total absence of remorsefor such behavior; a long-standing incapacity to develop emotional attachments;high or low intelligence that can thwart the therapeutic process; and the clinician’sintense countertransference fear for their personal safety. In short, the more thepatient resembles the dynamic proﬁle of the pure psychopath, the less likely theyare to respond to dynamic psychotherapy.
On the other hand, antisocial patients with narcissistic features may be
somewhat more amenable to psychotherapy. They may reveal some dependencyin the transferences, and their internal “ideal object” may be somewhat lessaggressive than in the pure psychopath (Meloy, 1988). The presence of majordepression may reﬂect amenability to psychotherapy (Woody et al., 1985). Turkat(1990) notes that the “hurting sociopath,” who is sincerely and genuinelydistressed, has potential for proﬁting from psychotherapy. However, the mostimportant predictor of treatment success is the ability to form a therapeutic alliance.Gertsley et al. (1989) showed a signiﬁcant association between the ability to forma therapeutic alliance and treatment outcome in their study of 48 methadone-maintained male opiate addicts who meet criteria for Antisocial PersonalityDisorder.
Parenthetically, a study of sex difference in treatment recommendations for
antisocial personality is thought-provoking. A survey was undertaken involving119 clinical psychologists who responded to case histories depicting either a maleor female with Antisocial Personality Disorder and somatization. Results showedthat clinicians were less likely to diagnose Antisocial Personality Disorder correctlyfor female than for male patients. Females were consistently given better prognosisand more likely to be recommended for insight-oriented psychotherapy than maleswho were given poorer prognoses and more likely to be recommended for grouptherapy and legal constraints (Fernbach, Winstead, & Derlega, 1989).
Therapeutic stance and intervention strategy and techniques are other
important factors in the treatment outcome equation. The traditional dynamicstance of neutrality is contraindicated. Gabbard (2000) contends that neutralityis tantamount to silent endorsement or collusion with the antisocial patient’sactions. Instead, the recommended therapeutic stance is active and confrontative.The clinician will need to repeatedly confront the patient’s minimization anddenial of antisocial behavior. Furthermore, confrontation must focus on here-and-now behavior rather than analyzing unconscious material from the past.
From a dynamic perspective, it is crucial for the clinician to assist the patient
in linking actions with internal states. Finally, the clinician’s expectation for64 Diagnosis and Treatment of DSM-5 Personality Disorders

therapeutic change must be starkly realistic. Gabbard (1994) cautions that antisocial
patients take delight in thwarting the clinician’s wishes for them to change.
Needless to say, countertransference issues are important in working with
antisocial patients. Two common forms are disbelief and collusion (Symington,1980). Disbelief involves the clinician’s rationalization that the patient is not really“that bad.” Collusion is perhaps the most problematic type of countertransference.Gabbard insists that the clinician be stable, persistent, and thoroughly incorruptible,as these patients will do whatever necessary to corrupt the clinical into dishonestor unethical behavior. Through simulated tearfulness, sadness, or remorse, theycan manipulate the clinician into empathizing with them.
As noted previously, there are studies of dynamic treatment with antisocial
patients. One study of severe personality disordered individuals, including thosewith Antisocial Personality Disorder, found that signiﬁcant split self-representationwas present in the 27 patients studied. Relaxation exercises and a mergingintervention were utilized to reduce the amnestic barriers that maintained thiscompartmentalization. Results showed the 24 patients responded with reducedresistance, increased treatment compliance, and improved daily functioning(Glantz & Goisman, 1990).
Meloy and Yakeley (2010) point out that many of the more recent therapeutic
approaches to antisocial individuals have been largely behavioral in nature. Theseinclude relapse prevention classes, social skills groups, and other such efforts atchanging surface behaviors and symptoms, while overlooking the changes toantisocial individuals’ internal mental states. One exception to this trend isBateman and Fonagy’s mentalization-based treatment (McGauley, Yakeley,Williams, & Bateman, 2011). Sometimes referred to as “mentalizing,” this is theprocess by which individuals interpret their own subjective cognitions, behaviors,and emotions, as well as those of others. Many antisocial individuals exhibit deﬁcitsin this ability, particularly with respect to reﬂecting the feelings of others. Thisrudimentary capacity for mentalization is combined with difﬁculty toleratinginternal states of anxiety, resulting in the type of aggressive behavior that is ahallmark of this disorder. Malancharuvil (2012) also provides a psychodynamicformulation for empathy deﬁcit in Antisocial Personality Disorder. It is importantto note that developing the capacity to mentalize without also increasing empathymay serve to make the antisocial individual a more effective predator rather thanachieving the treatment’s intended goal.
Cognitive Therapy Approach
Beck, Freeman, Davis, and associates (2004) provide an extended discussion ofthe cognitive therapy approach to Antisocial Personality-Disordered individuals.They note that it is particularly difﬁcult to develop a collaborative workingrelationship with these patients. These patients are difﬁcult to work with becausethey are likely to distrust the therapist, are uncomfortable accepting help, andAntisocial Personality Disorder 65

have little motivation because of the therapist’s countertransference. Establishing
rapport requires the therapist to avoid, or disengage from, positions of controlor power struggles with them, as well as to admit vulnerability to their manip -
ulativeness. Since these individuals are likely to lie, the therapist can avoidentrapment in the role of being arbiter of truth by admitting that it could happen.
To avoid premature termination, it is suggested that the therapist work gradually
to establish trust, explicitly acknowledge the antisocial individual’s strengths andcapabilities, and refrain from pressing the individual to acknowledge weaknesses.
Premature termination also may occur if the individual’s distress, i.e., depression
or anxiety symptoms, are quickly alleviated. In such instances Beck et al. suggestpointing out that continuing in therapy is in the individual’s best interest andidentifying any remaining distress that the individual may be denying or
minimizing.
Mitchell, Tafrate, and Freeman (2015) note that, contrary to the dramatic and
confrontational depictions of therapy with antisocial individuals found in popularmedia, a more collaborative approach is needed. Confrontation leads to loss ofmomentum and premature termination. Therapist qualities like warmth, empathy,and the willingness to reward are especially important with this population.Techniques such as Motivational Interviewing (Miller & Rollnick, 2013),reviewing signs and symptoms of the disorder to raise awareness of potentialconsequences and offer the choice to change, and focusing on the patient’s strengthsand values are speciﬁc ways to engage antisocial individuals in treatment. Selectingappropriate treatment goals can be challenging with this disorder, and considerabletime must be spent exploring these with this population. For those whoexperience negative symptoms of anxiety or depression, symptom relief is a primarymotivator. They see themselves as suffering, and the consequence of not actingis harmful to them alone. On the other hand, those who do not experiencenegative symptoms may see their antisocial behavior as rewarding and egosyntonic.In this case, motivation for change is minimal or outright resistant, as it is otherswho suffer and not the individual. Regardless of the individual’s preferences,reducing criminal behavior should remain an overarching goal of treatment becauseof the harm caused to others and society as a whole.
After treatment goals have been agreed upon, focusing on speciﬁc problem
situations with problem-solving and behavioral strategies is suggested. If impulse
control, acting out, or inappropriate expression of anger are treatment targets,impulse control and anger management strategies are advised. As these individuals
become better able to control impulses and anticipate consequences of their actions,
shifting the therapeutic focus to automatic thoughts and underlying schemas ispossible. This transition from a largely behavioral focus to a more cognitive onegradually allows these individuals to become less vulnerable and more comfortable
in disclosing thoughts and feelings. As planned termination of treatment
approaches, the focus shifts to the social pressures the individual faces to continued66 Diagnosis and Treatment of DSM-5 Personality Disorders

antisocial behavior. Relapse prevention strategies are useful in sensitizing these
patients to people, places, and circumstances that are potential triggers forantisocial thinking and behaviors. Presuming that the individual has learnedsufﬁcient social skills and can engage in therapeutic group work, the likelihoodof effective coping in the face of social pressures is increased. Beck et al. (2004)note that group and family therapy can be useful adjunct to individual treatment.
Furthermore, Freeman et al. (1990) believe that cognitive therapy can be
effective, not only in reducing antisocial behavior, but also in assisting the
individual to adopt a more prosocial lifestyle. They caution that these individuals
often terminate treatment prematurely unless they experience sufﬁcient distressfrom an Axis I condition, which provides an incentive for continuing to workin treatment.
An exploratory randomized controlled trial of cognitive behavioral therapy
for violent men with Antisocial Personality Disorder was conducted by Davidsonand colleagues (2009). Fifty-two adult men with acts of aggression within thepast six months were randomized to treatment as usual (TAU) plus CBT or TAUalone. Twelve-month followup indicated that there were no signiﬁcant outcomedifferences in the two groups. Both groups reported decreased frequency ofaggressive acts; however, trends in the data favored CBT in the areas of
problematic drinking, social functioning, and beliefs about others. Reﬂections
about working with this population and this study may be found in Davidson etal. (2010).
Schema Therapy. Schema Therapy is an elaboration of cognitive therapy
that has been developed by Young (1994, 1999) speciﬁcally for personalitydisorders and other difﬁcult individual and couples problems. Schema Therapyinvolves identifying maladaptive schemas and planning speciﬁc strategies and
interventions. Four main strategies are: cognitive, experiential, behavioral, and
the therapeutic relationship itself. Cognitive restructuring, modiﬁcation ofmaladaptive schemas, is an important cognitive strategy, but is combined with
imagery exercises, empathic confrontation, homework assignments, and “limited
reparenting,” i.e., a form of corrective emotional experience (Young, 1999).
Maladaptive schemas typically associated with Antisocial Personality Disorder
are: mistrust/abuse —the belief that others will abuse, humiliate, cheat, lie,
manipulate, or take advantage; entitlement— the belief that one is superior to others
and not bound by the rules and norms that govern normal social interaction;insufﬁcient self-control —the belief that one is incapable of self-control and frustration
tolerance; defectiveness— the belief that one is defective, bad, unwanted, or inferior
in important respects; emotional deprivation— the belief that one’s desire for
emotional support will not be met by others; abandonment— the belief that
signiﬁcant others will not or cannot provide reliable and stable support; and social
isolation— the belief that one is alienated, different from others, or not part of any
group (Bernstein, 2002).Antisocial Personality Disorder 67

Interpersonal Approach
For Benjamin (2003a), psychotherapeutic interventions with Antisocial
Personality-Disordered individuals can be planned and evaluated in terms ofwhether they enhance collaboration, facilitate learning about maladaptive patternsand their roots, block these patterns, enhance the will to change, and effectivelyencourage new patterns.
Benjamin notes that antisocial individuals do not respond well to individual
psychotherapy alone. She echoes the sentiments of others by cautioning that thekind and attentive therapist, as well as those who mistakenly believe they areﬁrmly in control, may be “taken for a ride” by these individuals. Conversely,
Benjamin notes that the opposite approach of being harsh and unsympathetic will
only serve to reconﬁrm the antisocial individual’s belief that they cannot trustthose who claim to care. This pattern of “hostile autonomy” guarantees that these
individuals are denied benevolent contact with those around them. The therapist’schallenge is to break through this barrier and develop a bond with these deeplyalienated clients. While individual therapy may be problematic, when combinedwith other modalities, such as milieu therapy, positive treatment outcome maybe possible. The goal of the collaborative phase of treatment is to establish a
bonding and some degree of interdependence. Since collaboration in individualpsychotherapy cannot be coerced and is seldom chosen by antisocial individuals,
Benjamin suggests joining the individual in their initial hostile position and thenprogressively moving toward collaboration.
Other ways of eliciting collaboration suggested by Benjamin are utilizing sports
heroes as role models. The antisocial individual may respond to a story about an
athlete’s warmth and benevolent power by internalizing these qualities, particularlyin conduct-disordered adolescents. Another strategy for cultivating warmth maybe to allow the antisocial individual the opportunity to occupy a nurturant position,
such as providing kittens to prison inmates or teaching kids to play basketball—all while under supervision, of course. Wilderness survival training is another
potential modality. In these instances, nurturance and bonding could be facilitated.Carefully managed group therapy can provide opportunities for bonding andcontrol. Family therapy can likewise lead to positive change, but family collusionin maintaining problem patterns must be considered.
Once bonding and interdependence begin, the preconditions for collaboration
have been met. Next, the antisocial individual is helped to recognize and
understand the self-destructive features of their exploitive lifestyle and pattern.Benjamin believes that these individuals can then begin to develop needed self-management and social skills such as self-care, delay of gratiﬁcation, and empathy
for others. Unfortunately, she offers little discussion and few suggestions for
facilitating change for individuals with this disorder.68 Diagnosis and Treatment of DSM-5 Personality Disorders

Group Therapy
Group therapy for Antisocial Personality Disorder is commonly considered to be
more effective than individual therapy because it offers antisocial individuals theability to connect with the experiences of others in a less direct manner than
individual therapy. This modality also enables these patients to see their behavior
through the eyes of others. Structured forms of group therapy may be quiteeffective with Antisocial Personality-Disordered individuals. Open, exploratory,and nondirective groups (Yalom, 1985) with heterogeneous composition are easilydisrupted by antisocial patients; therefore such groups are not advisable for thesepatients (Liebowitz et al., 1986).
Three types of group treatment have been utilized with these patients:
psychoeducational, psychotherapy, and support groups (Walker, 1992). Psycho -
educational groups combine didactic presentation by the clinician, which is thenprocessed by group members. Content and agenda is structured, as is patientparticipation. The group is composed of antisocial patients who meet given criteriafor participation, and are chosen by the clinician. The groups are time-limitedand meet weekly for 90 minutes. Because of the complexity of these patients’interpersonal and other problems, these groups have limited utility for antisocialpatients.
Psychotherapy groups have somewhat less structure than psychoeducational
groups, but make use of cohesive themes relevant to these patients. Groupmembership is determined by the clinician who is in charge of both content andprocess. These groups tend to be long term, meet weekly for 90 minutes, andare limited to nine or ten patients. Because a group of ten antisocial patients canbe quite formidable, two clinician group therapists are recommended.
Two group therapists serve to diminish the group’s potential for acting out
against the group leaders, as one clinician is an easy target for isolation, as wellas attack or dismissal, by group members. Two group leaders also offer patientsmore opportunity for constructive identiﬁcation because of differences inpersonality and therapeutic style of therapists. Furthermore, it allows for a “goodguy-bad guy” routine, and allows “lateral passes” by the leaders, who may ﬁndthemselves unable to handle a particular issue or patient (Walker, 1992).
Support groups for antisocial patients are useful for individuals who have had
intensive inpatient or outpatient group psychotherapy. While they are based ona self-help model, they are led by a clinician. The main focus of these ongoinggroups with open membership is relapse prevention and the development of peersupport.
Walker (1992) described some useful guidelines for setting up these three
different types of groups. He also described a number of rules and speciﬁc
procedures for doing group work with antisocial patients.
Meloy and Yakeley (2010) describe the group process for Antisocial Personality
Disorder from a psychodynamic perspective. They note that the therapy groupAntisocial Personality Disorder 69

acts as a container for the antisocial individual’s projections, as well as a collective
auxiliary ego that can reﬂect on behalf of the individual. This gradually movesthe patient to healthier ego functioning.
Therapeutic Community. An extension of group treatment in an inpatient
or residential setting in which the milieu is a medium of change is the therapeutic
community (TC). Recent research indicates that drug-addicted individuals with
Antisocial Personality Disorder can beneﬁt signiﬁcantly from therapeuticcommunity treatment, provided they complete the treatment program and
continue with aftercare in the community. Treatment completion was found to
be the most important factor in reducing recent drug use and post-discharge arrests(Messina, Wish, Hoffman, & Nemes, 2002).
Marital and Family Therapy
There are a considerable number of studies on the family dynamics and treatmentof the antisocial patient, mostly involving delinquent youths (Glueck & Glueck,1950; Minuchin et al., 1967). A few studies suggest that short term family therapycan also be effective with delinquent adolescents (Alexander & Parsons, 1973;Parsons & Alexander, 1973). Harbir (1981) notes that antisocial patients are seldommotivated to engage in family therapy, but to the extent that the clinician is able
to engage the patient’s parents or spouse, the more likely therapeutic change is
possible. Since the antisocial patient tends to precipitously leave outpatienttreatment when difﬁcult and anxiety-provoking issues are faced, it is incumbent
on the clinician to maximize therapeutic leverage. Speciﬁcally, this means
establishing a consistent therapeutic alliance and involving the family at the outset,usually at the beginning of hospital treatment, as a part of a court stipulation or
as a required adjunct to residential treatment.
A major treatment goal is to help family members, or the spouse in couples
therapy, set limits on the patient. Typically, family members and spouses haveminimized, ignored, or acted inconsistently in the face of the patient’s antisocial
behavior. As the family or spouse consistently sets and enforces limits, thepatient’s pathological behavior reduces, and sometimes treatment-amenable
symptoms like depression emerge. This suggests the patient is beginning to changeand is more motivated to stop destructive behaviors. As family treatment proceeds,
changes in destructive communication patterns can be achieved systematically
(Parsons & Alexander, 1973).
Nichols (1996) describes the marital interactional patterns and symptomatology
of individuals with Antisocial Personality Disorder and Histrionic PersonalityDisorder in close interpersonal relationships, as well as a suggested treatment planprotocol and strategies for dealing with such couples in a therapeutic context.70 Diagnosis and Treatment of DSM-5 Personality Disorders

Medication
Currently, there are no psychotropic medications speciﬁcally indicated for treating
individuals with this disorder. However, there is some evidence that those withthis disorder have responded to SSRIs (Silk & Feurino, 2012). For this reason,
these medications are used to target speciﬁc troubling symptoms, particularly
anxiety. Generally, they are used as an adjunct to psychotherapy and skills train -
ing. Because troubling symptoms often respond to medications sooner than mostpsychological interventions, medications are usually prescribed at the onset oftreatment (Sperry, 1995b). Unfortunately, there is limited research evidence to
provide guidelines for the use of SSRIs for other indications or for the use ofother medications (Silk & Feurino, 2012).
Combined/Integrative Treatment Approaches
Despite widespread pessimism about the treatability of this disorder, there is reasonfor cautious optimism provided that treatment is combined or multimodal andtailored to the particular needs and circumstances of the individual. There is clearevidence that time itself is the most effective treatment modality. In other words,
the intensity of antisocial behaviors tends to dissipate with age (Regier et al., 1988);purportedly that is due to the cumulative effects of personal, social, legal, and
ﬁnancial repercussions of antisocial behavior. The next most effective modality
is specialized treatment, therapeutic communities, or a wilderness program thatprovides ﬁrm limits and structure, group work with peers and a structured workprogram (Woody et al., 1985). To the extent that sufﬁcient therapeutic leverage
is present in outpatient settings, treatment outcomes for antisocial patients canbe at least guardedly optimistic.
As with Borderline Personality Disorder, most agree that pharmacotherapy
should not be the only treatment for Antisocial Personality Disorder (Gunderson,1986). Kellner (1986) suggests that treatment often begins with a psycho thera -
peutic modality, after which a trial of medication may be considered for a speciﬁc
target symptom such as impulsivity, aggressivity, explosiveness, and violence.Treatment, in many cases, will be long because of the patient’s unwill ing ness or
inability to persevere. It may consist of a few sessions interspersed with longintervals without any therapeutic work, or for medication monitoring only. In
any case, the clinician must attempt to establish a therapeutic relationship while
maintaining ﬁrm limits. Psychoeducation, whether in an individual or groupformat, is usually necessary. Kellner (1986) notes that data supports the use ofsustained treatment that invariably involves psychotherapies—individual, group,and family, behavior therapy, and psychoeducation—aimed at teaching self-control
and postponement of gratiﬁcation as well as the use of medication. Though such
interventions are exceedingly complex and difﬁcult, Kellner believes they canmake a substantial difference in the life and adjustment of these patients.Antisocial Personality Disorder 71

Many of the studies about combined treatment focus on the treatment of co-
occurring Antisocial Personality Disorder and substance use disorders. Ogloff,Talevski, Lemphers, Wood, and Simmons (2015) investigated the relationshipbetween mental illness, substance use disorders, Antisocial Personality Disorder,and offending in a sample of 130 males in a forensic mental health service facilityin Australia. They found that the majority of these individuals met the criteriafor multiple disorders, highlighting the need for an integrative treatment approach.Havens et al. (2007) investigated a case management intervention on admissionto substance abuse treatment for injection drug users with and without AntisocialPersonality Disorder. They found that injection drug users with AntisocialPersonality Disorder were 3.51 times more likely to enter substance abusetreatment after spending time with a case manager. Messina, Farabee, and Rawson(2003) examined the effectiveness of four different types of treatment for cocaine-dependent patients with Antisocial Personality Disorder. These were: cognitive-behavioral therapy (CBT); contingency management (CM); combined CBT andCM; and methadone maintenance. They found that patients with AntisocialPersonality Disorder were more likely to abstain from cocaine use during treat -
ment than those without this disorder, an effect that was signiﬁcantly related tothe contingency management condition.72 Diagnosis and Treatment of DSM-5 Personality Disorders

4
AVOIDANT PERSONALITY 
DISORDER
Individuals with avoidant personalities tend to be shy, lonely, hypersensitive
individuals with low self-esteem. Although they are desperate for interpersonalinvolvement, they avoid personal contact with others because of their heightenedfear of social disapproval and rejection sensitivity (Sanislow, da Cruz, Gianoli, &Reagan, 2012). While treatment of such individuals involves a number of uniquetherapeutic challenges, it can be highly effective and successful.
of this disorder. It includes sections on diagnosis, psychological assessment, caseconceptualization, and treatment interventions. It begins with backgroundinformation on the disorder as well as a DSM-5 description and a prototypicdescription of this disorder. The section on case conceptualization provides ﬁve common clinical formulations of this disorder: psychodynamic, biosocial,cognitive-behavioral, interpersonal, and an integrative conceptualization of thisdisorder. Several treatment approaches, modalities, and intervention strategies arealso described. These include individual psychotherapy, group therapy, maritaland family therapy, medication, and integrative and combined treatment.
Description of the Avoidant Personality Disorder
The Avoidant Personality Disorder can be recognized by the following descrip-tors or characteristics: style vs. disorder, triggering event(s), behavioral style, inter -
personal style, cognitive style, affective style, attachment style, and optimaldiagnostic criterion.
Style vs. Disorder . The avoidant personality can be thought of as spanning
a continuum from healthy to pathological, with the avoidant personality style onthe healthy and the Avoidant Personality Disorder on the pathological end. Table
4.1 compares and contrasts differences between the avoidant style and disorder.

74 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 4.1 A Comparison of Avoidant Personality Style vs. Disorder
Comfortable with habit, repetition, Exaggerates the potential difﬁculties,
and routine. Prefer the known to the physical dangers, or risks involved inunknown. doing something ordinary but outside
their usual routine.
Close allegiance with family and/or Has no close friends or conﬁdants—or
a few close friends; tend to be homebodies. only one—other than ﬁrst degree 
relatives; avoids activities that involve
signiﬁcant interpersonal contact.
Sensitive and concerned about what others Unwilling to get involved with others
think of them. unless certain of being liked; easily hurt
and worriers.
Very discrete and deliberate in dealing Fears being embarrassed by blushing,
with others. crying or showing signs of anxiety in 
front of other people.
Tend to maintain a reserved, self- Reticent in social situations because of
restrained demeanor around others. a fear of saying something inappropriate
or foolish, or of being unable to answer
a question.
Tend to be curious and can focus Tend to be underachievers, and ﬁnd it
considerable attention on hobbies, and difﬁcult to focus on job tasks or 
avocations; however, a few engage in hobbies.
counterphobic coping behaviors.Triggering Event(s) . The typical situation, circumstance or event that
triggers or activates the characteristic maladaptive response of the AvoidantPerson ality Disorder (Othmer & Othmer, 2002), as noted in behavioral, inter -
personal, cognitive, and affective styles, is: “demands for close interpersonal relatingand/or social and public appearances.”
Behavioral Style . The behavioral style of avoidant personalities is charac -
terized by chronic tenseness and self-consciousness. Their behavior and speechare controlled, and they appear apprehensive and awkward. They also tend to
be self-critical and devalue their achievements.
Interpersonal Style . Interpersonally, they are rejection-sensitive. Even
though they desire acceptance by others, they keep distance from others and
require unconditional approval before being willing to “open up.” They guardedly“test” others to determine who can be trusted to like them.
Cognitive Style . The cognitive style of such individuals can be described as
hypervigilant, meaning that they scan the environment looking for clues of potential
threat or acceptance. Their thoughts are often distracted by their hypersensitivity.
Not surprisingly, they have low self-esteem because of their devaluation of their
own achievements and their overemphasis of their own shortcomings.

Affective Style . Their emotional or affective style is marked by a shy and
apprehensive quality. Because they are seldom able to attain unconditionalapproval from others, they routinely experience sadness, loneliness, and tenseness.At times of increased distress, they will describe feelings of emptiness anddepersonalization.
Attachment Style . Individuals with a self-view that is negative and an
other-view that vacillates between positive and negative exhibit a compositepreoccupied and fearful style of attachment. Their avoidance is based on the desire
to be liked and accepted by others, while at the same time fearing of rejection
and abandonment. The Preoccupied-Fearful Attachment Style adult attachment
style is common in individuals with Avoidant Personality Disorder (Lyddon &
Sherry, 2001).
Optimal Diagnostic Criterion . Of the various criteria for the Avoidant
Personality Disorder, one has been found to be the most useful in diagnosingthis disorder. The belief is that by beginning with this criterion the clinician can
test for the presence or absence of the criterion and quickly diagnose the
personality disorder (Allnutt & Links, 1996). The “optimal criterion” for this
disorder is: “avoids occupational activities that involve signiﬁcant interpersonal
contact, fearing criticism, disapproval or rejection.”
The following two case examples illustrate the differences between the avoid -
ant personality style—Dr. Q and the Avoidant Personality Disorder—Ms. A.Avoidant Personality Disorder 75
CASE STUDY: AVOIDANT PERSONALITY STYLE
Peter Q. is a 31-year-old eye surgeon who had recently been hired by a large
HMO hospital and clinic. He had recently completed residency training, and
being new, good–looking, and single was quickly noticed by the female staff.His specialty was laser surgery for which he was exquisitely skilled andrespected by his patients. Although courteous, he was somewhat emotionally
distant and shy. Dr. Q seldom participated in staff get-togethers, and if he
did make an appearance he would politely excuse himself after his beepersounded—which seemed all the time—and he wouldn’t return. His social lifeseemed to be a mystery, and he had little contact after hours with his male
colleagues, except for one. Dr. S. had run into Peter at a civil war convention
in another city, and to his surprise learned of Peter’s long-standing hobbyand collection of civil war books and memorabilia. In time the two becamevery good friends, spending considerable time together. Although he had
his own apartment, Peter spent much of his free time at home with his
parents. Dr. S. soon became a regular guest at the Q. home and initially wassurprised at how warm, cordial, and comfortable Peter was in this small settingas compared to the hospital.

DSM-5 emphasizes speciﬁc behaviors for this disorders. Individuals who meet
criteria for this diagnosis are characterized by an unremitting pattern of beingsocially inhibited, feeling inadequate, and overly sensitive to the negativeevaluations of others. This is typically because they view themselves as sociallyinept, unappealing, or inferior to others. They consistently avoid work activitiesthat require close interpersonal contact for fear of being criticized or rejected.They will not get involved with others unless they are certain of being accepted.Fearing they will be shamed or ridiculed, they are uncomfortable and act withrestraint in intimate relationships. In anticipation of shame or ridicule, they areuncomfortable, and are hesitant in intimate relationships. Similarly, theyexperience feelings of inadequacy and inhibition in new interpersonal situations.Not surprising, they refuse to take personal risks or engage in activities that mayprove embarrassing (American Psychiatric Association, 2013).
Prototypic Description
A prototype is a brief description that captures the essence of how a particulardisorder commonly presents. Prototypic descriptions are useful and convenientand clinicians commonly rely on them rather than lists of behavioral criteria orcore beliefs (Westen, 2012). Here is a common prototypic description of theAvoidant Personality Disorder: These individuals are frightened and inter -
personally awkward. They are also extremely sensitive to criticism and rejection.Just the idea of meeting someone new engenders fear of being humiliated orembarrassed. So, it is much easier to avoid any new work or social relationshipthat could threaten their personal sense of security and safety. Still, they crave76 Diagnosis and Treatment of DSM-5 Personality Disorders
CASE STUDY: AVOIDANT PERSONALITY DISORDER
Ms. A. is a 27-year-old female student who contacted the University
Counseling Center for help with “difﬁculty concentrating.” She indicated thatthe problem started when Ms. A’s roommate of two years precipitously moved
out to live with her boyfriend. Ms. A. described herself as being “blown away
and hurt” by this. She noted that she had no close friends and describedherself as being shy and having had only one date since high school. Sincethen, she avoided attempts by men to date her because of being rejected
when she was a freshman by a guy who had dated her for a month and
never contacted her again. On examination, she had poor eye contact withthe admissions counselor and appeared very shy and self-conscious.

connection with others that they have come to trust. Accordingly, they may have
a friend or a relative with whom they can relax and feel safe (Frances, 2013).
Prevalence of this disorder has been estimated at 2.4 percent in the generalpopulation (American Psychiatric Association, 2013). In clinical settings, estimatesare that it is found in 5.1 to 55.4 percent, which is the most frequently occurringpersonality disorder in three epidemiological studies (Torgersen, 2012).
Table 4.2  summarizes these characteristics.Avoidant Personality Disorder 77
TABLE 4.2 Characteristics of Avoidant Personality Disorder
Triggering Event(s) Demands for close interpersonal relating
and/or social and public appearances
Behavioral Style Chronically tense and self-conscious
Aloof, controlled, and underactive behaviorSelf-critical and devalue their achievements
Interpersonal Style Avoids interpersonal contacts fearing rejection
Cautious to get involved with othersRestrained intimacy for fear of ridiculePreoccupied with social criticism or rejectionInhibited in new interpersonal situationsReluctant to take social risks
Cognitive Style Hypervigilant
Thinking is easily distracted by their hypersensitivity
Affective Style Shy and apprehensive
Feelings of emptiness and depersonalization
Attachment Style Preoccupied and fearfulTemperament IrritableParental Injunction “We don’t accept you, and probably nobody else will 
either.”
Self-View “I’m inadequate and frightened of rejection.”World-View “Life is unfair, people reject and criticize me, but I want
someone to like me. Therefore, be vigilant, demandreassurance, and, if all else fails, fantasize and daydream.”
Maladaptive Schemas Defectiveness, social isolation, approval-seeking, self-
sacriﬁce
Optimal Diagnostic Avoids occupational activities that involve signiﬁcant 
Criteria interpersonal contact, fearing criticism, disapproval, or
rejection

Conceptualizations of the Avoidant Personality Disorder
Psychodynamic Case Conceptualization
Shyness, shame, and avoidant behaviors are conceptualized as defenses against
embarrass ment, humiliation, rejection, and failure (Gabbard, 1990). Shame and
fear of exposure of the self to others are interconnected. Individuals with avoidantpersonalities tend to feel ashamed about their self-perceptions as weak, unable tocompete, physically or mentally defective, or disgusting and unable to controlbodily function (Wurmser, 1981). Shame evolves from many different develop -
mental experiences throughout the early childhood years. These developmentalexperiences, plus a constitutional predisposition to avoid stressful situations, tendto be reactivated in the avoidant patient upon exposure to individuals who mattera great deal to the patient (Gabbard, 1994). Psychodynamic theorists conceptualizethe behavior of those with avoidant personality as being motivated by shame fornot living up to their ego ideal (Eskedal & Demetri, 2006). This poor self-imageresults in numerous behaviors intended to protect avoidant individuals, includingmisreading others’ neutral and positive reactions as negative and restricting socialexperiences to avoid situations where their perceived inadequacies may berevealed.
Millon (1981), Millon and Everly (1985), and Millon and Davis (1996, 2000)
believe that the etiology and development of this personality disorder represents
an interactive constellation of biogenic environmental factors. They hypothesizethat the vigilance characterizing this personality reﬂects functional dominance of
the sympathetic nervous system with a lowered autonomic arousal threshold. This
could allow irrelevant impulses to intrude on logical association, diminish control
and direction of thought and memory processes resulting in marked interface with
normal cognitive processes. Research cited by Kagan, Resnick, and Snidman(1988) suggests that the trait of shyness is of genetic-constitutional origin, which
requires speciﬁc environmental experiences to develop into a full-blown patternof timidity and avoidance.
Parental and peer group rejection are two critical and prevalent environmental
inﬂuences. The amount of parental rejection appears to be particularly intenseand/or frequent. When peer group rejection reinforces parental rejection the child’ssense of self-worth and self-competence tends to be severely eroded, and resultin self-critical attitudes. As a result these individuals restrict their social experiences,are hypersensitive to rejection, and become excessively introspective. Byrestricting their social environment, they subsequently fail to develop socialcompetence, which tends to evoke the ridicule of others for their asocial behavior.Because of their hypersensitivity and hypervigilance, they are prone to interpret78 Diagnosis and Treatment of DSM-5 Personality Disorders

minor rebuffs as principal indicators of rejection, where no rejection was intended.
Finally, because of their excessive introspection, they are forced to examine thepainful condition they have created for themselves. Not surprisingly, theyconclude that they do not deserve to be accepted by others.
According to Beck (2015) individuals with avoidant personality are fearful ofinitiating relationships as well as fearful of responding to others’ attempts to relateto them because of their overriding belief that they will be rejected. For them,such rejection is unbearable, so they engage in social avoidance. Furthermore,they engage in cognitive and emotional avoidance by not thinking about thingswhich could cause them to feel dysphoric. Because of their low tolerance fordysphoria, they further distract themselves from their negative cognitions.Underlying these avoidance patterns are maladaptive schemas or long-standingdysfunctional beliefs about self and others. They tend to view themselves as ineptsocially and incompetent academically and vocationally. They typically view othersas critical, demeaning, and uninterested in them. Schemas about self include themesof being different, inadequate, defective, and unlikable. Schemas about othersinvolve themes of uncaring and rejection.
These individuals are likely to predict and interpret the rejection as caused
solely by their personal deﬁciencies. This prediction of rejection results indysphoria. Finally, avoidant individuals do not have internal criteria to judgethemselves in a positive manner. Thus, they must rely on their perception. Theytend to misread a neutral or positive reaction as negative, which furthercompounds their rejection-sensitivity and social emotional and cognitiveavoidance. In short, they hold negative schemas which lead them to avoid solutionswhere they could interact with others. They also avoid tasks that could engenderuncomfortable feelings, and avoid thinking about matters that produce dysphoria.Because of their low tolerance for discomfort, they utilize distractions, excuse-making, and rationalizations when they begin to feel sad or anxious (Padesky &Beck, 2015).
Turkat (1990) describes this disorder as primarily anxiety-based, and
characterized by timidity and anxiety concerning evaluation, rejection, and/orhumiliation. He notes that the disorder is very responsive to behavioralinterventions, particularly anxiety management desensitization methods where thehierarchy is based on fear of rejection, criticism, and/or evaluation.
According to Benjamin (2003a), persons diagnosed with Avoidant PersonalityDisorder tended to begin their development sequence with appropriate nurturanceand social bonding. As a result, they continued to desire social contact andAvoidant Personality Disorder 79

nurturance. Unfortunately, these individuals were subject to relentless parental
control with regard to creating an impressive social image. Visible ﬂaws werecause for great embarrassment and humiliation, particularly for the family. Besidesexhortations to be admirable, they experienced degrading mockery for failures,personal imperfections, or shortcomings. The adult consequence is that avoidantindividuals are socialized to perform adequately and manage an appropriateimpression while avoiding occasions for embarrassment or humiliation. Typically,this humiliation was associated with exclusion, banishment, or rejection. As aresult they anticipate rejection and thus socially isolate themselves. Because theyare well bonded, they crave relationships and social contact but are absolutelyconvinced there is little or no risk of rejection or dejection.
Furthermore, although they experienced rejection and ridicule from their
families, they also internalized the belief that family is their source of support.Thus, they have intense family loyalty, while harboring equally intense fears ofoutsiders. In short, avoidant individuals exhibit intense fear of humiliation andrejection. To avoid this, they socially withdraw and restrain themselves, whileprying for love and acceptance. They can become very intimate with a selectfew who pass their highly stringent safety test. Occasionally, they can lose controland explode with rageful indignation.
Integrative Case Conceptualizations
The following integrative formulation provides a biopsychosocial explanation forhow this personality is likely to have developed and how it is maintained.Biologically, these individuals commonly were hyperirritable and fearful as infants,and they most likely exhibited the “slow to warm” temperament (Thomas &Chess, 1977). Individuals with this personality pattern are also likely to haveexperienced various maturational irregularities as children. There irregularities and their hyperirritable pattern are attributed a low arousal threshold of theirautonomic nervous system (Millon & Everly, 1985).
Psychologically, those with Avoidant Personalities typically view themselves
as “See, I am inadequate and frightened of rejection.” They are likely to viewthe world as some variant of the theme: “Life is unfair—people reject and criticizeme—but, I still want someone to like me.” As such, they are likely to conclude:“Therefore, be vigilant, demand reassurance, and if all else fails, fantasize anddaydream about the way life could be.” A common defense mechanism of theavoidant personality is fantasy. Thus, it is not surprising that avoidant personalitiesare major consumers of romance novels and soap operas.
Socially, predictable patterns of parenting and environmental factors can be
noted for the avoidant personality disorder. The avoidant personality is likely tohave experienced parental rejection and/or ridicule. Later, siblings and peers willlikely continue this pattern of rejection and ridicule. The parental injunction islikely to have been: “We don’t accept you, and probably no one else will, either.”80 Diagnosis and Treatment of DSM-5 Personality Disorders

They may have had parents with high standards and worried that they may not
have or would not meet these standards and therefore would not be accepted.
This avoidant pattern is conﬁrmed, reinforced, and perpetuated by the
following individual and systems factors: a sense of personal inadequacy and afear of rejection leads to hypervigilance, which leads to restricted social experi -
ences. These experiences, plus catastrophic thinking, lead to increased hyper -
vigilance and hypersensitivity, leading to self-pity, anxiety and depression, whichleads to further conﬁrmation of avoidant beliefs and styles (Sperry, 2015).
Assessment of Avoidant Personality Disorder
Several sources of information are useful in establishing a diagnosis and treat-ment plan for personality disorders. Observation, collateral information, andpsychological testing are important adjuncts to the patient’s self-report in the clinicalinterview. This section brieﬂy describes some characteristic observations that theclinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e. MMPI-2 and MCMI-III) and projective tests (i.e.Rorschach and TAT) are also described.
In the initial interview, Avoidant Personality Disordered individuals tend to bemonosyllabic, circumstantial, and guarded. Some may even appear suspicious orquite anxious, but all are hypersensitive to rejection and criticism. Reluctance andguardedness should be approached with empathy and reassurance. The cliniciandoes well to avoid confrontation, which likely will be interpreted as criticism.Instead, empathic responses which encourage sharing of past pain and anticipatoryfears should be used. When these individuals feel that the clinician understandstheir hypersensitivity and will be protective of them, they are willing to trust andcooperate with treatment. After feeling safe and accepted, the character of theinterview can change dramatically. Rapport has been achieved, and they feelrelieved when they can describe their fears of being embarrassed and criticized,and sensitivity to being misunderstood. They may experience these fears of beingembarrassed as silly or foolish. If the clinician fails to respond empathically, theyare likely to feel ridiculed and withdraw again (Othmer & Othmer, 2002).
The Minnesota Multiphase Personality Inventory (MMPI-2), the Million ClinicalMultiaxial Inventory (MCMI-IV), and the Rorschach Psychodiagnostic Test canbe useful in diagnosing the Avoidant Personality Disorder as well as the AvoidantPersonality Style or trait (Groth-Marnat, 2009).Avoidant Personality Disorder 81

On the MMPI-2 a 2–7/7–2 (Depression-Psychasthenia) proﬁle is typical. This
proﬁle reﬂects depression about assumed rejection, as well as apprehension andself-doubt about relating to others (Graham, 2012). When social withdrawal isalso present, a high score on 0 (Social Introversion) is likely, as well as a lowered9 (Hypomania) scale. When social withdrawal and self-rejection lead to decreasedfunctioning, an elevation on scale 8 (Schizophrenia) may occur (Meyer, 1995).
On the MCMI-IV, an elevation of 85 or above on scale 2B (Avoidant) along
with low scores on 4 (Histrionic) and 7 (Compulsive) are likely. Moderate elevatorson scales 8B (Masochistic-Self-Defeating) and C (Borderline) may also be present(Millon et al., 2015). The higher S (Schizotypal) is elevated, the more likelydecompensation has occurred (Choca & Denburg, 1997).
On the Rorschach, blocked or relatively inactive M (Human Movement)
responses are likely. A high number of P (Popular) responses occurs, and C(Contrast) often involves passive animals such as deer and rabbits—sometimes beingmaimed or killed—or passive interactions in the M responses (Meyer, 1995).
Basically, the overall goals of treatment with avoidant personality-disordered
individuals are to increase their capacity to tolerate feedback from others andbecome more selectively trusting of others. That means that instead of auto matically
assuming that others intend to criticize, reject, or humiliate them, or reﬂexively“testing” the trustworthiness of others, avoidant individuals will be able to takesome measured risks in relating to others. This might mean assertively com -
municating their needs and wants, or it might mean taking the risk of requestingsome feedback from others who previously have been supportive of them.
Avoidant individuals already know how to relate to a small and select number
of individuals, often relatives. If the clinician simply becomes one of them, theindividual’s basic pattern of avoidance may remain unchanged. It is only whenthese individuals learn to recognize the impact of their pattern on others and takerisks in new relationships that they can change.
Although individual therapy can help avoidant individuals recognize and
analyze their pattern of avoidance and withdrawal, couples therapy and grouptherapy permit both clinician and individual to observe the impact of this patternon others, and for the individual to risk new behaviors. If the individual is marriedor in a long-term relationship, triangular patterns are often present. For instance,the avoidant individual may be married to a spouse who travels extensively andmakes few if any emotional demands on their avoidant partner, providing theavoidant partner the opportunity for a secret extramarital affair. This triangularpattern provides some degree of intimacy as well as protection from publichumiliation, while also insuring interpersonal distance (Sperry & Sperry, 2016).82 Diagnosis and Treatment of DSM-5 Personality Disorders

Psychodynamic Psychotherapy Approaches
Both expressive and supportive aspects of psychodynamic psychotherapy can be
most effective in the treatment of the Avoidant Personality-Disordered individual(Gabbard, 1994). The supportive aspect involves an empathic appreciation of thehumiliation and embarrassment associated with exposure to fearful interpersonalcircumstances and the pain connected with rejection. The supportive aspect alsoinvolves the clinician’s prescription of exposure to the feared situation. Needlessto say, ﬁrm encouragement must accompany this prescription. More of theirfantasies and anxieties will be activated in the actual situation of exposure ratherthan in their defensive posture of withdrawal. Explaining this fact will furtherencourage avoidant patients to seek out fearful situations.
The expressive aspect of therapy focuses on exploring the underlying causes
of shame as related to past developmental experiences. To the extent the patientis willing to risk confronting the feared circumstance, the expressive aspect oftherapy is greatly enhanced. Initial exploratory efforts can be frustrating in thatavoidant individuals may be somewhat uncertain about who it is they fear. Theytend to provide vague and global explanations such as “rejection” and “shyness”rather than speciﬁc fantasies. Thus, the clinician does well to explore speciﬁcfantasies within the context of the transference.
These individuals tend to have a considerable degree of anxiety about the
psychotherapeutic requirement to openly share thoughts and feelings. Accord -
ingly, when they nonverbally react, i.e. blush, about something that has beenverbalized, the clinician might ask them to share their embarrassment and whatthey imagine the clinician could be thinking and feeling. By pursuing the detailsof speciﬁc situations, these patients can develop a greater awareness of thecorrelates of the shame affect (Gabbard, 1994).
Interpretive techniques are also useful as either the primary intervention or as
adjunctive to behavioral and interpersonal approaches. The basic strategy involvesinterpretive unconscious fantasies that their fear or impulses will become uncon -
trollable and harmful to self and others. Not surprisingly, their avoidant behaviormaintains a denial of unconscious wishes or impulses (Mackinnon & Michels,1971). Furthermore, these patients tend to have harsh superegos and subsequentlyproject their own unrealistic expectations of themselves onto others. In doing so,they evade expected criticism and embarrassment by avoiding relationships withothers. A complete interpretation, then, identiﬁes the unconscious impulse andthe fear, and traces the resulting avoidant defensive pattern in early life experiences,in outside relationships, and in the transference (Fenichel, 1945).
Compared to other personality disorders, there has been relatively little formal
study of the effectiveness of long-term psychodynamic treatment for this disorder.Svartberg, Stiles, and Seltzer (2004) conducted a randomized trial of 40 sessionsAvoidant Personality Disorder 83

of cognitive therapy versus psychodynamic therapy with 50 participants who met
the criteria for Cluster C personality disorders. Thirty-one of them qualiﬁed fora diagnosis of Avoidant Personality Disorder. Results indicated that both formsof therapy led to signiﬁcant positive changes; however, only the psychodynamictherapy group showed signiﬁcant decreases in symptom distress at the end oftreatment. Porcerelli, Dauphin, Ablon, Leitman, and Bambery (2007) conducteda ﬁve-year case study of a 50-year-old male computer technician who receivedpsychoanalysis four times per week. Later sessions after year two included elementsof cognitive-behavioral and interpersonal therapies. Results indicated that long-term psychoanalysis resulted in clinically signiﬁcant reductions in symptomseverity and relational pathology, with gains being maintained at the one-yearfollow up.
Cognitive-Behavioral Therapy Approaches
Beck et al. (2015) provide an in-depth discussion of the Cognitive Therapyapproach with Avoidant Personality-Disordered individuals. Avoidant individualsare often difﬁcult to engage in treatment given their basic strategy of avoidanceand their hypersensitivity to perceived criticism. The therapist must workdiligently yet carefully at building trust. Trust tests are common in the early stageof treatment and can include a pattern of cancelling appointments or havingdifﬁculty scheduling regular appointments. It is important not to prematurelychallenge automatic thoughts, as such challenges can be viewed as personalcriticism. Only after these individuals are solidly engaged in treatment should thetherapist use cognitive interactions to test their expectancies in social situations.To the extent the therapist utilizes collaboration rather than confrontation andguided discovery rather than direct disputation, these individuals are more likelyto view therapy as constructive and are likely to remain in treatment.
Since these individuals often experience high levels of interpersonal anxiety,
it is useful to employ anxiety management interventions early in the course oftreatment. Because these individuals work at avoiding not only unpleasant affectsbut also avoid thinking about matters that elicit unpleasant feelings, it is useful
to work in increasing emotional tolerance with desensitization methods andreframing. Furthermore, since these individuals may not have learned the basicsof social interaction, structured social skills training may need to be incorporated.
Later in therapy, when these individuals have achieved some of their short-
term treatment goals and developed sufﬁcient trust in the therapist, efforts tochallenge automatic thoughts and restructure maladaptive schemas are appropriate.Issues involving risk of developing close relationships and intimacy are central.Typically, it is necessary to decatastrophize disapproval and rejection. To the extentthese individuals have developed sufﬁcient self-efﬁcacy and have experiencedenough success on a variety of levels of relationships, they are more receptive to84 Diagnosis and Treatment of DSM-5 Personality Disorders

entertaining the notion that disapproval in a close relationship does not equal
rejection or devastation. Adding group therapy has a place in the treatment ofthis disorder, so that they can learn new attitudes and practice new skills in asocially benign and accepting environment. Padesky and Beck (2015) suggest threeprimary treatment goals: target emotional avoidance in and between sessions tohelp the patient become aware of how this pattern contributes to problems; buildself-reﬂection and interpersonal skills such as self-expression, assertion, and conﬂictnegotiation; and develop alternative cognitions that allow for both intimacy andassertiveness in relationships.
In summary, the cognitive therapy approach to this disorder recognizes the
signiﬁcant challenge of engaging the avoidant individual in treatment and utilizesseveral efforts to build trust, reduce social anxiety, and cognitive and emotional
avoidance. It then proceeds to correcting social skills deﬁcits with behavioral
methods before turning to cognitive analysis and disputation of automatic thoughtsand schemas and provides a safe environment to try out socially proactivebehavior.
From a behavioral perspective, management of the avoidant pattern is relatively
straightforward (Turkat, 1990). Anxiety-management procedures, assertiveness andsocial skills training through role-playing, direct instruction, and modeling areeffective in developing conﬁdent social behavior. However, graded exposure isthe single most effective behavioral intervention strategy for extinguishingavoidant behavior and anxiety intolerance (Greist & Jefferson, 1992).
Paradoxical intention may also prove useful, particularly with avoidant patients
who are also oppositional. With this strategy, the patient seeks rejection in a waythat is both predictable, and under the patient’s control. For instance, a singlemale with a fear of dating agrees to an experiment requiring that he be rejected
for dates by two women in the coming week. If one of the women approached
accepted his offer, he could go out with her, on the condition that he had askedout an additional woman who rejected him. In other words, being rejected
becomes a treatment goal. This intervention reduces rejection sensitivity. Use of
such a paradoxical intervention may work with the appositionally avoidantpatient by accentuating the patient’s need to defeat the clinician by doing the opposite of what is suggested or prescribed (Haley, 1978; Weeks & L’Abate,
1982).
Regarding treatment involving comorbid Avoidant Personality Disorder and
social phobia, Brown et al. (1995) found that individuals with both generalized
and nongeneralized social phobia treated with cognitive behavior therapy
improved similarly to those with the more generalized form of social phobia butremained more impaired after treatment. Curiously, the presence of AvoidantPersonality Disorder was not predictive of treatment outcome; however, several
individuals who met criteria for this diagnosis before treatment no longer met
criteria after treatment. Similarly, Osterbaan, van Balkom, Spinhoven, de Meij,Avoidant Personality Disorder 85

and van Dyck (2002) found that individuals with social phobia and comorbid
Avoidant Personality Disorder had a poorer response to treatment and remainedmore impaired in the short term compared to those with the comorbidity.Nevertheless, after 15 months, those with comorbid Avoidant Personality Disordershowed similar progress in the long term.
Schema Therapy . Schema Therapy is an elaboration of cognitive therapy
that has been developed by Young (Young et al., 2003) speciﬁcally for personalitydisorders, and other difﬁcult individual and couples problems. Schema Therapy
involves identifying maladaptive schemas and planning speciﬁc strategies and
interventions. Four main strategies are cognitive, experiential, behavioral, and thetherapeutic relationship itself. Cognitive restructuring, modiﬁcation of maladaptiveschemas, is an important cognitive strategy, but is combined with imagery exer -
cises, empathic confrontation, homework assignments, and “limited reparenting,”
i.e., a form of corrective emotional experience (Young et al., 2003).
Maladaptive schemas typically associated with Avoidant Personality Disorder
include: defectiveness : i.e., the belief that one is defective, bad, unwanted, or inferior
in important respects; social Isolation , i.e., the belief that one is alienated, different
from others, or not part of any group; self-sacriﬁce, i.e., the belief that one must
meet the needs of others at the expense of one’s own gratiﬁcation; and approval-
seeking , i.e., the belief that one must constantly seek to belong and be accepted
at the expense of developing a true sense of self (Bernstein, 2002).
For Benjamin (2003a) psychotherapeutic interventions with Avoidant Personality-Disordered individuals can be planned and evaluated in terms of whether theyenhance collaboration, facilitate learning about maladaptive patterns and their roots,block these patterns, enhance the will to change, and effectively encourage new
patterns.
Fortunately, avoidant individuals already know how to relate to a select few
individuals and thus a supportive therapist can easily provide a safe haven for them.Avoidant individuals respond favorably to accurate empathy and warm support.
Gradually, as they share intimacies and feelings of inadequacy, guilt, or shame,they begin to increase self-acceptance. Only then can they realistically begin
exploring maladaptive patterns. Since they are exquisitely sensitive to criticism,
premature confrontation must be avoided.
General reconstructive changes will occur only if these individuals understand
and appreciate the impact of their maladaptive patterns in a way that helps themdecide to change. Benjamin advocates couples therapy for avoidant individuals
in marriages of long-term relationships. Typically, these relationships are
characterized by intimacy that assures interpersonal distance and safety for theavoidant partner. Such a pattern of hiding on the margins of relationships is often86 Diagnosis and Treatment of DSM-5 Personality Disorders

rooted in unconscious loyalty to the family mandate that avoidant individuals
remain isolated and safe. In couples therapy, the clinician would block attemptsof partners to humiliate or thrash each other which previously justiﬁed thatavoidant individual’s withdrawal. The most difﬁcult therapeutic task for avoidantindividuals is deciding to sacriﬁce the beneﬁts of their maladaptive patterns andaccept the risk of developing new ones. Insight into their humiliation and loyaltyto abusive parents or siblings is insufﬁcient. However, Benjamin believes thatsteady reassurance in a context of competent, protective instruction fosters thischange.
Fiore, Dimaggio, Nicolo, Giuseppe, Semerari, and Carcione (2008) reported
a case study using metacognitive interpersonal therapy to treat a 48-year-old malecomputer manager with Obsessive-Compulsive Personality Disorder and Avoid -
ant Personality Disorder. He completed both individual and group therapy to
accomplish goals of modulating perfectionism, reducing avoidance behaviors andacknowledging suppressed desires. Following one year of treatment, this individualno longer met the full criteria for any personality disorder. Gilbert and Gordon(2012) likewise reported the case of a 24-year-old female graduate student beingtreated with interpersonal therapy for Avoidant Personality Disorder anddepression. Following two years of twice-monthly IPT and skills training (a total
of 44 sessions), the participant experienced improvements in the areas of self-
conﬁdence, somatic complaints, worry, anxiety, and depression.
Avoidant Personality-Disordered patients typically fear group therapy in the sameway they fear other new and socially demanding situations. It is for this very reasonthat group therapy may be speciﬁcally and especially effective for the avoidantpatients who can be persuaded and role-induced to undertake the exposure
(Yalom, 1975). Empathetic group therapy can assist these individuals inovercoming social anxieties and developing interpersonal trust and rapport.
Group therapy presents avoidant individuals an opportunity to belong and feelwanted, which challenges their previously held negative beliefs about themselves.
Other group members may provide positive feedback about behavior in groupthat counteracts the avoidant individual’s self-image, and the therapist can
reinforce this feedback in individual therapy (Fiore et al., 2008). Benjamin
(2003a) maintains that safe group therapy, in which the therapist blocks negative
or abusive behavior (“trashing”) from other members, can have enormous beneﬁtsin the areas of self-acceptance and social skills development.
A combination of cognitive therapy and social skills training appears effective.
Alden (1989) included aspects of cognitive therapy in the group process. These
were: (1) identifying underlying fears, (2) increasing awareness of the anxiety relatedto fears, and (3) shifting attentional focus from fear-related thinking to behavioralAvoidant Personality Disorder 87

action. Didactic information, modeling, and the practice of role-playing were
basic techniques incorporated into the sessions. Stravynski, Grey and Elie (1987)found that a briefer course of group therapy centered on social skills training canbe highly effective in ameliorating social skills deﬁcits that exacerbate anxiety aboutsocial relatedness.
This type of individual tends to avoid activities that involve signiﬁcant
interpersonal contact for fear of being exposed or ridiculed. Therefore, it takesthem longer to adapt to a group setting and begin to actively participate intreatment. The group therapist’s role in pacing the avoidant patient’s disclosureand engagement within the group can be very important (Cramer Azima, 1983).Rennenberg et al.(1990) found clients with this disorder so extremely anxiousand avoidant that processing directly to social skills training and behavioralrehearsal was unproductive. Stravynski, Grey, and Elie (1987) suggest beginningwith progressive relaxation training and systematic desensitization. Behavioralreversal was used in the group for exposure, itself an effective treatment for socialphobia (Stravynski, Marks, & Yule, 1982). Turner used communication and socialskills training during behavioral rehearsal as well.
Structured activities will help the avoidant individuals organize how they think
and act so they are more efﬁcient in therapy. Alden (1989) established speciﬁcgoals for patients to accomplish between sessions in order to enhancegeneralization from treatment sessions to daily life. The patients selected severalsocial tasks to try, beginning with easier situations and progressing to more difﬁcultones. In the group setting, she also introduced interpersonal skills training. Theprocess of friendship formation was presented and clients were encouraged toincorporate these skills into their weekly social tasks. Four sets of behavioral skillsthat facilitate relating to others were described, modeled by therapists, anddiscussed and practiced by group members. They included listening/attendingskills, empathic sensitivity, appropriate self-disclosure, and respectful assertiveness.
Rennenberg et al. (1990) found that treatment gains through group inter vention
were stable over one year; however, most patients continued with individualtherapy after completing group treatment. It is quite possible that the continuedtherapy served to reinforce and maintain gains made during the group treatmentprogram. Clinically important changes were reported by patients themselves ortheir individual therapists. Treated subjects reported decreases in their socialreticence, less interference due to social anxiety at work and in social situations,fewer symptoms of social anxiety, and greater satisfaction with social activities(Alden, 1989). Wilberg, Karterud, Urnes, Pedersen, and Friis (1999) measuredthe effectiveness of cognitive behavioral therapy groups for individuals with person -
ality disorders, most of whom were classiﬁed as avoidant. They found signiﬁcantimprovements for those who participated in the groups compared to those whodid not. Harper (2004) found that avoidant individuals who completed a 10-weekbehavioral group program showed greater improvement in a number of areasthan did the control group.88 Diagnosis and Treatment of DSM-5 Personality Disorders

Although avoidant individuals need to recognize how their current dysfunctional
patterns were developed, they need to focus on their current interpersonalexperiences with signiﬁcant others in their life. As Avoidant Personality-Disordered individuals generally provide clinicians with vague descriptions of theirinterpersonal experiences, others may be helpful in ﬁlling in the important gapsof information. Couple and family treatments may be indicated in order to establisha family structure that allows more room for interpersonal exploration outsidethe tightly closed family circle (Gurman & Kniskern, 1991). Benjamin (2003a)advocates couples therapy for avoidant individuals in marriages or long-termrelationships, as typically these are characterized by intimacy that assuresinterpersonal distance and safety for the avoidant partner. She also notes that thosewith avoidant personality disorder may likely feel disloyal discussing anyhumiliation or abuses experienced in the family of origin, which may create anobstacle to family participation in therapy. If they do agree to participate, familymembers may make matters worse by mocking the therapist, the treatment, orthe individual’s desire for change.
Currently, there are no psychotropic medications speciﬁcally indicated for treatingthe Avoidant Personality Disorder (Silk & Feurino, 2012). Nevertheless, medica -
tions are used that target speciﬁc troubling symptoms associated with the disorder,such as depression, anxiety, or sleep problems. Generally, these medi cations are
used as an adjunct to psychotherapy and skills training. Because troublingsymptoms often respond to medications sooner than most psychological inter -
ventions, medications are usually prescribed at the onset of treatment. Unfortun -
ately, there is little research evidence to provide guidelines for the use of suchmedications. However, because of the comorbidity of this disorder to social anxietydisorder, it was speculated that this personality disorder might respond well tomedications with anxiety-reducing effects such as selective serotonergic reuptakeinhibitors (SSRIs). There is now evidence from a randomized controlled trialthat individuals with avoidant personality disorder do respond to low doses ofsertraline (Zoloft), an SSRI medication (Silk & Feurino, 2012).
Combined and Integrated Treatment Approaches
Clinical experience reveals that many Avoidant Personality-Disordered individualsare often unable to focus on the patient-clinician relationship to the extentnecessary to work with a purely dynamic therapy. Millon and Davis (2000) suggestan overall poor prognosis for Avoidant Personality Disorder precisely because theproblem features of this disorder are the antithesis of what makes psychotherapyAvoidant Personality Disorder 89

successful, such as an open, trusting relationship. Similarly, many have difﬁculty
fully utilizing cognitive-behavioral interventions in the interpersonal context oftherapy. Thus, an integrative treatment strategy may be required. Alden (1992)describes an integration of the cognitive and the psychodynamic-interpersonalapproaches. The cognitive is, of course, based on Beck, Freeman, and associates(1990) and the psychodynamic-interpersonal is based on the Time-LimitedDynamic Psychotherapy approach developed by Strupp and Binder (1984).
The cognitive-interpersonal patterns that characterize the avoidant personality
are dysfunctional beliefs of being different or biologically defective, as well as
beliefs that these defects and feelings are visible to others who will react withdisgust, disapproval, or dismissal. These individuals tend to protect themselves bylooking to the clinician to provide direction and by understating or even with -
holding feelings and reactions of what they fear the clinician will disapprove. Thus,
the clinician’s primary task is to work collaboratively with the patient to modifytheir cognitive-interpersonal style. Alden (1992) describes four steps in theintegrative approach. The ﬁrst step is recognition of treatment process issues. Theclinician must quickly recognize that these patients tend to withhold or understateinformation that is clinically relevant. Clinicians should expect these patients torespond to direct questions with “I’m not sure” or “I don’t know.” Such evasive
and avoidant responses characterize the thought process and prevent these patients
from encoding details about social encounters.
Unfortunately, clinicians may ﬁnd themselves interpreting “resistance” or
focusing on global and vague interpersonal beliefs and behavior as treatment targets.
In either instance, both clinician and patient will experience discouragement andtreatment outcomes will be limited. Furthermore, clinicians must recognize theavoidant patient’s infectious “hopelessness” and depression largely due to their
inability to process positive information, lack of attentiveness, and their ﬁrmly
established negative beliefs and schemas.
The second step is increased awareness of cognitive-interpersonal patterns.
Patients need to be encouraged to observe their interpersonal encounters outside
sessions by means of self-monitoring and diary-keeping. Alden notes fourcomponents of the interpersonal pattern: their beliefs and expectancy of the otherperson; the behavior that arises from these beliefs; the others’ reaction to them;
and the conclusion they draw from the experience. As this process of self-
observation and analysis proceeds, these patients come to realize their mutualunderstanding of their interpersonal problem is incomplete and a common pattern
emerges. The clinician’s role is to draw attention to the beliefs that underlie self-
perception that leads to self-protective behaviors.
Step three focuses on alternative strategies. As patients recognize and
understand these cognitive-interpersonal pattern and style, the clinician can
increase their motivation to try new behavior by helping them recognize that
old and new views of self are in conﬂict and that this conﬂict can be reconciled.90 Diagnosis and Treatment of DSM-5 Personality Disorders

Helping patients integrate their current beliefs with their earlier interpersonal
experiences helps them understand that their social fears and expectations resultedin part from their temperament and parenting. As the patient continues toidentify and understand their cognitive-interpersonal patterns they begin to trynew strategies, either on their own or at the clinician’s prompting.
Step four involves behavioral experimentation and cognitive evaluation. These
therapeutic strategies are discussed in detail by Beck, Freeman, and associates(1990), to which the reader is referred. Friendship formation and assertive com -
munication are the two basic interpersonal skills that avoidant patients must
increase. Role-playing and directed assignments are particularly useful in this regard.In addition, Zimbardo’s (1977) social skills training exercises have been extremelyuseful in treating avoidant patients. Patients are gently guided through exercises
to develop assertive communication skills. As a matter of fact, the entire book is
an invaluable adjunct in the treatment of the avoidant personality.
The basic premise of this book is that a single treatment modality like psycho -
therapy may well be effective for the highest functioning personality-disordered
individual, but less effective for moderate functioning, and largely ineffective formore severely dysfunctional individuals. These lower functioning patients tend
to be more responsive to combined treatment modalities. Combined modalities
include integrative psychotherapeutic intervention with medication and/or grouptreatment such as group therapy or support groups. As noted in the section ongroup therapy, avoidant patients have considerable difﬁculty with any kind of
group. Ideally, lower functioning avoidant patients should be involved in bothindividual and group therapy concurrently. When this is not possible, time-limited
skill-oriented group training sessions or a support group may be sufﬁcient. Aware
that their pattern of avoidance and social inhibition makes entry into and
continuation with therapeutic groups distressing, individual sessions should befocused on transitioning the patient into the group.
Medication is often necessary in the early stages of treatment, and can be
particularly useful in reducing distress and self-protective behavior during thetransition into concurrent group treatment.
The co-occurrence between personality disorders and substance use disorders
is very common, with some estimating that a personality disorder is present in90 percent of those being treated for polyvalent addiction (Rentrop, Zilker,Lederle, Birkhofer, & Horz, 2014). Dimaggio et al. (2015) conducted a case studyof a 43-year-old male musician with comorbid avoidant personality disorder andsubstance use disorder (heroin). Treatment progressed according to stages, asfollows: drug therapy to manage the symptoms of abstinence from heroin;forming a therapeutic bond; fostering awareness of emotions and triggers;Avoidant Personality Disorder 91

exploring maladaptive interpersonal schemas; understanding the link between
interpersonal events and substance use; acquiring distance from maladaptiveschemas; and using adaptive coping skills instead of resorting to substance use.
To overcome the difﬁculty of treating those with avoidant personality due to
their social, emotional, and cognitive avoidance, some novel treatments have been
explored. Eikenaes, Gude, and Hoffart (2006) reported on a quasi-experimental
study integrating traditional inpatient treatment with a wilderness program, withpositive results.92 Diagnosis and Treatment of DSM-5 Personality Disorders

5
BORDERLINE PERSONALITY 
DISORDER
Individuals with borderline personality tend to lack a sense of self, as a result of
which they experience fears of abandonment and feelings of emptiness. They arealso likely to experience intense but unstable relationships, emotional instability,outbursts of anger and violence, and impulsivity. Suicidal threats and acts of self-harm are also common.
Of all the personality disorders, the Borderline Personality Disorder (BPD) is
of most concern for clinicians. Speciﬁcally, many clinicians believe that this disorderis untreatable, and this belief persists despite research evidence to the contrary.In fact, more research has been published on this disorder than any otherpersonality disorder, and increasingly it indicates that this disorder is quitetreatable. For example, Zanarini and colleagues (Zanarini et al., 2010) followednearly 300 individuals prospectively over a 10-year period. They found that onehalf these individuals achieved total recovery. That meant that they no longermet diagnostic criteria for this disorder, and also attained reasonable social andoccupational functioning. The good news of this important prospective study isthat for individuals with this disorder treatment can be quite successful.
of this disorder. It includes sections on diagnosis, case conceptualization,psychological assessment, and treatment interventions. It begins with backgroundinformation on the disorder as well as a DSM-5 description and a prototypicdescription of this disorder. The section on case conceptualization provides ﬁve common clinical formulations of this disorder: psychodynamic, biosocial,cognitive-behavioral, interpersonal, and an integrative conceptualization of thisdisorder. Several treatment approaches, modalities, and intervention strategies arealso described. These include individual psychotherapy, group therapy, maritaland family therapy, medication, and integrative and combined treatment.

94 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 5.1 Comparison of the Borderline Personality Style and Disorder
Maintenance of stable interpersonal Pattern of intense and unstable 
relationships in which negative and relationships marked by alternating 
positive perceptions of another are between devaluation and 
integrated rather than polarized. overidealization.
Low levels of impulsivity that fall within Impulsive behavior that can be self-
the normal range of culturally approved damaging, such as spending, sex, indulgence and do not cause devastation substance abuse, shoplifting, recklessto self or others. driving, or binge eating
Affective stability with tolerable levels Affective instability marked shifts from 
of negative emotions. baseline mood to depression, irritability,
or anxiety, usually lasting a few hoursand only rarely more than a few days.
Ability to manage and diffuse Inappropriate and intense anger or lack 
anger in ways appropriate to the of control of anger, e.g.,frequent context in which they occur. displays of temper, constant anger, 
recurrent physical ﬁghts.
Sense of connection to self, body, Persistent feelings of boredom or 
and place in the world. emptiness.
Possessing an accurate sense of self that is Marked and persistent identity 
consistent over time without being overly disturbance with uncertainty about at 
inﬂexible or overly malleable. least two of the following: self-image,
sexual orientation, long-term goals orcareer choice, type of friends desired,preferred values.
Ability to tolerate and manage experiences Frantic efforts to avoid imagined or 
of loss; capacity to realistically assess actual experiences of abandonment.abandonment/loss.
Absence of suicidal behavior, gestures Repeated suicidal gestures, behavior, 
and threats (excludes suicidal ideation), threats, or self-mutilating behavior.
self-mutilating behavior.
Capacity to manage stressful situations Brief, stress-related paranoid ideation or 
and stay cognitively and physically severe dissociative symptoms.
present.

Borderline Personality Disorder 95
Description of the Borderline Personality Disorder
The Borderline Personality Disorder can be recognized by the following descrip -
tors and characteristics: styles vs. disorders, triggering event, behavioral style, inter -
Styles vs. Disorders . The borderline personality can be thought of as span -
ning a continuum from healthy to pathological, wherein the borderline person -
ality style is on the healthy end, and the Borderline Personality Disorder is onthe pathological end. Table 5.1  compares and contrasts the antisocial personality
style and disorder.
The following case examples further illustrate the differences between the
Borderline Personality Disorder—Mr. J—and the borderline personality style—Ms. B.
CASE STUDY: BORDERLINE PERSONALITY DISORDER
Mr. J is a 31-year-old unemployed male who was referred to the hospital
emergency room by his therapist at a community mental health center after
two days of sustained suicidal gestures. He appeared to function adequatelyuntil his senior year in high school, when he became preoccupied with
Transcendental Meditation. He had considerable difﬁculty concentrating
during his ﬁrst semester of college and seemed to focus most of his energieson ﬁnding a spiritual guru. At times, massive anxiety and feelings of emptinessswept over him, which he found would suddenly vanish if he lightly cut his
wrist enough to draw blood. He had been in treatment with his current
therapist for 18 months and became increasingly hostile and demanding asa patient, whereas earlier he had been quite captivated with his therapist’sempathy and intuitive sense. Lately, his life seemed to center on these twice-
weekly therapy sessions. Mr. J’s most recent suicidal thoughts followed the
therapist’s disclosure that he was moving out of the area.
CASE STUDY: BORDERLINE PERSONALITY STYLE
Janice P. is a 29-year-old graduate student in Oriental Literature. She hadcompleted her undergraduate degree at the university in business andmanagement with honors and had planned on starting her MBA that fall. A
summer tour of Japan and China dramatically changed her life. She fell in
love with the Orient: the people, the food, the customs, the ambience, butespecially a literature professor at a Tokyo university she met. She fell madly

likely triggers or activates the characteristic maladaptive response of the BorderlinePersonality Disorder Personality Disorder (Othmer & Othmer, 2002), as notedin behavioral, interpersonal, cognitive, and affective styles, is: “frantic efforts toavoid real or imagined abandonment.”
Behavioral Style . Behaviorally, borderlines are characterized by physically
self-damaging acts such as suicide gestures, self-mutilation, or the provocation ofﬁghts. Their social and occupational accomplishments are often less than theirintelligence and ability warrant. Of all the personality disorders, they are morelikely to have irregularities of circadian rhythms, especially of the sleep-wake cycle.Thus, chronic insomnia is a common complaint.
Interpersonal Style . Interpersonally, borderlines are characterized by their
paradoxical instability. That is, they ﬂuctuate quickly between idealizing andclinging to another individual to devaluing and opposing that individual. Theyare exquisitely rejection-sensitive, and experience abandonment depressionfollowing the slightest of stressors. Millon and Davis (1996) consider separationanxiety as a primary motivator of this personality disorder. Interpersonal relation -
ships develop rather quickly and intensely, yet their social adaptiveness is rathersuperﬁcial. They are extraordinarily intolerant of being alone and they go to greatlengths to seek out the company of others, whether in indiscriminate sexual affairs,late-night phone calls to relatives and recent acquaintances, or late-night visits to hospital emergency rooms with a host of vague medical and/or psychiatriccomplaints.
Cognitive Style . Their cognitive style is described as inﬂexible and impulsive
(Millon, 1981). Inﬂexibility of their style is characterized by rigid abstractionsthat easily lead to grandiose, idealized perceptions of others, not as real people,but as personiﬁcations of “all good” or “all bad” individuals. They reason byin love with him the ﬁrst time she met him, and spent the next two weeks
before her ﬂight back to the United States totally engrossed with his poetry,
his stories, and his life. Although he was married, his wife was on a holidayalone. Janice was conﬂicted about returning home even though he broke off
the relationship. Janice was crushed that he would not leave his wife.
Nevertheless, she returned to the university with an ardent desire to immerseherself in the study of Oriental literature. But, she had fantasies of returningto Tokyo as a visiting professor and working alongside the love of her life,
with the goal of eventually having him all to herself. Yet, even though she
was doing well in her classes, she occasionally got in touch with the angerand hurt she had experienced that summer. Midway in her ﬁrst semester ingrad school she met a stunning Oriental graduate student, with whom she
instantly fell in love.96 Diagnosis and Treatment of DSM-5 Personality Disorders
instability. they ﬂuctuate quickly between idealizing and
clinging to another individual to devaluing and opposing that individual.
rejection-sensitive, abandonment depression
separation
anxiety as a primary motivator of this personality disorder.
y intolerant of being alone and they go to great
lengths to seek out the company of others, 
“all good” or “all bad”

analogy from past experience and thus have difﬁculty reasoning logically and
learning from past experiences and relationships. Because they have an externallocus of control, the borderlines usually blame others when things go wrong. Byaccepting responsibility for their own incompetence, borderlines believe theywould feel even more powerless to change circumstances. Accordingly, theiremotions ﬂuctuate between hope and despair, because they believe that externalcircumstances are well beyond their control (Shulman, 1982). Their cognitivestyle is also marked by impulsivity, and just as they vacillate between idealizationand devaluation of others their thoughts shift from one extreme to another: “Ilike people, no I don’t like them”; “Having goals is good, no it’s not”; “I needto get my life together, no I can’t, it’s hopeless.” This inﬂexibility and impulsivitycomplicate the process of identity formation. Their uncertainty about self-image,gender identity, goals, values, and career choice reﬂects this impulsive and ﬂexiblestance. Gerald Adler (1985) suggested that borderlines have an underdevelopedevocative memory, such that they have difﬁculty recalling images and feeling statesthat could structure and soothe them in times of turmoil. Their inﬂexibility andimpulsivity are further noted in their tendency toward “splitting,” the inabilityto synthesize contradictory qualities, such that the individual views others as allgood or all bad and utilizes “projective identiﬁcation,” that is, attributing his orher own negative or dangerous feelings to others. Their cognitive style is furthercharacterized by an inability to tolerate frustration. Finally, micropsychoticepisodes can be noted when these individuals are under a great deal of stress.These are ill-deﬁned, strange thought processes especially noted in response tounstructured rather than structured situations and may take the form ofderealization, depersonalization, intense rage reactions, unusual reactions to drugs,and intense brief paranoid episodes. Because of difﬁculty in focusing attentionand subsequent loss of relevant data, borderlines also have a diminished capacityto process information.
Affective Style . The emotional style of individuals with this disorder is
characterized by marked mood shifts from a normal or euthymic mood to adysphoric mood. In addition, inappropriate and intense anger and rage may easilybe triggered. On the other extreme are feelings of emptiness, a deep “void,” orboredom.
Attachment Style . Individuals with vacillating views of both self and others
exhibit the disorganized attachment style; “Disorganized attachment develops fromrepeated experiences in which the caregiver appears frightened or frightening tothe child” (Siegel, 1999, p. 117). This style is associated with dissociative symp -
tomatology which increases their proneness to posttraumatic stress disorder. TheBorderline Personality Disorder is characterized by unstable personality structurethat seems to shift among the various insecure attachment styles creating a dis -
organized proﬁle, called the disorganized attachment style (Lyddon & Sherry, 2001).
Optimal Diagnostic Criterion . Of all the criteria for the Borderline
Personality Disorder, one has been found to be the most useful in its diagnosis.Borderline Personality Disorder 97
d difﬁculty reasoning logically and
learning from past experiences and relationships. external
locus of control, usually blame others when things go wrong.
beyond their control 
mood shifts from a normal or euthymic mood to a
dysphoric mood.  inappropriate and intense anger and rage may easily
be triggered. r a deep “void,” or
boredom.
e disorganized attachment style; 
unstable personality structure
that seems to s hift amon g the various insecure attac hment st yles creatin g a dis-
organized proﬁle, called the disorganized attachment style

The belief is that, by beginning with this criterion, the clinician can test for the
presence or absence of the criterion and quickly diagnose this disorder. The optimalcriterion for this disorder is: frantic efforts to avoid real or imagined abandonment(Allnutt & Links, 1996).
Childhood Abuse and Etiology . There is increasing research evidence that
a history of early abuse or neglect is common in adults with personality disorders,particularly Borderline Personality Disorder (Van der Kolk, Perry, & Herman,1989; Zanarini et al., 2010). Bernstein (2002) indicates that childhood historiesof severe emotional abuse are noted in adults diagnosed with Borderline Personality
Disorder. Data on sexual abuse among individuals with this disorder are troub-ling, in that the odds of such an individual attempting suicide in adulthood isover 10 times that of those who were never sexually abused (Soloff, Lynch, &Kelly, 2002).
Many clinicians have come to assume that this disorder is caused by such
childhood abuse. Research largely supports this presumption. Nevertheless, it doesnot suggest that abuse is the primary cause of all cases of Borderline Person-ality Disorder. But exactly how prevalent is such trauma in those presenting for treatment? A recent meta-analytic study (Fossatti, Madeddu, & Maffei, 1999)indicates that in individuals diagnosed with Borderline Personality Disorder, the prevalence rates of abuse are in the range of 60–80 percent. This means that20–40 percent of these individuals do notreport such histories. Presumably, 
such individuals are more likely to be the so-called “higher functioning” border -
lines. In other words, while there are traumatic pathways in the development ofperson ality disorders, there are also nontraumatic pathways. An important
treatment implication is that such clients, who were not traumatized but rathermay have been otherwise wounded as children in their efforts to meet emotionalneeds, may be responsive to a broader range of therapeutic interventions thanmore focused approaches such as Dialectical Behavior Therapy. These otherinterventions might include exploratory, uncovering, and abreactive interventions,which are less likely to be regressive or iatrogenic than they would be with clientswith trauma histories (Graybar & Boutilier, 2002).
Individuals with this personality disorder are characterized by an unremittingpattern of unstable relationships, emotional reactions, identity, and impulsivity.They engage in frantic efforts to avoid abandonment, whether it is real or imagined.Their interpersonal relationships are intense, unstable, and alternate between theextremes of idealization and devaluation. They have chronic identity issues andan unstable sense of self. Their impulsivity can result in self-damaging actionssuch as reckless driving or drug use, binge eating, or high-risk sex. These indi -
viduals engage in recurrent suicidal threats, gestures, acting out, or self-mutilatingbehavior. They can exhibit markedly reactive moods, chronic feelings of98 Diagnosis and Treatment of DSM-5 Personality Disorders
 frantic efforts to avoid real or imagined abandonment
g an unremitting
pattern of unstable relationships, emotional reactions, identity, and impulsivity.
reckless driving or drug use, binge eating, or high-risk sex.
g t suicidal threats, gestures, acting out, or self-mutilating
behavior.

emptiness, emotional outbursts, and difﬁculty controlling their anger. They may
also experience brief, stress-related paranoid thinking or severe episodes ofdissociation (American Psychiatric Association, 2013).
described as instability of self-image, goal-striving, interpersonal relating, and affects
accompanied by impulsivity, hostility, and risk-taking. Characteristic difﬁcultiesare noted in identity, self-direction, empathy, and intimacy, as well as hostility,
risk-taking, impulsivity, depression, and separation insecurity.
These individuals have intense and frustrating relationships which begin with high
hopes but predictably degenerate into conﬂict and disappointments. Because they
are terriﬁed of being abandoned, they drive others away with unrealistic demands,
relentless anger, and self-fulﬁlling expectations of abandonment. Real or imaginedlosses can lead to suicide attempts or self-mutilation. The result is repeated destruc -
tive relationships and a fragile sense of self. They may engage in impulsive sexualand aggressive behaviors. Suicide rates are high for such individuals. However,those who survive may ﬁnd some sense of balance and serenity in midlife(Frances, 2013).
Prevalence of this disorder has been estimated at between 1.6 and 5.9 percent inthe general population. In primary care settings the ﬁgure is 6 percent, but 10percent of outpatient settings and 20 percent in inpatient settings (AmericanPsychiatric Association, 2013).
Conceptualizations of the Borderline Personality Disorder
Kernberg (1975) targets the rapprochement sub-phase of Mahler’s separation-
individuation developmental theory as the point of ﬁxation for borderline
pathology. At this phase children lack object constancy and thus cannot integratethe good and bad aspects of themselves or their mothers. Neither can they separatefrom the mother, since they have yet to internalize a whole, soothing internalizedusage of her that sustains them during her physical absence. Kernberg points toa disturbance in the mother’s emotional availability during the rapprochementsub-phase, which is attributable to the constitutional excess of aggression in thechild, to maternal problems with parenting, or both.Borderline Personality Disorder 99

Masterson (1976) and Masterson and Klein (1989) implicate the rapprochement
sub-phase but emphasize the mother’s behavior rather than the child’s aggression.Typically a borderline herself, the mother is deeply conﬂicted about her childrengrowing up and becoming their own person. Thus, these children receive themessage that if they grow up, something awful will happen to them and/or totheir mothers, and that remaining dependent is the only way of maintaining thematernal bond. This prospect of separation and individuation thus provokes“abandonment depression” in borderlines. No integration between a rewardingobject unit and a withdrawing object unit is possible at this rapprochement sub-phase, accounting for the symptom of the borderline syndrome.
Adler’s (1985) understanding of borderline pathology is inﬂuenced by Kohut
(1971, 1977) and Fraiberg (1969) and is based on a deﬁcit rather than a conﬂictmodel, as with Kernberg. Inconsistency in maternal behavior and availability results in the borderline’s failure to develop a “holding-nothing” internalizedobject. This accounts for feelings of emptiness, depressive tendencies, and oralrage. Furthermore, the borderline individual has difﬁculty summoning up internalimages of the natural nurturing ﬁgure in stressful situations. This cognitive deﬁcitof evocative memory suggests a regression to developmental age of between 8 and 18 months. These inadequate resources leave the borderline prone tofragmentation of the self, which is accompanied by profound emptiness called“annhilation panic.”
Mentalization Approach . Bateman and Fonagy’s (2007) mentalization
approach to Borderline Personality Disorder is rooted in object relations andattachment theory. Sometimes referred to as “mentalizing,” this is the process bywhich individuals interpret their own subjective cognitions, behaviors, andemotions, as well as those of others. The ability to mentalize is believed to ariseas a function of childhood development by age 4. Rather than an automaticconsequence of maturation, it is dependent on the quality of an individual’s earlyobject relationships. Interactions with the primary caregiver, usually the mother,act as the foundation from which individuals make sense of their mental statesand interpersonal interactions. To fully develop this capacity, infants must havea stable, affectionate, safe, and attentive adult to mirror their experiences. Batemanand Fonagy suggest that those with borderline personality lack the ability tointerpret mental states and accurately understand their relationships due topsychological trauma in early or late childhood. Neglect, abuse, and incongruentemotional mirroring all lead to insecure/hypersensitive attachments and poor self-regulation.
Transference-Focused Psychotherapy Approach . Clarkin, Yeomans, and
Kernberg (2015) subscribe to a similar etiology for Borderline Personality Disorderin their approach, called Transference-Focused Psychotherapy (TFP). Groundedin object relations theory, Clarkin et al. theorize that the speciﬁc symptoms ofBPD result from a lack of identity integration and incoherence between anindividual’s experience and understanding of self and others. This unintegrated100 Diagnosis and Treatment of DSM-5 Personality Disorders

psychological state is called identity diffusion. Those with Borderline Personality
Disorder rely on defensive strategies that distort reality, such as dissociation andsplitting. The result of these cognitive distortions is that negative or aggressiveaffects are not seen as coming from within but from outside the self, leading tofeelings of helplessness, anger, and insecurity. Transference-Focused Psycho therapy
conceptualizes psychological structure as the product of early interactions withcaregivers, which are internalized as the individual develops. In the case of BPD,this process is interrupted by traumatic and/or inconsistent relationships withcaregivers. The absence of an integrated self leads to chronic distress and feelingsof emptiness for which borderline individuals impulsively act out in an attemptto relieve their discomfort.
Millon and Davis (1996) view the borderline’s lack of a clear, coherent sense ofidentity as central to the pathogenesis of this disorder. He believes that identityconfusion and/or diffusion is the result of biopsychosocial factors that combineto impair a coherent sense of identity. Because of this central deﬁcit, poorcoordinated actions, overmodulated affects, poorly controlled impulses, and afailure of consistent effort result. Thus, the borderline individuals are dependenton others for protection and reassurance, and are hypersensitive to loss orseparation of these supports. Based on this research, Millon (1981) and Millonand Everly (1985) contend that the borderline syndrome is essentially more severeand regressed variants of the Dependent, Histrionic, or passive-aggressivepersonality disorders. They describe three subtypes of this disorder.
Borderline-dependent individuals tend to exhibit a passive infantile pattern and
possess family histories of low energy levels. This pattern evokes parental warmthand overprotection, and they subsequently form strong attachments anddependency to a single caregiver, which ultimately restricts their opportunity tolearn the necessary skills of social independence and self-efﬁcacy. This sets thestage for rejection by those on whom they have come to rely.
Borderline-histrionic individuals more often possess family histories characterized
by high autonomic reactivity, and they exhibit hyperresponsiveness as a result ofexposure to high levels of stimulation. Parental control tends to be exercised bycontingent reinforcement patterns for which these children feel competent andaccepted only if their behavior is explicitly approved by others, and thus they“perform” to secure support, attention, and nurturance.
Borderline-passive aggressive individuals tend to have exhibited “difﬁcult child”
(Thomas & Chess, 1977) temperaments. As irritable, difﬁcult-to-soothe infantsthey likely received inconsistent responses from their caregivers, caring at times,harried and frustrated at others, and even withdraw. They might have beenproducts of broken homes, and likely had a parent who modeled the erratic,vacillating, passive aggressive behavior they display as adults.Borderline Personality Disorder 101

Cognitive-Behavioral Case Conceptualization
Three common cognitive behavioral case conceptualizations have been described:
Cognitive Therapy, Schema Therapy, and Dialectical Behavior Therapy.
Cognitive Therapy . According to Beck (2015; Beck et al., 1990), three basic
assumptions are noted in those with this personality disorders: “I am powerlessand vulnerable”; “I am inherently unacceptable”; and “the world is dangerousand malevolent”(Arntz, 2015; Pretzer, 1988). Because of their inherent belief,they are helpless in a hostile world; without a source of security they vacillatebetween autonomy and dependence without being able to rely on either. Inaddition, borderlines tend to display “dichotomous thinking,” the tendency toevaluate experiences in mutual exclusive categories, all good or all bad, successor failure, trustworthy or deceitful. The combination of dichotomous thinkingand basic assumptions are the basis of borderline emotion and behavior, includingacting-out, self-destructive behaviors.
Schema Therapy . Young (1990; Young et al., 2003) describes a schema-
focused conceptualization of this disorder. The basic premise is that “earlymaladaptive schemas” develop during childhood and result in maladaptivebehavior patterns that reinforce these schemas. These schemas include theabandonment/loss schema “I’ll be alone forever. No one would love me or wantto be close to me if they really got to know me,” and the emotional deprivationschema “No one is ever there to meet my needs, to be strong for me, to carefor me.”
Dialectical Behavior Therapy . Linehan (1987, 2015) describes a behavioral
conceptualization of this disorder. The basic premise is that inadequate emotionalregulation and an invalidating environment predispose an individual to thisdisorder. In addition, there is an invalidating environment “in which com mun -
ication of private experience is met by erratic, inappropriate, and extremeresponses. In other words, the expression of private experience is not validated;instead, it is often punished, and/or trivialized” (Linehan, 1993, p. 49). Linehan(1993) contends that a poor ﬁt between a difﬁcult child and an invalidatingenvironment fosters the development of this disorder. The borderline pattern isbelieved to be physiologically based and reinforced by experiences with signiﬁcantothers who discount their emotional experiences. Subsequently, borderlineindividuals develop little or no skill in emotion regulation. In short, the com -
bination of intense emotional responses, inadequate emotional regulation skills,and an invalidating environment predispose an individual for unrelenting crisis,for which these individuals are unable to effectively cope.
Structural Analysis of Social Behavior Approach . Benjamin’s (2003a)
approach to case conceptualization Structural Analysis of Social Behavior posits102 Diagnosis and Treatment of DSM-5 Personality Disorders

that individuals with Borderline Personality Disorder typically grew up in a family
marked by a chaotic, soap-opera lifestyle. Without these dilemmas, life was experi -
enced as hollow, boring, and empty. Whether these chaotic dramas were blatantor sequestered from public view, the borderline-to-be played a central role,resulting in the impulsivity, mood instability, and unpredictable characteristic oflife without constancy. The developmental histories of these individuals oftenincluded traumatic abandonment experiences, the isolation of which was typicallymarked by physical and/or sexual abuse. This abuse-laden aloneness becameinexorably linked with the notion that the borderline-to-be was a bad person.These abuse experiences “taught” the individual to shift from idealization todevaluation. And, to the extent that sexual abuse experiences were painful, theyset the stage for self-mutilation, as pleasure became confused with pain duringsuch episodes. Family norms dictated that autonomy was bad, while dependencyand sympathetic misery with the family were good. As such movement towardindependence, competence, or happiness elicited self-sabotage. Furthermore,young borderline individuals learned from their families that misery, sickness, anddebilitation draw forth love and concern from others. The adult consequence isthat the borderline-disordered individuals believe that caregivers and loverssecretly love misery. In short, there is a morbid fear of abandonment and a wishfor protective nurturance particularly from a lover or caregiver. Initially, friendlydependency on the nurturer gives way to hostile control when the caregiver orlover fails to deliver enough. Borderline individuals believe that signiﬁcant otherssecretly like dependency and neediness, and a vicious introject attacks the self inthe face of any signs of success or happiness. Treatment based on this model iscalled Interpersonal Reconstructive Therapy (Benjamin, 2003b, 2007).
Interpersonal Psychotherapy Approach . A related interpersonal concep -
tualization of this disorder is an adaptation of Interpersonal Psychotherapy, whichwas originally developed for treatment of chronic depression or DysthymicDisorder, called Persistent Depressive Disorder in DSM-5 (Weissman, Markowitz,& Klerman, 2000, 2007). In this adaptation, Borderline Personality Disorder ischaracterized as a mode-inﬂected condition similar to chronic depression butpunctuated by sporadic, ineffective outbursts of anger and impulsivity (Markowitz,Bleiberg, Pessin, & Skodol, 2007).
The following integrative formulation provides a biopsychosocial explanation for how this personality is likely to have developed and how it is maintained.Bio logically, borderlines can be understood in terms of the three main subtypes:
borderline-dependent, borderline-histrionic, and borderline-passive aggressive. The temperamental style of the borderline-dependent type is that of the passiveinfantile pattern (Millon, 1981). Millon hypothesized that low autonomic nervoussystem reactivity plus an overprotective parenting style facilitates restrictiveBorderline Personality Disorder 103

interpersonal skills and a clinging relational style. On the other hand, the histrionic
subtype was more likely to have a hyperresponsive infantile pattern. Thus,because of high autonomic nervous system reactivity and increased parentalstimula tion and expectations for performance, the borderline-histrionic pattern
was likely to result. Finally, the temperamental style of the passive aggressiveborderline was likely to have been the “difﬁcult child” type noted by Thomasand Chess (1977). This pattern plus parental inconsistency marks the affectiveirritability of the borderline-passive aggressive personality.
Psychologically, borderlines tend to view themselves, others, the world, and
life’s purpose in terms of the following themes. They view themselves by somevariant of the theme “I don’t know who I am or where I’m going.” In short,their identity problems involve gender, career, loyalties, and values, while theirself-esteem ﬂuctuates with each thought or feeling about their self-identity.Borderlines tend to view their world with some variant of the theme “Peopleare great, no they are not”; “Having goals is good, no it’s not”; or, “If life doesn’tgo my way, I can’t tolerate it.” As such they are likely to conclude: “Thereforekeep all options open. Don’t commit to anything. Reverse roles and vacillatethinking and feelings when under attack.” The six defensive operations utilizedby the Borderline Personality Disordered individuals are denial, splitting, primitiveidealization, projective identiﬁcation, omnipotence and devaluation (Shulman,1982).
noted for the Borderline Personality Disorder. Parenting style differs dependingon the subtype. For example, in the dependent subtype, overprotectivenesscharacterizes parenting, whereas in the histrionic subtype a demanding parentingstyle is more evident, while an inconsistent parenting style is more noted in thepassive aggressive subtype. But, because the borderline personality is a syndromalelaboration and deterioration of the less severe Dependent, Histrionic, or passiveaggressive personality disorders, the family of origin in the borderline subtypesof these disorders is likely to be much more dysfunctional, increasing thelikelihood the child will have learned various self-defeating coping strategies. Theparental injunction is likely to have been “If you grow up and leave me, badthings will happen to me [parent].”
This borderline pattern is conﬁrmed, reinforced, and perpetuated by the
following individual and systems factors. Diffuse identity, impulsive vacillation,and self-defeating coping strategies lead to aggressive acting out, which leads tomore chaos, which leads to the experience of depersonalization, increaseddysphoria, and/or self-mutilation to achieve some relief. This leads to furtherreconﬁrmation of their beliefs about self and the world, as well as reinforcementof the behavioral and interpersonal patterns (Sperry, 2015).
Table 5.2  summarizes the characteristic features of this disorder.104 Diagnosis and Treatment of DSM-5 Personality Disorders

Borderline Personality Disorder 105
TABLE 5.2 Characteristics of Borderline Personality Disorder
Triggering Event(s) Expectation of meeting personal goals and/or maintaining 
close relationships
Behavioral Style Impulsivity
Acting out behaviors
Helpless, empty “void”
Interpersonal Style Fear of abandonment
Unstable, intense relationships
Alternates between extremes of idealization and 
devaluation
Cognitive Style Inﬂexible, rigid thinking
Failure to learn from experienceExternal loss of control
Affective Style Emotionally reactive and dysregulated
Inappropriate, intense angerExtreme lability of mood and affect
Attachment Style DisorganizedTemperament Dependent type : passive infantile pattern—low autonomic
nervous system reactivity
Histrionic type: hyperresponsive infantile pattern—high 
autonomic reactivity
Passive-Aggressive type : “difﬁcult” infantile pattern—affect 
irritability
Parental Injunction “If you grow up, bad things will happen to me [parent].”
Overprotective or demanding or inconsistent parenting
Self -View “I don’t know who I am or where I’m going.”
Identity problems involving gender, career, loyalties, and 
values
Self-esteem ﬂuctuates with current emotion
World-View “People are great, no they’re not. Having goals is good,
no it’s not. If life doesn’t go my way, I can’t tolerate it.Don’t commit to anything.”
Maladaptive Schemas Abandonment, defectiveness, abuse/mistrust, emotional
deprivation, social isolation, insufﬁcient self-control
Optimal Criteria Frantic efforts to avoid real or imagined abandonment

Assessment of Borderline Personality Disorder
logical testing are important adjuncts to the patient’s self-report in the clinicalinterview. This section brieﬂy describes some characteristic observations that the
clinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e. MMPI-2 and MCMI-IV) and projective tests (i.e.Rorschach and TAT) are also described.
Interviewing Borderline Personality-Disordered individuals presents a special
challenge because of their instability and ambivalence. Instability or lability is notedin their moods, goals, and rapport with the clinician. Instability regarding rapport
is handled by empathically focusing on it. This is done by directing the discussion,
keeping the discussion on track, and curbing diversions and outbursts. Askingopen-ended questions is preferable to seeking precise answers to closed-endedpointed questions (Ackley et al., 2011). Instability is also processed by separatingit as a pathological part that needs to be explored. Since it also affects rapport,
the clinician must continually acknowledge its presence and effect. The result is
that these patients become less defensive and more willing to disclose, thus
furthering rapport.
Dealing with ambivalence requires confronting their contradictions while at
the same time exhibiting and understanding their ambivalent feelings. Therapeutic
confrontation illustrates their splitting and projective identiﬁcation and moderatesoveridealization or devaluation. It further helps these individuals realize that their
ambivalence results from perceived lack of support and understanding of mother,which they allow to profoundly inﬂuence their sense of well-being (Othmer &Othmer, 2002).
The Minnesota Multiphasic Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-IV), the Rorschach Psychodiagnostic Test, and theThematic Apperception Test (TAT) can be useful in diagnosing the BorderlinePersonality Disorder as well as the borderline personality style (Groth-Marnat,2009).
On the MMPI-2, elevations on scales 2 (Depression), 4 (Psychopathic Deviate),
and 8 (Schizophrenia) are common (Graham, 2012). Scales O (Social Introversion)and K (Correction) tend to be high, and F (Frequency) is typically low. If
emotional dysregulation—particularly of anger—is prominent, scale 6 (Paranoia)106 Diagnosis and Treatment of DSM-5 Personality Disorders

will be high. Although relatively rare, 2–6 (Depression-Paranoia) 6–2 proﬁle is
associated with borderline pathology (Meyer, 1995).
On the MCMI-IV, elevation on scale C (Borderline) is most likely and
concurrent elevation on scale 8A (Negativistic—passive aggressive) is also likely
(Millon et al., 2015). Elevations on such clinical scales as A (Generalized anxietydisorder), H (Somatic symptom disorder), N (Bipolar I disorder), and/or D
(Dysthymia Disorder) can be expected (Choca & Denburg, 1997).
On the Rorschach, illogical and confabulated combinations (i.e., “A horse’s
head with two sea horses growing out of his ears” for Card 10) are common
(Singer & Larsen, 1981; Swiercinsky, 1985). Such responses are most likely oncards 10.9 and 2.
On the TAT, “primitive splitting” may be noted in characters that are judged
as all bad, (i.e., devils), in characters wherein only one side of the personality is
admitted to or portrayed, or when good-bad characteristics are juxtaposedincongruously. Separation anxiety themes, extreme portrayals of affect, and actingout rather than delayed gratiﬁcation themes are not uncommon (Bellak, 1997).
Included in the differential diagnosis of the Borderline Personality Disorder are
these other Axis II personality disorders: Passive Aggressive, Histrionic, Depend -
ent, and Schizotypal personality disorders. The most common Axis I syndromesassociated with the personality disorder are Generalized Anxiety Disorder, PanicDisorder, and Dysthymia. In addition, other syndromes may be Brief ReactivePsychoses, Schizoaffective Disorder, Hypochondriasis, or the DissociativeDisorders, especially Psychogenic Fugue.
The Borderline Personality Disorder (DBT) may be the most common Axis
II presentation seen in both the public sector and in private practice. It can beamong the most difﬁcult and frustrating conditions to treat. Clinical experience
suggests that it is important to assess the individual for overall level of functioningand treatment readiness in making decisions about treatment approaches, modal -
ities and strategies. The Borderline Personality Disorder is the most researchedof all the personality disorders. To date, several randomized controlled treatmentstudies have been published. An evaluation of seven controlled trials of DBTconcluded that DBT met the criteria for a well-established treatment accordingto the American Psychological Association’s Division 12 Task Force forempirically supported therapies (Lynch, Trost, Salsman & Linehan, 2007).
Many consider individual psychotherapy to be the cornerstone of treatment forthe Borderline Personality Disorder. Although there are widely divergent opinionsBorderline Personality Disorder 107

on the appropriateness or efﬁcacy of the various individual psychotherapeutic
approaches, there is consensus on some general principles. Waldinger (1986)describes ﬁve points of consensus on treating the borderline personality. First,the therapist must be active in identifying, confronting, and directing the patient’sbehaviors during sessions. Second, a stable treatment environment must beafforded in terms of setting and maintaining limits and boundaries, scheduling,payment of fees, and role expectations of patient and clinician. Third, connectionbetween the patient’s actions and feelings needs to be established. Fourth, self-destructive behavior must be made ungratifying. And, ﬁfth, careful attention mustbe paid to countertransference feelings.
Regardless of the speciﬁc psychotherapeutic approach utilized, the literature
indicates that treatment of the borderline patient is difﬁcult, countertransferenceproblems are common, and the results are uneven (Gunderson, 1989). Someborderline patients experience negative therapeutic reaction and others untowardeffects of individual psychotherapy. In some instances, these patients should notbe afforded individual treatment. Frances et al. (1984) offer the “no treatmentoption” and offer speciﬁc criteria for its use. Nevertheless, when treatment isindicated, attention to the patient’s needs and expectations for treatment and effortsto match and tailor treatment are essential in maximizing treatment outcomes.
This section describes various psychodynamic, cognitive-behavioral, and
interpersonal approaches.
Here is a brief outline of various psychodynamic approaches to the borderlinepersonality: psychoanalytic psychotherapy, supportive psychotherapy, and short-term dynamic psychotherapy.
Psychoanalytic Psychotherapy . There are basically two psychoanalytic
opinions regarding the treatment of the borderline patients based on the role ofearly interpretation and the management of negative transference. One view isthat confrontation must occur early in the course of treatment and thatinterpretation of primitive transference be made in here-and-now situations. Theother view is that the early interpretation of aggressive theme is ineffective andpossibly disruptive. Kernberg (1984) and Masterson (1976), among others, espousethe ﬁrst view, while Chessick (1982) and Buie and Adler (1982) and othersadvocate the second. Nevertheless, both views agree that personality recon struction
is the goal of treatment, requiring three or more sessions a week for a minimumof four years.
Masterson (1976) and Masterson and Klein (1989) have elegantly described
the psychotherapeutic process with borderline patients. Supportive psychotherapyis differentiated from reconstructive psychotherapy. The goal of reconstructivepsychotherapy is to work through the abandonment depression—feelings ofdepression, anger and rage, fear, guilt, passivity and helplessness, emptiness, and108 Diagnosis and Treatment of DSM-5 Personality Disorders

void that follow a recent experience of separation and loss—associated with the
original separation-individuation phase. This leads to the achievement of egoautonomy and the transformation of split object relations into whole object rela -
tions and the split ego into a whole ego. Three stages of psychotherapy are notedby Masterson: the testing phase in which confrontation, where the clinician utilizescommunicative matching to support the patient’s emerging individuation, is theprincipal technique, the working-through phase and the separation phase.
The expected outcome of such treatment is not only reduction in impulsive
behavior and other regressive reactions to stressors, but also improved stability ininterpersonal relationships. Such personality reconstruction allows the individualto function normally or on a neurotic level (Gunderson, 1989).
Mentalization Based Treatment . Based on the work of Bateman and Fonagy
(2007, 2010), Mentalization Based Treatment (MBT) is intended to helpborderline patients develop the capacity to accurately identify and respond to thesubjective mental states of themselves and others. This includes helping patientsmaintain a stable sense of self and appropriate level of arousal. The originators ofthis treatment maintain that MBT is not a unique therapy model, but rather atherapeutic stance intended to achieve a speciﬁc goal. As such, MBT permits theuse of many different techniques that may be found in other treatments.
Two important aspects of Mentalization Based Treatment are the therapeutic
stance and mentalizing the transference between the patient and therapist. Thetherapeutic stance encompasses a number of factors, including therapist humilityderived from “not knowing”; patience in understanding differences in perspectivebetween therapist and patient; validating and accepting different perspectives;actively seeking to understand the patient’s experience by asking questions; notsearching for explanations; and clarifying when something is unclear.
In this method of treatment, the primary vehicle for change is the relationship
between therapist and patient. Bateman and Fonagy do not focus on transferenceinterpretation to increase the patient’s insight, as is common in other psycho -
dynamic therapy approaches. They assert that the ability to beneﬁt frominterpretation requires a level of mentalizing capacity that borderline patientstypically do no possess. Rather, MBT uses the transference relationship to en -
cour age patients to focus their attention on another individual’s mind and
examine their own perceptions. Mentalizing the transference is accomplished insix steps: validation of the patient’s transference with the therapist; explorationof events which generated the transference; accepting enactment on the part ofthe therapist; collaborating with the patient to develop an interpretation; offeringan alternative perspective; and monitoring the patient’s reaction to the process.A randomly controlled trial comparing outpatient mentalizing-based treatmentand structured clinical management for Borderline Personality Disorder foundthat borderline patients in the MBT group experienced a steeper reduction inproblems such as suicide attempts and hospitalizations (Bateman & Fonagy,2009).Borderline Personality Disorder 109

Transference Focused Psychotherapy . Clarkin, Cain, and Livesey (2015)
developed transference focused psychotherapy (TFP) with the goals of improvingbehavioral control, increasing self-reﬂection, and cultivating affect regulation skillsin borderline patients. This is accomplished through the relationship between thetherapist and patient, as in Mentalization Based Treatment. Transference focusedpsychotherapy is a highly structured, manualized, evidence-based approach to thetreatment of Borderline Personality Disorder. Therapy sessions are 45 minuteslong and are held two times a week. During the ﬁrst year of treatment, the primarygoal is to contain parasuicidal behaviors and other forms of self-destructive actingout. The ultimate goal of TFP is identity integration.
Techniques include contracting and limit-setting, along with exploring the
patient’s inner world in the here-and-now transference relationship. Thetreatment contract is especially important for this type of treatment, as thisstructure provides a safe context in which the patient’s patterns may manifest andgives the therapist a way to explore the meaning behind deviations from thecontract. In transference focused psychotherapy, interpretation is seen as the meansby which integration occurs.
Supportive Psychotherapy . From a dynamic perspective, supportive
psychotherapy is less intensive and regressive than psychoanalytic psychotherapyor psychoanalysis. The goals of supportive therapy with borderline individualsare principally to improve their adaptation to daily life and reduce their self-destructive responses to interpersonal stressors (Kernberg, 1984).
The basic techniques of supportive psychotherapy consist of exploring the
patient’s primitive defenses in the here-and-now for the purpose of helping themachieve control by nonanalytic means, and fostering a better adaptation to realityby helping them become more aware of the disorganizing affect of their defensiveoperations. Manifest and suppressed transferences—rather than unconscious andrepressed transferences—are explored and utilized for classiﬁcation of relatedinterpersonal problems faced by the patient (Kernberg, 1984).
Such supportive psychotherapy is utilized commonly with moderate and
lower functioning borderline outpatients. Typically, sessions are scheduled weeklyand may continue for several years. The results of the Menninger Outcome Studysuggest that supportive treatment is able to bring about the basic personality changesthat were expected only from reconstructive dynamic psychotherapy (Wallerstein,1986). So, despite Kernberg’s (1984) characteristic of supportive psychotherapyas “a treatment of last resort,” supportive psychotherapy is a potent intervention.
Klein (1989a) describes two types of supportive treatment for lower functioning
borderlines. In the ﬁrst, confrontive psychotherapy, the treatment process involvesconfronting resistances that maintain maladaptive behaviors until they becomeego-dystonic. A therapeutic alliance takes the place of transference acting out.Treatment also involves the implementation of adaptive modes of dealing withunderlying affects, such as new patterns replacing previous self-destructivebehaviors and defenses. Unlike reconstructive psychotherapy, this approach does110 Diagnosis and Treatment of DSM-5 Personality Disorders

not facilitate the patient working through abandonment depression. The goals
of this therapy are limited to increasing the patient’s capacity to work to achievesome consistency in interpersonal relationships.
Klein (1989a) also describes an approach to “counseling” with very low
functioning borderline patients. This approach is the treatment of choice forpatients with a history of repeated early abuse, neglect or separation trauma, orrepeated, severe psychiatric regressive episodes, or a history of repeating life-threatening suicidal or homicidal actions. The goal of this treatment is to reduceanger, anxiety, and depressive affects that persistently interfere with the patient’scapacity to function adaptively. The counselor serves as an auxiliary ego for thepatient and utilizes a combination of such techniques as reality testing,encouragement, direction, problem solving, and medication.
Short-Term Dynamic Psychotherapy . While it was previously assumed
that borderline patients were unﬁt for short-term dynamic psychotherapy, it nowappears that short-term and time-limited approaches have some utility withselective patients. In as few as 10 to 20 sessions, treatment can be focused onspeciﬁc relational or situational problems. And, because there is such a speciﬁcfocus, the likelihood of a regressive transference developing is limited. Thisapproach may be suitable for borderline patients who present with concerns aboutbeing engulfed, overwhelmed, or too dependent. It may also be useful for thosewho have a history of terminating more regressive treatment. Furthermore, itmay serve as a springboard for moving into long-term therapy.
Klein (1989b) describes a short-term treatment protocol for borderline patients.
The goals are containment—they come to recognize, control, and contain theirpropensity to act out; learning—emerging affects that covered their defenses canand must be verbalized rather than acted out; and adaptation—they channel theirenergies associated with these affects into adaptive and sublimated behavior andexpressions. This short-term approach follows Masterson’s model, except that thefrequency of sessions is limited and confrontation is the principal technique utilized,although clariﬁcation, interpretation, and communicative matching are sometimesneeded. Sessions are scheduled only once or twice a week for a year or less, andday-to-day problems of adaptation and healthy defenses are the focus of treatment.
Research Support for Psychodynamic Interventions . There are now
some empirical studies supporting the clinical value and utility of dynamicallyoriented therapy with Borderline Personality Disorder. In one study, individualstreated with an approach based on self-psychology and who remained in treatmentfor two years appeared to have proﬁted from therapy (Meares, Stevenson, &Comerford, 1999; Stevenson & Meares, 1992). Because it was a post-hoc,naturalistic study with a waiting list control group for comparison, it cannot becertain that the results can be attributed to this dynamic approach.
A random controlled study of a psychoanalytically oriented approach to
treatment in a partial hospitalization study has also been reported (Bateman &Fonagy, 1999, 2001). The treatment was intensive and extensive and consistedBorderline Personality Disorder 111

of weekly psychoanalytic psychotherapy, thrice-weekly group analytic psycho -
therapy, weekly psychodrama and expressive therapy, and a weekly com munity
meeting, along with mediation management. Whether positive treatment out -
comes could be attributed to the speciﬁc structure and milieu of the partialhospitalization program itself, or to the psychodynamic approach utilized bytherapists in the program, is unclear.
A structured, manualized approach, speciﬁcally designed for treating Borderline
Personality Disorder and called “Transference Focused Psychotherapy,” appearspromising. This approach focuses on affect-laden themes in the current patient-therapist relationship. These include containment of self-destructive and suicidalbehaviors, various ways of sabotaging treatment, and the identiﬁcation andrecapitulation of signiﬁcant object relations patterns. This uncontrolled trialshowed markedly decreased hospitalizations, day hospital treatment, and very lowdrop out rate (Clarkin, Foelsch, Levy, Hull, Delaney, & Kernberg, 2001).
Cognitive Behavior Therapy Approaches
Cognitive Therapy . According to Beck et al. (1990), the Cognitive Therapy
approach has signiﬁcant advantages over other approaches in the treatment ofBorderline Personality-Disordered individuals. Basically, completion of CognitiveTherapy is possible in 18 to 30 months (Freeman et al., 1990), as compared topsychoanalytical-oriented therapies, which typically require ﬁve to seven years(Masterson, 1981).
Establishing a collaborative working relationship is the very challenging ﬁrst
step in the treatment process. Since trust and intimacy are major issues for theseindividuals, taking a collaborative, strategic approach based on guided discoveryis suggested. Explicitly acknowledging and accepting the individual’s difﬁcultyin trusting the therapist, communicating clearly, assertively, and honestly,following through on agreements, and behaving in a consistently trustworthymanner provides the individual with evidence on which trust can be based.Furthermore, setting limits including specifying a treatment contract is advised.An initial focus in concrete behavioral goals is useful in reducing the impact ofthe borderline individual’s difﬁculty with intimacy and trust. Many of theseindividuals ﬁnd it less threatening to work on issues for which little introspec-tion is required, and where the focus is on behavior rather than on feelings orthoughts. Not surprisingly, a major focus in Cognitive Therapy is changingmaladaptive schema. Borderline individuals here believe that the world is adangerous place, that they are helpless, and that they are inherently ﬂawed in a way that inevitably leads to rejection and abandonment by others. It is suggestedthat these beliefs must be gradually challenged by “chipping away” at them, bytesting expectancies against previous experience, by developing behavioralexperiences to test expectancies, and developing new competencies and copingskills. These indi viduals must learn to challenge dichotomous thinking both during112 Diagnosis and Treatment of DSM-5 Personality Disorders

and between sessions, as decreased dichotomous thinking often results in decreased
mood liability and impulsivity. Behavioral interventions, such as self-instructionaltraining (Meichenbaum, 1977), may be useful in further reducing self-destructiveimpulsive behaviors.
Noncompliance with treatment is not an uncommon problem with borderline
individuals, and often the reason is fear of change. Since they assume the worldis dangerous and they have a low tolerance for ambiguity, they ﬁnd change—including growth in the course of treatment—threatening. Addressing changeopenly, examining risks and beneﬁts, planning changes as a series of small steps,and not pressing for change too quickly are recommended. Fears about termina-tion of treatment evoke abandonment and rejection issues, which must becarefully addressed. In summary, the Cognitive Therapy of Borderline Personality-Disordered individuals begins by developing a collaborative working relationshipof trust and then focuses on modulating moods, impulses, and behavior withcognitive-behavioral methods, setting the stage so that basic schemas such asabandonment, defectiveness, incompetence, and mistrust can be modiﬁed andchanged.
In line with Turkat’s (1990) formulation that the basic issue for borderlines is
problem-solving deﬁciencies, Turkat proposes a treatment methodology involvingseveral strategies. They are basic problem-solving training, concept formationtraining, categorization management, and processing speed management.
Dialectical Behavior Therapy . The deﬁning feature of this treatment
approach is its emphasis on dialectics, the reconciliation of opposites. The basicdialectic for therapists working with DBT clients is accepting their behaviors,thoughts, and affects in the moment while simultaneously encouraging them tochange. Accordingly, DBT treatment requires “moment to moment changes inthe use of supportive acceptance versus confrontation and change strategies. Thisemphasis on acceptance as a balance to change ﬂows directly from the integrativeof a perspective drawn from Eastern (Zen) practice with Western Psychologicalpractice” (Linehan, 1993, p. 19).
Linehan (1993, 2015) speciﬁed four primary modes of treatment in DBT:
individual therapy; group-based skills training, telephone contact, and therapistconsultation. Group therapy and other modes of treatment may be added at thediscretion of the therapist.
The individual therapist is the primary therapist and the main work of therapy
is carried out in the individual therapy sessions. Individual therapy is concep -
tualized as having three stages: beginning, middle, and end (Marra, 2005).Essential components of individual therapy from a DBT perspective include:dialectical analysis and coaching clients to think dialectically about their ownsituation; validation of the client’s feelings, thoughts and experiences; balancingemotion-focused and solution-focused coping; prompting improved shifting ofattention from internal to external cues; teaching new psychological coping skills,and non-pejorative interpretation of the client’s behavior and affect.Borderline Personality Disorder 113

other than the individual therapist. In the skills training groups clients are taughtskills considered relevant to the particular problems of personality-disorderedindividuals. There are four groups of skills: core mindfulness skills, interpersonaleffectiveness skills, emotion modulation skills, and distress tolerance skills. Each
of these skills targets key style/temperament overmodulations. However, it is
possible to accomplish skills training in the context of individual therapy with
select clients (Marra, 2005).
Telephone contact with the therapist after hours is offered, not as psycho -
therapy but rather to help and support in clients to ﬁnd alternatives to self-injuryand for relationship repair when the client believes she damaged her relationship
with her therapist and wants to rectify it prior to the next session.
DBT therapists are encouraged to participate regularly in therapist consultation
groups. These groups provide both emotional support for therapists dealing withdifﬁcult clients, as well as for ongoing training in DBT methods.
Following an initial period of pre-treatment involving assessment, commitment
and orientation to therapy, DBT consists of three stages of treatment.
1 This stage focuses on reducing parasuicidal and suicidal behaviors, therapy
interfering behaviors and behaviors that comprise quality of life. It also focuseson developing the necessary skills to resolve these problems. Skills trainingis usually carried out in a group context, ideally by someone other than theindividual therapist. In the skills training groups clients are taught skillsconsidered relevant to the particular problems of personality-disorderedindividuals. There are four groups of skills: core mindfulness skills, inter -
personal effectiveness skills, emotion modulation skills, and distress toleranceskills.
2 This stage deals primarily with difﬁcult problems of living, including
treatment of posttraumatic stress-related issues when present. Much of this
work is done in individual sessions.
3 The focus of this stage is on self-esteem and individual treatment goals. The
targeted behaviors of each stage are brought under control before movingon to the next phase. In particular, posttraumatic stress-related problems suchas those related to childhood sexual abuse are not dealt with directly until
stage 1 has been successfully completed. Therapy at each stage is focused onthe speciﬁc targets for that stage, which are arranged in a deﬁnite hierarchy
of relative importance. These include: decreasing suicidal behaviors,
decreasing therapy interfering behaviors, decreasing behaviors that interfere
with the quality of life, increasing behavioral skills, decreasing behaviors related
to posttraumatic stress, improving self-esteem, and individual targetsnegotiated with the client.114 Diagnosis and Treatment of DSM-5 Personality Disorders

The core strategies in DBT are “validation” and “problem solving.” Attempts
to facilitate change are surrounded by interventions that validate clients’ behaviorand responses in relation to the client’s current life situation, and that demonstratean understanding of their difﬁculties and suffering. Problem solving focuses onthe establishment of necessary skills. Other treatment modalities includecontingency management, cognitive therapy exposure based therapies, andmedication. Because parasuicidal, suicidal, and other forms of acting-out behaviorsare common with BPD individuals, contingency management is commonlyemployed in each stage of treatment.
The provision of DBT therapy is easier to accomplish in an inpatient, partial
hospitalization, or residential treatment setting than in private practice. The reasonis that, as described by Linehan (1993), DBT is best implemented with a treatmentteam in which one therapist provides psychosocial skill training, another providesindividual therapy, others can provide a consultation function, and the therapistshave access to a therapist consultation group for support.
Marra (2005) has offered suggestions for adapting DBT treatment in private
practice settings. While he recommends that skills training be provided byanother therapist, he offers guidelines when that is not possible. Nevertheless, heencourages therapists in private practice who want to use DBT to have regularcontact with a psychotherapy consultant as a substitute for involvement in atherapist consultation group. The purpose of such consultation is to clarifydiagnosis, treatment plans and speciﬁc interventions with another professional whocan offer a fresh perspective, confront the therapist’s interpretation of data andsituations, and warn of potential boundary violations.
Cognitive Coping Therapy . This is an active, directive, didactic, and struc -
tured cognitive behavioral approach for treating personality-disordered individuals(Sharoff, 2002). It is a complete and self-contained approach to treatment whichbegins with assessing an individual’s coping skills—in terms of skill chains, sub -
skills, and microskills—and then increasing skill competence in targeted areas asneeded. Five key skill areas with representative treatment modalities include:cognitive skills —problem solving, self-instruction training, and self-management;
emotion skills —emotional containment and compartmental ization; perceptual skills
—perspective taking, thought stopping, and psychological distance taking; physio logical skills —meditation and relaxation training; and behavior skills —
com munication and assertiveness training. Sharoff (2002) describes a detailed
protocol, and case example, for using this structured approach with BorderlinePersonality Disorder.
that has been developed by Young (1994, 1999; Young et al., 2003) speciﬁcallyfor personality disorders, and other difﬁcult individual and couples problems.Schema Therapy involves identifying maladaptive schemas and planning speciﬁcstrategies and interventions. Four main strategies are cognitive, experiential,behavioral, and the therapeutic relationship itself. Cognitive restructuring,Borderline Personality Disorder 115

modiﬁcation of maladaptive schemas, is an important cognitive strategy, but is
combined with imagery exercises, empathic confrontation, homework assign ments,
and “limited reparenting,” i.e., a form of corrective emotional experience (Young,1999; Young et al., 2003).
Maladaptive schemas typically associated with Borderline Personality Disorder
are: abandonment, i.e., the belief that signiﬁcant others will not or cannot provide
reliable and stable support; defectiveness —the belief that one is defective, bad,
unwanted, or inferior in important respects; mistrust/abuse —the belief that others
will abuse, humiliate, cheat, lie, manipulate, or take advantage; emotional —the
belief that one’s desire for emotional support will not be met by others; social
isolation —the belief that one is alienated, different from others, or not part of any
group; and insufﬁcient self-control — the belief that one is incapable of self-control
and frustration tolerance (Bernstein, 2002). Young et al. (2003) provide a detailedtreatment protocol for utilizing the schema-focused approach with BorderlinePersonality Disorder.
Other Cognitive-Behavioral Interventions. Smucker (1999) describes a
cognitive behavioral approach that incorporates guided imagery to focus directlyon images and affects associated with early childhood abuse in borderlineindividuals. This approach developed out of Smucker’s experience working withseverely traumatized borderline individuals who often met criteria for Post-Traumatic Stress Disorder and had failed in previous treatments.
Benjamin (2003a, 2007) has written extensively about this approach. In her view,psychotherapeutic interventions with Borderline Personality-Disordered indi viduals
are best planned and evaluated in terms of whether they enhance collaboration,facilitate learning about maladaptive patterns and their roots, block these patterns,enhance the will to change, or effectively encourage new patterns.
Benjamin offers a number of observations on facilitating collaboration. She
insists that therapists offer these individuals a contract for strength building ratherthan in enabling regression. A collaboration based on strength building mustemphasize in sessions as well as in phone calls or in the clinic lobby that the mutualgoal is to build on strengths so these individuals can pull themselves back together.The collaboration must be against “it,” their destructive pattern(s). Healthycollaboration further requires that transference and countertransference disastersbe avoided through ﬁrm physical and verbal boundaries. Benjamin cautions thatthe treatment approach she advocates is not appropriate for individuals who areunable to agree to a contract in strength building.
Borderline individuals need to learn to recognize that perceived abandonment
sets off a chain of self-destructive patterns. These individuals are likely to relinquishself-mutilation, self-sabotage, and homicidal or suicidal acting out if they can“divorce” their internalized abusive attachment ﬁgures. Essentially, they must give116 Diagnosis and Treatment of DSM-5 Personality Disorders

up the desire to be afﬁrmed by these internalized representations. This occurs by
developing a dislike of those ﬁgures, or by developing a superseding attachmentto someone more constructive, such as the clinician. Once these tasks areachieved, the focus of treatment shifts to facilitating new learning. The basic goalis learning how to give and take autonomy while remaining friendly.
Interpersonal Reconstructive Therapy (IRT) . IRT was developed by
Benjamin (2003b, 2007) for the treatment of this disorder. Like many othertreatments for Borderline Personality Disorder, IRT conceptualizes the problemas one of inadequate attachment to caregivers in early development. Problempatterns are categorized according to the Structural Analysis of Social Behavior(SASB), a method developed by Benjamin. Behaviors are described according tothe focus (on other, self, or self as if by other), afﬁliation (placed on a love-hateaxis), and interdependence (placed on an emancipate-control axis). The borderlinepatient’s behavior towards the therapist is classiﬁed in the IRT system as either“Regressive Loyalist,” or “Red,” when the patient is engaging in old, destructivepatterns; or “Growth Collaborator,” or “Green,” when the patient responds tothe therapist in new, effective ways. Red and Green remain in conﬂict throughoutthe course of treatment until ﬁnally the Growth Collaborator becomes dominantin the patient’s mind. There are ﬁve stages in Interpersonal ReconstructiveTherapy: establishing collaboration between therapist and patient; learning aboutold patterns of behavior, such as where they originate and what purpose theyserve; blocking destructive patterns; increasing the will to change; and learningnew patterns. As with other treatments with personality reconstruction as the goal,IRT is a long-term form of therapy that may span multiple years.
Data on the efﬁcacy of group therapy for the treatment of personality disordersis rather “soft.” There are many case reports and even a few controlled studies,but no randomized clinical trials, except for the Borderline Personality Disorder.There are numerous case reports and clinical trials, and even one randomizedclinical trial reported on group treatment with Borderline Personality-Disorderedindividuals. What’s more, there is general consensus that group therapy, underspeciﬁed conditions, has enormously therapeutic efﬁcacy. This section will reviewboth dynamic and behavioral group approaches as well as highlight somerepresentative research studies.
The psychodynamic group literature on borderline personality begins in the
1950s. There is general consensus that group dynamic therapy can be a usefuladjunct to individual dynamic therapy, but that it cannot be the only treatment(Day & Semrad, 1971; Horowitz, 1980; Hulse, 1958; Slavson, 1964). Horowitz(1980) cautions that borderline patients require individual psychotherapy tosupport them throughout group engendered stress and to integrate the affects thegroups provokes in them. Furthermore, without individual psychotherapyBorderline Personality Disorder 117

premature termination from group therapy is likely. On the other hand, Pines
(1975) contends that concurrent dynamic individual psychotherapy is notnecessary, because the group process of itself is a potent holding environmentcapable of containing primitive impulses and projections. Horowitz (1977) alsocontends that the individual psychotherapist not function as the group therapistin order to reduce the possibility of jealousy and fantasies of favoritism amongother group members.
Most writing on dynamic group therapy for borderline patients prefer
heterogeneous to homogenous groups. They insist that borderline patients aremore effectively treated in groups consisting of higher functioning individualswith neuroses and other personality disorders (Day & Semrad, 1971; Horowitz,1977; Stone & Weissman, 1984). There is, however, outcome research thatsupports the use of homogeneous groups wherein all patients have BorderlinePersonality Disorder diagnoses (Finn & Shakir, 1990; Linehan et al., 1991;O’Leary, Tunrer, Gardner & Cowdry, 1991).
The advantages of dynamic group therapy include “dilution of intense
transference” (Horowitz, 1980), which results from the presence of multipletransferential objects, instead of the single all-encompassing individual clinician.Rage is instead diluted and directed toward other group members. Borderlinepatients also ﬁnd it easier to accept feedback and confrontation from group peersthan from a therapist. Groups also provide many opportunities to understand andmaster such borderline defenses as splitting and projective identiﬁcation.
There are some disadvantages and difﬁculties with group treatment of
borderline patients. First, these patients may be easily scapegoated because of theirprimitive manner of expression. Second, they may feel deprived amidst thecompetition of other group members for the group leader’s nurturance. And,they may maintain a certain distance in the group because of their privacyattachment to their individual psychotherapist (Gabbard, 2014).
Dynamically oriented groups with borderlines tend to span the continuum
from ego psychology (Finn & Shakir, 1990; O’Leary et al., 1991) to self-psychology (Harwood, 1992).
Behavioral group therapies for borderline patients focus less on underlying
explanations from the symptomatic behavior, and more helping these patientsacquire the speciﬁc skills necessary to control their affects, reduce their cognitivedistortions and projective identiﬁcations, and ﬁnd alternatives to self-destructivebehaviors. Linehan (1987, 1993, 2015) provides a manual-guided strategy for thetreatment of self-destructive behavior and impulsivity called “dialectical behaviortherapy.” Although geared primarily to chronically parasuicidal borderline females,the treatment strategies and interventions have applicability to higher functioningindividuals. The group session employs didactic, shell training, and behavioralrehearsal techniques directed at dependency and other interpersonal patterns, aswell as improving affect tolerance. These twice-weekly sessions for one year arecomplemented with weekly individual counseling.118 Diagnosis and Treatment of DSM-5 Personality Disorders

There is some noteworthy research with borderlines in group treatment that
will be brieﬂy highlighted. Nehls (1991; Nehls & Diamond, 1993) reports processand outcome data on group therapy of borderline patients in homogeneoustreatment format. The group format was highly structured, though groupmembers deﬁned their own treatment goals. Patient outcomes included decreaseddepression and hostility, which was associated largely with two interventions:providing and seeking information. Dick and Wooff (1986) reported data on atime-limited dynamic group therapy with heterogeneous groups containing anumber of borderline patients. The group met daily for 12 weeks. The one yearpost-group follow-up showed an 82 percent reduction in the use of psychiatricservices compared to a control group of untreated patients. Three-year follow-up showed the gains had been maintained. Finally, Linehan et al. (1991) examinedparasuicidal female borderline patients randomly assigned to dialectical behaviortherapy groups or to traditional community treatment for a one-year period. Thosein behavioral groups had fewer incidents of parasuicide, were more likely to remainin individual therapy, and had fewer inpatient psychiatric days as compared tothose in traditional treatment. Follow up measures two years after this initial study,as well as subsequent studies, indicated that DBT was an effective treatment andgains were maintained over time (Linehan, 1993, 2015). Another randomlycontrolled trial in which DBT was compared to general psychiatric managementfound that both forms of treatment were equally effective in treating borderlinepersonality disorder (McMain et al., 2009).
A manual-guided approach called Relationship Management Psychotherapy
is a time-limited group approach. This form of therapy allows borderline patientsto choose their own treatment and requires those who threaten self-harm or actin aggressive ways to be expelled from the inpatient program for 24 hours. It hasbeen compared with open-ended individual dynamic psychotherapy in arandomized clinical trial (Clarkin, Marziali, & Munroe-Blum, 1991). Hoch,O’Reilly and Carscadden (2006) compared the mean annual outcome rates for27 patients consecutively enrolled in a relationship management therapy programfrom 1998 to 2000. They found signiﬁcant reductions in the use of restraint, staffobservation, self-harm, and days of inpatient treatment.
Families of borderline patients often exhibit severe pathology, which may be ofetiological signiﬁcance. Parents of borderline patients have high incidence ofaffective disorders, alcoholism, antisocial personality disorder, and BorderlinePersonality Disorder or traits. The parental relationship is usually characterizedby neglect and overprotectiveness. Family therapy can be useful, and in someinstances necessary, in maintaining borderline patients in outpatient psychotherapy.This is particularly the case when borderline patients remain ﬁnancially and/oremotionally dependent on their parents.Borderline Personality Disorder 119

Family therapy with borderlines has been developed along at least three
theoretical lines. The ﬁrst is the psychodynamic, particularly in terms of objectrelations and systems theory. Everett, Halperin, Volgy and Wissler (1989) havethe most complete discussion of this approach in their book Treating the Borderline
Family: A Systemic Approach. They specify the following treatment goals: (1)
increasing the family’s ability to reduce the systemic splitting process; (2) increasingfamily members’ capacities for owning split-off objects and moving towardinteracting with others as a “whole person”; (3) reducing oppositional andstereotypic behavior of all family members; (4) “resetting” external boundary forboth unclear and intergenerational systems; (5) “resetting” internal boundary for spousal, parent-child, and sibling subtypes; and (6) permitting a clearer alliancebetween the parents and limiting reciprocal intrusiveness of children and parents.Five treatment strategies for accomplishing these goals in an outpatient familytreatment setting are: developing and maintaining a therapeutic structure; realitytesting in the family; interactional disengagement; intervening in the intergener-ational system; and solidiﬁcation of the marital alliance and sibling subsystem.
Another treatment orientation is the structural family approach developed by
Minuchin (1974). Schane and Kovel (1988) describe severe borderline pathologyin terms of a spousal subsystem that is internally overinvolved and contemporarilydistant and disengaged from the family system. In effect, borderline females havea systems equivalent of object splitting wherein family subsystems are organizedaround dichotomous extremes: collusion and sabotage; loyalty and scapegoating;inclusion and rejection; nurturance and neglect; and symbiosis and abandonment.It is this structural pattern of family interaction that is the focus of systemic change.Lachkar (1992) provides an extensive discussion of an integrated object relationsand self-psychology approach to the marital treatment of the borderline patient.She provides a detailed treatment protocol and several case reports illustratingthis method.
A third option is the Relationship Enhancement Therapy approach for
borderline families and couples. Relationship Enhancement was developed byGuerney (1977) and integrates social skills training, psychodynamic principles,and interpersonal therapy techniques. Since borderline patients have major deﬁcitsin self-differentiation and communication, Relationship Enhancement’s focus onskill building in some areas seems promising with couple and family settings,particularly for mild to moderately dysfunctional borderline patients (Harman &Waldo, 2001; Waldo & Harman, 1993). The clinician functions largely as a coachto develop the necessary relational skills, usually in two-hour sessions. Waldo andHarmon (1993) report a case of time-limited intervention that was successful. A12-month follow-up showed that the changes had been maintained. Theseauthors also describe and illustrate the use of two therapists working conjointlywith couples in which one partner presents with Borderline Personality Dis-order (Waldo & Harman, 1998). The fundamental principles of relationshipenhancement therapy are further discussed in Accordino, Keat, and Guerney120 Diagnosis and Treatment of DSM-5 Personality Disorders

(2003), as well as a case study of an adolescent with serious mental illness and
substance dependence.
Lachkar (1999) offers additional insight into the treatment of couples in which
one partner has a borderline personality structure while the other partner presentswith a narcissistic pattern. Solomon (1999) also addresses the treatment of theborderline-narcissistic couple from a somewhat different psychoanalyticperspective.
Medication is commonly used in the treatment of this disorder. Usually thetreatment targets are affective instability, interpersonal sensitivity, impulsivity,aggressivity, transient psychotic episodes, and self-harming behavior. Lithium andcarbamazepine have targeted affective instability, while serotonergic agents havebeen effective with impulsivity and aggressivity. Serotonergic agents, likeﬂuoxetine and sertraline, are effective for reducing the interpersonal sensitivityand reactivity (Reich, 2002). For those with rejection sensitivity, and a historyof good treatment compliance, a trial of an MAOI (monoamine oxidase inhibitor)can be considered if all other approaches have failed. Serotonergic agents havesome efﬁcacy in lower functioning histrionic individuals who exhibit impulsivityand affective instability (Reich, 2002). Transient psychotic episodes, includingmild thought disorders and dissociation, are best addressed with atypicalantipsychotics instead of traditional neuroleptics, which have the risk of tardivedyskinesia. Finally, for self-harming behavior, trials of SSRIs have been helpful.If not, an adjunctive trial of naltrexone can be considered, if necessary (Reich,2005).
In recent years, quetiapine (Seroquel) has become the most commonly
prescribed medication for Borderline Personality Disorder probably because itreduces various symptoms such as anxiety, presumably because it has a sedatingeffect. It is an antipsychotic medication that is generally well tolerated. That meansit has few adverse effects and speciﬁcally has low potential for extrapyramidal(tremor and stiffness) symptoms. However, it can cause weight gain (Diamond,2009). Very well-designed research has been reported that conﬁrms what clinicianshave known for some time. In a randomized controlled trial it was found thatlow-dose quetiapine (150 mg/day) was effective in reducing the overall severityof symptoms in those with Borderline Personality Disorder. Most improvementwas noted in verbal and physical aggression, but less on impulsivity and depression(Black et al., 2014).
There are some potential complications or disadvantages with pharmacotherapy
in the treatment of borderline individuals. First is the matter of noncompliancerelated either to side effects or to secondary gain. Medications can serve as leverageto control the prescribing clinician or other caregivers. Demands for frequentchanges in dosage or type of medication, overdosing, and failure to take theBorderline Personality Disorder 121

medication prescribed are all means of transference acting out. Second, borderline
individuals may appear to others to have improved from medication but reportthey feel worse, or vice versa. Gunderson (1989) suggested that this apparentparadox may ensue to the extent that the individual believes that symptomaticimprovement will result in undesirable consequences, such as loss or abandonmentof dependent gratiﬁcations.
There is considerable consensus that combined treatment is essential, or at leastpreferable, for borderline pathology, given its severity and apparent treatmentresistance. Clearly, differences exist between the prognosis and treatability of thehigh functioning borderline (i.e., GAF over 65) and the low functioningborderline (i.e., GAF below 45). Reports of treatment success using onlytraditional individual psychoanalytic psychotherapy may be possible with thehighest functioning borderline individual, but are not likely with lowerfunctioning borderline individuals. In line with the basic premise of this book,the lower the patient’s functioning and motivation and readiness for treatment,the more treatment must be integrated and combined.
The most common recommendation for combined treatment is to prescribe
both individual therapy and group therapy. There is currently no consensus onwhich theoretical approaches to combine or whether both should be combinedor sequenced. The earliest recommendation of combined treatment was byTacbacnik (1965), who advocated concurrent dynamic individual psychotherapyand dynamic group therapy. On the other hand, Horowitz (1977, 1980) advocatessequencing dynamic group and individual therapy in which the group experienceprepares the patient to productively utilize individual therapy. Clarkin et al. (1991)also recommend combined individual and group modalities, but favor individualbehavior treatment with long-term manual-guided group treatment.
Others recommend combining individual therapy and family therapy. These
include Kernberg (1984), who describes the indications for concurrent as well assequential utilization of these modalities.
Berger (1987) recommends combined psychotherapy and pharmacotherapy
because these individuals are difﬁcult to treat with only one modality. He notesthat combined treatment can be complicated by the borderline’s tendency toidealize one treatment and negate the other. Koenigsberg (1993) offers a verythoughtful review of combining medications and psychotherapy, highlighting theindications and contraindications for this treatment decision. He also describesthe complications inherent in combined treatment strategy but believes these canbe addressed by special structuring of treatment, attention to countertransferenceissues, and vigilance for splitting. Koenigsberg contends that combiningmedication and psychotherapy has considerable value for seriously symptomaticpatients, those prone to treatment noncompliance or to intractable affective storms122 Diagnosis and Treatment of DSM-5 Personality Disorders

and psychotic regression. Bellino and associates (Bellino, Rinaldi, & Bogetto, 2010)
found that combined therapy with antidepressants and interpersonal psychotherapywas more effective than single pharmacotherapy alone in the treatment ofborderline patients. Further examination by these researchers revealed that patientswith more severe psychopathology had a better chance to improve with thiscombined treatment (Bellino, Bozzatello, & Bogetto, 2015).
Lazarus (1985), the developer of Multimodal Therapy, endorses the combined
use of several modalities, concurrently or sequential, for a variety of difﬁcultpatients, including borderline individuals. Vaccani (1989) describes treating thealcohol-abusing Borderline Personality Disorder with psychotherapy, familytherapy, group therapy, and Alcoholics Anonymous meetings. Nehls andDiamond (1993) describe the modalities for lower functioning borderlines in acommunity-based setting. The modalities that are coordinated and continuousinclude: individual therapy, group therapy, medication, drug and alcohol services,psychosocial rehabilitation, crisis intervention, and crisis houses.
It is now generally accepted that an integrated treatment model is best suited
to address personality disorders (Clarkin, Cain, & Livesley, 2015; Livesley, 2012).While there exist some signiﬁcant differences between the various treatmentmodels developed for borderline personality disorder, certain elements commonto all of them that contribute to treatment success have been identiﬁed. Perhapsthe most important of these is the cultivation and maintenance of a positivetherapeutic relationship between therapist and patient. This comprises ﬁve mainelements regardless of orientation or model: cultivating emotional awareness;structuring treatment; being responsive; supervision or team involvement andsupport; and exploring ruptures in the relationship (McMain, Boritz, & Leybman,2015).Borderline Personality Disorder 123

6
DEPENDENT PERSONALITY 
DISORDER
Individuals with dependent personalities present with a pervasive pattern of
dependency and submissiveness. They tend to be excessively passive, insecure,self-sacriﬁcing, and nonassertive individuals who become overly dependent onone or more persons for guidance and support (Bornstein, 2012). Despite thefact that it is one of the least studied personality disorders (Simon, 2009),treatment of the Dependent Personality Disorder can be highly effective andsuccessful.
of this disorder. It includes sections on diagnosis, psychological assessment, caseconceptualization, and treatment interventions. It begins with backgroundinformation on the disorder as well as a DSM-5 description and a prototypicdescription of this disorder. The section on case conceptualization provides ﬁvecommon clinical formulations of this disorder: psychodynamic, biosocial,cognitive-behavioral, interpersonal, and an integrative conceptualization of thisdisorder. Several treatment approaches, modalities, and intervention strategies arealso described. These include individual psychotherapy, group therapy, maritaland family therapy, medication, and integrative and combined treatment.
Description of the Dependent Personality Disorder
The Dependent Personality Disorder can be recognized by the followingdescriptors and characteristics: style vs. disorder; triggering event; behavioral style,interpersonal style, cognitive style, affective style, attachment style, and optimaldiagnostic criterion.
Style vs. Disorder . The dependent personality can be thought of as spanning
a continuum from healthy to pathological, with the dependent personality styledependency and submissiveness. excessively passive, insecure,
self-sacriﬁcing, and nonassertive 
guidance and support

at the healthy end and the Dependent Personality Disorder at the pathological
end. Table 6.1  compares and contrasts differences between the dependent style
and the disorder.
The two case examples following further illustrate differences between the
Dependent Personality Disorder—Ms. C.—and the dependent personality style—Mr. B.
likely triggers or activates the characteristic maladaptive response of the DependentPersonality Disorder (Othmer & Othmer, 2002), as noted in behavioral,interpersonal, cognitive, and affective styles, is “expectations of self-relianceand/or being alone.”
Behavioral Style . The behavioral style of dependent personalities is charac -
terized by docility, passivity, and nonassertiveness.Dependent Personality Disorder 125
TABLE 6.1 Comparison of Dependent Personality Style and Disorder
When making decisions they are comfortable Unable to make everyday decisions 
seeking out the opinions and advice of others, without an excessive amount of advice but ultimately make their own decisions. or reassurance from others; allows
others to make the most of theirimportant decision.
Carefully promote harmony with important Agrees with people even when they 
persons in their life through being polite, believe they are wrong, because of fear agreeable, and tactful. of being rejected.
Although they respect authority and prefer Has considerable difﬁculty initiating 
the role of team member, they can initiate projects or doing things on their own.and complete tasks on their own.
Thoughtful and good at pleasing Volunteers to do things that are 
others. Occasionally, they will endure unpleasant or demeaning in order to get personal discomfort in accomplishing other people to like them.a good deed for the key people in their lives.
Tend to prefer the company of one or Feels uncomfortable or helpless when 
more individuals to being alone. alone, or goes to great lengths to avoid
being alone.
Tend to be strongly committed to Feels devastated or helpless when close
relationships and work hard to sustain relationships end, and frequently them. preoccupied with fears of being
abandoned.
Can take corrective action in response Easily hurt by criticism or disapproval.
to criticism.
“expectations of self-reliance
and/or being a lone.”
docility, passivity, and nonassertiveness.

126 Diagnosis and Treatment of DSM-5 Personality Disorders
Interpersonal Style . In interpersonal relations, they tend to be pleasing, self-
sacriﬁcing, and clinging, and constantly require the assurance of others. Theircompliance and reliance on others lead to a subtle demand that others assumeresponsibility for major areas of their lives.
Cognitive Style . The cognitive style of dependent personalities is charac -
terized by suggestibility. They easily adopt a Pollyannaish attitude toward life.Furthermore, they tend to minimize difﬁculties, and because of their naiveté arereadily persuadable and others easily take advantage of them. In short, this styleof thinking is uncritical and unperceptive.
Affective Style . Their emotional or affective style is characterized by
insecurity and anxiousness. Because they lack self-conﬁdence, they experienceCASE STUDY: DEPENDENT PERSONALITY DISORDER
Ms. C. is a 38-year-old, single woman with panic symptoms that had begun
approximately three years earlier. Once the panic attacks began, Ms. C.moved back into her parents’ home and has become nearly totally
housebound, fearing that “panic could strike any time.” She described both
of her parents as caring, concerned, and “my best friends,” on whom she isoverly reliant. She looks to them to support her ﬁnancially and emotionally,and to make decisions for her. Ms. C. has also become progressively
habituated to the Valium that she was prescribed for panic symptoms.
CASE STUDY: DEPENDENT PERSONALITY STYLE
Mr. B. has been a social worker at a foster care agency for the past seven
years. He ﬁnds his job fulﬁlling and is well liked by the other staff members,as well as the children and prospective parents with whom he works. He is
a very concerned, caring, and gentle person. A year earlier, he had begun
dating Sandra, one of the pediatricians who consults to the agency. Theirrelationship has been happy and fulﬁlling for both of them, probably becauseof Mr. B.’s efforts. He cannot get over the fact that a doctor would be
interested in being with him, and he expresses his appreciation in numerous
ways. He cannot spend enough time with her, or do enough things for her.He idealizes her, makes every effort to make her feel comfortable and secure,and regularly seeks her opinions and advice. Yet he insists that he has a mind
of his own; after much deliberation and soul-searching, he bought an
expensive sports car even though Sandra thought it was extravagant.
a subtle demand that others assume
responsi bility for major areas o f their lives.constantly require the assurance of others.
they tend to minimize difﬁculties, and because of their naiveté are
readily persuadable and others easily take advantage of them. 
uncritical and unperceptive.
insecurity and anxiousness. lack self-conﬁdence,

considerable discomfort at being alone. They tend to be preoccupied with the
fear of abandonment and of the disapproval of others. Their mood tends to beone of anxiety or fearfulness, as well as having a somber or sad quality.
Attachment Style . The preoccupied attachment dimension is characterized
by a sense of personal unworthiness and a positive evaluation of others. Theseindividuals tend to be very externally oriented in their self-deﬁnitions. ThisPreoccupied Attachment Style is common in individuals with DependentPersonality Disorder (Lyddon & Sherry, 2001).
Dependent Personality Disorder, one has been found to be the most useful indiagnosing this disorder. The belief is that, by beginning with this criterion, theclinician can test for the presence or absence of the criterion and more quicklydiagnose the personality disorder (Allnutt & Links, 1996). The optimal criterionfor this disorder is: needs others to assume responsibility for most major areas ofhis or her life.
Individuals with this personality disorder are characterized by an excessive andunremitting need to be cared for and cling to others because of their fear ofseparation. They constantly seek the advice and reassurance of others when makingdecisions. More than anything, they want others to take responsibility for mostmajor areas of their lives. Not surprisingly, they seldom express disagreement withothers for fear they will lose their support and approval. Because they lackconﬁdence in their own judgment and ability, they have difﬁculty startingprojects and doing things on their own. These individuals will even engage inactions that are difﬁcult and unpleasant in order to receive support and caringfrom others. Because of unrealistic fears of being unable to take care of themselves,they feel helpless or uncomfortable when faced with being alone. When a closerelationship is about to end, they immediately seek out another caring andsupportive relationship. Finally, they become preoccupied with fears of being leftto take care of themselves (American Psychiatric Association, 2013).
A prototype is a brief description that captures the essence of how a particulardisorder commonly presents. Prototypic descriptions are useful and convenientand clinicians commonly rely on them rather than lists of behavioral criteria orcore beliefs (Westen, 2012). Here is a common prototypic description of theDependent Personality Disorder: These individuals feel inadequate, weak, andneedy. They don’t take very good care for themselves. They ﬁnd it nearly im -
possible to make their own decisions, and they don’t feel good about being alone.Their neediness makes them submissive and subservient. So they are more thanDependent Personality Disorder 127
discomfort at being alone. tend to be preoccupied with the
fear of abandonment and of the disapproval of others.
f anxiety or fearfulness, as well as having a somber or sad quality.
a sense of personal unworthiness and a positive evaluation of others.
tend to be very externally oriented in their self-deﬁnitions.
Preoccupied Attachment Style 
an excessive and
f unremittin g need to be cared for and clin g to others because of their fear o f
separation. g y constantly seek the advice and reassurance of others when making
decisions. they want others to take responsibility for most
major areas of their lives.  they seldom express disagreement with
others for fear they will lose their support and approval.
g have difﬁculty starting
projects and doing things on their own.
they feel helpless or uncomfortable when faced with being alone. When a close
d relations hip is about to en d, they imme diately seek out anot her carin g and
supportive relationship.  they become preoccupied with fears of being left
to take care of themselves 
feel inadequate, weak, and
needy.
Their neediness makes them submissive and subservient.

willing to put others’ needs and views above their own. Basically, they will do
whatever it takes to get others to care for them, to give them affection, and givedirection to their lives (Frances, 2013).
Prevalence of this disorder has been estimated at between 0.49 and 0.6 percentin the general population (American Psychiatric Association, 2013). In clinicalsettings, estimates are that it is found in 1.4 to 47 percent of patients (Torgersen,2012).
Conceptualizations of the Dependent Personality 
Disorder
Early psychoanalytic writers posited that dependent personalities were formed in
the oral phase of psychosexual development. Contemporary formulations viewthe development of dependency as a function of parental—particularly maternal—overinvolvement and intrusiveness throughout all phases of development. Theseindividuals often present histories of parental reward for maintaining loyalty, andsubtle parental rejection whenever they attempted separation and independence.They would react with crying and clinging behavior, while being immobilizedby fear and dread of abandonment. Their submissive stance is the result of multiplydetermined unconscious factors. Gabbard (1990) notes that dependent personalitiestypically seek to be cared for by others because of their underlying anxiety, whichoften masks aggression. Dependency thus may be viewed as a compromiseformation defending against hostility. Furthermore, dependent behavior can alsobe used to avoid reactivation of past traumatic experiences.
Millon and Everly (1985) speculate that dependent personalities exhibited fearful,withdrawing, or sad temperaments as infants. Accordingly, such behaviors werelikely to elicit overly protective behavior from caretakers. Millon (1981) notesthat these dependent individuals tend to have ectomorphic (thin and frail) orendomorphic (heavy and cumbersome) body types, which contribute to lowenergy thresholds and a lack of physical vigor.
Environmental factors such as parental overprotection, competitive deﬁcits,
and social-role programming appear to interact with these biological predis -
positions, resulting in the dependent personality pattern. Parental overprotectionoften precludes the development of autonomous coping behavior, such asassertiveness, problem solving, and decision making. Hend, Baker, and Williamson128 Diagnosis and Treatment of DSM-5 Personality Disorders
willing to put others’ needs and views above their own. they will do
whatever it ta kes to get others to care for them, to give them affection, an d give
direction to their lives (
0.49 and 0.6 percent
in the general population 
y seek to be cared for by others because of their underlying anxiety, which
often masks aggression. Dependency thus may be viewed as a compromise
formation defending against hostility.
Parental overprotection

(1991) report that families of individuals with Dependent Personality Disorders
are characterized by low expressiveness and high control, as compared with familiesin clinical and normal control groups, which is indicative of the pervasivereinforcement of dependent behavior. Outside the parental relationship, thesechildren often experience social humiliation and doubts about their efﬁcacy ininterpersonal situations. Through such repeated experiences, they learned,particularly as adolescents, that it is better to remain submissive than to strive tobe competitive. Furthermore, cultural and social norms seem to reinforce passivedependent behavior patterns among women and endomorphically and ecto -
morphically built men. Finally, dependent personality patterns are self-perpetuating through reinforcement of dependent behaviors; avoidance ofgrowth-promoting activities, that is, those that might be challenging, threatening,
or anxiety-producing; and self-detraction, by which they not only convince others
that they are inferior, defective, and incapable of independence, but alsothemselves (Millon & Davis, 1996).
According to Beck (2015), the dependent personality is rooted in basicassumptions about the self and the world. Typically, they view themselves asinadequate, weak, helpless, incompetent, and needy. They view others as strong,
nurturing, supportive, and able to care for them. Related beliefs include needing
the assistance of strong and caring individuals in order for them to survive andto make decisions for them. They also are convinced that they must remain close
to and not displease such individuals. Not surprisingly, such beliefs are reﬂectedin their main strategy or pattern of subordinating themselves and pleasing others(Beck, 2015; Brauer & Reinecke, 2015).
Therefore these individuals are likely to conclude that they must rely on
someone else who is stronger and more adequate to take care of and protect them.
For this security they pay a considerable price. First, they must relinquishresponsibility and subordinate their own needs. Second, they must relinquish
opportunities to learn such skills as assertiveness, decision making, and problem
solving. Finally, they must contend with fears of rejection and abandonment iftheir clinging relationship ends. The main cognitive distortion of such dependentindividuals is dichotomous thinking with respect to independence (Brauer &Reinecke, 2015). For example, they believe that they are both totally connectedto another and dependent or totally alone and independent, with no gradationbetween. Also, they believe that things are either “right” or “wrong,” and thatthere is either “absolute success” or “absolute failure.” Another cognitive dis -
tortion observed among dependent personalities is “catastrophizing,” particu larly
regarding relationships. Common cognitive distortions are: “I never would beable to do that,” “I can’t,” and “I’m too dumb to do that.”Dependent Personality Disorder 129
children o ften ex perience socia l humiliation an d doubts about their efﬁcacy in
interpersonal situations. Through such repeated experiences, they learned,
particu larly as a dolescents, t hat it is better to remain su bmissive t han to strive t o
be competitive. 
f avoidance of
growth- promotin g activities, that is, those that mi ght be challen ging, threatenin g,
or anxiet y-producing; and self-detraction, by which they not on ly convince ot hers
that they are in ferior, defective, an d inca pable of independence, but also
themselves 
inadequate, weak, helpless, incompetent, and needy. view others as strong,
nurturing, supportive, and able to care for them. g needing
the assistance o f strong an d caring in dividuals in or der for them to survive an d
to make decisions for them. 
their main strategy or pattern of subordinating themselves and pleasing others
that they must rely on
someone e lse who is stronger an d more a dequate to ta ke care o f and protect t hem.
For this security they pay a considerable price. 
they must relinquish
solving. f , they must contend with fears of rejection and abandonment if
their clinging relationship ends.
independence 
d they believe that they are both totally connected
to another and dependent or totally alone and independent, 
they believe that things are either “right” or “wrong,” and that
there is either “absolute success” or “absolute failure.
“I’m too dumb to do that.

Turkat (1990) suggests a behavioral formulation for this disorder that centers
on a pervasive fear of decision making and an inability to act assertively. Sincethese individuals have not previously learned either of these skills, these becomebasic therapeutic tasks, after their overwhelming anxiety is effectively managed.
According to Benjamin (2003a), persons with Dependent Personality Disorderexperienced sufﬁcient caring and attention as infants to enable them to bond withothers. They also learned to rely on others, and expect that others will be thereto meet their needs. However, the parents of potential dependent-disorderedindividuals did not wean this level of nurturing when it was developmentallyappropriate to do so. Subsequently, these individuals learned compliant dependentbehavior, as well as to avoid autonomy at all costs. As a result, they developedpoor self-concepts by default, and as adults continue to view themselves asinadequate and overly tolerant of the blaming of others. Because they have notlearned to take care of self and life’s demands, they must depend on others. Sincethey have limited coping resources, they must tolerate abuse, which is the priceof the needed caretaking. Typically, dependent individuals-in-training weremocked by peers and siblings for their incompetence. As a result, their feelingsof inadequacy and incompetence were reinforced and reconﬁrmed. In short, theseindividuals are characterized by marked submissiveness to a dominant other person,who presumably will provide unending nurturance and guidance. Such arelationship is maintained even if it means tolerating abuse, since dependent-disordered individuals believe themselves to be incompetent and unable tosurvive without the dominant other.
The following integrative formulation provides a biopsychosocial explanation for how this personality is likely to have developed and how it is maintained.Biologically, these individuals are characterized by a low energy level. Theirtemperament is usually described as melancholic. As infants and young childrenthey were characterized as fearful, sad, or withdrawn.
Psychologically, they can be understood and appreciated in terms of their view
of themselves, their world-view, and their life goal. The self-view of theseindividuals tends to be a variant of the theme “I’m nice, but inadequate (orfragile).” Their view of self is self-effacing, inept, and self-doubting. Their viewof the world is some variant of the theme “Others are here to take care of me,because I can’t do it for myself.” Their life goal is characterized by some variantof the theme “Therefore, cling and rely on others at all cost.”
The social features of this personality disorder can be described in terms of
parental, familial, and environmental factors. The dependent personality is most130 Diagnosis and Treatment of DSM-5 Personality Disorders
experience d sufﬁcient carin g and attention as in fants to ena ble them to bond with
others. learned to rely on others, and expect that others will be there
to meet their needs.
to avoid autonomy at all costs.
they must depend on others.
d by marked submissiveness to a dominant other person,
who presumably will provide unending nurturance and guidance. Such a
relations hip is maintaine d even i f it means to leratin g abuse, since dependent-
disordered individuals believe t hemselves to be incom petent an d unable to
survive without  the dominant other.
these individuals are characterized by a low energy level. 
melancholic. As infants and young children
they were characterized as fearful, sad, or withdrawn.
“I’m nice, but inadequate 
“Others are here to take care of me,
because I can’t do it for myself.”
cling and rely on others at all cost.

Dependent Personality Disorder 131
likely to be raised in a family in which parental overprotection is prominent. It
is as if the parental injunction to the child is “I can’t trust you to do anythingright (or well).” The dependent personality is likely to have been pampered andoverprotected as a child. Contact with siblings and peers may engender feelingsof unattractiveness, awkwardness, or competitive inadequacy, especially duringthe preadolescent and adolescent years. These can have a devastating impact onthe individual and further conﬁrm the individual’s sense of self-deprecation anddoubt.
This personality is reinforced and becomes self-perpetuating by a number of
factors: a sense of self-doubt, an avoidance of competitive activity, and particularlyby the availability of self-reliant individuals who are willing to take care of andmake decisions for the dependent person in exchange for the self-sacriﬁcing anddocile friendship of the dependent personality (Sperry, 2015).
Table 6.2  summarizes the characteristics of this disorder.
TABLE 6.2 Characteristics of Dependent Personality Disorder
Triggering Event(s) Expectations of self-reliance and/or being alone
Behavioral Style Docile, passive, insecure, and submissive
Lacks assertivenessSelf-doubting and lacks self-conﬁdence
Interpersonal Style Pleasing, clinging, and compliant
Requires reassurance to make decisionsAbdicates responsibility to othersAvoids disagreementsSelf-abasing to receive the support of othersUrgently seeks new relationships when one ends
Cognitive Style Suggestible and pollyannaishAffective Style Pleasant and anxious, timid, or sad when stressedTemperament Low energy level; fearful, sad or withdrawn, melancholicAttachment Style PreoccupiedParental Injunction “You can’t do it by yourself.”Self-View “I’m nice, but inadequate (or fragile).”World-View “Others are here to take care of me, because I can’t do it
myself.”
Maladaptive Schemas Defectiveness; self-sacriﬁce; approval-seekingOptimal Diagnostic Needs others to assume responsibility for most major 
Criterion areas of his or her lifef unattractiveness, awkwardness, or competitive inadequacy,

Assessment of Dependent Personality Disorder
logical testing are important adjuncts to the patient’s self-report in the clinicalinterview. This section brieﬂy describes some characteristic observations that theclinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e., MMPI-2 and MCMI-IV) and projective (i.e.,Rorschach and TAT) tests are also described.
In the initial interview, individuals with Dependent Personality Disorders willcommonly wait for the clinician to initiate the conversation. After an openingstatement by the clinician, these patients can present an adequate description oftheir current situation, but then will retreat to silence. Predictable comments are:“I don’t know what to say. I’ve never seen a therapist before,” or “Ask mequestions so I’ll know what’s important to talk about.” When the clinician respondsand asks other questions, the cycle may repeat itself. Nonetheless, interviewingthese individuals can be enjoyable, and establishing rapport is relatively easy. Aftersome initial anxiety, they will begin to trust the clinician and the therapeuticprocess. So long as the clinician provides pleasant advice and support, and showsempathy for their indecisiveness and failures, the interview ﬂows smoothly.However, when the clinician attempts to explore the detriments engendered by their submissiveness, they become uncomfortable and want support. If thedependency is not pursued with an empathic ear, they will change therapists. Ifpursued sympathetically, they will cooperate and meet their clinician’s expec -
tations. They answer questions to the point and will clarify and elaborate ondemand. They can tolerate abrupt transitions and will allow deep feelings to beprobed. But they cannot tolerate confrontation and interpretation of theirdependency (Othmer & Othmer, 2002).
The Minnesota Multiphasic Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-IV), the Rorschach Psychodiagnostic Test, and theThematic Apperception Test (TAT) can be useful in diagnosing DependentPersonality Disorder, as well as the dependent personality style or trait (Groth-Marnat, 2009).
On the MMPI-2, the most likely proﬁle is the 2–7/7–2 (Depression-
Psychasthenia), which characterizes individuals who are passive, dependent, anddocile. A high 3 (Hysteria) scale is common, as is a mildly elevated K (Correction)scale (Graham, 2012). Passivity and naiveté are reﬂected in a high L (Lie) scale,132 Diagnosis and Treatment of DSM-5 Personality Disorders
commonly wait for the clinician to initiate the conversation. g After an opening
f statement by the clinician, t hese patients can present an a dequate description o f
their current situation, but then will retreat to silence.
d establishing rapport is relatively easy.
they will begin to trust the clinician and the therapeutic
process. the clinician provides pleasant advice and support, and shows
empathy for their indecisiveness and failures, the interview ﬂows smoothly.
d when the clinician attempts to explore the detriments engendered
by their submissiveness, they become uncomfortable and want support.
fIf
pursued s ympatheticall y, they will coo perate and meet their clinician’s ex pec-
tations.
r they cannot tolerate confrontation and interpretation of their
dependency

while the F (Frequency) scale is in the average range. Acceptance of the
stereotypical female role is reﬂected by a low scale 5 (Masculinity-Femininity).Lack of resistance to coercion from authority shows in a low 4 (PsychopathicDeviate) scale. A low scale 9 (Hypomania) reﬂects passivity and lack of initiative(Meyer, 1995).
On the MCMI-IV a high score on scale 3 (Dependent) would be anticipated
(Millon et al., 2015). An elevation on scale A (Generalized Anxiety Disorder) iscommon, particularly when these individuals feel insecure about placing theirwelfare in the hands of others (Choca et & Denburg, 1997).
With regard to the Rorschach, if dependent personalities feel accepted by the
examiner and believe that the examiner expects a high number of responses, theywill produce an extensive record. Otherwise, fewer than average responses canbe expected. Most common are A (Animal), M (Human Movement), and P(Popular) responses. Finally, C (Color) tends to be used more often than F (Form)in determining responses (Meyer, 1995).
Generally speaking, the TAT responses of dependent personalities are not
particularly distinctive. However, themes of dependency and compliance arecommon on card 2 (Bellak, 1997).
The differential diagnoses for this personality disorder include the Histrionic
Personality Disorder and the Avoidant Personality Disorder. Common symptomdiagnoses that are associated with the Dependent Personality Disorder includethe anxiety disorders, particularly Simple Phobia and Social Anxiety Disorder,and Panic Disorder. Other common DSM-5 disorders include ConversionDisorder, and Somatic Symptom Disorder. The experience of loss of a supportiveperson or relationship can lead to a number of affective disorders, includingPersistent Depressive Disorder and Major Depressive episodes. Finally, becauseDependent Personality Disorders can have lifelong training in assuming the “sickrole” they are especially prone to the Factitious Disorders.
In general, the long-range goal of psychotherapy with a dependent personality
is to increase the individual’s sense of independence and ability to functioninterdependently. At other times, the therapist may need to settle for a more modestgoal. That is, helping the individual become a “healthier” dependent personality.Treatment strategies typically include challenging the individual’s convictions ordysfunctional beliefs about personal inadequacy, and learning ways in which toincrease assertiveness. A variety of methods can be used to increase self-reliance.Among these are providing the dependent person directives and opportunitiesfor making decisions, being alone, and taking responsibility for his or her ownwell-being (Sperry, 2015).Dependent Personality Disorder 133

For the various individual psychotherapeutic modalities, there are reports of
successful treatment for Dependent Personality Disorder. Although no large caseseries or controlled treatment trials have yet to be published, several case reportssuggest that positive treatment outcomes are common. Treatment tends to beshorter and less difﬁcult than for other personality disorders, such as the Borderline,Narcissistic or Antisocial personality disorders.
A central purpose of psychodynamic psychotherapy is to help patients cope betterwith previous separations and object losses. Patients enter therapy with the
unconscious wish to reinstate earlier relationships and bring them to a more
satisfactory resolution. Accordingly, the clinician comes to symbolize the objectlosses, and therapy succeeds if the clinician becomes a better object than the objectsof the patient’s childhood. The clinician gratiﬁes certain fundamental wishes that
the parent-object did not adequately gratify, as well as provides a more reasonable
and benign model for identiﬁcation. If therapy is a success, the internalization ofthe objects will be more positive and less laden with anger and guilt, thereby
making separation a genuine maturational event (Strupp & Binder, 1984). A majordilemma in the psychotherapy with patients with Dependent Personality Disorder
is that they do not readily relinquish the new object, and tend to cling tenaciously
to the clinician.
In this form of resistance, the patient leans dependently on the clinician as an
end in itself, rather than as a means to an end. Thus, as therapy unfolds, these
patients may forget what complaint or symptom brought them into treatment,and their only purpose becomes the maintenance of their attachment to the
clinician. Dreading termination, they tend to experience a reexacerbation of theirinitial symptoms. They will endeavor to make the clinician collude in theiravoidance of making decisions or asserting themselves in the hope of continuingtheir dependency. The clinician, however, must frustrate these wishes and promptindependent thoughts and actions in these patients. By conveying that the anxietyproduced by this frustration is tolerable and productive, the clinician encouragesthe patient toward achieving insight and independence (Gabbard, 1994).
In long-term psychodynamic psychotherapy, the emergence of a dependent
transference toward the clinician is thus promoted, which is then dealt with ina way to promote emotional growth. Patients are told that extra sessions may be
allowed early in therapy, particularly during periods of heightened anxieties. This
assurance of readily available support aids in developing a trusting relationshipwith and transferring dependent wishes onto the clinician. The clinician mustencourage patients to express feelings and wishes and to bear the anxiety of makingdecisions dealing with episodes of anxiety and accepting pleasurable experiences.134 Diagnosis and Treatment of DSM-5 Personality Disorders

Furthermore, the clinician will need to clarify and interpret the transference
elements, as well as support the patients in ﬁnding more self-reliant ways of copingwhen they plead with the clinician to take a more directive role in their lives.During the ﬁnal stage of therapy, the clinician gradually increases the level ofexpectation for self-initiated behavior and autonomous decision making. Theclinician reinforces the patient’s increased ability to cope with crises without extrasessions and to self-soothe and self-manage episodes of heightened anxiety. Thisrequires resolution of the patient’s wish to be dependent and instead to accept amore self-reliant position in the therapeutic relationship (Hill, 1970). Finally, itshould be noted that individuals with Dependent Personality Disorder commonlycreate countertransference problems in their clinicians related to dependencyconﬂicts. Thus clinicians must anticipate countertransference contempt or disdaintoward dependent patients (Gabbard, 1994).
According to Bornstein (2012), Western society’s demands to become
autonomous and self-sufﬁcient result in a series of implicit rules and restrictionsplaced on individuals during childhood. Ambivalence about this expectation mayresult in both conscious and unconscious conﬂicts about the “unacceptable” desirefor dependency. Bronstein suggests that psychoanalytic psychotherapy is par ticularly
well-suited to address this conﬂict, with the goal being to make individualsconsciously aware of it and open to change. Luborsky and Crits-Cristoph (1990)developed the Core Conﬂictual Relationship Theme (CCRT) method to resolvedependency dynamics and conﬂicts. The main element of the CCRT method isan in-depth analysis of the patient’s relationships. This included wishes, fears, andintentions; the other person’s response; and the patient’s reaction. The therapistalso creates a supportive “holding environment” within the therapeutic relation -
ship to minimize anxiety and defensiveness while working through dependency-related transference and countertransference.
Time-Limited Dynamic Psychotherapy . Kantor (1992) notes that long-
term analytic psychotherapy is arduous and time-consuming, and should berecommended primarily when patients are highly motivated and the dependencyis ego-syntonic. Otherwise, the treatment may become interminable because ofsuch resistances as unwillingness to work hard in treatment because this meansterminating therapy, which they anticipate will be unbearable. Generally speaking,long-term psychotherapy with motivated patients requires two to four sessions aweek over three or more years to work through a dependent transference.
For these and other reasons, time-limited dynamic psychotherapy has been
advocated as the treatment of choice for most of these patients (Flegenheimer,1982; Gunderson, 1989). Knowing at the outset that treatment will end after 12,16, or 20 sessions means that these patients must confront their deepest anxietiesabout loss and individuation, as well as their fantasies about unlimited nurturanceand timelessness (Mann, 1973). Such time-limited therapies are most likely tosucceed when three conditions are present: a circumscribed, dynamic conﬂict orfocus; a patient who can quickly form a therapeutic alliance; and little or noDependent Personality Disorder 135

tendency to act out or regress to severe dependency (Luborsky, 1984; Strupp &
Binder, 1994). Time-limited therapy is less successful with dependent individualswho have limited ego strengths or greater degrees of separation anxiety (Gabbard,1994). For such patients, Wallerstein (1986) suggests a supportive treatmentapproach in which sessions are tapered down to one every few months, providedthere is no threat to termination.
Flegenheimer (1982) has critically reviewed six different brief dynamic
psychotherapy approaches—those of Sifneos, Alexander, Mann, Malan, Davanloo,and Wolberg. He believes that Mann’s, Alexander’s, and Wolberg’s approachesare tailor-made for the many dependent personality-disordered individuals.Passive, indecisive patients are likely to feel comfortable with the paternalisticstances of Alexander or Wolberg, where the clinician initially takes charge, givesadvice, and makes decisions. The approach enables these patients to try newbehaviors because they are “told to.” The positive response to new behaviorsengenders and reinforces those new patterns of behavior. Likewise, more passivedependent patients tend to do well with Mann’s approach, wherein a terminationdate is set at the ﬁrst session. The dependency of the patient allows the “goldenglow” of Mann’s ﬁrst phase of therapy to develop to the fullest, setting the stagefor subsequent disillusionment and preparing for a meaningful separationexperience.
Mann’s (1973) approach requires little modiﬁcation of the standard analytically
oriented approach, and requires the least amount of confrontation of the brieferpsychotherapies. Not surprisingly, this rather gentle technique tends not toengender major resistances in dependent patients.
Time-limited approaches are advocated as the starting point for treatment of
most dependent patients. For those who have multifocal conﬂicts or otherwisefail to improve in briefer therapies, longer-term dynamic therapies, supportivetherapy, or psychoanalysis would be treatment options.
Cognitive-Behavioral Approaches
Beck et al. (2004) provides an extended description of the cognitive therapyapproach with individuals with Dependent Personality Disorder. The basic goalof therapy is increased autonomy and self-efﬁcacy. Autonomy is deﬁned as thecapability to act independently of others, along with the capability to developclose and intimate relationships. Because dependent individuals are squeamish aboutthe word “independent” and fear that competence will lead to abandonment,achieving these goals must be accomplished with considerable delicacy. Since theseindividuals often come to treatment anticipating that clinicians will solve theirproblems and make their decisions, it is necessary to allow some dependenceinitially in order to engage them. The structured collaborative nature of cognitivetherapy encourages the dependent individual to play an active role in thetreatment process, beginning with the agenda and goal setting. The use of guided136 Diagnosis and Treatment of DSM-5 Personality Disorders

discovery and Socratic questioning early in treatment helps these individuals to
begin to face their own solutions and decisions, reducing overreliance on thetherapist and others. As therapy proceeds, progress toward goals can be utilizedas powerful evidence to challenge the dependent individual’s assumptions ofpersonal helplessness.
Challenging the dichotomous belief about independence—that one is both
totally dependent and helpless or totally independent and isolated—helps to modifythe distorted notion that autonomy is a commitment to total alienation. Besideschallenging and disputing automatic beliefs and maladaptive schemas concerningdependency and helplessness, therapists are encouraged to utilize behavioralmethods such as assertiveness training and behavioral experiments, as well as tomodify the very structure of therapy.
This modiﬁcation can be accomplished in several ways, such as by gradually
changing to a group format or concurrent individual and group therapy,“weaning” sessions by scheduling them less frequently toward the end of thetherapy, or setting a speciﬁc termination date early in treatment and focusingtherapy as preparation for termination. Since termination typically evokes rejectionand abandonment schemas in these individuals, offering the option of one or twobooster sessions, late in the course of treatment, following termination can easethe transition. In short, the cognitive treatment of Dependent Personality Disorderbegins with a collaborative relationship in which the therapist allows a measureof dependency, which is gradually replaced with guided discovery, and challengesthe dichotomy beliefs of independence. As treatment proceeds, schemareconstruction and modiﬁcation of the structure of treatment, along withbehavioral methods, are utilized to achieve treatment goals.
It is particularly important that the therapist monitor his or her thoughts and
feelings toward the dependent patient. Therapists may feel the urge to foregothorough evaluation or make other exceptions for these seemingly “pathetic”individuals. In this case, the therapist’s directiveness is covertly aiding the patient’spathological pattern and undermining the goal of autonomy. It may be useful forthe therapist to create a Dysfunctional Thought Record to determine whetherany deviations from protocol are in the interest of the patient or whether theyfoster continued dependence. Beck et al. (2004) note that dependent patients aremore likely than others to report that they have fallen in love with therapists.Therefore, it is of particular importance to avoid “special” treatment.
A more behaviorally oriented approach to this disorder is based on the
formulation that the dependent personality is hypersensitive to independentdecision making (Turkat, 1990). The corresponding behavioral strategy isbidirectional anxiety management procedures focused on independent decisionmaking. Since individuals with Dependent Personality Disorder are oftenundersocialized, social skills training may be indicated. Assertive communicationand friendship and dating skills are often minimal in lower functioning dependentpatients. Fay and Lazarus (1993) offer cognitive-behavioral protocols inDependent Personality Disorder 137

assertiveness, friendship, and dating skills. Brauer and Reinecke (2015)
recommend that therapists help dependent patients face the sources of their anxietyby developing behavioral skills in a systematic, graduated fashion. This may beaccomplished via modeling by the therapist during sessions, in vivo practice, and
observing others who are more autonomous and assertive.
Cognitive Coping Therapy . Cognitive Coping Therapy is an active,
directive, didactic and structured approach for treating personality-disorderedindividuals (Sharoff, 2002). It is a complete and self-contained approach totreatment which begins with assessing an individual’s coping skills—in terms of skill chains, subskills and microskills—and then increasing skill competence intargeted areas as needed. Five key skill areas with representative treatmentmodalities include: cognitive skills —problem solving, self-instruction training and
self-management; emotion skills —emotional containment and compart mental -
ization; perceptual skills —perspective taking, thought stopping, and psychological
distance taking; physiological skills —meditation and relaxation training, and behavior
skills—communication and assertiveness training. Sharoff (2002) describes a
detailed protocol (and clinical example) for using this structured approach witha complex and difﬁcult Dependent Personality Disorder case.
that has been developed by Young (Young et al., 2003) speciﬁcally for personalitydisorders, and other difﬁcult individual and couples problems. Schema Therapyinvolves identifying maladaptive schemas and planning speciﬁc strategies andinterventions. Four main strategies are cognitive, experiential, behavioral, and thetherapeutic relationship itself. Cognitive restructuring, modiﬁcation of maladaptiveschemas, is an important cognitive strategy, but is combined with imageryexercises, empathic confrontation, homework assignments, and “limited reparent -
ing,” i.e., a form of corrective emotional experience (Young et al., 2003).
Maladaptive schemas typically associated with Dependent Personality Disorder
are: defectiveness —the belief that one is defective, bad, unwanted, or inferior in
important respects; dependence —the belief that one is unable to competently carry
out everyday responsibilities without considerable help from others; approval-
seeking— the belief that one must constantly seek to belong and be accepted at
the expense of developing a true sense of self; and self-sacriﬁce— the belief that
one must meet the needs of others at the expense of one’s own gratiﬁcation(Bernstein, 2002).
For Benjamin (2003a), psychotherapeutic interventions with persons withDependent Personality Disorder can be planned and evaluated in terms ofwhether they enhance collaboration, facilitate learning about maladaptive patternsand their roots, block these patterns, enhance the will to change, and effectivelyencourage new patterns.138 Diagnosis and Treatment of DSM-5 Personality Disorders

According to Benjamin, those with Dependent Personality Disorder appear
to be the ideal patient—at least superﬁcially. They comply with all recommenda-tions and prescriptions, from homework to paperwork and payment. The moreauthoritative the therapist is, the more the dependent goes along for the ride.However, she notes that the dependent individual’s apparent attitude of friendlycooperation actually complicates the development of a collaborative therapeuticalliance and undermines efforts to change. Essentially, eliciting more and betterhelp from clinicians is the agenda for dependent individuals. They see no reasonto collaborate with clinicians against their maladaptive pattern of dependency.Therapy may go on forever. The clinician’s challenge at the onset of treatmentis to engage with the position opposite their usual one: stop submitting, learnabout being independent, and separate. Initially, this seems impossible for theseindividuals because, with their histories of intense enmeshment, they cannotunderstand what it means to be differentiated. They believe that there are onlytwo options: to control others or to submit to others. Since they believe thatcontrolling represents bossiness, aggressivity, and bullying of others, they rejectit in favor of submission. However, if they are helped to understand thatseparation and competence, rather than control, are the opposite of submission,they can change. Blocking maladaptive patterns in dependent individuals oftenrequires the assistance of their signiﬁcant others, such as family members. Theparadoxical suggestion that others restrict their offers of help at times whendependent individuals are functioning well is a way to reward independentbehavior. Such suggestions must be followed with other interventions that changethe strong wish to be dependent and strengthen the wish to become morecompetent and independent.
Essentially, dependent individuals must ﬁrst recognize their dependent pattern
and the high price they pay to maintain it, and then explore alternatives. To theextent that they can collaborate against “it” and face the present-day meaning ofthis pattern, they may decide to change. As this occurs, the implementation ofa new pattern is relatively straightforward. Benjamin points out that standardbehavioral techniques such as assertiveness communication and feelingidentiﬁcation and expression can be quite effective.
Group treatment has been shown to be successful in the treatment of DependentPersonality Disorder. Two considerations are involved in deciding whethergroup treatment will be an effective format. The ﬁrst consideration relates to thepatient’s degree of impairment; where motivation and potential for growth exist,a more interactional psychotherapy group may be indicated. Such a contextprovides a therapeutic milieu for exploring the inappropriateness of passivedependent behavior and for experimenting with greater assertiveness (Yalom,1985). However, if dependent traits reﬂect severe personality impairment or theDependent Personality Disorder 139

absence of prosocial behavior such as assertive communication, decision making,
and negotiation, an ongoing supportive problem-solving group or a social skillstraining group might be indicated. The second consideration refers to whetherreferral should be made to a homogeneous group, with treatment targeted atdependency issues shared by all group members, or a heterogeneous group, wheregroup members have different personality styles or disorders. Frances et al. (1984)provide selection criteria for both types of group formats. Clinical lore suggeststhat dependent patients tend to get “lost” in heterogeneous groups. Yalom (1995)seems to be describing the dependent personality in his discussion of the “silentpatient” in groups. Yet time-limited assertiveness-training groups that arehomogeneous and have clearly deﬁned goals have been shown to be veryeffective (Lazarus, 1981).
Two studies involving the treatment of dependent patients have been reported
in the literature. Montgomery (1971) utilized homogeneous group formats fordependent patients who were previously being seen in an individual format in aclinical setting. The patients were described as clinging and dependent, and asexpecting magical cures and medication. Engagement within the group providedthe patients with the opportunity to redirect their attention-seeking behavior fromregressive to more socially adaptive purposes. Montgomery reports that all butthree of 30 patients eventually discontinued medication. Sadoff and Collins(1968) reported group therapy for dependent patients who also stuttered. Weeklygroup treatment, which emphasized dynamic interpretation, was shown to beeffective. Positive changes in stuttering and dependency were reported.
The professional literature on family therapy interventions with this disorder isalmost nonexistent. Harbir (1981) notes that individuals with DependentPersonality Disorder are usually brought to family therapy by their parents. Theyare frequently older adolescents or young adults between the ages of 20 and 35 who present with a neurotic or psychotic symptom. Harbir describes a proto-typical case of a 29-year-old man with a diagnosis of dependent personality whoessentially was totally dependent on his parents for his maintenance. A morefunctional younger sister had moved out on her own the previous year. Althoughhe did some part-time work at home for his father, he neither made his ownmeals, cleaned his own room, nor washed his own clothes. He was content tolive the rest of his life with his parents, if they would permit it. There was noclear-cut presenting problem, other than the identiﬁed patient’s unwillingness to work outside the home. Clearly, the son, mother, and father were deeply en -
meshed, although the son was much more dependent on the mother than thefather, and vice versa. Structural techniques were employed by the clinician to decrease the intensity of the mother-child interaction. Essentially, various taskswere prescribed that encouraged the father and son to form a separate relationship.140 Diagnosis and Treatment of DSM-5 Personality Disorders

Tasks that encouraged social activities outside the family also were prescribed.
Since the son had developed few peer relationships, these tasks initially were quitedifﬁcult for both the son and his parents.
After one year of family treatment, the son was able to emancipate sufﬁciently
and could work and socialize outside the home. Could these results have beenaccomplished in individual therapy? Perhaps, but it was not likely in that timeframe, and without some cooperation from the parents. Changing the enmeshedfamily relationship tends to be anxiety-provoking for all parties, and thus thereis considerable resistance from other family members when only one member ofthe family is in therapy.
Very little has been published on marital therapy with persons with Dependent
Personality Disorder. Malinow (1981) notes that dependent patients can functionadequately if their marital partners consistently meet their needs, but typicallybecome symptomatic and impaired when that support is withdrawn or withheld.Turkat (1990) believes that it is useful to engage the cooperation of the maritalpartner in treatment for two reasons: (1) because of the negative impact on therelationship as the dependent individual becomes less anxious and moreindependent, and (2) because the patient’s progress can be facilitated if thepartner collaborates in accomplishing the treatment goals. Barlow and Waddell(1985) describe a time-limited couples group for the treatment of agoraphobia.Most of the symptomatic partners exhibited features of the dependent personality.In group, the nonsymptomatic partners took the roles of “coach” and “conﬁdant,”collaborating on treatment goals. Taking on these roles meant relinquishing therole in which they reinforced their partner’s agoraphobia and dependency.During the course of this 10-session treatment protocol, not only did panic andagoraphobia symptoms remit, but the marital relationship shifted from dependencyto more interdependency.
A common marital relational pattern is the dependent/narcissistic couple in
which one partner presents with Dependent Personality Disorder and the otherpartner presents with Narcissistic Personality Disorder. Nurse (1998) provides adetailed rationale and treatment protocol for working with such couples basedon Millon’s theory of personality disorders (Millon & Davis, 1996).
Links, Stockwell, & McFarlane (2004b) examined couples therapy for patients
with Dependent Personality Disorder and identiﬁed two dimensions of depend -
ency that determine whether or not patients beneﬁt from this type of intervention.They provide details surrounding two cases to represent each dimen sion. The
ﬁrst focuses on interpersonal dependency that results from insecure attachment.Links et al. note that this couple failed to beneﬁt from couples therapy becauseof an enmeshed relationship. The second dimension involves a lack of assertivenessand self-conﬁdence in the dependent individual. These deﬁcits result in a crisiswithin the relationship that may successfully be addressed in the context of couplestherapy. The authors maintain that it is imperative to determine which depend -
ence dimension predominates to evaluate the appropriateness of couples therapy.Dependent Personality Disorder 141

Beck et al. (2004) explain that treatment geared towards increasing the
autonomy and assertiveness of the dependent individual may result in upsettinghis or her spouse. Oftentimes, the signiﬁcant others of those with DependentPersonality Disorder enjoy the unequal balance of the power in the relationshipand may see changes to this as a threat. In this case, marital or family therapy canhelp family members adjust to changes in the identiﬁed patient and potentiallygrow as a unit. If, however, signiﬁcant others are not willing to accept the changesbrought about in treatment, the dependent individual must determine whetheror not to end the relationship.
Currently, there are no psychotropic medications speciﬁcally indicated for treatingindividuals with Dependent Personality Disorder (Silk & Feurino, 2012).Nevertheless, medications are used that target speciﬁc troubling symptomsassociated with the disorder, such as depression, anxiety, or sleep problems.Generally, these medications are used as an adjunct to psychotherapy and skillstraining. Because troubling symptoms often respond to medications sooner thanmost psychological interventions, medications are usually prescribed at the onsetof treatment (Sperry, 1995b). Unfortunately, there is little research evidence toprovide guidelines for the use of such medications with this disorder (Silk &Feurino, 2012).
In many ways, the dependent personality is an “orphan” in the clinical literature,and this certainly is evident in the area of combined and integrative treatment.Another type of combined treatment involves utilizing different modalitiessimultaneously. Barlow and Waddell’s (1985) effort to combine behavior therapyin a group setting with couples was previously described. Not surprisingly, theresults of combining modalities are noteworthy. Lazarus (1981, 1985) providesfurther documentation of the overall efﬁcacy, and cost effectiveness, of multimodalinterventions
Little has been written regarding integrative treatment. However, clinical
practice is replete with efforts to utilize anxiety-reducing strategies in bothdynamic and cognitive therapies. For example, Glantz and Goisman (1990)describe a unique integration of relaxation techniques with object-relations psy -
cho dynamic psychotherapy with dependent patients. A breath-controlling and
progressive muscle-relaxation strategy was used to merge split self-representationsin the course of exploration psychotherapy. The technique was introduced aftersigns of split self-representation had been identiﬁed. Patients were taught thetechnique and it was prescribed as an intersession treatment task. Once they wereable to relax adequately in session, they were asked for visual images of ﬁrst one142 Diagnosis and Treatment of DSM-5 Personality Disorders

and then another of the conﬂicting self-representations. After clear images had
been elicited and discussed, they were encouraged to merge the images. Twenty-four of the 27 personality-disordered patients in the study, many of whom weredependent personalities, responded with greater compliance, improvedinterpersonal relationships, and reduced resistance.
For those with comorbid dependent personality and substance use disorders,
Ekleberry (2014) states that participation in self-help programs such as AlcoholicsAnonymous (AA) and Narcotics Anonymous (NA) may be helpful; however,she cautions that these individuals may fall prey to aggressive and narcissistic groupmembers.Dependent Personality Disorder 143

7
HISTRIONIC PERSONALITY 
DISORDER
Individuals with histrionic personalities initially appear to be charming, likable,
energetic, and seductive, but as time passes they may be viewed as emotionallyunstable, immature, and egocentric. While it is noted in males, this personalitypattern predominates in females, and typically presents with a caricature of femi -
ninity in dress and manner (Blashﬁeld, Reynolds & Stennett, 2012). Whiletreatment of such individuals involves a number of unique therapeutic challenges,it can be highly effective and successful.
Description of the Histrionic Personality Disorder
The Histrionic Personality Disorder can be recognized by the followingdescriptors and characteristics: styles vs. disorders, triggering event, behavioral styles,interpersonal styles, cognitive styles, affective styles, attachment style, and optimalcriterion.
Style vs. Disorder . This histrionic personality can be thought of as spanning
a continuum from healthy to pathological, wherein the histrionic personality stylee charming, likable,
energetic, and seductive, emotionally
unstable, immature, and egocentric.
predominates in females, a caricature of femi -
ninity in dress and manner

Histrionic Personality Disorder 145
TABLE 7.1 Comparison of Histrionic Personality Style and Disorder
Enjoys compliments and praise. Constantly seeks or demands 
reassurance, approval or praise.
Charming, engaging, and appropriate Inappropriately sexually seductive
appearance or behavior. in appearance and behavior.
Attentive to their appearance and grooming, Overly concerned with physical
enjoying clothes, style, and fashion. attractiveness.
Lively and fun-loving, often impulsive, Expresses emotion with inappropriate
but can delay gratiﬁcation. exaggeration; self-centered and little
tolerance for gratiﬁcation.
Enjoy being the center of attention, and Uncomfortable in situations where 
can rise to the occasion when all eyes are they cannot be the center of attention.on them.
Sensation-oriented, emotionally Displays rapidly shifting and shallow
demonstrative, and physically affectionate. expression of emotion.
Reacts emotionally but appropriately.
Utilizes a style of speech which is Utilizes a style of speech that is 
appropriately global and speciﬁc. excessively impressionistic and lacking
in detail.
is on the healthy end and the Histrionic Personality Disorder is on the pathological
end. Table 7.1  compares and contrasts the histrionic personality style and disorder.
The following two case examples further illustrate differences between the
Histrionic Personality Disorder—Ms. P.—and the histrionic personality style—Mr. M.
CASE STUDY: HISTRIONIC PERSONALITY DISORDER
Ms. P. is a 20-year-old female undergraduate student who requested
psychological counseling at the College Health Services for “boyfriendproblems.” Actually, she had taken a nonlethal overdose of minortranquilizers the day before coming to the Health Services. She said she took
the overdose in an attempt to kill herself because “life wasn’t worth living”
after her boyfriend had left the afternoon before. She was an attractive, well-dressed woman adorned with makeup and nail polish, which contrastedsharply with the very casual fashion of most coeds on campus. During the
initial interview she was warm and charming, maintained good eye contract,

Triggering Event . The typical situation, circumstance or event that most
likely triggers or activates the characteristic maladaptive response of the HistrionicPersonality Disorder Personality Disorder (Othmer & Othmer, 2002), as notedin behavioral, interpersonal, cognitive, and affective styles, is: “opposite sexrelationships.”
Behavioral Style . The behavioral style is characterized as charming, dramatic,
and expressive, while also being demanding, self-indulgent, and inconsiderate.
Persistent attention-seeking, mood lability, capriciousness, and superﬁcialityfurther characterize their behavior.yet was mildly seductive. At two points in the interview she was emotionally
labile, shifting from smiling elation to tearful sadness. Her ex-boyfriend had
accompanied her to the evaluation session and asked to talk to the clinician.He stated the reason he had left the patient was because she made demands
on him which he could not meet, and that he “hadn’t been able to satisfy
her emotionally or sexually.” Also, he noted that he could not afford to “takeher out every night and party.”
CASE STUDY: HISTRIONIC PERSONALITY STYLE
Mr. M. is a 41-year-old literary agent who spent the early years of his careerrepresenting nonﬁction writers with major publishing houses. He has been
quite successful for several years but has also become somewhat
disenchanted with his behind-the-scenes efforts. While he has made severalof his clients extraordinarily wealthy and famous, he dreamed of the timewhen he too would be ﬁnancially independent and in the limelight. When
cable TV licenses became available, he sensed the opportunity to fulﬁll his
dream. He would become president of his own station and host his own talkshow; after all, he had several high-visibility clients whom he could get tobe guests on his show. He set out to garner ﬁnancing for his plan. With his
charming manner and alluring vision, he quickly intrigued several backers
and got the station launched. The only problem was, he hadn’t thought muchabout the production side of the enterprise. He quickly arranged interviewsfor an executive producer. William T. was the fourth person he interviewed.
Mr. M. knew as soon as he walked in that he was right for the job, and after
a 10-minute interview, William was hired. Mr. M’s hunch about both Williamand the success of the talk show he hosted proved to be right.146 Diagnosis and Treatment of DSM-5 Personality Disorders
Persistent attention-seeking,“opposite sex
relations hips.”
 charming, dramatic,
and expressive, being demanding, self-indulgent, and inconsiderate.

Interpersonal Style . Interpersonally, these individuals tend to be exhibition -
istic and ﬂirtatious in their manner, with attention-seeking and manipulativenessbeing prominent. They also tend to have empathic deﬁcits, just as NarcissisticPersonality-Disordered individuals.
Cognitive Style . The cognitive or thinking style of this personality can be
characterized as impulsive and thematic, rather than being analytical, precise, and
ﬁeld-independent. Their tendency is to be nonanalytic, vague, and ﬁeld-dependent. They are highly suggestible and rely heavily on hunches and intuition.
They avoid awareness of their own hidden dependency and other self-knowledge,
and tend to be “other-directed” with respect to the need for approval from others.Therefore, they can easily dissociate their “real” or inner self from their “public”or outer self.
Affective Style . Their emotional or feeling style is characterized by
exaggerated emotional displays and excitability, including irrational outbursts andtemper tantrums. Although they are constantly seeking reassurance that they areloved, they respond with only superﬁcial warmth and charm and are generallyemotionally shallow. Finally, they are exquisitely rejection-sensitive.
by a sense of personal unworthiness and a positive evaluation of others. These
individuals tend to be rather externally oriented in their self-deﬁnitions. The
Preoccupied Attachment Style is common in individuals with HistrionicPersonality Disorder.
Dependent Personality Disorder, one criterion has been found to be the mostuseful in diagnosing this disorder. The belief is that, by beginning with thiscriterion, the clinician can test for the presence or absence of the criterion and
quickly diagnose the personality disorder (Allnutt & Links, 1996). The “optimal
criterion” for this disorder is: “uncomfortable in situations in which he or she isnot the center of attention.”
Individuals with this personality disorder are characterized by an unremittingpattern of attention seeking and emotionality. They tend to be uncomfortable in
situations where they cannot be the center of attention. Their emotional reactions
tend to be shallow and rapidly shifting. Typically, they draw attention to them -
selves with the way they dress. Their manner of speech tends to be impressionistic,with few details. These individuals are easily inﬂuenced by others or circumstances.
They are likely to perceive relationships as more intimate than they really are.
They often engage in provocative and inappropriate seductive sexual behavior.Furthermore, they are dramatic and overly exaggerate their emotional expressions
(American Psychiatric Association, 2013).Histrionic Personality Disorder 147
 exhibition -
istic and ﬂirtatious attention-seeking and manipulativeness
empathic deﬁcits,
impulsive 
nonanalytic, vague,
d rely heavily on hunches and intuition.
They avoi d awareness o f their own hidden dependency an d other self-knowledge,
and tend to be “other-directed” with respect to the need for approval from others.
dissociate their “real” or inner self from their “public”
or outer self.
exaggerate d emotiona l displays an d excita bility, inc luding irrationa l outbursts an d
temper tantrums. 
they respond with only superﬁcial warmth and charm and are generally
emotionally shallow. rejection-sensitive.
tend to be rather externally oriented in their self-deﬁnitions.
f attention seeking and emotionality. uncomfortable in
situations where they cannot be the center of attention.  Their emotional reactions
tend to be shallow and rapidly shifting. they draw attention to them -
selves with the way they dress.  Their manner of speech tends to be impressionistic,
with few details. 
They are likely to perceive re lations hips as more intimate t han they rea lly are.
They often engage in provocative an d inappropriate se ductive sexua l behavior.
 they are dramatic and overly exaggerate their emotional expressions

A prototype is a brief description that captures the essence of how a particular
disorder commonly presents. Prototypic descriptions are useful and convenientand clinicians commonly rely on them rather than lists of behavioral criteria orcore beliefs (Westen, 2012). Here is a common prototypic description of theHistrionic Personality Disorder: These individuals are the exhibitionists in life. If
they are female, they use charm, physical appeal, and seductiveness to commandattention. There is an intensity to their relationships and emotions, but ashallowness at the same time. If they are male, they are more likely to commandattention by bragging about a business deal or investment, or their prowess in sportsor sex. Their interests and attitudes are easily inﬂuenced by what others think andvalue. They come on strong and seek intimacy quickly. But, such intimacy wearsthin quickly, which leaves them feeling unappreciated (Frances, 2013).
Prevalence of this disorder has been estimated at 1.84 percent in the generalpopulation (American Psychiatric Association, 2013). In clinical settings, thisdisorder is the most infrequent in presenting for treatment, with estimates of 1.0to 22.9 percent (Torgersen, 2012).
Conceptualizations of the Histrionic Personality Disorder
Gabbard (1990) argues that the Histrionic Personality Disorder needs to be
distinguished from the Hysterical Personality Disorder. The latter has a centralplace in the tradition of psychoanalytic thinking and refers to a higher functioninghealthier group of patients than the group characterized by DSM-IV criteria.Histrionic females typically lack maternal nurturance and turn to their fathers forgratiﬁcation of their dependence needs. They learn that they can gain their father’sattention through ﬂirtatious and exhibitionistic displays of emotion. As shematures she learns she must repress her genital sexuality to remain “daddy’s littlegirl.” Similarly, histrionic males will have also experienced maternal deprivationand turned to their fathers for nurturance. If their father is emotionally unavailable,they may develop a passive, effeminate identiﬁcation or hypermasculine one inreaction to anxiety about effeminacy. He may not become homosexual, but hisheterosexual relationships are means of reassuring himself relative to underlyinggenital inadequacy. These men will be disappointed with all women, since theycannot measure up to mother. Some will choose a celibate lifestyle to maintaintheir loyalty to their mother, while others will indulge in macho behavior suchas bodybuilding and Don Juanism, i.e., compulsive seduction of women, to reassurethemselves they are “real men” (Kellerman & Burry, 1989).148 Diagnosis and Treatment of DSM-5 Personality Disorders
d they use charm, physical appeal, and seductiveness to command
attention. There is an intensity to their relationships and emotions, but a
shallowness at the same time. If they are male, they are more likely to command
attention b y bragging about a business deal or investment, or their prowess in s ports
or sex. T heir interests an d attitu des are easi ly inﬂuence d by what others think and
value. They come on strong and seek intimacy quickly.  But, such intimacy wears
thin quickly, which leaves them feeling unappreciated 
1.84 percent in the general
population 
“daddy’s little
girl.”  They learn that they can gain their father’s
attention through ﬂirtatious and exhibitionistic displays of emotion.
maternal deprivation
and turned to their fathers for nurturance. 
while others will indulge in macho behavior such
as bodybuilding an d Don Juanism, i.e., compu lsive se duction o f women, to reassur e
themselves they are “real men”

Biosocial Case Conceptualizations
Millon (1981) and Millon and Davis (1996) note that individuals with Histrionic
Personality Disorders often display a high degree of emotional lability andresponsiveness during infancy and early childhood, which they attribute to lowexcitability thresholds for limbic and posterior hypothalamic nucleus. However,environmental factors seem to play the major role in the development of thispathology. Millon and Everly (1985) list three such factors: parental reinforcementof attention-seeking behavior; histrionic parental role models; and reinforcementof interpersonally manipulative behavior. In effect, as children these individualslearned to employ cuteness, charm, attractiveness, and seduction to secure parentalreinforcement. Furthermore, this disorder is self-perpetuated through short-livedrelationships, preoccupation with externals, and massive repression. Speciﬁcally,by sealing off and repressing aspects of their inner worlds, histrionic individualsdeny themselves opportunities to develop psychologically.
Beck (2015) describes a cognitive therapy view of the Histrionic PersonalityDisorder based on speciﬁc underlying assumptions and cognitive distortions. Twounderlying assumptions are posited: “I am inadequate and unable to handle lifeby myself” and “I must be loved by everyone to be worthwhile.” Believing theyare incapable of caring for themselves, histrionic individuals actively seek theattention and approval of others and expect others to take care of them and theirneeds. Believing they must be loved and approved by others promotes rejectionsensitivity. Finally, feeling inadequate and desperate for approval, they are underconsiderable pressure to seek attention by “performing” for others. These beliefsalso give rise to a thinking style characterized as impressionistic, global, andunfocused, which is not conducive to a differentiated sense of self (Sungar &Gunduz, 2015). Not surprisingly, this global, exaggerated thinking style engenderscommon cognitive distortions (Beck, 2015), such as dichotomous thinking,overgeneralization, and emotional reasoning.
Taking a more behavioral tack, Turkat (1990) differentiates the Histrionic
Personality Disorder in two types: the controlling type in which the basicmotivation is achieving total control through the use of manipulative and dramaticploys; and the reactive type in which the basic motivation is seeking reassuranceand approval. Turkat does not believe the controlling type is amenable tobehavior treatment. Unable to read others’ emotions and interventions accurately,these individuals remain shallow, self-centered, and uncomfortable whenimmediate reinforcement is not immediately forthcoming from others. In short,they suffer from a primary deﬁcit in empathy.Histrionic Personality Disorder 149
low
excitability thresholds 
learne d to emp loy cuteness, c harm, attractiveness, an d seduction to secure parenta l
reinforcement.
“I am inadequate and unable to handle life
by myself” “I must be loved by everyone to be worthwhile.
actively seek the
r attention an d approva l of others an d expect ot hers to ta ke care o f them an d their
needs. Believing they must be loved and approved by others promotes rejection
sensitivity. r feeling inadequate and desperate for approval, they are under
considerable pressure to seek attention by “performing” for others.
the controlling type in which the basic
motivation is ac hieving tota l contro l through the use o f manipu lative an d dramati c
ploys; and the reactive type in which the basic motivation is seeking reassurance
and approval. 
 Unable to read others’ emotions and interventions accurately,
these in dividuals remain s hallow, se lf-centere d, and uncom fortable when
imme diate rein forcement is not imme diately forthcoming from ot hers. In s hort,
they suffer from a primary deﬁcit in empathy.

Interpersonal Case Conceptualizations
For Benjamin (2003a), persons with Histrionic Personality Disorder were likely
to be loved for their good looks and entertainment value, rather than forcompetence or personal strength. They learned that physical appearance and charmcould be used to control important others. The household of histrionicpersonalities tended to be a shifting stage. Unpredictable changes stemmed fromparental instability, possibly associated with alcohol or substance use. The chaosin these families was more likely to be dramatic and interesting rather than primitiveand life-threatening, as with borderline personalities. On the other hand, the help-seeking histrionic subtypes were likely to be nurtured for being ill. They learnedthat complaints and disabilities were an effective way to elicit warm concern.Along with encouragement of denial, these families rewarded sickness. Finally,they exhibit a strange fear of being ignored, together with a wish to be lovedand taken care of by important others, who can be controlled through charm orguile. In short, a friendly trust is accompanied by a secretly disrespectful agendaof forcing delivery of the desired nurturance and love. Inappropriate seductivebehaviors and manipulative suicide attempts exemplify such coercions.
The following integrative formulation provides a biopsychosocial explanation forhow this personality is likely to have developed and how it is maintained.Biologically and temperamentally, the histrionic personality is characterized by ahigh energy level and emotional and autonomic reactivity. Millon and Everly(1985) noted that histrionic adults tended to display a similarly high degree ofemotional lability and responsiveness, as they did in infancy and early childhood.Their temperament then can be characterized as hyperresponsive and externallyoriented for gratiﬁcation.
of themselves, their world-view, and their life goal. The self-view of the histrionicwill be some variant of the theme “I am sensitive and everyone should admireand approve of me.” The world-view will be some variant of “Life makes menervous so I am entitled to special care and consideration.” Life goal is somevariant of the theme “Therefore, play to the audience, and live in the moment.”
In addition to biological and psychological factors, social factors such as
parenting style and injunction, and family and environmental factors, inﬂuencethe development of the histrionic personality. The parental injunction for thehistrionic personality involves reciprocity: “I’ll give you attention, if you do X.”A parenting style that involves minimal or inconsistent discipline helps ensureand reinforce the histrionic pattern. The histrionic child is likely to grow up withat least one manipulative or histrionic parent who reinforces the child’s histrionicand attention-seeking behavior. Finally, the following sequence of self- and system150 Diagnosis and Treatment of DSM-5 Personality Disorders
to be loved for their good looks and entertainment value, 
 They learned that physical appearance and charm
could be used to control important others.
d they ex hibit a strange fear of being ignore d, toget her wit h a wis h to be loved
r and taken care o f by important ot hers, w ho can be contro lled through charm o r
guile. In short, a friendly trust is accompanied by a secretly disrespectful agenda
of forcing delivery o f the desired nurturance an d love. Inappropriate se ductive
behaviors an d manipu lative suici de attempts exemp lify such coercions.
high energy level and emotional and autonomic reactivity.
hyperresponsive and externally
oriented for gratiﬁcation.
“I am sensitive and everyone should admire
and approve of me. f “Life makes me
nervous so I am entitled to special care and consideration.
play to the audience, and live in the moment.

perpetuants are likely to be seen in the Histrionic Personality Disorder: denial of
one’s real or inner self; a preoccupation with externals; the need for excitementand attention-seeking, which leads to a superﬁcial charm and interpersonalpresence; and the need for external approval. This, in turn, further reinforces thedissociation and denial of the real or inner self from the public self, and the cyclecontinues (Sperry, 2015).
Table 7.2  summarizes these characteristics.
Assessment of Histrionic Personality Disorder
logical testing are important adjuncts to the patient’s self-report in the clinicalinterview. This section brieﬂy describes some characteristic observations that theclinician makes and the nature of the rapport likely to develop in initial encountersHistrionic Personality Disorder 151
TABLE 7.2 Characteristics of Histrionic Personality Disorder
Behavioral Style Self-dramatization
SuggestibilityCharming and excitement-seeking
Interpersonal Style Needs to attract others’ attention
Seductive or provocative interactionsExhibitionistic and/or ﬂirtatiousMisreads intimacy of relationships
Thematic, ﬁeld-dependentImpressionistic style of speech
Affective Style Rapidly shifting, shallow expression of emotions
Exaggerated emotional display
Temperament Hyperresponsive infantile pattern
Externally oriented for gratiﬁcation
Attachment Style PreoccupiedParental Injunction “I’ll give you attention when you do what I want.”Self-View “I need to be noticed.”World-View “Life makes me so nervous, so I’m entitled to special care
and consideration.”
Maladaptive Schemas Approval-seeking; emotional deprivation; defectivenessOptimal Diagnostic Is uncomfortable in situations in which he or she is not 
Criterion the center of attention

with speciﬁc personality-disordered individuals. Characteristic response patterns
on various objective (i.e., MMPI-2 and MCMI-III) and projective tests (i.e.,Rorschach and TAT) are also described.
Interviewing Histrionic Personality-Disordered individuals can be enjoyable but,at the same time, challenging. Initially these individuals may be more interestedin admiration and approval than in a therapeutic relationship. Rapport, therefore,may be difﬁcult to establish. Exaggerated emotionality, vagueness, superﬁciality,and phoniness are common in the ﬁrst encounter. With a male clinician, histrionicfemales may be ﬂirtatious and seductive, but with a female clinician they are morelikely to engage in a power struggle. To elicit sufﬁcient information to completea diagnostic evaluation usually requires the clinician to overcome their vaguenessand dramatic exaggerations. Open-ended and unstructured questions are not useful,since these individuals easily become sidetracked. It is preferable to pursue a maintheme, such as a work problem or an interpersonal conﬂict, and elicit concreteexamples, while curbing rambling and contradictions. Confronting contradictionstypically results in anger and loss of rapport. Instead, express empathy andencouragement. It is predictable that, when they feel empathy and understandingis slipping away, they will return to dramatization (Othmer & Othmer, 2002).
The Minnesota Multiphase Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-II), the Rorschach Psychodiagnostic Test, and theThematic Apperception Test (TAT) can be useful in diagnosing the HistrionicPersonality Disorder as well as the Histrionic Personality Style or trait (Groth-Marnat, 2009).
On the MMPI-2, the 2–3/3–2 (Depression-Hysteria) proﬁle is most
commonly found. When clinically distressed these individuals are likely to haveelevations on 2 greater than 7OT. If not, scale 3 will be more elevated. The3–4/4–3 (Hysteria-Psychopathic deviant) and 4–9/9–4 (Psychopathic Deviant-Hypermania) patterns are also noted in these individuals (Graham, 2012). Scales4, 7 (Psychasthenia), and 8 (Schizophrenia) may also be moderately elevated, withscale 4 reﬂecting their tendency to be overdramatic and self-absorbed, while self-doubt and anxiety raise the 7 score, and impulsive emotionality elevates the 8.Scale 5 is also likely to be elevated in males—but quite low in females—reﬂectingthe association of hysteria with traditional feminine role behavior (Meyer, 1995).
On the MCMI-IV, an elevation on scale 4A (Histrionic) is expected (Millon
et al., 2015). Because these individuals are attention-seekers, scales 1 (Schizoid)and 2 (Avoidant) tend to be very low, while H (Somatic symptom disorder) maybe high, since somatization can be used as an attention-getting device, as can N152 Diagnosis and Treatment of DSM-5 Personality Disorders
s can be enjoyable but,
at the same time, challenging. d these individuals may be more interested
in admiration and approval than in a therapeutic relationship.  Rapport, therefore,
may be difﬁcult to establish. Exaggerated emotionality, vagueness, superﬁciality,
and phoniness are common in the ﬁrst encounter. . With a male clinician, histrionic.
females ma y be ﬂirtatious an d seductive, but wit h a female clinician t hey are mor e
likely to engage in a power struggle. 
d contradictions. Confronting contradictions
typically results in anger and loss of rapport.

(Bipolar I disorder) (Choca & Denburg, 1997).
On the Rorschach, these individuals provide a low number of responses, as
well as a low number of W (Whole), M (Human Movement), C (Pure Color),and shading (Y, YF or T) responses. Occasionally, these individuals will give a“blood” response to a color card (Meyer, 1995).
On the TAT, these individuals typically produce stories containing dependency
and control themes. Their stories may also become personalized, generating someaffective display. Occasionally, blocking occurs on cards with sexual or aggressivepercepts. Rarely, primitive splitting may be noted in characters that are all goodor all bad on incongruous juxtapositions (Bellak, 1997).
The differential diagnosis of the Histrionic Personality Disorder includes the
Narcissistic Personality Disorder and the Dependent Personality Disorder. It alsoincludes the Histrionic-Borderline Disorder, which is a decompensated versionof the Histrionic Personality Disorder. Also, Millon (1981) describes a Histrionic-Antisocial Personality Disorder. Associated symptom diagnoses include: PersistentDepressive Disorder, Social Anxiety Disorder, and Obsessive CompulsiveDisorder. In addition, Major Depression and Bipolar disorders are common inthe decompensated Histrionic Personality Disorder.
The treatment of the Histrionic Personality Disorder may present a
considerable challenge for clinicians. For the purposes of this discussion, we willlimit ourselves to some general considerations about treatment goals, limits, andmedications. General treatment goals include helping the individual integrategentleness with strength, moderating emotional expression, and encouragingwarmth, genuineness, and empathy. Because the histrionic personality can presentas dramatic, impulsive, seductive, and manipulative with potential for suicidalgestures, the clinician needs to discuss the matter of limits early in the course oftherapy regarding professional boundaries and personal responsibilities. Somehistrionic personalities, particularly those that bear some resemblance to “hysteroiddysphoria,” may respond to certain antidepressants. Otherwise, unless a concurrentacute psychotic or major depressive episode is present, psychotherapy is theprincipal mode of treatment (Sperry, 2015).
This section will brieﬂy review the major psychotherapeutic approaches for treatingthe Histrionic Personality Disorder in an individual psychotherapy format. Latersections will describe other treatment formats, such as group therapy, couplestherapy, and pharmacotherapy. The individual treatment approaches are:Histrionic Personality Disorder 153

psychodynamic psychotherapy, cognitive-behavioral therapy, and interpersonal
psychotherapy.
Gabbard (1990) is quite optimistic about the responsiveness of higher functioningindividuals with Histrionic Personality Disorder to psychoanalytically orientedpsychotherapy. He reports that such individuals readily develop a therapeuticalliance and perceive the therapist as helpful. On the other hand, Gabbardbelieves that treatment with lower functioning individuals with this personalitydisorder should employ therapeutic strategies utilized for the BorderlinePersonality Disorder.
Winer and Pollock (1989) indicate the basic dynamic in all presentations of
the Histrionic Personality Disorder is the excessive, unresolved effort to have all
of their needs met by someone else. The general goal of dynamically oriented
therapies is to examine the origins of the pattern and explore the neuroticstrategies—seductiveness, temper tantrums, charm, or logical thinking—theseindividuals employ in order to fulﬁll their needs.
The classical psychoanalytic method emphasizes therapist neutrality and
abstinence, and requires that the patient have sufﬁcient ego strength to regressin a controlled manner. The transference that develops is analyzed with mutativeinterpretations, and presumably lends to enduring personality change. Thus, properhandling of transference, particularly erotic transference, is important. Gabbard(1990) notes that mishandling of erotic transference is probably the most frequentcause of treatment failure with these individuals. However, with more disturbedand unstable Histrionic Personality-Disordered individuals, transference distortionsrequire that resolving transference distortions by interpretation be undertaken withgreat caution. In fact, some (Havens, 1976; Khan, 1975) suggest that erotictransference not be allowed to develop too ﬁrmly or to be interpreted. Rather,counterprojective techniques are advised. These are direct or subtle, verbal ornonverbal responses which communicate to the patient that the therapist is nota transference ﬁgure of childhood (Havens, 1976).
Horowitz and Lerner (2010) have more recently identiﬁed three phases of the
psychodynamic treatment of Histrionic Personality Disorder: therapistinterventions to increase state stability and reduce crises; increasing connection
with others and eliminating obstacles to personality growth; and increasing self-
coherence and developing intimacy with a sense of integrity. Psychodynamicpsychotherapy with histrionic patients has also been examined by Fernandez (2010)
in a single-case study involving a 25-year-old female psychology student. Thistreatment, consisting of couch analysis four times per week, was deemed to be
a failure. While the patient had good capacity for insight and provided rich materialto process in sessions, she frequently missed appointments or arrived late. This154 Diagnosis and Treatment of DSM-5 Personality Disorders

manner of resistance is common for histrionic patients seeking attention, and
ultimately derailed the therapy process. O’Donohue, Fowler, and Lilienfeld(2007) note that the effectiveness of psychodynamic psychotherapy speciﬁcallyfor Histrionic Personality Disorder has not been demonstrated in controlled studies.
Brief Dynamic Psychotherapy
While long-term psychoanalytically-oriented psychotherapy is considered themainstay of dynamic treatment (Quality Assurance Project, 1991), time-limitedindividual psychotherapy may also be quite useful, particularly with higherfunctioning histrionic individuals. The approaches of Malan (1976) and Sifneos(1972, 1984) seem quite promising. The short-term-anxiety-provoking psycho -
therapy (STAPP) approach developed by Sifneos may be a particularly “good ﬁt”for higher functioning histrionic individuals who present with satisfactoryimpersonal relationships psychological mindedness, the ability to easily engageand interact with a therapist, and a circumscribed presenting complaint. On the
other hand, Mann’s (1973, 1984) time-limited approach, which requires patients
to quickly engage and disengage from therapy “without suffering unduly,” maypose considerable difﬁculty for these individuals who characteristically developintense and sticky transference with the therapist (Chodoff, 1989). Winston and
Pollack (1991) describe Brief Adaptive Psychotherapy (BAP) as particularlyeffective with histrionic individuals. BAP has an ego psychological orientation,which focuses on maladaptive patterns of beliefs and behaviors. The maladaptivepattern is thoroughly assessed as its underlying elements are explored in detail,
with particular attention on transference and resistance.
Cognitive Analytic Therapy (CAT) (Ryle, 2004) is another time-limited
model of psychodynamically oriented treatment that has been used for personalitydisorders. It consists of a narrative reformulation and the sequential diagrammaticreformulation (SDR). Patients receive 24 weekly sessions and four follow-upsessions spread out over a six-month period. Following the ﬁrst three assessment
sessions, personality patients are read a letter from the therapist that reformulates
the origins of their distress and identiﬁes target problems and procedures. In Kellet’s(2007) single-case study with a woman diagnosed with histrionic personalitydisorder, these were: the need to be noticed; pacing of relationships; focus on
physical appearance; and trust issues. The SDR was developed over the next foursessions. This is used to create therapeutic “exits” from the problem roles and
behaviors identiﬁed in the SDR. These included, among others, less self-criticism,interacting with others without wearing makeup or “provocative” clothes, and
learning to tolerate not being the center of attention. Cognitive Analytic Therapyends with a “goodbye letter” jointly formulated by the patient and therapist to
summarize achievements, prepare for future obstacles, and address any feelings
of abandonment related to the termination of therapy.Histrionic Personality Disorder 155

Cognitive Therapy Approaches
According to Beck et al. (2004), Cognitive Therapy is particularly appropriate
in treating Histrionic Personality-Disordered individuals provided they remain
in treatment. Although usually cooperative and motivated for therapy, thehistrionic’s global, diffuse thinking style is quite different from the systematic,structural nature of Cognitive Therapy. Thus, these individuals initially ﬁndtreatment difﬁcult and frustrating, as they learn to focus attention on a single issueat a time and then monitor their thoughts and feelings. There are a number ofnecessary conditions for successful cognitive treatment of this disorder. Since theseindividuals are generally dependent and demanding in relationships, their use of
collaborative and guided discovery is particularly well suited. Taking an activerole and utilizing questioning is quite helpful in stemming the histrionic
individual’s view of clinicians as rescuers and saviors. Setting limits that are clearand ﬁrm, while rewarding assertive requests within these limits and demonstratingcare in other ways, is another necessary condition of treatment. The nextcondition is establishing treatment goals. These goals must be meaningful andperceived as urgent by these individuals and be speciﬁc and concrete enough thatshort-term as well as long-term beneﬁts can become realities. This counters thehistrionic individual’s tendency to set broad, vague, noble-sounding goals. Animportant key to keeping these individuals in therapy is achieving one or moreof the speciﬁc, short-term goals that were collaboratively established.
The mainstay of treatment with these individuals involves: challenging auto -
matic thoughts; the self-monitoring of cognition, which is helpful in controllingtheir impulsivity; and the restructuring, modiﬁcation, and interpretation ofmaladaptive schemas. Challenging their most basic assumptions such as “I aminadequate and have to rely on others to survive” is aided by cognitive-behavioralmethods such as assertion, problem solving, and behavioral experiments, whichcan increase their self-efﬁcacy and help them feel more competent. Another centralbelief that must be modiﬁed is that the loss of a relationship is always disastrous.Fantasizing about the reality of what would happen if a relationship would end,and recalling how they survived before that relationship began, can help theseindividuals “decatastrophize” their beliefs about rejection. The behavioralapproach with the “controlling type” of histrionic personality (Turkat, 1990) has
not been shown to be effective (Turkat, 1990; Turkat & Maisto, 1985). The
“reactive type” is more amenable to change, speciﬁcally with empathy training.Turkat (1990) describes this intervention, which consists of social skills trainingin active listening, paraphrasing, and reﬂection. The goal is to teach these patientsto focus increasingly on others’ needs and feelings. Role-playing with videofeedback has been particularly effective. The use of dramatic behavioral experi -
ments and training in problem-solving skills are also advocated by Beck et al. (1990).
Sungar and Gunduz (2015) outline several treatment goals that may be used,
depending on individual patient needs. The ﬁrst of these is affect awareness and156 Diagnosis and Treatment of DSM-5 Personality Disorders

regulation skills. This is intended to help histrionic patients improve frustration
tolerance and learn new, more adaptive behaviors in order to reduce the frequencyof dramatic or aggressive behavior. The second possible treatment goal is toconfront fears about rejection and decatastrophize ideas about loss of approval orattention. This can be accomplished by separating the patient’s behaviors fromthe “self,” so that any criticisms are not taken as attacks to self-worth that requiredefensiveness. Sungar and Gunduz also point to the goal of social and com -
munication skills development in the treatment of Histrionic Personality Disorder.
This includes building empathy, active listening, and being a good audience
member rather than being at the center of the stage. The ﬁnal goal is increasingself-sufﬁciency, problem-solving skills, and a sense of identity without dependenceon others’ approval.
In short, effective Cognitive Therapy approach to the Histrionic Personality
Disorder will be systematic and structural—including ﬁrm limit setting andspeciﬁc treatment goals—and include cognitive (disputation of automatic thoughtsand schemas, restructuring of basic maladaptive beliefs and schemas) as well asbehavioral methods.
that has been developed by Young (Young et al., 2003) speciﬁcally for personality
disorders, and other difﬁcult individual and couples problems. Schema Therapy
involves identifying maladaptive schemas and planning speciﬁc strategies andinterventions. Four main strategies are cognitive, experiential, behavioral, and the
therapeutic relationship itself. Cognitive restructuring, modiﬁcation of maladaptive
schemas, is an important cognitive strategy, but is combined with imagery exer -
cises, empathic confrontation, homework assignments, and “limited reparenting,”i.e., a form of corrective emotional experience (Young et al., 2003).
Maladaptive schemas typically associated with Histrionic Personality Disorder
include: emotional deprivation— the belief that one’s desire for emotional support
will not be met by others; defectiveness —the belief that one is defective, bad,
unwanted, or inferior in important respects; and approval-seeking— the belief that
one must constantly seek to belong and be accepted at the expense of developinga true sense of self (Bernstein, 2002).
For Benjamin (2003b), psychotherapeutic interventions with Histrionic
Personality-Disordered individuals can be planned and evaluated in terms of
whether they enhance collaboration, facilitate learning about maladaptive patternsand their roots, block these patterns, enhance the will to change, and effectively
encourage new patterns.
Benjamin notes that to establish a therapeutic alliance facilitating collaboration
with the histrionic individual based on knowledge of the basic pattern, wishes,Histrionic Personality Disorder 157

and fears of that individual. It is essential that the therapist communicate warmth
and competent support while not reinforcing the histrionic’s dependent, needyposition. The working contract is with the individual’s observing ego, while the“enemy” is the damaging pattern. A major task of beginning treatment istransforming the histrionic’s view of treatment as making fantasies come true toa place where personal development can be facilitated. Thus, treatmentinterventions can be evaluated on the basis of whether or not they accomplishthis. If an intervention results in more demanding dependency, then it has failedto achieve the aforementioned goals.
Facilitating collaboration with the histrionic patient is no easy task. Gender
dynamics can play a particularly important role. For example, female therapistsmay have difﬁculty communicating the accepting warmth and support so desired
by the female histrionic patient because of the latter’s dim view of the therapist’s
competence. Male therapists will have an easier time establishing the therapeuticcontract—at least at ﬁrst. Regardless of gender, therapists must be clear in theirboundaries and intentions for their relationship with the histrionic patient. Thetherapy relationship is for the needs and learning of the patient, not the therapist.Benjamin notes it should be clear that the therapist’s salary or fees are enough tomeet his or her needs in this relationship, and that it is not a social relationship.
This challenges the marriage fantasy commonly held by histrionic patients.
The task of learning to recognize patterns is complicated in that histrionic
individuals have not sufﬁciently developed an observing ego to help them to
recognize and reﬂect on patterns. In fact, they’ve come to believe that if they
become competent, they would be left alone and no one would care for them.Establishing stability is tantamount to losing their identity. While the femalehistrionic can internalize the female clinician’s modeling of benign and
constructive examination of patterns, the male clinician must help the individual
look at her fears that if she becomes competent the clinician will conclude thatshe is unattractive and stop treatment.
Next, the clinician focuses the histrionic individual’s attention on potentially
destructive patterns of acting out based on underlying fears and wishes. Byproviding gentle challenges, the clinician protects these individuals from their ownpast. The goal is to expand options and enhance awareness in light of what is
being learned about patterns. The therapist doesn’t block patterns with advice
giving as much as reviewing options. Developing the will to change patterns isenhanced if these patterns can be uncovered and clearly connected in an
experiential way to the past. This often facilitates the individual’s “decision” to
give up the goals that drive the patterns. Finally, Benjamin advocates traditionaltechniques from other approaches that can be utilized to build new patterns andways of functioning, once the “unconscious underbrush” has been cleared away.
Warmth, active listening, and support, are keys to successful therapy. The
therapist must remain a loyal and optimistic ally in treatment.158 Diagnosis and Treatment of DSM-5 Personality Disorders
It is essential that the therapist communicate warmth
and competent support w hile not rein forcing t he histrionic’s dependent, nee dy
position. 
r therapists must be clear in their
boundaries and intentions for their relationship with the histrionic patient.

The literature on the histrionic personality is quite interesting with regard to
treatability of this disorder in group settings. There are clear warnings in the olderpsychoanalytic literature about the impact of these patients on other groupmembers. Slavson (1939) cautioned that their changeability and unpredictabilitywould engender stress and anxiety in a group. Thus, he believed these patientsshould be treated only in individual therapy. On the other hand, contemporaryclinicians like Gabbard (1990, 1994) contend that histrionic patients who areappropriate for individual dynamic psychotherapy are also appropriate for dynamicgroup psychotherapy. In fact, Gabbard ﬁnds these patients are highly valued byother group members for their ability to express affects directly, and because oftheir concern for other group members. Rutan, Stone, and Shay (2014) provide
a detailed analysis of a mixed diagnosis psychodynamic therapy group with ahistrionic member. They draw attention to the strong negative reactions theseindividuals can have on the group facilitator and fellow members, as well as the
beneﬁts of having the histrionic patient’s honesty.
The group treatment format has a number of advantages over individual
treatment. First, a group setting frustrates the wish and demand these patientshave for the exclusive attention of the therapist which now must be undeniablyinevitably challenge the approval-seeking posture of these patients. Thus, the riskof an eroticized transference developing is relatively small in contrast withindividual therapy.
Second, their global cognitive style and associated defenses of repression and
denial can be more effectively treated in a group setting. Group members willconfront the distorted manner in which histrionic patients view themselves and
others by their style, omission of details, and focus on affects over thought.
Finally, histrionic patterns tend to form positive maternal transference and
expect the group to make up for the maternal nurturance they missed as children(Gabbard, 1990). While this transference is particularly challenging for the clini -
cian in individual therapy, it is considerably “diluted” in a group treatment format.
Relatively little has been published about the effectiveness of group treatment
of histrionic patients. But one study is encouraging. Cass, Silvers, and Abrams(1972) reported a behavioral group treatment that signiﬁcantly modiﬁedinappropriate passivity, manipulativeness, and acting out, replaced by moreeffective assertive interpersonal behavior.
The question of indication and contraindication has been addressed by some
writers. Halleck (1978) notes that histrionic patients who cannot participate in agroup process without monopolizing or disrupting it should be excluded.Similarly, Gabbard (1990) cautions that individuals might still be candidates forgroup therapy if they are concurrently in individual psychotherapy. Scheidlingerand Porter (1980) indicate that combined treatment—individual plus group
therapy—may be the treatment of choice for such histrionic patients.Histrionic Personality Disorder 159

There are no reports of family therapy, per se, with histrionic patients. However,
there are a number of case reports on marital therapy with these patients. Typi -
cally, the marriage consists of an obsessive-compulsive husband and a histrionicwife, wherein the obsessive-compulsive spouse tends to assume increasingresponsibility while the histrionic spouse becomes increasingly helpless (Berman,1983). Treatment may be sought following some primitive outburst, which can
include some threat of self-destructive behavior, typically during separation or
divorce. The loss of a stable dependent ﬁgure is a major stressor for the histrionic
patient, who may exhibit aggressive attention-seeking behavior, increased affectivedisplay and seductiveness, and/or possibly promiscuity, in an effort to make theother spouse jealous, etc. (Harbir, 1981).
The general goal of treatment is to facilitate changing this pattern in both
spouses. This is better accomplished in a couple’s therapy format rather than inindividual session. Harbir (1981) offers a treatment protocol for couples whereindivorce and child custody are issues.
Nichols (1996) describes the interactional patterns and symptomatology of
individuals with Histrionic Personality Disorder and Antisocial PersonalityDisorder in close interpersonal relationships as well as a suggested treatment planprotocol and strategies for dealing with such couples in a therapeutic context.
An integrative marital therapy approach involving dynamic, cognitive-
behavioral, and systemic interventions is described by Sperry and Maniacci (1996)for couples in which one partner presents with Histrionic Personality Disorderand the other with Obsessive-Compulsive Personality Disorder. Three phases ofthe treatment process are discussed and illustrated: establishing a therapeutic alliance,
restoring balance to the couple relationship, and modifying individual partner
dynamics. The ﬁrst two phases involve conjoint couples sessions, while much ofthe third phase involves individual sessions (Sperry & Maniacci, 1996).
Links, Stockwell, and McFarlane (2004a) point to the apparent paradox of the
histrionic/obsessive-compulsive couple. Despite the fact that they demonstrate
healthier personality styles compared to other personality disorders, they are oftenmore difﬁcult to engage in treatment than those with more severe forms ofpsychopathology. This paradox is explained by these individuals’ particular
attachment styles. Couples with histrionic/obsessive-compulsive styles are ableto form attachment relationships; however, when their attachment needs are left
unsatisﬁed, they look for compromises or alternatives that can be damaging tothe relationship. These include leaving the relationship for another individual orforming triangulated relationship with a third party to maintain stability. Becauseof these additional options, these individuals may present as more ambivalent aboutcouples therapy or change. As such, the authors point to the importance ofevaluating these possibilities when determining the appropriateness of couple’s
therapy. The speciﬁc style of the histrionic/obsessive-compulsive couple are further160 Diagnosis and Treatment of DSM-5 Personality Disorders

illustrated by Landucci and Foley (2014). Couples of this composition are polar
opposites: spontaneous vs. controlled; vague vs. detailed and rational. These twoindividuals are said to form one full person when taken together, so it is notsurprising that there is often an instant attraction between these opposites.However, these dramatic differences are also the source of conﬂict. Couplestherapists should normalize the belief that the other partner is “crazy” by discussingthese dynamics.
Generally speaking, there are no psychotropic medications speciﬁcally indicatedfor treating individuals with Histrionic Personality Disorder (Silk & Feurino, 2012).Histrionic Personality-Disordered individuals may exhibit anxiety disorders,depressive disorders, or somatoform symptoms. Nevertheless, medications are usedthat target speciﬁc troubling symptoms associated with the disorder, such asdepression, anxiety, or sleep problems. Generally, these medications are used asan adjunct to psychotherapy and skills training. Because troubling symptoms oftenrespond to medications sooner than most psychological interventions, medicationsare usually prescribed at the onset of treatment (Sperry, 1995b). Unfortunately,there is little research evidence to provide guidelines for the use of suchmedications (Silk & Feurino, 2012). However, there appears to be an exception.One variant of the histrionic personalities, called “hysteroid dysphoria,” hasresponded to certain antidepressant agents, speciﬁcally Parnate and Nardil(Liebowitz & Klein, 1981).
Combined/Integrative Treatment Approach
The basic premise of the book is that symptomatic and lower functioningpersonality disordered individuals are less likely to respond to single treatmentapproach or modality. Since personality disorders are biopsychosocial phenomena(Pies, 1992), combined or integrative, tailored treatment is indicated, particularlyfor the more symptomatic and severe presentations. Stone (1993) advocatescombined treatments, wherein two or more approaches or modalities are utilizedconcurrently or in tandem.
Previously, it was mentioned that combining individual psychotherapy with
group therapy concurrently was indicated for histrionic patients who monopolizedor were disruptive in group settings (Scheidlinger & Porter, 1980). It has alsobeen noted that behavioral techniques may be integrated with psychodynamicor a cognitive approach. Finally, medications may be a useful adjunct topsychotherapy, either concurrently or in tandem, if speciﬁc Axis I or Axis IIsymptoms or trait clusters are prominent.
Horowitz (1997) discusses guidelines for the psychotherapeutic treatment for
the Histrionic Personality Disorder that integrates cognitive and psychodynamicHistrionic Personality Disorder 161
depression, anxiety, or sleep problems.

principles and methods. This personality disorder is formulated in terms of levels:
states of mind, defensive control processes, and schemas. A phase-oriented treat -
ment plan is linked to these three formulation levels. Speciﬁc psycho therapeutic
guidelines for each of these phases are described.
Dorfman (2000) provides a case study with a 49-year-old histrionic woman
who sought treatment for severe depression, anxiety, and problems with herboyfriend. The time-limited nature of the treatment included elements from acombination of models with three speciﬁc treatment goals. First, the therapistdealt with acute emotional distress by developing a supportive and empathictherapeutic relationship to help the patient contain and modulate her emotions.Second, a combination of cognitive challenges, communication skills training,and insight-oriented interpretations of the patient’s childhood addressed herdistorted self-concept and maladaptive style. Finally, the treatment focused ondeveloping the conﬁdence necessary to resume appropriate functioning at workand achieve some degree of independence.162 Diagnosis and Treatment of DSM-5 Personality Disorders

8
NARCISSISTIC PERSONALITY 
DISORDER
Individuals with narcissistic personalities tend to be grandiose, entitled, and self-
centered. They are often impulsive and anxious, have ideas of grandiosity and“specialness,” become quickly dissatisﬁed with others, and maintain superﬁcial,exploitative interpersonal relationships (Ronningstam, 2012). While treatment ofsuch individuals involves a number of unique therapeutic challenges, it can behighly effective and successful.
Description of the Narcissistic Personality Disorder
The Narcissistic Personality Disorder can be recognized by the following descrip -
tors and characteristics: style vs. disorder, triggering event(s), behavioral style,
interpersonal style, cognitive style, affective style, attachment style, and optimaldiagnostic criterion.
Style vs. Disorder . The narcissistic personality is quite common in western
culture particularly among certain occupations and professions such as law,medicine, entertainment and sports, and politics. The narcissistic personality can

164 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 8.1 Comparison of Narcissistic Personality Style and Disorder
Although emotionally vulnerable to Reacts to criticism with feelings of 
negative assessments and reaction of rage, stress, or humiliation (even if not others, they can handle these gracefully. expressed).
Shrewd in dealing with others, utilizing Interpersonally exploitive, taking 
the strengths and advantages of others advantage of others to achieve his or to achieve their own goals. her own ends.
Can energetically sell themselves, their Grandiose sense of self-importance.
ideas, and their projects.
Tend to be able competitors who love Believe their problems are unique and
getting to the top and enjoy staying understood only by other special there. people.
Can visualize themselves as the best or Preoccupied by fantasies of unlimited 
most accomplished in their ﬁeld. success, power, brilliance, beauty, or 
ideal love.
They believe in themselves, their abilities, Have a sense of entitlement and 
and their uniqueness, but do not demand unreasonable expectations of especially special treatment or privilege. favorable treatment.
Accept accomplishments, praise, and Require constant attention and 
admiration gracefully and with self- admiration.possession.
Possess a keen awareness of their thoughts Lack of empathy; inability to recognize 
and feelings, and have some awareness and experience how others feel.of those of others.
Expect others to treat them well at Preoccupied with feelings of envy.
all times.be thought of as spanning a continuum from healthy to the pathological, with
the narcissistic personality style on the healthy end and the personality disorderon the pathological end. Table 8.1  compares and contrasts differences between
the narcissistic style and disorder.
The following two case examples illustrate the differences between the
Narcissistic Personality Disorder—Mr. C.—and the narcissistic personality style—Mr. J.
Although DSM-5 only describes one type or presentation of the Narcissistic
Personality Disorder, research describes three types: overt, covert, and themalignant (Caligor, Levy, & Yeomans, 2015). All three types are highly self-absorbed and have little genuine regard for the needs or feelings of others.
Overt Type. This type presents as grandiose and thick-skinned and is the
embodiment of DSM-5 criteria. These individuals are characterized by overt

Narcissistic Personality Disorder 165
CASE STUDY: NARCISSISTIC PERSONALITY DISORDER
Mr. C. is a 41-year-old male who presented for therapy after his wife of six
years threatened to leave him and because his employer was pressuring himto resign his position as a sales executive for a condominium project.
Apparently, Mrs. C. had told her husband that he loved himself “a hundred
times more than you love me.” Mr. C. dismissed this by saying he neededto buy $600 suits because his job demanded that he look his best at all timesand that he was “tall, dark, handsome, and sexy—all any woman could want
in a man.” Mr. C. denied that he used scare tactics, exaggerated claims, or
other pressure-selling techniques with customers. “Sure, I’m a bit aggressive,but you don’t get into the ‘Millionaire’s Club’ by being a wimp.” He addedthat his employer would “go belly-up without me,” and that he was too
important to be dismissed for such petty reasons.
CASE STUDY: NARCISSISTIC PERSONALITY STYLE
Mr. J. is chairman of his state’s democratic party and caucus. Throughout
most of his career, he had been incredibly successful and effective. He isextroverted, witty, and charming interpersonally, and astute, visionary, and
effective in mobilizing support for his party’s political agenda. However, in
graduate school a political science professor had criticized a ﬁrst draft of hisMaster’s thesis, evaluating his arguments as weak and conclusions onlypartially substantiated by the research cited. Prior to this, he had held the
professor in high esteem, but questioned the professor’s competence after
this criticism. Nevertheless, he swallowed his pride and reworked the thesisaccording to the professor’s suggestion and graduated. A short time aftergraduation, Mr. J. lost his ﬁrst job as a speech writer for a state senator because
the opinions and conclusions cited in his drafts were not sufﬁciently well
documented. Fortunately, Mr. J. took these lessons to heart and foundothers to research his own speeches when he ran for ofﬁce. Mr. J. recognizedthat this was not one of his strengths and could delegate it while focusing
on his real strengths, which were envisioning policy and political agendas
and galvanizing support for them.

grandiosity, attention-seeking, entitlement, arrogance, and little observable
anxiety. They can be socially charming, despite being oblivious to the needs ofothers, and are interpersonally exploitative. The problem is that they have a fragilesense of self that is predicated on maintaining a self-view that they are exceptional.Because genuine engagement can result in the painful realization that others haveattributes that they lack, these individuals engage in superﬁcial relationships andseek out external feedback that supports this grandiose self-deﬁnition (Levy, 2012).
Covert Type. This type presents as vulnerable, “fragile” and thin-skinned. These
individuals are characterized as inhibited, manifestly distressed, hypersensitive tothe evaluations of others, while chronically envious and evaluating themselves inrelation to others. Interpersonally they tend to be shy, outwardly self-effacing,and hypersensitive to slights, but are covertly or secretly grandiose and jealous.Unlike the overt type, these tend to withdraw from social situations (Levy, 2012).
Malignant Type . This type is also referred to as “malignant narcissism”
(Kernberg, 1984). These individuals are characterized by the typical symptomsof Narcissistic Personality Disorder, as well as prominent antisocial behavior,paranoid features, and sadism toward others. They may engage in chronic lying,intimidation, and ﬁnancial or interpersonal secondary gains which maintain theirmalignant pattern (Caligor et al., 2015).
likely triggers or activates the characteristic maladaptive response of the NarcissisticPersonality Disorder (Othmer & Othmer, 2002), as noted in behavioral,interpersonal, cognitive, and affective styles, is: “evaluation of self.”
Behavioral Style . Behaviorally, narcissistic individuals are seen as conceited,
boastful, and snobbish. They appear self-assured and self-centered, and they tendto dominate conversation, seek admiration, and act in a pompous and exhibition -
istic fashion. They are also impatient, arrogant, and thin-skinned or hypersensitive.
Interpersonal Style . Interpersonally, they are exploitive and use others to
indulge themselves and their desires. Their behavior is socially facile, pleasant,and endearing. However, they are unable to respond with true empathy to others.When stressed, they can be disdainful, exploitive, and generally irresponsible intheir behavior.
Cognitive Style . Their thinking style is one of cognitive expansiveness and
exaggeration. They tend to focus on images and themes rather than on facts andissues. In fact, they take liberties with the facts, distort them, and even engagein prevarication and self-deception to preserve their own illusions aboutthemselves and the projects in which they are involved. Their cognitive style isalso marked by inﬂexibility. In addition, they have an exaggerated sense of self-importance and establish unrealistic goals of power, wealth, and ability. They justifyall of this with their sense of entitlement and exaggerated sense of their own self-importance.
Affective Style . Their emotional or affective style is characterized by an aura
of self-conﬁdence and nonchalance, which is present in most situations except166 Diagnosis and Treatment of DSM-5 Personality Disorders

when their narcissistic conﬁdence is shaken. Then they are likely to respond with
rage at criticism. Their feelings toward others shift and vacillate between over -
idealization and devaluation. Finally, their inability to show empathy is reﬂectedin their superﬁcial relationships, with minimal emotional ties or commitments.
self-view that vacillates between positive and negative exhibit a composite fearful-
dismissing style of attachment. They tend to view themselves as special and entitled,but are also mindful of their need for others who can potentially hurt them.
Accordingly, they use others to meet their needs while being wary and dismissive
of them. The fearful-dismissing attachment style is common in individuals withthis disorder.
Antisocial Personality Disorder, one has been found to be the most useful in
diagnosing this disorder. The belief is that, by beginning with this criterion, theclinician can test for the presence or absence of the criterion and more quicklydiagnose the personality disorder (Allnutt & Links, 1996). The optimal criterionfor this disorder is: has a grandiose sense of self-importance.
Individuals with this personality disorder are characterized by an unremittingpattern of self-centeredness and grandiosity. More speciﬁcally, they have anexaggerated sense of their own abilities and achievements. They may have a
constant need for attention, afﬁrmation, and praise. Typically, they believe they
are unique or special and should only associate with others of the same status.They are likely to have persistent fantasies about attaining success and power.These individuals can exploit others for personal gain. A sense of entitlement andthe expectation of special treatment are common. They may come across assnobbish or arrogant. They appear to be incapable of showing empathy for others.In addition, they can be envious or think that others are envious of them (American
Psychiatric Association, 2013).
The “Alternative DSM-5 Model for Personality Disorders”—in Section III—
better reﬂects the emerging research on Narcissistic Personality Disorder(Ronningstam, 2011). The updated deﬁnition of Narcissistic Personality Disorder
includes “variable and vulnerable self-esteem, with attempts at regulation through
attention and approval seeking, and either overt or covert grandiosity” (AmericanPsychiatric Association, 2013, p. 767). This deﬁnition includes additional styles
of narcissism that were not in DSM-IV-TR. In Section III of the DSM-5,
vulnerability of self-esteem is now emphasized as a core feature of NarcissisticPersonality Disorder and recognizes the covert type. In contrast, Section II ofthe DSM-5 emphasizes the dimension of grandiosity and only includes the overttype.Narcissistic Personality Disorder 167

disorder commonly presents. Prototypic descriptions are useful and convenientand clinicians commonly rely on them rather than lists of behavioral criteria orcore beliefs (Westen, 2012). Here is a common prototypic description of theNarcissistic Personality Disorder: These individuals are the center of their worlds.They believe and act as if they are special in every way. They can be showoffsand name-droppers. Without a doubt, they are legends in their own minds. There
is no limit to their sense of self-importance and entitlement. They are haughty,
high-handed, and superior, and expect others to show deference and admiration.They seldom recognize the needs, concerns, or feelings of others. Not surprisingly,they experience disappointments and anger when others fail to live up to their
highly unrealistic expectations (Francie, 2013).
Prevalence of this disorder has been estimated at between 0.6 and 6.2 percent of
the general population (American Psychiatric Association, 2013). In clinicalsettings, estimates are that it is found in 2.3 to 35.7 percent of patients (Torgersen,2012).
Table 8.2  summarizes the characteristics of this disorder.
Conceptualizations of the Narcissistic Personality Disorder
Freud (1914/1976) described the original psychoanalytic formulation of narcissistic
personality. For Freud, parental overevaluation or erratic, unreliable caretakingin early life were factors disrupting the development of object love in the child
providing. As a result of this ﬁxation or arrest at the narcissistic phase of
development, Freud posited that narcissists would be unable to form lastingrelationships. In other words, the etiology of the Narcissistic Personality Disorderis that it is the outcome of insufﬁcient gratiﬁcation of the normal narcissistic needsof infancy and childhood. The contrary hypothesis is that the disorder stems fromnarcissistic overgratiﬁcation during childhood and, because of this ﬁxation,interferes with the normal maturation and integration of the superego, leadingto difﬁculties in regulation of self-esteem (Fernando, 1998). Another commonbelief is that the disorder arises from faulty parenting or disturbed object relations.
Imbesi (2000) suggests this hypothesis is the common etiology of most personality
disorders and instead proposes that the caretaker’s failure to provide optimalfrustrating experiences necessary to foster the development of a more realisticself-image in the child is the etiology of the narcissistic personality.168 Diagnosis and Treatment of DSM-5 Personality Disorders

In the past two decades the formulations of the narcissistic personality by Kohut
and Kernberg have become the dominant models. Kohut (1971, 1977) believedthe narcissistic is developmentally arrested at the stage which requires speciﬁc
responses from individuals in their environment to maintain cohesive selves, i.e.,the structures of the grandiose self and the idealized parental image are not
integrated. He described the formulation of self-object transferences—bothmirroring and idealizing—that recreate the situation with parents that was not
fully successful during childhood. When such responses are not forthcoming (anempathic deﬁcit), the narcissistic is prone to fragmentation of the self (narcissistic
injury).Narcissistic Personality Disorder 169
TABLE 8.2 Characteristics of Narcissistic Personality Disorder
Triggering Event(s) Evaluation of self
Behavioral Style Sense of entitlement
Arrogant, thin-skinnedSelf-assured and pompous
Interpersonal Style Requires excessive admiration
Lacks empathy
Envies or feels envied
Arrogant and haughtyExploits others
Cognitive Style Cognitive expansiveness and exaggeration
Takes liberties with factsImpatient, persistent, and inﬂexible
Affective Style Self-conﬁdent
Narcissistic rage
Temperament Active and responsive
Special talents and early language development
Parental Injunction “Grow up and be wonderful, for me.”
Self-View “I’m special and unique, and I’m entitled to extraordinary
rights and privileges whether I’ve earned them or not.”
World-View “Life is a banquet table to be sampled at will. People owe
me admiration and privilege. Therefore, I’ll expect anddemand this specialness.”
Maladaptive Schemas Entitlement; defectiveness; emotional deprivation;
insufﬁcient self-control; unrelenting standards
Optimal Diagnostic Has grandiose sense of self-importance
Criterion

Unlike Kohut, who worked with high functioning professionals in
psychoanalysis, Kernberg (1975, 1984) based his conceptualization of narcissisticpathology on his work with inpatients as well as outpatients. He views thenarcissist’s grandiosity and exploitation as evidence of oral rage, which he believesresults from the emotional deprivation caused by an indifferent and covertly spiteful
mother ﬁgure. Concurrently, some unique attribute, talent, or role provides the
child with a sense of being special, which provides an emotional escape valve in
a world of perceived threat or indifference. Thus, grandiosity and entitlement
shelter a “real self” that is “split off,” i.e., outside consciousness. Parenthetically
for Kernberg, the real self contains strong but unconscious feelings of envy,deprivation, fear, and rage. Finally, Kernberg (1975) views the defensive structure
of the narcissist as remarkably similar to the borderline, differentiating the twoon the basis of their integrated but pathological grandiose self.
According to Millon and Everly (1985), the Narcissistic Personality Disorderprimarily arises from environment factors, since the role of biogenic factors is
unclear. The principal environmental factors are parental indulgence and
overvaluation, learned exploitive behavior, and only-child status. Essentially then,
children are pampered and given special treatment by the parents such that they
learn to believe the world revolves around them. They become egotistical in their
perspectives and narcissistic in their expressions of love and emotion. Notsurprisingly, they come to expect special treatment from others outside the home.
When special treatment is not forthcoming, the children experiment with
demanding and exploitive tactics and subsequently develop considerable skill in
manipulating others so as to receive the special consideration they believe they
deserve. At the same time they come to believe that most others are inferior,weak, and exploitable. Furthermore, Millon (Millon & Davis, 2000; Millon &Everly, 1985) indicate that parental overindulgence is particularly likely with onlychildren. Finally, the narcissistic pattern is self-perpetuated through their illusionof their superiority, a lack of self-control manifested by their disdain for situationsand persons that do not support their exalted beliefs, deﬁcient social responsibility,
and the self-reinforcement of the narcissistic pattern itself.
According to Beck (2015), the key feature of this disorder is self-aggrandizement.
Individuals with this disorder can be characterized by speciﬁc core, conditional,
and instrumental beliefs. Their core beliefs include deserving special treatment and
dispensations because of their specialness. They also include believing that theyare not bound by the rules and social conventions that govern others. Their170 Diagnosis and Treatment of DSM-5 Personality Disorders

conditional beliefs are that others should be punished if they do not recognize their
special status, and that to maintain their special status others must be subservientto them. Their instrumental belief is to continually strive to demonstrate their
superiority. Underlying these various beliefs are their beliefs about self and theworld. These individuals tend to view themselves as special, superior, entitled tospecial favors and treatment, and vulnerable to loss of status. They view othersas inferior but also potential admirers, who recognize their superiority andgrandiosity. Not surprisingly, such beliefs are reﬂected in their main strategy or pattern of seeking prestige, power, position, and wealth as a way of reinforcingtheir image of superiority. If necessary, they will use manipulation and guile toachieve these goals (Beck, 2015; Behary & Davis, 2015).
Speciﬁc schemas characterize this disorder. The central schema is the
superior/special schema which develops from direct and indirect messages fromparents, siblings, and signiﬁcant others as well as by experiences that mold beliefsabout personal uniqueness and self-importance. The schema of being superiorcan be shaped by ﬂattery, indulgence, and favoritism. Similarly, the schema ofbeing special can be shaped by experiences of rejection, limitations, exclusion,or deﬁcits. The common denominator for such beliefs about self is that theindividual perceives himself or herself as different from others in signiﬁcant ways(Behary & Davis, 2015).
Taking a more behavioral tack, Turkat (1990), differentiates this disorder into
three types: the self-centered impulsive type, the ruthless impression-managementtype, and the acceptance-oriented impression-management type. Of these, heconsiders the last type to have the best therapeutic prognosis. Nevertheless, heformulates each type as behavioral manifestations of an impulse control deﬁcitthat is learned in early childhood. Speciﬁcally, these individuals learned to seekreinforcers without having to work for them. This resulted in their developmentas self-indulgent, egocentric, and impulsive individuals. Individuals with the secondand third types focus on creating a favorable impression on others. However,they are unable to maintain close relationships because, while they have excellentskills at reading superﬁcial cues, they have empathic deﬁcits (Turkat, 1990).
For Benjamin (2003a), a person with Narcissistic Personality Disorder typicallywas raised in an environment of selﬂess not contingent love and adoration.Unfortunately this adoration was not accompanied by genuine self-disclosure. Asa result the Narcissistic-Personality-Disorder-to-be learned to be insensitive toothers’ needs and views. The adoring parent is likely to have been consistentlydifferential and nurturant to the narcissistic-in-training. As a result, the adultnarcissist held the arrogant expectation that others will continue to provide theseemotional supplies. Along with this nurturance and adoration is the ever-presentthreat of a fall from grace. As such the narcissistic individual who is simply “normal”Narcissistic Personality Disorder 171

and ordinary creates unbearable disappointment for the parent(s). Thus, the
burden of being special or perfect can be overwhelming for the narcissisticindividual. Since this individual’s self-concept derives from an internalization ofunrealistic adoration and nurturance, the substitution of criticism or disappoint -
ment for love can be particularly devastating. Thus, the narcissistically-disorderedindividual can “dish it out,” but is not well-equipped to “take it.” In short, there
is extreme vulnerability to criticism or being ignored, together with a strong 
wish for love, support, and admiration from others. Noncontingent love and 
pre sumptive control of others is expected and even demanded. If support is
withdrawn, or lack of perfection is evident, the self-concept degrades into severeself-criticism. Totally devoid of empathy, these individuals tend to treat others
with contempt and rage if their demand for entitlement fails.
The following integrative formulation provides a biopsychosocial explanation forhow this personality is likely to have developed and how it is maintained.Biologically narcissistic personalities tend to have hyperresponsive temperaments
(Millon, 1981). As young children they were viewed by others as being special
in terms of looks, talents, or “promise.” Often as young children they had early
and exceptional speech development. In addition, they were likely keenly aware
of interpersonal cues.
Psychologically, the narcissists’ view of themselves, others, the world, and life’s
purpose can be articulated in terms of the following themes: “I’m special and
unique, and I am entitled to extraordinary rights and privileges whether I have
earned them or not.” Their world-view is a variant of the theme “Life is a banquet
table to be sampled at will. People owe me admiration and privilege.” Their goal
is “Therefore, I’ll expect and demand this specialness.” Common defensemechanisms utilized by the narcissistic personality involve rationalization andprojective identiﬁcation.
Socially, predictable parental patterns and environmental factors can be noted
for the narcissistic personality. Parental indulgence and overevaluation characterize
the narcissistic personality. The parental injunction was likely: “Grow up and bewonderful—for me.” Often they were only children, and, in addition, may havesustained early losses in childhood. From an early age they learned exploitive andmanipulative behavior from their parents. This narcissistic pattern is conﬁrmed,
reinforced, and perpetuated by certain individual and systems factors. The illusion
of specialness, disdain for others’ views, and a sense of entitlement lead to anunderdeveloped sense of social interest and responsibility. This, in turn, leads to
increased self-absorption and conﬁrmation of narcissistic beliefs (Sperry, 2015;
Sperry & Mosak, 1996).172 Diagnosis and Treatment of DSM-5 Personality Disorders

Assessment of Narcissistic Personality Disorder
logical testing are important adjuncts to the patient’s self-report in the clinicalinterview. This section brieﬂy describes some characteristic observations that theclinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e. MMPI-2 and MCMI-IV) and projective tests (i.e.,Rorschach and TAT) are also described.
Interviewing Narcissistic Personality-Disordered individuals is singularly differentthan interviewing other personality-disordered individuals. Throughout theinterview, these individuals give clinicians the impression that the interview hasonly one purpose: to endorse their self-promoted importance (Othmer & Othmer,2002). These individuals typically present as self-assured, pretentious, andunwilling to adapt to the basic cultural differences customary to the patient role.They behave as though they are indifferent to the clinician’s perspective. As longas the clinician plays the expected role, they are idealized as a marvelous clinician.However, confronting their grandiosity early in the treatment process willinevitably lead to rage and possibly premature termination. They prefer open-ended questions, which permit them extended descriptions of their many talents,accomplishments, and future plans. Rapport is established after a considerableperiod of mirroring and soothing. Typical clinician countertransferences in theinitial interviews are boredom, frustration, and anger. To the extent the cliniciancan patiently wait through this period of mirroring, the work of confronting andinterpreting the grandiosity of the disordered individual can begin.
This section describes typical themes and patterns noted for the narcissisticpersonality on the Minnesota Multiphasic Personality Inventory (MMPI-2), theMillon Clinical Multiaxial Inventory (MCMI-IV), the Rorschach Psycho -
diagnostic Test, and the Thematic Apperception Test (TAT). This data has beenuseful in diagnosing the Narcissistic Personality Disorder as well as the narcissisticpersonality style or trait.
On the MMPI-2, a 4–9 (Psychopathic Deviant-Hypomania) proﬁle or an
elevation on scale 4 is most likely. Since they develop only superﬁcial relationships,a low score on 0 (Social Introversion) might also be noted (Graham, 2012). And,since they often ﬁt stereotypic sexual roles, scale 5 (Masculinity-Femininity) maybe low particularly in narcissistic males. If they also tend to be suspicious or irritable,an elevation on scale 6 (Paranoia) may be noted (Meyer, 1995).Narcissistic Personality Disorder 173

On the MCMI-IV, elevation on scale 5 (Narcissistic) is expected. Scales 4A
(Histrionic), 6A (Antisocial), and 6B (Sadistic) could also be elevated. Duringperiods of stress, elevations on P (Paranoid) and PP (Delusional Disorder) maybe noted. Since these individuals are averse to admitting psychic distress or personalweakness, elevations on scales A (Generalized Anxiety Disorder) and D(Dysthymia disorder) and S (Schizotypal) are not likely (Choca & Denburg, 1997).
On the Rorschach, these individuals are likely to produce records with a high
number of C (Pure Color) and CF (Color Form) responses. They seldom responddirectly to Shading (Y, YF, or FY) but often make texture (T, TF, or FT)responses. Responses that reﬂect the ornate, the exotic, or the expensive are charac -
teristics of narcissism (Shafer, 1954).
On the TAT, these individuals tend to avoid the essential features of the cards
and thus their stories may be void of meaningful content. Cards that demand aresponse to potentially anxiety-producing fantasy, such as 13 MF, may yield asuperﬁcially avoidant story or are with blatant shocking or lewd content (Bellak,1997).
Included in the differential diagnosis of the Narcissistic Personality Disorder are
the following personality disorders: Histrionic Personality Disorder, AntisocialPersonality Disorder, and Paranoid Personality Disorder. The most commonconcurrent symptom disorders are Anxiety Disorders, Persistent DepressiveDisorder, Somatic Symptom Disorders, and Delusional Disorders.
The efﬁcacy of psychotherapeutic and psychopharmacological treatment
approaches for Narcissistic Personality Disorder has not been systematically orempirically investigated (Caligor et al., 2015). Clinical practice guidelines for thedisorder have yet to be formulated, and psychopharmacological intervention isoften symptom-driven. Regardless of severity, the grandiosity and defensivenessthat characterize Narcissistic Personality Disorder make engagement in any formof psychotherapy difﬁcult (Ronningstam, 2011).
Treatment recommendations for the narcissistic personality are currently based
on clinical experience and theoretical formulations (Caligor et al., 2015). In theabsence of empirically supported treatments for this disorder, it is commonpractice to utilize efﬁcacious treatments for similar disorders, typically withtreatment modiﬁcations based on theoretical and clinical rationales regardingdifferences in the disorders (Levy, 2012). These include empirically supportedtreatments for Borderline Personality Disorder that have adaptations for narcissisticpersonality such as mentalization-based therapy (Allen & Fonagy, 2006),transference-focused psychotherapy (Stern, Yeomans, & Diamond, 2012), andschema-focused psychotherapy (Young et al., 2003). All three treatments target174 Diagnosis and Treatment of DSM-5 Personality Disorders

psychological capacities thought to underlie and organize descriptive features of
Narcissistic Personality Disorder. Dialectical behavioral therapy (Linehan, 2015)is another option for those with signiﬁcant self-destructive behaviors.
Alone, or in conjunction with group or marital and family therapy, individualpsychotherapy is viewed by many as the basic treatment of choice for individualswith Narcissistic Personality Disorder. Indeed, some have agued that this disorderand psychotherapy itself are both products of the modern world’s intense focuson the self (Lasch, 1991). Because of their empathic deﬁcit and proclivity to devalueothers, psychotherapy with these individuals can be very trying: giving little,treating others shabbily, and demanding much tends to frustrate the naturalinclination of therapists to respond empathically. And, although the literature isdivided over whether to utilize either confrontation or mirroring techniques, bothapproaches must be part of the therapist’s armamentarium. Generally speaking,higher functioning narcissistic personalities eventually do well in psychotherapy,as their sense of entitlement gives way to emulation. On the other hand, lowerfunctioning narcissistic personalities have fewer of the necessary personality assetsand relational skills for changing, and unless the therapeutic process addresses thesedeﬁcits, these individuals may predictably leave treatment precipitously to avoidthe humiliation of admitting how ill-equipped they are to achieve realistictreatment goals. Psychodynamic, cognitive behavioral, and interpersonalapproaches are brieﬂy described.
This section will brieﬂy outline the various psychodynamic approaches: psycho -
analysis, psychoanalytic psychotherapy, supportive psychotherapy, and briefpsychoanalytic psychotherapy.
Psychoanalysis . Although Freud (1914/1976) was not optimistic about the
treatability of the narcissistic personality, Kernberg (1984) and Kohut (1971) believethat higher functioning Narcissistic Personality-Disordered individuals areparticularly suited for psychoanalysis. Kernberg views the core of the disorder asinvolving anger, envy, and distorted self-sufﬁciency, and so emphasizes an activeinterpretation and confrontation of the individual’s defenses. Kohut, on the otherhand, views the core of the disorder as stunted development of the grandioseself. As such, he emphasizes that through the establishment of self-objecttransference, both mirroring and idealizing, missing element of the self structurecan be added. When a correct empathic interpretation is made, the individualreinte grates by way of the reestablishment of the self-object transference—
cohesion—and the disappearance of ﬁgmentation. In short, then, Kernberg’s goalof psychoanalysis is to effect a signiﬁcant personality change so that envy and rageNarcissistic Personality Disorder 175

no longer overwhelm the individual and lead to a protective need to withdraw
to a self-sufﬁcient position. For Kohut, the goal is to heal the individual’s incom -
plete self-structure and increase self-esteem through transmuting internal ization,
i.e., taking in of missing functions from the self-object analyst. The process ofpsychoanalysis for both Kohut and Kernberg is expected to take several years,since signiﬁcant personality change is the goal. Kernberg (2010) maintains thatpsychoanalysis is preferable for higher functioning narcissistic patients, as cognitive-behavioral or supportive modalities may successfully reduce symptoms but do notaddress the unconscious dynamics behind them. However, he states thatpsychoanalytically oriented psychotherapy is contraindicated for overwhelmingnegative prognostic indicators.
Psychoanalytic Psychotherapy . In what he calls expressive psychotherapy,
Kernberg (1984) describes a modiﬁed psychoanalytic treatment as an alternativeto psychoanalysis and supportive psychotherapy. In expressive psychotherapy thetherapeutic effort focuses on the negative transference in which early manifesta -
tions of anger toward the therapist are explored and interpreted. Also includedare the defenses of splitting, projection, and projective identiﬁcation. Masterson(1981) and Rinsley (1982) further emphasize the value of this approach in thedevelopment of a therapeutic alliance. Masterson also emphasizes the import-ance of exploring the individual’s exquisite sensitivity to the therapist’s empathicfailures and the importance of therapeutically exploring this vulnerability.Although Kohut did not describe a psychotherapeutic treatment of the NarcissisticPersonality Disorder, Goldberg (1973) and Chessick (1985) have shown that self-object transference does become established in psychotherapy and can beinterpreted in light of Kohut’s approach. Goldberg (1989) describes the use ofthe mirroring and idealizing, and the twinship transference, in a self-psychologyapproach to the narcissistic patient.
Psychoanalytically oriented psychotherapy of narcissistically disordered
individuals typically involves one to three sessions a week for two or more years.Kantor (1992) offers a number of proactive suggestions for use in the course ofpsychotherapy. Among them is the use of predictive interpretation. He pointsout how painful therapy will be, as the individual feels forced to abandon theirentitlement and grandiosity. Such forewarning of the individual is less likely toleave therapy precipitously.
The idea of dependence on another person for help is anathema to the
narcissistic individual. Kernberg (2010) notes that this dependence is often seenas humiliating, and the narcissist’s defense mechanisms are activated in order toprotect against this feeling. Individuals may attempt to wrest control of thetreatment from the therapist by engaging in “self-analysis.” They treat therapistsas “vending machines” of interpretations, accepting those with which they agreeand rejecting others. Narcissistic patients may alternatively compete with andidealize their therapists, both of which are intended to create distance and assumecontrol. Treatment is ﬁlled with feelings of envy and hostility on the part of the176 Diagnosis and Treatment of DSM-5 Personality Disorders

patient. These may manifest in attempts to seduce the therapist or self-injurious
behaviors intended to destroy the legitimacy of the therapist’s role. As such, psycho -
analytically oriented psychotherapy with narcissistic individuals must account forthese particular defenses.
Supportive Psychotherapy . According to Kernberg (1984), supportive
psychotherapy emphasizes an avoidance of working with the negative transference,and instead focuses on supporting the individual in developing expanding egofunctions, skills, and capacities. According to Kernberg, rapid symptomaticimprovement is more likely in supportive psychotherapy than in more expressiveapproaches. The reader is referred to Kernberg’s (1984) chapter on “SupportivePsychotherapy” for an extended discussion of treatment goals and techniques.Kantor (1992) recommends palliation as the goal of supportive psychotherapy,wherein the disordered narcissistic personality is maintained while reducing oreliminating its destructive sequelae. He recommends a number of palliative strat -
egies, such as teaching the individual to become a better narcissist. For instance,Kantor shows the individual how excessive self-adoration actually interferes withthe ability to receive more realistic, wanted, and needed adoration from others.
Brief Psychoanalytically Oriented Psychotherapy . Not surprisingly, the
least explored treatment modality of the psychodynamic therapies of NarcissisticPersonality Disorder are the shorter-term and brief approaches. Until recently, aself-deﬁcit disorder like the narcissistic personality was considered unamenableto any but long-term treatment. However, as economic realities collide withideology, this view may be changing somewhat. Kernberg (1984) describes a short-term crisis intervention for Narcissistic Personality Disorder until the individualis ready and motivated for long-term treatment. Lazarus (1982) and Binder (1979)report utilizing a brief approach for increasing the individual’s self-esteem andself-cohesion, again as preparation for longer-term treatment.
Klein (1989b) describes a shorter-term treatment which is not a preparation
for longer-term therapy. Admittedly, the goals are not ego repair, but are morelimited. The goals are learning—increased awareness and anticipation of personalvulnerability to injury, shame, and disappointment; containment—increasedability to modulate affects, especially narcissistic rage; and adaptation—seriouslytaking into account those aspects of reality previously ignored and their destruc -
tive consequences. Interpretation of narcissistic vulnerability and clariﬁcation ofthe need for containment of defensive devaluation and withdrawal are thecornerstones of this approach. Klein, a colleague of Masterson, describes twoselection criteria. An acute interruption of narcissistic “supply lines” (i.e., inter -
personal rejection or disappointment) results in narcissistic injury amenable to asubstitute “supply line” (i.e. the therapist’s mirroring). Second, when the nar -
cissistic injury milieus makes conscious a persistent vulnerability (often experiencedas depression or somatic preoccupation) and these individuals are motivated tolearn more adaptive ways of managing their environment. Klein speciﬁcallyexcludes individuals who present or are referred with chronic, nonspeciﬁc, vagueNarcissistic Personality Disorder 177

or ego-syntonic symptoms from his brief approach. He describes a course of time-
limited treatment (i.e., six months) with a young male, which effected symptomrelief and circumscribed improvement in functioning. Oldham and Skodol (2000)describes a 24-session treatment strategy that he describes as a dynamicallyinformed directive approach with limited, focused treatment goals. Marmar andFreeman (1988) also describe a brief dynamic approach, as does Trujillo (2013).
Cognitive Therapy . Beck et al. (2004) provide an in-depth discussion of the
Cognitive Therapy approach to Narcissistic Personality-Disordered individuals.Early in the course of therapy with these individuals, three treatment objectivesmust be met: developing a collaborative working relationship, socializing theindividuals to the cognitive theory and model of treatment, and agreeing ontreatment goals. Narcissistic individuals often arrive to treatment somewherebetween pre-contemplation and contemplation in a stance that is opposed tochange. Even while experiencing distress, these individuals are ambivalent aboutaccepting help or examining their own thoughts and behaviors, because this may activate their core negative belief of inferiority. Forming a collaborativerelationship is challenging, in that narcissistic individuals are deeply invested inbeing special and superior, and usually have a limited capacity for workingcollaboratively. These self-protective strategies can easily provoke strong reactionsin the therapist, such as annoyance, anxiety, defensiveness, or lapses in judgment.Establishing and maintaining ﬁrm treatment guidelines and limits, in a neutral,matter-of-fact tone, is necessary. It should be pointed out that sticking to an agreed-upon agenda allows the therapist to more effectively address the narcissisticindividual’s important concerns. Similarly, the therapist can approach othercounterproductive behaviors in therapy by appealing to the individual’s self-interest. With these particular individuals, it is important to offer praise and supportfor their strengths in order to meet their expectations for the relationship andkeep them engaged in treatment. Of course, this must be done strategically toreinforce desired behaviors without contributing to problem ones.
Because disclosing shortcomings and weaknesses is alien to the narcissist’s style,
behavioral interventions are usually easier to implement earlier in treatment, sincethey require less self-disclosure than most cognitive techniques. The rhythm oftreatment with narcissistic individuals alternates focus among increasing responsi -
bility for behavior, decreasing cognitive distortions and dysfunctional affects—such as rage reactions—and, developing healthier attitudes and beliefs. Thechallenge of treatment with these individuals is to tailor treatment for the threecomponents of grandiosity, hypersensitivity to criticism, and emphatic deﬁcits.Cognitive techniques are useful in revising a distorted self-view, partic ularly with
dichotomous, black-white thinking. Furthermore, magical restruc turing methods
wherein a realistic and pleasure fantasy replaces a grandiose one are useful.178 Diagnosis and Treatment of DSM-5 Personality Disorders

Systematic desensitization and role reversal can be used to address hypersensitivity.
Working with empathy deﬁcits is a major focus of treatment and involves severaltechniques. After bringing these deﬁcits to the attention of the individual,emotional schemas related to the feelings and reactions of others are activated,usually through role plays including role reversal. Then alternative ways ofrelating to others can be discussed, and new statements of belief, such as “others’feelings count too,” are formulated. The use of signiﬁcant others in therapy—such as in couples sessions—has been found useful in developing and practicingempathy and in reinforcing changes, as well as helping the signiﬁcant other copemore effectively with the narcissistic individual.
According to Behary and Davis (2015), ﬁve key treatment goals are: recognize
maladaptive coping modes and weaken their predominance; build affect regulationskills, emphasizing tolerance of frustration and imperfection; increase respect andempathy for others; increase attunement to natural strengths rather than contingentself-worth; and increase role involvement and appropriate reciprocity. Theultimate purpose of these goals is not to create homogenous individuals who areunfalteringly loving and tolerant; rather, it is to allow narcissistic individuals thecapacity to be more ﬂexible and adaptive manner.
In summary, cognitive therapy with the Narcissistic Personality Disordered
individual can be most challenging, nevertheless, they can make signiﬁcantchanges. Beck indicates that the best predictors of success are the degree ofnarcissism and the therapist’s ability to withstand the individual’s demands forapproval and special treatment. Positive treatment outcomes are likely to the extentthat (1) a collaborative working relationship is established, (2) limits are set andmaintained regarding the control of therapy and special treatment, (3) schemasof grandiosity, hypersensitivity and empathy are changed, and (4) associatedbehaviors and affects are modulated.
that has been developed by Young (1999) speciﬁcally for personality disorders,and other difﬁcult individual and couples problems. Schema Therapy involvesidentifying maladaptive schemas and planning speciﬁc strategies and interventions.Four main strategies are cognitive, experiential, behavioral, and the therapeuticrelationship itself. Cognitive restructuring, modiﬁcation of maladaptive schemas,is an important cognitive strategy, but is combined with imagery exercises,empathic confrontation, homework assignments, and “limited reparenting,” i.e.,a form of corrective emotional experience (Young, 1999).
Maladaptive schemas typically associated with Narcissistic Personality Disorder
include: entitlement— the belief that one is superior to others and not bound by
the rules and norms that govern normal social interaction; emotional deprivation—
the belief that one’s desire for emotional support will not be met by others;defectiveness —the belief that one is defective, bad, unwanted, or inferior in
important respects; unrelenting standards— the belief that striving to meet
unrealistically high standards of performance is essential to be accepted and toNarcissistic Personality Disorder 179

avoid criticism; and insufﬁcient self-control —the belief that one is incapable of self-
control and frustration tolerance (Bernstein, 2002). Young et al. (2003) providea detailed treatment protocol for treating Narcissistic Personality Disorder.
Interpersonal Psychotherapy
For Benjamin (2003b) psychotherapeutic interventions with Narcissistic
whether they enhance collaboration, facilitate learning about maladaptive patterns
and their roots, block these patterns, enhance the will to change, and effectively
encourage new patterns. As with other interpersonal psychotherapy applications,the success of interventions aimed at treating Narcissistic Personality Disordershould be evaluated in terms of their impact on the patient and not the therapist’sintention. This means the occurrence of rage, angry withdrawal from the therapist,or regal autonomy signal that an error has been made. Any subtle suggestion of
blame may elicit problem patterns.
Facilitating collaboration with narcissistic individuals is rooted in accurate,
consistent empathy. Consistent empathy provides the afﬁrmation and soothingneeded to learn self-regulation through the experience of being accuratelymirrored, able to internalize this empathic afﬁrmation of self. Another importantaspect of collaboration involves the individual’s learning to tolerate his or herfaults. This is facilitated through modeling, as the therapist acknowledges mistakes
or error, such as an occasional minor lapse in understanding the individual. In
therapy, narcissistic individuals must learn to recognize and block the patterns 
of entitlement, grandiosity, and envy of others’ success. Gentle confrontationsembedded in strong support are utilized for this purpose. Benjamin considers thisa fragile practice, one that may easily result in a hurt narcissistic individualabandoning treatment. To accomplish this successfully, the therapist must master
the delicate art of pushing the edge of awareness without destroying the thera -
peutic relationship. Couples therapy can be useful in the recognition and blocking
of maladaptive patterns.
Once these individuals understand their maladaptive patterns and choose to
relinquish the quest for unattainable or maladaptive goals, new learning isrelatively easy. According to Benjamin, the basic focus of interpersonal learningis empathy. Empathy can effectively be taught in couples therapy. Role-playingand other empathy training approaches can be particularly useful. Benjamincontends that, when utilizing role-playing, it is important that a collaborative andbenign use of the individual’s exact words and inﬂections be employed, as inexactmirroring can elicit rage and withdrawal.
There is growing literature in the treatment of Narcissistic Personality-Disorderedindividuals in group therapy formats. Many of the recent reports are based on180 Diagnosis and Treatment of DSM-5 Personality Disorders

object relations and/or self-psychology approaches (Leszcz, 1989). Outcome
research demonstrates that group therapy is as effective as any other therapy intreating the Narcissistic Personality Disorder (Alonso, 1992). A number of factorscontribute to the effectiveness of groups with this personality disorder. First, peerrather than therapist feedback is likely to be more acceptable to the individual.Second, transference is likely to be less intense than in individual therapy.Working through intense affects is more possible because of the individual’s positiveattachments within the group and because of peer group scrutiny of theindividual’s disavowed affects. Third, group membership provides the narcissistindividual with three unique needs: mirroring of needs, objects for idealization,and opportunities for peer relationships (Grotjahn, 1984). Finally, the groupprovides individuals with opportunities to increase their capacity to empathizewith others, as well as enhance self-esteem and self-cohesion.
Most of the recent reports suggest that groups consisting exclusively of
narcissistic individuals can have successful therapeutic outcomes. Alonso (1992)notes that, while narcissistic pathology undermines the usual forces that lead togroup cohesion, a properly run group can function as a container for splittingand oscillation of self-love and hate. She also notes that a high drop-out rate iscommon in groups for Narcissistic Personality-Disordered individuals, with upto 50 percent of the individuals dropping out in ongoing—rather than time-limited—groups. Alonzo recommends intermittent individual therapy focused onhelping individuals remain in the group. Horowitz (1987) describes the indicationand contraindications for group treatment of narcissistic individuals. He notes fourindications: demandingness, egocentrism, social isolation and withdrawal, andsocially deviant behavior. Even though these traits may be taxing to both therapistand group members, Horowitz believes individuals with such traits are quiteamenable to group treatment. Stone and Whiteman (1980) note that attentionto the unique needs of the individual might warrant a deemphasis on inter pretations
geared to the entire groups, with a focus on an individual members’ needs orcapacities that are different from that of the group. Finally, Rutan et al. (2014)maintain that group therapy does not provide narcissistic individuals with the safetyof individual psychotherapy. The presence of others triggers fears of non -
responsiveness and, as such, presents a serious danger to the self. Groups providean opportunity for narcissistic individuals to face their difﬁculties in vivo , gaining
valuable reparative experiences in self-other interactions. While all group membersmay suffer narcissistic injury from time to time, it is important to distinguishbetween the narcissistic needs of all individuals and the pathology of this disorder.
The early family therapy literature emphasized the treatment of adolescents infamilies with severe narcissistic pathology (Berkowitz et al., 1974; Shapiro, 1982).Typically, such families identify the adolescent as the patient and project ontoNarcissistic Personality Disorder 181

him or her their own devalued view of themselves. Not surprisingly, when the
adolescent attempts to separate and individualize, the parent’s rage and projectionsintensify. In a family therapy format, the therapist functions to contain displaced,projected, and acted-out impulses and affects. Furthermore, the therapist mustacknowledge, work through, and redirect these responses and so provide the familyan opportunity to restore previously severed communication and mutual supportduring this critical phase of adolescent development.
More recent applications of family therapy to Narcissistic Personality Disorder
involve entire family systems for one or both parents/spouses. Jones (1987)
advocates a family systems approach to the narcissistic family. He suggests severalstrategies, particularly, determining the dilemma the family faces regarding changeby analyzing the metaphorical themes that paradoxically bind the family to resist
change. Subsequently, the therapist must join—rather than challenge or confront
—the family’s resistance. Such an empathic relationship is useful in understandinghow resistance can be lowered. Usually, family sessions are scheduled weekly for90 minutes with all family members. Such family treatment has been describedas up to or more than a year’s duration.
Considerably more has been published about marital therapy with the
narcissistic spouse or couple. Berkowitz (1985) has described a couples therapy
protocol based on Kohut’s view of narcissistic vulnerability, self-object needs, and
projective identiﬁcation. The couple is seen conjointly in weekly sessions—usually75–90 minutes—with the goal of “owning” projections and internalizing needed
self-object functions. Lachkar (1986, 1992) describes a common spousal bond:
the narcissistic dominated by mirroring needs, and the others by fears of aban -
donment. She describes a psychoanalytic treatment approach—combining bothobject relations theory and self-psychology—in which the therapist functions 
as a self-object so that the exhibitionistic/bonding expectations can become
channeled into more realistic goals. Therapy is envisioned as involving threedevelopmental phases: fusion, separation, and interaction. It should be noted 
that Lachkar views conjoint marital therapy as a precursor to individual psycho -
therapy or psycho analysis of one or both spouses. Furthermore, she adds that, in
conjoint work, the therapeutic alliance must be joined with the spouse who ispredominantly narcissistic because of their tendency to ﬂee, isolate, and withdrawfrom therapy.
Solomon (1989) describes marital therapy wherein one or both spouses meet
criteria for the Narcissistic Personality Disorder. Elucidating a self-psychology
perspective of narcissism in marriage, she described a conjoint treatment protocol
wherein marital therapy session functions as a “holding environment.” Further -
more, she believes that distorted conscious and unconscious communication iscentral to marital conﬂict and its resolution. Finally, she describes the therapist’sempathic self as the basic tool of treatment. Masterson and Orcutt (1989) describea conjoint approach to working with the narcissistic couple.182 Diagnosis and Treatment of DSM-5 Personality Disorders

Relationship Enhancement Therapy . This approach has recently been
adapted to couples therapy with narcissistic spouses (Snyder, 1994). Relationshipenhancement therapy is a unique blending of object relationship theory, sociallearning theory, interpersonal theory, and system theory, which provides apsycho educational format for incorporating skills training in either an individual
psychotherapy or conjoint couples therapy.
Relationship enhancement couples therapy focuses on the learning and
application of four core interpersonal skills: empathy; effective expression;
discussion—mode switching between empathic and expressor roles; and problem
solving/conﬂict resolution. The therapist explains, demonstrates, and coaches eachskill in the conjoint session, and the spouse then practices these skills during andbetween sessions with progressively difﬁcult issues. Not surprisingly, the empathic
skills and the subjective aspect of the expressor skill are notably deﬁcient for 
the narcissistically vulnerable couple. Furthermore, the therapist provides a“holding” environment” in which narcissistic vulnerability is minimally acted outand instead is experienced and addressed productively. As a result, both spouseslearn to express feelings with less risk of shaming the other and more ability toempathize with the feelings of the other spouse that previously evoked defensivereactions. Snyder (1994) provides a detailed case example of this promising
approach.
There have been a number of recent developments in couples therapy wherein
one or both partners present with narcissistic personality issues or the full-blown
personality disorder. Kalojera et al. (1998) provide a detailed rationale and
treatment strategy for approaching such couples from a self-psychology perspectivethat incorporate systemic dynamics. These authors present a useful ﬂowchart ofthe process of relational work with such couples and a detailed case example
illustrating the application of this approach.
Lachkar (1999) offers additional insight into the psychoanalytic treatment of
couples in which one partner has a narcissistic personality structure, while the
other partner presents with a borderline personality pattern or meets criteria for
the Borderline Personality Disorder. Solomon (1999) also addresses the treatmentof the narcissistic-borderline couple from a somewhat different psychoanalyticperspective. This line of research has been continued by Landucci and Foley (2014).
They note that the therapist’s job in working with the narcissistic-borderline 
couple is to assist the couple in understanding how their dysfunctional interactionsreplay developmental problems and do not necessarily signal problems in the
relationship itself. Therapist empathy and the ability to contain the narcissistic
partner’s rage enable the other partner to feel safe in the session and therebyrekindle the developmental process for both. Another common relational patternis the dependent/narcissistic couple. Nurse (1998) provides a detailed rationale
and treatment protocol for working with such couples based on Millon’s theory
of personality disorders (Millon & Davis, 1996).Narcissistic Personality Disorder 183

individuals with Narcissistic Personality Disorder (Silk & Feurino, 2012). Never -
theless, medications are used that target speciﬁc troubling symptoms associatedwith the disorder, such as depression, anxiety, or sleep problems. Generally, thesemedications are used as an adjunct to psychotherapy and skills training. Becausetroubling symptoms often respond to medications sooner than most psychologicalinterventions, medications are usually prescribed at the onset of treatment (Sperry,1995b). Unfortunately, there is little research evidence to provide guidelines forthe use of such medications with this disorder (Silk & Feurino, 2012).
As noted in the opening chapter of this book, there is seldom a single treatmentof choice, be it speciﬁcally method—i.e., mirroring—or general approach—i.e.,psychoanalysis—that can ensure positive treatment outcomes with personality-disordered individuals. Rather, depending on the individual’s overall level offunctioning, temperamental patterns, defensive style, and skill deﬁcits, a focused,speciﬁc, and sequentially coordinated tailored treatment protocol is usuallynecessary to accomplish treatment goals and objectives in a timely matter andfashion. Pincus, Wright, and Cain (2014) describe narcissistic grandiosity andnarcissistic vulnerability in the context of psychotherapy, with links to theprevious discussion of overt and covert narcissism. Symptoms of social anxiety,depression, and suicidality often drive narcissistic individuals into treatment-seekingrelief, and addressing these with a combined/integrative treatment strategy isparticularly useful. Roche, Pincus, Lukowitsky, Ménard, and Conroy (2013) alsoprovide an integrative approach to the assessment of this disorder.184 Diagnosis and Treatment of DSM-5 Personality Disorders

9
OBSESSIVE-COMPULSIVE 
PERSONALITY DISORDER
Individuals with obsessive compulsive personalities often present as inhibited,
stubborn, perfectionistic, judgmental, overconscientious, rigid, and chronicallyanxious. They tend to avoid intimacy and experience little pleasure from life.They may be successful, but at the same time can be indecisive and demanding(Samuels & Costa, 2012). All of these factors can impede personal change.However, despite a number of unique therapeutic challenges, it can be highlyeffective and successful. Furthermore, although there are some similarities, thisdisorder differs from the Obsessive Compulsive Disorder, which is characterizedby ritualistic compulsions and obsessions (Samuels & Costa, 2012).
of this disorder. It includes sections on diagnosis, case conceptualization,psychological assessment, and treatment interventions. It begins with backgroundinformation on the disorder as well as a DSM-5 description and a prototypicdescription of this disorder. The section on case conceptualization provides ﬁvecommon clinical formulations of this disorder: psychodynamic, biosocial,cognitive-behavioral, interpersonal, and an integrative conceptualization of thisdisorder. Several treatment approaches, modalities, and intervention strategies arealso described. These include individual psychotherapy, group therapy, maritaland family therapy, medication, and integrative and combined treatment.
Description of the Obsessive-Compulsive Personality
Disorder
The Obsessive-Compulsive Personality Disorder can be recognized by the
following descriptors and characteristics: style vs. disorder, triggering event(s),behavioral style, interpersonal style, cognitive style, affective style, attachment style,and optimal diagnostic criterion.

Style vs. Disorder . The obsessive compulsive personality can be thought of
as spanning a continuum from healthy to pathological, with the obsessive person -
ality style on the healthy, and the Obsessive-Compulsive Personality Disorderon the pathological end. Table 9.1  compares and contrasts differences between
the obsessive compulsive style and disorder.186 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 9.1 A Comparison of the Obsessive-Compulsive Personality Style and 
Disorder
Desires to complete tasks and projects Perfectionism that interferes with task
without ﬂaws or errors. completion.
Takes pride in doing all job or tasks Preoccupation with details, rules, lists,
well, including the smallest details of it. order, organization, or schedules to the
extent that the major point of theactivity is lost.
Tends to want things to be done “just Unreasonable insistence that others 
right” and in a speciﬁc manner, but has submit exactly to their way of doing some tolerance for things being done. things, or unreasonable reluctance to 
allow others to do things because of theconviction that they will not do themcorrectly.
Dedicated to work and working hard Excessive devotion to work and 
and capable of intense, single-minded productivity to the exclusion of leisure effort. activities and friendships (not accounted
for by obvious economic necessity).
Carefully considers alternatives and Indecisive: decision making either 
their consequences in making decisions. avoided, postponed, or prolonged 
(but not due to excessive need foradvice or reassurance from others).
Tends to have strong moral principles and Overconscientious, scrupulous, and
strongly desires to do the right thing. inﬂexible about matters of morality,
ethics, or values.
No-nonsense individuals who do their Restructured expression of affection.
work without much emotional expenditure.
Generally, careful, thrifty, and cautious, Lack of generosity in giving time, 
but able to share from their abundance. money, or gifts when no personal gain
is likely to result.
Tend to save and collect objects and is Unable to discard worn-out or
reluctant to discard objects that have, worthless objects even when they haveformerly had or someday may have no value.
sentimental value for them.

Obsessive-Compulsive Personality Disorder 187
CASE STUDY: OBSESSIVE-COMPULSIVE PERSONALITY
DISORDER
Mr. Z. is a 39-year-old male business executive who wanted to begin a course
of psychotherapy because his “whole world was closing in.” He gave a history
of long-standing feelings of dissatisfaction with his marriage, which hadworsened in the past two years. He described his wife’s increasing demands
for time and affection from him, which he believed was a weakness she had.
His professional life also had become conﬂicted when his partner of 10 yearswanted to expand their accounting ﬁrm to another city. Mr. Z. believed this
proposal was fraught with dangers and had come to the point of selling out
his share of the business to his partner. He knew he had to make some
decisions about his marriage and his business, but found himself unable to
do so. He hoped therapy would help with these decisions. He presented asneatly dressed in a conservative three-piece blue suit. His posture was rigid
and he spoke in a formal and controlled tone with constricted affect. His
thinking was characterized by preoccupation with details and was somewhatcircumstantial.
CASE STUDY: OBSESSIVE COMPULSIVE PERSONALITY
STYLE
Mr. C. is a 41-year-old assistant vice president of personnel for a public utility.
He rose through the ranks because of his loyalty and accomplishmentsabove and beyond the call of duty. Because of his thoroughness and attention
to detail, he has saved his corporation nearly $3 million in the past two years
on insurance and health beneﬁts for the employees of the utility. Most
evenings, Mr. C. takes a briefcase of work home with him. Although he didn’t
really mind this intrusion into his family life, his wife of 18 years did.Accordingly, they’ve reached an agreement that Mr. C. will spend at least
two hours with his wife and three kids before turning to his briefcase.The following case examples further illustrate the differences between the
personality disorder—Mr. Z.—and the personality style—Mr. C.

188 Diagnosis and Treatment of DSM-5 Personality Disorders
Triggering Event . The typical situation, circumstance, or event that 
most likely triggers or activates the characteristic maladaptive response of theObsessive-Compulsive Personality Disorder (Othmer & Othmer, 2002), as notedin behavioral, interpersonal, cognitive, and affective styles, is: “authority;unstructured situations, and/or demands of intimate and close relations.”
Behavioral Style . Behaviorally, this disorder is characterized by perfectionism.
Individuals with this disorder are likely to be workaholics. In addition todependability, they tend to be stubborn and possessive. They tend to be indecisive
and procrastinating.
Interpersonal Style . Interpersonally, these individuals are exquisitely
conscious of social rank and status and modify their behavior accordingly. Thatis, they tend to be deferential and obsequious to superiors, and haughty and
autocratic to subordinates and peers. They can be doggedly insistent that others
do things their way without an appreciation or awareness of how others react tothis insistence. At their best they are polite and loyal to the organizations andideals they espouse.
Cognitive Style . Their thinking style can be characterized as constricted and
rule-based. They have difﬁculty establishing priorities and perspective. They are“detail” people and often lose sight of the larger project. In other words, they“can’t see the forest for the trees.” Their indecisiveness and doubts make decisionmaking difﬁcult. Their mental inﬂexibility is matched by their nonsuggestibleand unimaginative style, suggesting they have a restricted fantasy life. Like passiveaggressive individuals, obsessive compulsive individuals have conﬂicts betweenassertiveness and deﬁance, and pleasing and obedience, but for different reasons.
Affective Style . Their affective or emotional style is characterized as grim
and cheerless. They have difﬁculty with the expression of intimate feelings such
as warmth and tenderness. They tend to avoid the “softer” feelings, although
they may express anger, frustration, and irritability quite freely. This grim,feeling-avoidant demeanor shows itself in stilted, stiff relationship behaviors.
by a sense of personal unworthiness and a positive evaluation of others. Theseindividuals tend to be very externally oriented in their self-deﬁnitions. Thispreoccupied attachment style is common in individuals with Obsessive-
Compulsive Personality Disorder.
Dependent Personality Disorder, one has been found to be the most useful in
diagnosing this disorder. The belief is that, by beginning with this criterion, the
clinician can test for the presence or absence of this criterion and more quicklydiagnose the personality disorder (Allnutt & Links, 1996). The optimal criterionfor this disorder is: shows perfectionism that interferes with task completion.

pattern of perfectionism, orderliness, and control instead of ﬂexibility, openness,and efﬁciency. They are overly preoccupied with details, rules, and schedules.Their perfectionism interferes with completing tasks due to their overly strictstandards. They are overly devoted to work and productivity to the exclusion ofleisure activities and friendships. When it comes to matters of values, morality,or ethics, these individuals are inﬂexible, scrupulous, and overconscientious. Often,they are unable to discard worn-out or worthless objects that have no sentimentalvalue. They will not delegate tasks or work with others unless it can be on theirterms. Not surprisingly, these individuals are also rigid and stubborn. Finally, theyare misers with money, and it is hoarded in the event of future catastrophes(American Psychiatric Association, 2013).
description of this disorder (American Psychiatric Association, 2013). It isdescribed as difﬁcult in establishing and maintaining close personal relationships,associated with perfectionism, restricted emotional expression, and inﬂexibility.Characteristic difﬁculties are noted in identity, self-direction, empathy, andintimacy, as well as restricted affect, intimacy avoidance, perseveration, and rigidperfectionism.
disorder commonly presents. Prototypic descriptions are useful and convenient
and clinicians commonly rely on them rather than lists of behavioral criteria andcore and instrumental beliefs (Westen, 2012). Here is a common prototypicdescription of the Obsessive-Compulsive Personality Disorder: These individualsare perfectionists and unyielding control freaks. They cannot rest until they getevery detail exactly right. Because they insist that others can never be careful or
competent enough, they never delegate or trust important matters to others. Their
lives are controlled by schedules, rules, and rigid routines. Because of their
scrupulous attention to details and their projects, they cannot relax, be spon taneous,
or enjoy close and intimate relationships. They are unusually tight with money,feelings, and affection. They make it clear they must always have their way, orelse (Frances, 2013).
Prevalence of this disorder has been estimated at between 2.1 and 7.9 percent inthe general population (American Psychiatric Association, 2013). In clinicalsettings, estimates are that it is found in 2.8 to 34.6 percent of patients (Torgersen,2012).Obsessive-Compulsive Personality Disorder 189

Conceptualizations of Obsessive-Compulsive Personality
Disorder
Early psychoanalytic writers formulated the obsessive compulsive personality as
a regression from the Oedipal phase to the anal phase of development. Becauseof a punitive superego, the obsessive compulsive individual was observed to employ
intellectualization, isolation of affect, undoing, development and reactionformation as defenses. Presumably, these individuals experienced difﬁculty
expressing aggression as a result of power struggle with maternal ﬁgures over toilettraining.
However, contemporary writers formulate this pattern much broader than anal
ﬁxation. As children, these individuals were not sufﬁciently valued or loved bytheir caretakers and subsequently developed overwhelming doubt. Salzman (1980)believes the obsessive pattern is basically a device for preventing any thought orfeeling that could produce shame, loss of pride or status, or a feeling of deﬁciencyor weakness, irrespective of whether the feelings are hostile, sexual, or otherwise.He views obsessive compulsivity as a neurotic strategy, which protects theseindividuals from exposure of any thoughts or feelings that could endanger theirphysical or psychological existence. This overriding need to control their innerand outer world requires these individuals to lead overly structured andmanageable lives. They tend to maintain doubts, are willing to make commit -
ments, and strive for perfection. Thus, it is necessary for them to know everythingto predict the future and prepare for every exigency. To maintain the ﬁction ofperfection, they must never make an error or admit any deﬁciency. Furthermore,their tendency to procrastinate is related to their tendency to doubt as a meansof guaranteeing their omniscience when life forces a decision or choice. As such,they are deeply ambivalent, which allows them to maintain security, but at theprice of productivity and positive feelings and attitudes. These individuals ﬁndboth anger and dependency consciously unacceptable and so defend against thesefeelings with defenses like reaction formation and isolation of affect as well asdifferential and obsequious behaviors. Intimacy poses major concerns for theseindividuals, who fear being overwhelmed by powerful wishes to be taken careof, while also experiencing the frustration of those wishes along with the fear ofbeing out of control. In addition, these individuals harbor the secret convictionthat, if they could become perfect, they would ﬁnally receive the parentalapproval and esteem they missed in early life. Finally, psychodynamic writers havenoted the unique cognitive style of obsessive compulsive individuals (Horowitz,1988; Horowitz et al., 1984; Shapiro, 1965), as characterized by drivenness, carefulattention to detail, lack of spontaneity, and ruminative thinking.190 Diagnosis and Treatment of DSM-5 Personality Disorders

To date there is no research evidence that biological predisposing factors underlie
this disorder (Millon & Davis, 1996). Nonetheless, clinical observations suggestthat many obsessive compulsive individuals display an anhedonic temperament(Millon, 1981) and tend to be the ﬁrst-born in their families of origin (Toman,1961). Certain environmental factors may be etiologic: parental overcontrol,learned compulsive behavior, and responsibility training. Rather than beingoverprotective, parents of obsessive compulsive individuals overcontrol with
ﬁrmness and punitiveness. This attempt to prevent their children from causing
trouble for themselves or others, is punitive when the child misbehaves or failsto meet expectations. These children learn compulsive behavior directly andindirectly within the family matrix. They learn to avoid punishment by accepting
and meeting the demands and expectations of perfectionistic and punitive parents.
Furthermore, they learn compulsivity by imitating the compulsive behaviorsmodeled by one or both parents. As a result, they do not develop the ability togenerate options and explore alternatives and thus fail to function autonomously.
Obsessive compulsive individuals are regularly exposed to conditions that 
teach them to overvalue a sense of responsibility to others. They are taught to feel guilt when these responsibilities are not met, and shame when they actimpulsively or even playfully. Instead they learn to be polite, pleasing and loyalto superiors. These inﬂuences typically yield individuals who are hard-driving,perfectionistic, polite, pleasing and who lead rather restrictive, tentative, colorlesslives.
This obsessive compulsive pattern is self-perpetuated through an interaction
of cognitive and behavioral rigidity, strict adherence of roles, regulations and social
convention, and a tendency to be highly self-critical. While their cognitive rigidity
serves to reduce anxiety associated with ﬂexibility and ambivalence, they tend tolead overstructured, one-sided lives. Self-criticism serves to keep them in line,while striving for perfection reduces opportunities for risk-taking and adventure.
Beck (2015) identiﬁed the core beliefs or schemas held by obsessive compulsiveindividuals: perfectionism and control. The perfectionism schema involves beliefssuch as: “To be worthwhile I must avoid making mistakes because to make amistake is to fail which would be intolerable,” and “If the perfect course of actionis unclear, it is better to do nothing.” The control schema involves beliefs suchas: “I must be perfectly in control of myself and my environment, because lossof control is intolerable and dangerous,” “Without my rules and rituals, I’ll collapseinto an inert pile,” and “Magical rituals or obsessive ruminations prevent theoccurrence of catastrophes.”  Typically, they view themselves as responsible andaccountable for most everything in their lives. At the same time they believe theyObsessive-Compulsive Personality Disorder 191

are inadequate, helpless, or defective. They view others as incompetent, careless,
and less concerned about matters than they are. Related beliefs include needingrules and regulations in order to survive. Because of their beliefs about controland perfection, should they fail at a task, they are likely to conclude that theymust be failures and worthless. Not surprisingly, such beliefs are reﬂected in theirmain strategy or pattern of exercising maximum control over themselves and othersthrough the use of directiveness, coercion, and disapproval (Beck, 2015; Simon,2015).
Guidano and Liotti (1983) provide a similar but different cognitive formulation
which involves three maladaptive schemas. They are: perfectionism, the need forcertainty, and the belief that there is an absolute correct solution for humanproblems. Guidano and Liotti note that these individuals received mixed, contra -
dictory messages from at least one parent. They also describe typical automatic
thoughts of obsessive compulsive individuals. “I need to get this assignment doneperfectly,” “I have to do this project myself or it won’t be done right,” “Thatperson misbehaved and should be punished,” and “I should keep these old reportsbecause I might need them some day.” In addition to these schemas and automaticthoughts, individuals with this personality pattern often utilize the cognitivedistortions of dichotomous thinking and magniﬁcation or catastrophizing.
Turkat (1990) and Turkat and Maisto (1985) suggest a behavioral formulation
of this pattern. These individuals are noted to have been reared in families thatemphasized productivity and rule-following at the expense of emotional ex -
pressivity and interpersonal relationships. Accordingly, these individuals did not
acquire adequate levels of empathy skills or skills in interacting with others onan emotional basis.
According to Benjamin (2003a), persons diagnosed with Obsessive-CompulsivePersonality Disorder were likely raised in an atmosphere of unreasonable andrelentless coercion to perform correctly and follow rules regardless of personalcost. As a consequence, the obsessive compulsive individual has an unbalanceddevotion to perfection of self and others. These parents typically held extremelyhigh expectations for self-control and perfection, and not only punished theirchildren for not being perfect, but gave them little or no reward for success.Subsequently, these children focused primarily on avoiding mistakes and self-criticism by trying hard to be good and right. Furthermore, there tended to belittle warmth in these households. Laughter, hugging, holding, and other signsof affection were seldom, if ever, modeled. Expression of feelings was considereddangerous. The adult consequence of their lack of warmth and demand forperfection is social correctness, albeit inaccessibility of feelings. Finally, there is afear of making mistakes and a penchant for rule-following. A quest for order192 Diagnosis and Treatment of DSM-5 Personality Disorders

underlies blame and inconsiderate control of others with control alternating with
blind obedience to authority of principle. This stance is supported by excessiveself-discipline, feeling avoidance, self-criticism, as well as neglect of the self.
The following integrative formulation provides a biopsychosocial explanation forhow this personality is likely to have developed and how it is maintained.Biologi cally, these individuals were likely to have exhibited an anhedonic
temperament as children. Not surprisingly, ﬁrst-born children have a greater
propensity for developing a compulsive style than other siblings.
Psychologically, these individuals view themselves, others, the world, and life’s
purpose in terms of the following themes. They tend to view themselves withsome variant of the theme “I’m responsible if something goes wrong, so I haveto be reliable, competent, and righteous.” Their world-view is some variant ofthe theme “Life is unpredictable and expects too much.” As such, they are likelyto conclude, “Therefore, be in control, right, and proper at all times.”
Socially, predictable patterns of parenting and environmental conditioning are
noted for this personality. The parenting style they experienced could becharacterized as both consistent and overcontrolled. As children they were trainedto be overly responsible for their actions and to feel guilty and worthless if theywere not obedient, achievement-oriented, or “good.” The parental injunctionto which they were most likely exposed was “You must do and be better to beworthwhile.”
This obsessive compulsive pattern is conﬁrmed, reinforced, and perpetuated
by a number of factors: exceedingly high expectations plus harshly rigid behaviorand beliefs, along with a tendency to be self-critical, lead to rigid rule-basedbehavior and avoidance of social, professional, and moral unacceptability. Thisin turn further reconﬁrms the harshly rigid behaviors and beliefs of this personalitypattern (Sperry, 2015).
Table 9.2  summarizes the characteristics of this disorder.
Assessment of Obsessive-Compulsive Personality Disorder
clinician makes and the nature of the rapport likely to develop in initial encounters
with speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e., MMPI-2 and MCMI-IV) and projective (i.e.,Rorschach and TAT) tests are also described.Obsessive-Compulsive Personality Disorder 193

The obsessive compulsive’s dynamics of circumstantiality, perfectionism, and
ambivalence make interviewing these individuals difﬁcult and challenging. Their
preoccupation with, and focus on, details and need for control leads to a seeminglyendless struggle about words, issues, and who is in charge without being able todevelop an atmosphere of understanding and cooperation. Open-ended questionslead them to confusion. Instead they want more focused questions, but interpretthem too narrowly when this kind of question is asked. They may bring a notebookof their medical history, diet, and exercise pattern, or even dreams, expecting toreview these details with you. And, while they may admit that affects and feelings194 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 9.2 Characteristics of Obsessive-Compulsive Personality Disorder
Triggering Event(s) Demands of authority ﬁgures; unstructured situations,
and/or demands of intimate and close relations
Behavioral Appearance Perfectionistic and righteous
Workaholic
Dependable, reliable, and overly conscientious
Indecisive and procrastinates
Interpersonal Behavior Devotion to tasks or work limits relationships
Unwillingness to delegate or collaborateRigid and stubbornJudgmentalAutocratic to subordinates but deferential to superiors
Polite and loyal
Cognitive Style Constricted—rule-based
Inﬂexibility
Unimaginative
Affective Style Grim and cheerless
Feeling avoidance
Temperament Irritable, difﬁcult, or anxious
Attachment Style PreoccupiedParental Injunction “You must do/be better to be worthwhile.”
Self-View “I’m responsible if something goes wrong.”
World-View “Life is unpredictable and expects too much. Therefore,
be in control, be right and proper and don’t makemistakes.”
Maladaptive Schemas Unrelenting standards; punitiveness; emotional inhibitionOptimal Diagnostic Shows perfectionism that interferes with task completion
Criterion

are associated with the details, they are unwilling to admit the value of expressing
those affects, much less talking about them. Their ambivalence is difﬁcult to over -
come, since they cannot accept others’ assurances that their problems are solvableor that they can tolerate less control in their lives.
The clinician’s expression of empathy is problematic for them, since they insist
they are objective and have no feelings. Thus, they are perturbed at the expression
of empathy and reject it as irrelevant. They may insist that their problems, nottheir suffering, are important. Yet, their problems are unsolvable! The only thera -
peutic leverage for the clinician is to attempt to get and keep this individual in
touch with their anger and other feelings. But, this is difﬁcult, as they will attemptto defend or deny affects, and put forth even more obstructive obsessive thinkingto neutralize such therapeutic leverage. Needless to say, forming a therapeutic
alliance is difﬁcult and the interview often consists of aborted attempts, frustrations,
and struggles (Othmer & Othmer, 2002).
The Minnesota Multiphase Personality Inventory (MMPI-2), the Millon Clinical
Multiaxial Inventory (MCMI-IV), the Rorschach Psychodiagnostic Test, and the
Thematic Apperception Test (TAT) can be useful in diagnosing the CompulsivePersonality Disorder as well as the personality style (Groth-Marnat, 2009).
On the MMPI-2 there is likely to be a moderately high K (Correction) scale.
Since individuals with obsessive compulsive features are not inclined to self-disclosure, they seldom leave elevated proﬁles. However, scales 1 (Hypo -
chondriasis) and 3 (Hysteria) tend to be elevated. If physical complaints are thefocus of the distress, scale 1 may be particularly elevated. An elevation on scale9 (Hypomania) usually reﬂects the degree to which these individuals are autocraticand dominant in interpersonal relationships. Since scale 7 (Psychasthenia) reﬂectsobsessionalism, elevation of this scale usually indicates a complaining and querulousattitude in them (Graham, 2012; Meyer, 1995).
On the MCMI-IV, a high score on scale 7 (Compulsive) is likely (Millon 
et al., 2015). Elevations on scale A (anxiety) are not likely, since these individualstend to express anxiety somatically, thus scale H is likely to be elevated (somaticsymptom disorder) (Choca & Denburg, 1997).
On the Rorschach test, there is likely to be an emphasis on Dd (Unusual Detail)
and D (Common Detail) responses. Also, a high F+% (Form Plus) and fewer W(Whole) response and color-based responses. Obsessive compulsive individualstend to describe some responses in overly speciﬁc detail and make criticisms ofthe ink blots (Meyer, 1995).
The TAT stories of these individuals tend to be lengthy, with a variety of
themes. Sometimes the primary theme is lost amid the detailing of their response.This is particularly likely on card 2 and 13 MF (Bellak, 1997).Obsessive-Compulsive Personality Disorder 195

Included in the differential diagnosis of this disorder is the Dependent Personality
Disorder, and the so-called Passive Aggressive Personality Disorder. Commonsymp tom diagnoses that are associated with the Dependent Personality Disorder
include the Anxiety Disorders, particularly Simple Phobia, Social Anxiety Dis -
order, and Panic Disorder. Other common DSM-5 disorders include ConversionDisorders and Somatic Symptom Disorders.
The Obsessive Compulsive Disorder (OCD) has a long tradition of treatment
dating back to Freud’s case of the “Rat Man” and Adler’s “Case of Mrs. A.”
Note that OCD is a symptom disorder, while the Obsessive-CompulsivePersonality Disorder is personality disorder. Since the “Rat Man” exhibited both
Axis I and II disorders, many who have read Freud’s account of this case and its
treatment have incorrectly assumed that both disorders are the same and are treatedthe same. They are not the same disorder, but in about one third of cases bothdisorders have been shown to be present (Jenike, Baer, & Minichiello, 1998;
Phillips & Stein, 2015). When both disorders are present together, treatment has
been shown to be much more challenging than if only OCD is present.
The goals of treatment include increased cognitive constriction and increased
feeling expression, so that a more reasonable balance can be obtained between
thoughts and feelings. Treatment strategies for the Obsessive-Compulsive Person -
ality Disorder usually involve long-term, insight-oriented therapy. Unlike theObsessive Compulsive Disorder, where antidepressants plus behavior therapy canresult in amelioration of obsessions and compulsions in a relatively short periodof time, the Obsessive-Compulsive Personality Disorder does not lend itself toshort-term treatment outcomes. However, psychodynamic and cognitive behav -
ioral intervention both appear to be effective. Medication is usually not needed
with this disorder if the restitution of the accompanying symptom disorder isattainted (Sperry, 2015).
The therapy of the obsessive compulsive patients involves exposing the patient’s
extreme feelings of insecurity and uncertainty. As they come to identify their
neurotic structure as a defense against recognizing these weaknesses, they can begin
to develop a more adaptive security system. At the outset of treatment, thesepatients are unable to abandon their obsessive compulsive defense, fearing
unspeakable consequences. However, as their self-esteem grows and awareness196 Diagnosis and Treatment of DSM-5 Personality Disorders

of their strengths increases, they are able to take the risks of abandoning these
patterns and are thus freer to function more productively. The goal of therapyis to switch from impossible expectations for self and others to more realisticachievable ones. In short, these individuals come to learn that by relinquishingtheir rigid, inﬂexible patterns of control and protection, they can actually feelmore productive as well. Doing psychodynamically oriented psychotherapy withobsessive compulsive patients requires a number of modiﬁcations. Themodiﬁcation involves the clinician’s level of activity. The clinician must be activefrom the beginning through the end of treatment. Clinician passivity, accordingto Salzman (1980), can lead only to interminable analysis and an atmosphere ofconfusion. Speciﬁcally, free association, and a tendency to endless detail andcircumstantiality must be con trolled and limited. Because of these patients’ need
for perfection, they tend to qualify and quantify their descriptions, which, rather
than clarifying, confuses and obfuscates. The free association process tends to defeatits own purpose. Thus, the clinician must be active to prevent this tangentialityand distraction by attempt ing to interrupt the irrelevances and avoidances. Of
course the major avoidance is affects. While these patients may talk about feelingsand emotions, and even about transference and countertransference, theyassiduously avoid the expression of affect. The clinician must, therefore, focus
on real feelings and their expression, and limit intellectual discussion of affects.
Another modiﬁcation from traditional analytic methods involves a focus on
recent events. While obsessive compulsive individuals can discuss anger and hostile
behavior associated with past events, they ﬁnd it very difﬁcult to disclose tender
impurities and feelings with recent and here-and-now experiences. Such tenderimpulses and feelings are viewed as threatening and dangerous, and Salzman (1980)contends this is the essence of obsessive compulsive defenses. It is the failure to
express these feelings, rather than their hostile behavior, that initiated retaliatory
behavior from others, which in turn stirs up their wrath and hostile responders.
Finally, the usual instruction to forgo major decisions during the course of
therapy must be modiﬁed. Because of their fear of making mistakes, such
instruction can serve to reinforce their pathological pattern. Rather, risk-takingand decision making must be promoted. The techniques for dealing with theirindecisiveness are clariﬁcation and interpretation of their need for absolutes and
certainties. If dream material is utilized, the emphasis must be in the here-and-
now, and dream content treated as data dealt with in the same manner as theirother therapeutic material.
The outcome goal of treatment is that these individuals achieve some degree
of balance and compromise, and, instead of needing to be superhuman, be ableto function as fallible human persons. Because of their anticipatory anxiety,termination issues abound with these patients. It must be clearly understood by
both patients and clinicians that anxiety episodes will occur throughout life, and
that continuation in therapy is no guarantee against life’s distress.Obsessive-Compulsive Personality Disorder 197

A related goal is superego modiﬁcation, so much that these patients can accept
that their wish to transcend such feelings as anger, lust, and dependency are doomedto failure, and must be integrated rather than disowned. Gabbard (1994) notesthat such changes occur through detailed interpretation of conﬂicts aroundaggression, sexuality, and dependence.
There is a consensus that long-term psychodynamic treatment is needed with
these patients. This is because of their constricted emotionality and theirvulnerability to deﬂation of self-esteem under their rigid exterior. Treatment
typically lasts two to three years of one or two sessions per week. The prevailing
wisdom is that dynamic psychotherapy, with the ancillary support of medicationand behavioral interventions, is effective (Salzman, 1989).
Schanche, Stiles, McCullough, Svartberg, and Nielsen (2011) provide a useful
discussion of Cluster C personality disorders from a psychodynamic perspective,
including commentary on treatment for Obsessive-Compulsive PersonalityDisorder.
Time-Limited Supportive-Expressive Therapy
Supportive-expressive therapy was provided to individuals with both obsessivecompulsive and Avoidant Personality-Disordered individuals. Those withObsessive-Compulsive Personality Disorder lost their personality disorder
diagnosis in a signiﬁcantly shorter period of time than those with Avoidant Person -
ality Disorder. While both groups responded to this time-limited therapy onmeasures of personality disorder, depression, anxiety, general functioning, and
inter personal problems, those with Obsessive-Compulsive Personality Disorder
no longer met Axis II criteria within the ﬁrst 17 sessions (Barber, Morse,Krakauer, Chittams, & Crits-Christoph, 1997).
Which cognitive behavioral approach and treatment targets have the besttreatment outcomes with Obsessive-Compulsive Personality Disorder? Unfortun -
ately, no randomly controlled trials have been published to date which offer theclinician usable and reliable guidelines. Bailey (1998) describes and critiques thetwo most common cognitive approaches: Young’s schema-focused approach andBeck’s more traditional approach. Kyrios (1999) describes several cognitive-behavioral treatment targets in treating Obsessive-Compulsive Personality Dis -
order. These include targeting dysfunctional cognitions, restricted behavioralrepertoires, negative affective dispositions, and issues related to attachment and
identity. Until research-based guidelines are forthcoming, a careful assessment ofclient and situational attributes and clinician judgment must continue to guide
treatment decisions.198 Diagnosis and Treatment of DSM-5 Personality Disorders

Cognitive Therapy Approach . Beck et al. (2004) provide an extended
discussion of the Cognitive Therapy approach with Obsessive-CompulsivePersonality-Disordered individuals. The general outcome goal in workingtherapeutically with these individuals is helping them modify and restructure theirmaladaptive schemas that underlie behaviors and effects. Establishing acollaborative working relationship is the ﬁrst task of therapy. This can be quitedifﬁcult for these individuals because of their rigidity, feeling avoidance, andtendency to minimize the importance of interpersonal relationships. Therefore,rapport is based on the individual’s respect for the therapist’s competence andthe belief that the therapist will be respecting and helpful. Efforts to develop acloser emotional relationship early in treatment may result in premature termin -
ation. However, Strauss et al. (2006) conducted a nonrandomized trial of cognitive
therapy for Obsessive-Compulsive Personality Disorder and Avoidant Personality
Disorder and found that stronger early therapeutic alliances predicted moreimprovement in symptoms. Even ruptures in the relationship later in therapy maybe used as learning experiences if they are managed properly. As such, there areboth risks and rewards to early investments in the alliance with these clients. Itis also essential to introduce the obsessive compulsive individual to the cognitivetheory of emotion early in the course of therapy, as well as establishing therapeutic
goals. Usually these involve presenting problems. After collaboratively establishing
these, they are ranked in the order they are to be addressed. A given problem ismonitored between sessions with the Dysfunctional Thought Record, which
includes the situation as well as the feelings and thoughts about when the
problem occurred. The record is reviewed at the next session, which is the basisfor discuss ing automatic thoughts and the assumptions or schemas underlying the
thoughts. In this collaborative relationship, the individual can identify and
understand the negative consequences of the schema and ways of refuting them.
This process of cognitive disputation and restructuring is particularly useful andwell received by obsessive compulsive individuals because of its structured 
and problem-centered, here-and-now focus.
Several speciﬁc strategies and techniques have been found to be particularly
useful with these individuals as adjunctive to cognitive therapy. Setting an agenda,prioritizing problems, utilizing problem-solving and thought-stopping techniquesare effective with issues of rumination, procrastination, and indecisiveness. Salzman(1989) reports that ﬂooding, desensitization, response prevention, and satiationtraining have been used in treating this disorder. Relaxation training is usefulwith anxiety and psychosomatic symptoms, while behavioral experiments can beused instead of direct disputation of maladaptive beliefs. Because of their difﬁcultyin attending to their emotions and those of others, empathy training and rolereversal have been used effectively. In sum, Obsessive-Compulsive PersonalityDisorder is a challenging but very treatable disorder. With collaboration, cognitiverestructuring, and systematic application of cognitive and behavioral strategies andObsessive-Compulsive Personality Disorder 199

techniques, the obsessive compulsive individual’s automatic thoughts and schemas,
that underlie their maladaptive behavior and affects, can be effectively modiﬁedand changed.
Turkat (1990) concludes that behavioral modiﬁcation alone is not sufﬁcient
for effective treatment outcomes with most of these patients. Turkat’s treatment
regimen involved social skills training to increase pleasure and emotion-related
experience and to decrease their overcommitment to work. He note that, whilethese patients would agree with the clinical formulation and treatment plan, most
would not agree to undergo the training. Turkat and Maisto (1985) report similar
experience, leading them to conclude that behavior modiﬁcation alone was noteffective for Obsessive-Compulsive Personality Disorder.
Simon (2015) identiﬁes four main goals in the cognitive treatment of OCPD:
educating the patient about the role of perfectionism in the development and
maintenance of symptoms; testing the rigidity of long-held rules and routines byevaluating whether or not they are working; evaluating the automatic thoughts,underlying assumptions, and core beliefs that maintain perfectionism; and, ﬁnally,linking all of the above goals to work and interpersonal relationships to developmore targeted treatment goals.
disorders, and other difﬁcult individual and couples problems. Schema Therapyinvolves identifying maladaptive schemas and planning speciﬁc strategies and
interventions. Four main strategies are cognitive, experiential, behavioral, and the
therapeutic relationship itself. Cognitive restructuring, modiﬁcation of maladaptiveschemas, is an important cognitive strategy, but is combined with imagery exer -
Maladaptive schemas typically associated with this disorder include: unrelenting
standards— the belief that striving to meet unrealistically high standards of
performance is essential to be accepted and to avoid criticism; punitiveness— the
belief that others should be harshly punished for making errors; and emotional
inhibition— the excessive inhibition of spontaneous action, feeling, or communi -
cation (usually to avoid disapproval by others), feelings of shame, or losing controlof one’s impulses (Bernstein, 2002).
For Benjamin (2003a), psychotherapeutic interventions with Obsessive-Com -
pulsive Personality-Disordered individuals can be planned and evaluated in termsof whether they enhance collaboration, facilitate learning about maladaptivepatterns and their roots, block these patterns, enhance the will to change, andeffectively encourage new patterns.200 Diagnosis and Treatment of DSM-5 Personality Disorders

Because of the centrality of control in their lives, obsessive compulsive indi -
viduals ﬁnd collaboration difﬁcult. These individuals are often inconsistent in theirattitudes about control of the therapy, sometimes wanting to take control, andother times wanting the clinician to take it. Benjamin suggests breaking througha potential power struggle by describing their typical patterns of control,submission, and self-control, and their opposites—afﬁrmation, disclosure, and self-afﬁrmation—and how and why the obsessive compulsive patterns developed.She notes that these individuals quickly grasp—intellectually—the idea of friendlydifferentiation as the opposite of hostile control, and will develop an interest incollaboration. After this shared goal of openness and warmth has been established,they can begin working in experiencing feeling and changing their relationalbehaviors. Not surprisingly, the work of learning to let go is not easy.
As these individuals begin seeking connections between early life experiences
and present difﬁculties, they must be helped to develop compassion and empathyfor themselves as children. Benjamin notes that couples therapy is a particularlypotent format for learning about and changing maladaptive patterns in obsessivecompulsive individuals. Dealing with control and power struggles betweenpartners is aided by reframing and paradoxical injunctions. A paradoxical use oftheir preference for rule-following would involve the clinician “ordering” the
obsessive compulsive individual to collaborate with the partner to develop “rules”
for dealing with the problematic relational issues.
Therapeutic efforts to block maladaptive patterns should be targeted to power
struggles, feeling avoidance and perfectionism. With regard to perfectionism,
undercutting the need to reach perfection through control usually results in angerreduction. As the obsessive compulsive individual no longer needs to make othersperfect, there is no need to be angry at them; similarly, with the anxiety that
comes from fear of not reaching perfection. Since the individuals do not need
to be perfect to survive, they no longer need to be anxious about not being perfect.As these individuals come to understand the origins of their quest for perfection,
and compare their early life situations with the present, they are better able to
relinquish their past neurotic strivings. Developing empathy for the self as a childand for the parent at that distant time can strengthen their will to give up theirmaladaptive patterns.
Cognitive therapy is particularly useful in modifying their constricted cognitive
style and self-criticism. Likewise, insight can increase the probability theseindividuals will become more comfortable with fallibility and ordinariness.
Benjamin concludes that both insight and transference are important parts of the
process of change for obsessive compulsive individuals. A caring, benevolentrelationship with the therapist as a trustworthy caregiver who accurately respondsto the individual’s needs enhances the insight. However, she cautions that treating
this disorder, as with the other personality disorders, is a long-term process with
no easy short cuts.Obsessive-Compulsive Personality Disorder 201

Because a major deﬁcit of the obsessive compulsive personality is the inability to
share tenderly and spontaneously with others, group treatment has particularadvantages with such patients. Nonetheless, there are certain complications,
because of these patients’ tendency to competitiveness and control of situations.
Yalom (1995) uses the description “monopolist” to refer to this obsessive com -
pulsive pattern in group therapy. They can easily dominate a group with theirrambling and excessive speech patterns. They may ﬁnd the affective atmospherein a psychotherapy group particularly overwhelming at ﬁrst, resulting in either
further isolation or detached intellectualization. The group leader may need tointervene and to avoid unnecessary power struggles. If this is achieved, these
patients may be able to vicariously model the emotional expressiveness of othergroup members.
Actually, group therapy offers a number of advantages over individual therapy,
as the obsessive compulsive personality pattern tends to make the dyadic therapyprocess tedious, difﬁcult, and unrewarding, particularly during the inevitable
“constipated” period of treatment when clinicians commonly err with prematureinterpretations or behavioral prescriptions (Salzman, 1980; Wells, Glickauf-Hughes, & Buzzell, 1990).
A group format can diffuse intensity of the patient’s impact, particularly in a
heterogeneous group (Frances et al., 1984). Group treatment can also reducetransference and countertransference traps, because patients are more likely to accept feedback from peers without the same power struggle that often accom -
panies feedback from the clinician (Gabbard, 1994). Furthermore, group therapypropels these patients into having problems rather than just talking about them(Alonso & Rutan, 1984). Rutan et al. (2014) also echo this notion from apsychodynamic perspective. Their review suggests that group therapy is par-ticularly helpful for those with strict or otherwise problematic superegos. Theseindividuals may use the group members to offset the intensity of transference found in individual therapy, allowing them to work on issues without thisdisruption.
Wells et al. (1990) note the following contraindications for group therapy for
these patients. They are severe depression or strong suicidal potential, impulsivedyscontrol, strong paranoid propensities, acute crisis, difﬁculty in establishing trust,fear of relinquishing obsessive compulsive defenses, the need to establish superi -
ority, and the use of “pseudo insight” to avoid dealing with both hostile andtender feelings.
These authors have described a unique group approach combining inter personal
and psychodynamic principles based on the premise that this personality disorder
arises from the unsuccessful resolution of the developmental tasks of autonomyvs. shame and doubt. The process of treatment involves six goals: (1) modifyingcognitive style; (2) augmenting decision making and action taking; (3) modifying202 Diagnosis and Treatment of DSM-5 Personality Disorders

harsh superego; (4) increasing comfort with emotional expression; (5) resolving
control issues; and (6) modifying interpersonal style.
The professional literature in this area is particularly limited; however, some ofthe dynamics and treatment discussed regarding group therapy are relevant in afamily treatment context.
Harbir (1981) notes that Obsessive-Compulsive Personality-Disordered
individuals typically enter family treatment because close family members are angrywith their rigidity, procrastination, constricted affect, perfectionism, and somberor joyless outlook. The spouse of an obsessive compulsive individual may threatendivorce if the individual does not change. Often, such a threat of separation ordivorce is the only motivation for treatment. The anxiety of the complainingspouse may be the only leverage for treatment, and the clinician may need towork with that spouse to deal more effectively with the other spouse’s obsessivecompulsive personality pattern. Harbir adds that it is not uncommon for anobsessive compulsive individual to marry an individual with a histrionicpersonality.
Salzman (1989) cautions that obsessive compulsive patients who are particularly
anxious may not be able to participate in family therapy until their anxiety hasbeen sufﬁciently ameliorated in individual psychotherapy or combinedpsychotherapeutic and psychopharmacological treatment. Even when excessiveanxiety is not a particular concern, these patients are often tyrants in family sessions.They may immobilize other family members to such an extent that treatment isjeopardized. The use of structural and strategic intervention directed at redis -
tributing power may be particularly advantageous in such situations (Minuchin,1974).
Regarding treatment outcomes, no controlled research studies have been
published. However, Minuchin (1974) and Haley and Hoffman (1976) havereported favorable outcomes with family therapy interventions with obsessivecompulsive personalities and particularly those with permanent eating disorders.Harbir (1981) and Perry, Francis, and Clarkin (1990) present a case example ofmarital therapy wherein one partner exhibits an obsessive compulsive personalityand the other a histrionic personality. This case is quite instructive with regardto treatment strategy and technique.
An integrative approach involving dynamic, cognitive-behavioral, and sys-
temic interventions is described for couples in which one partner presents withObsessive-Compulsive Personality Disorder and the other with Histrionic Person -
ality Disorder. Three stages of the treatment process are discussed and illustrated:establishing a therapeutic alliance, restoring balance to the couple’s relationship,and modifying individual partner dynamics. The ﬁrst two phases involve conjointcouples sessions, while much of the third phase involves individual sessions (SperryObsessive-Compulsive Personality Disorder 203

& Maniacci, 1996). This particular relationship conﬁguration is also addressed by
Landucci and Foley (2014), who state that the spontaneity and liveliness of thehistrionic partner provides the obsessive compulsive individual with a welcomebreak from his or her mundane routines.
For additional commentary on family therapy with Obsessive-Compulsive
Personality Disorder, refer to Benjamin (2003b). She notes that many disordersare the result of patients’ desire to gain the approval of a critical parent. Thisdream of reconciliation is rarely realized as a clinical goal, however. The likelihoodof the patient’s own internalizations or the family members themselves under -
mining the process is high. Rather, Benjamin suggests that family therapy mayaccomplish change only when the obsessive-compulsive patient gives up thisfantasy.
Currently, there are no psychotropic medications speciﬁcally indicated for treatingthis personality disorder (Silk & Feurino, 2012). Nevertheless, medications areused that target speciﬁc troubling symptoms associated with the disorder, suchas depression, anxiety, or sleep problems. Generally, these medications are usedas an adjunct to psychotherapy and skills training. Because troubling symptomsoften respond to medications sooner than most psychological interventions,medications are usually prescribed at the onset of treatment (Sperry, 1995b).Because antidepressants have been effective in the treatment of obsessive com -
pulsive disorder, it was expected that these medications might also reduce thesymptoms of this personality disorder. However, there is no evidence to supportthis expectation. Furthermore, there is little research evidence even to provideguidelines for the use of any medications with this disorder (Silk & Feurino, 2012).
Salzman (1989) elegantly makes the case for a combined/integrated approach tothe treatment of the Obsessive Compulsive Disorder, particularly for the moresevere cases. He argues that the various treatment modalities and approaches aresupplementary rather than mutually exclusive.
Combining treatment should follow a protocol. Since high levels of anxiety
or depression may limit participation in psychotherapy, an appropriate medicationtrial may be useful at the onset of treatment. If rituals or obsessions are prominent,speciﬁc behavior interventions—such as response prevention, exposure, habitu -
ation, and thought stopping (Salkovskis & Kirk, 1989) are indicated. The basicdynamics of perfectionism, indecisiveness, and isolation of affect are best reachedby psychotherapeutic approaches. The decision to choose an individual, group,or a marital modality, or a combination of modalities, is best based on severityof the disorder, the particular treatment target, and speciﬁc contraindications. 204 Diagnosis and Treatment of DSM-5 Personality Disorders

For instance, where isolation of affect and perfectionism manifest primarily as
rambling speech pattern, integrative group therapy approach, such as describedby Wells, et al. (1990), may greatly delimit resistance and subsequent counter -
transference so common in dynamic treatment formats. Where indecisiveness isa prominent issue, modelling and other behavioral methods, as well as role playingmight be incorporated in individual treatment formats. In general, the more severethe disorder, the more treatment needs to be tailored and multimodal.
Salzman (1989) concludes that a true understanding and appreciation of the
obsessive compulsive personality “requires an integration of psychodynamic,pharmacologic, and behavior therapies, because the resolution of the disablingdisorder demands cognitive clarity plus behavioral and physiologic alterations. Eachmodality alone deals with only a piece of the puzzle. A therapist who can combineall these approaches will be the most effective” (Salzman, 1989, p. 2782).
Developmental Therapy . Developmental approaches to therapy focus on
fostering optimal functioning. For individuals with obsessive-compulsivepersonality style who seek to develop beyond the adequate level of functioning,the current endpoint of therapy, a developmental-focused therapy utilizes avariety of interventions to facilitate this process and goal. Various developmentalapproaches have been proposed (Blocher, 2000; Cortright, 1997; Sperry, 2002).A protocol for conducting developmental therapy for individuals with Obsessive-Compulsive Personality is described and illustrated by Sperry (2002).
Manduchi and Schoendorff (2012) provide a case study of a 36-year-old mother
of three undergoing Functional Analytic Psychotherapy (FAP) for a diagnosis ofObsessive-Compulsive Personality Disorder with borderline features. This typeof treatment involves using the therapist’s in-the-moment private experiencesregarding the client to promote changes in behavior. It is an integrative approachthat may include exploration of past signiﬁcant relationships as well as the practiceof new interpersonal skills in the session. This is accomplished through the analysisof three types of Clinically Relevant Behaviors (CRBs). CRB1s are behaviorsthat are directly observable in session and linked to client reports of outside-of-session problems; CRB2s are in-session behaviors that represent improvementsover CRB1s; ﬁnally, CRB3s are the client’s functional explanations for his orher behavior, including antecedents and consequences.Obsessive-Compulsive Personality Disorder 205

10
PARANOID PERSONALITY 
DISORDER
Individuals with paranoid personalities are aloof, emotionally cold individuals who
display unjustiﬁed suspiciousness, hypersensitivity, jealousy, and a fear of intimacy.In addition they can be grandiose, rigid, contentious, and litigious. Because oftheir hypersensitivity to criticism and tendency to project blame on others, theytend to lead isolated lives and are often disliked by others (Hopwood & Thomas,2012). Paranoid Personality Disorder can be thought of as a paranoid spectrumdisorder ranging from this personality disorder through the delusional disorderto paranoid schizophrenia. The distinguishing feature of this personality disorderfrom others on the spectrum is the lack of clear-cut delusions, hallucination, orother psychotic features.
of this disorder. It includes sections on its description, case conceptualizations,assessment, and treatment interventions. It begins with background informationon the disorder as well as a DSM-5 description and a prototypic description ofthis disorder. The section on case conceptualizations provides ﬁve common clinicalformulations of this disorder: psychodynamic, cognitive-behavioral, interpersonal,biosocial, and an integrative conceptualization of this disorder. Several treatmentapproaches, modalities, and intervention strategies are also described. Theseinclude individual psychotherapy, group therapy, marital and family therapy,medication, and integrative and combined treatment.
Description of the Paranoid Personality Disorder
The Paranoid Personality Disorder can be recognized by the following descriptorsand characteristics: style vs. disorder, triggering event(s), behavioral style, inter -
personal style, cognitive style, affective style, attachment style, and optimal diag -
nostic criterion.

Style vs. Disorder . The paranoid personality can be thought of as spanning
a continuum from healthy to the pathological, with the paranoid personality styleon the healthy end and the Paranoid Personality Disorder on the pathologicalend. Table 10.1  compares and contrasts differences between the paranoid person -
ality style and disorder.
The following two cases further illustrate differences between the Paranoid
Personality Disorder—Mr. W.—and the paranoid personality style—Ms. L.Paranoid Personality Disorder 207
TABLE 10.1 Comparison of the Paranoid Personality Style and Disorder
Self-assured and conﬁdent in their ability Reluctant to conﬁde in others because
to make decisions and take care of of unwarranted fear that the themselves. information will be used against them.
Good listeners and observers, keenly Reads hidden meanings or threats
aware of subtlety, tone, and multiple levels into benign remarks or events, i.e.,of meaning. suspects that a neighbor put out trash
early to annoy them.
Take criticism rather seriously without Bears grudges or is unforgiving of 
becoming intimidated. insults or slights.
Place a high premium on loyalty, ﬁdelity, Questions, without justiﬁcation, the
working hard to earn and maintain loyalty, ﬁdelity of spouse or sexual partner, and never taking it for granted. friends, and associates.
Careful in dealings with other people, Expects, without sufﬁcient basis, to be
preferring to size up individuals before exploited or harmed by others.entering into relationships with them.
Are assertive and can defend themselves Easily slighted and quick to react with
without losing control and becoming anger or to counterattack.
aggressive.
CASE STUDY: PARANOID PERSONALITY DISORDER
Mr. W. is a 53-year-old male referred for psychiatric evaluation by his attorney
to rule out a treatable psychiatric disorder. Mr. W. had entered into ﬁve
lawsuits in the past two and one-half years. His attorney believed that each
suit was of questionable validity. Mr. W. was described as an unemotional,highly controlled male who was now suing a local men’s clothing store “for
conspiring to deprive me of my consumer rights.” He contends that the store
manager had consistently issued bad credit reports on him. The consultingpsychiatrist elicited other examples of similar concerns. Mr. W. had longdistrusted his neighbors across the street and regularly monitors their activity,

since one of his garbage cans disappeared two years ago. He took an early
retirement from his accounting job one year ago because he could not get
along with his supervisor, whom he believed was faulting him about hisaccounts and paperwork. He contends he was faultless. On examination, Mr.
W.’s mental status is unremarkable except for constriction of affect and for
a certain hesitation and guardedness in his response to questions.
likely triggers or activates the characteristic maladaptive response of the ParanoidPersonality Disorder (Othmer & Othmer, 2002), as noted in behavioral, inter -
personal, cognitive, and affective styles, is: “close interpersonal relationshipsand/or personal queries.”
Behavioral Style . Behaviorally, paranoid individuals are resistive of external
inﬂuences. They tend to be chronically tense because they are constantlymobilized against perceived threats from their environment. Their behavior alsois marked by guardedness, defensiveness, argumentativeness, and litigiousness.CASE STUDY: PARANOID PERSONALITY STYLE
Ms. L. is a 46-year-old tax attorney for a major corporation. Although she had
been reluctant to leave her private law practice, the corporation had courted
her for several years. They really needed a skilled and successful female to
round out their legal team. They made her an offer she couldn’t refuse, and
after ensuring that she could maintain sufﬁcient independence in the job, she accepted. Although she had a loose reporting relationship to the chief
counsel and two corporate vice-presidents, from the beginning Ms. L.
maintained cordial but somewhat distant relationships with them. Sheattended only those meetings and social gatherings that were absolutely
required. She kept small talk to a minimum and went about her work with a
single-minded vigor that others came to respect, although they couldn’t quite
understand her style of relation. When others began to question her
standofﬁsh manner, she replied she was hired “to be a competent litigator,not a social butterﬂy.” In the courtroom she was an awesome sight: cool, calm,
and collected. She was totally in charge of examining and cross-examining
witnesses, and in her opening and closing statements. No stone was leftunturned and no verbal or nonverbal cue was missed. She instinctively went
for the “juggler,” as her peers would say, and seldom lost a judg ment. There
was never a question about her worth or loyalty to the cor poration, and, in
time, her peers and superior came to accept her unique style. 208 Diagnosis and Treatment of DSM-5 Personality Disorders

Interpersonal Style . Interpersonally, these individuals tend to be distrustful,
secretive, and isolative. They are deeply suspicious of others’ motives. They arealso intimacy-avoiders by nature, and repudiate nurturant overtures by others.
Cognitive Style . Their cognitive style is characterized by mistrusting
preconceptions. They carefully scrutinize every situation, and scan the environ -
ment for “clues” or “evidence” to conﬁrm their preconceptions rather than objec -
tively focus on data. Thus, while their perception may be accurate, their judgmentoften is not. The paranoid personalities’ prejudices mold the perceived data toﬁt their preconceptions. Thus, they tend to disregard evidence that does not ﬁttheir preconceptions. When under stress their thinking can take on a conspiratorialor even delusional ﬂavor. Their hypervigilance and need to seek evidence toconﬁrm their beliefs lead them to have a rather authoritarian and mistrustfuloutlook on life.
Affective Style . Their emotional or affective style is characterized as cold,
aloof, unemotional, and humorless. In addition, they lack deep sense of affection,warmth, and sentimentality. Because of their hypersensitivity to real or imaginedslights, and their subsequent anger at what they believe to be deceptions andbetrayals, they tend to have few, if any, friends. The two emotions they experienceand express with some depth are anger and intense jealousies.
Attachment Style . Individuals with a fearful attachment style exhibit a sense
of personal unworthiness combined with an expectation that other people willbe rejecting and untrustworthy. They trust neither their own internal cognitionsor feelings nor others’ intentions. While they believe themselves to be specialand different from others, they guard against threats and unexpected circumstances,since they cannot trust that others will protect them. This fearful attachment styleis common in individuals with Paranoid Personality Disorder.
Dependent Personality Disorder, one has been found to be the most useful indiagnosing this disorder. The belief is that, by beginning with this criterion, theclinician can test for the presence or absence of the criterion and more quicklydiagnose the personality disorder (Allnutt & Links, 1996). The optimal criterionfor this disorder is: suspects, without sufﬁcient basis, that others are exploiting,harming, or deceiving him or her.
Individuals with this personality disorder are characterized by an unremittingpattern of distrust and suspicion and interpret others’ motives as harmful. Withoutsufﬁcient basis, they suspect that others are exploiting, harming, or deceiving them.They are obsessed with unfounded doubts about the loyalty of friends and associ -
ates. Because of their unfounded fears, they are reluctant to conﬁde in others.They are likely to interpret otherwise benign remarks and situations as threateningand dangerous. Not surprisingly, they are unforgiving of slights, insults, and injuries.Paranoid Personality Disorder 209

These individuals are quick to react angrily or to counterattack when they believe
that their character or reputation is being attacked. They are likely to continuallysuspect, without justiﬁcation, that their spouse or sexual partner is unfaithful(American Psychiatric Association, 2013).
A prototype is a brief description that captures the essence of how a particulardisorder commonly presents. Prototypic descriptions are useful and convenientand clinicians commonly rely on them rather than lists of behavioral criteria andcore and instrumental beliefs (Westen, 2012). Here is a common prototypicdescription of the Paranoid Personality Disorder: These individuals grew upbelieving that the world is dangerous and that others—particularly those closestto them—are never to be trusted. They are constantly checking to make surethat no one takes advantage of them, makes fun of them, or plots against them.Convinced that it will be used against them, they will not share their thoughtsor feelings. They hold on to grudges, never forget a slight, nor pass up a chancefor revenge.
Prevalence of this disorder has been estimated at between 2.3 and 4.4 percent inthe general population (American Psychiatric Association, 2013). In clinicalsettings, estimates are that it is found in 4.2 to 27.6 percent of patients (Torgersen,2012).
Conceptualizations of the Paranoid Personality Disorder
Psychoanalytic formulations of the paranoid personality focus on the phenomenon
of projection. Essentially, paranoid individuals inaccurately perceive in others thatwhich is true of them, and, as by projecting unacceptable feelings and impulsesonto these experience reduction of anxiety and distress (Shapiro, 1965).
The self-representation of the paranoid personality involves the coexistence
of a special, entitled grandiose self with a weak, worthless, inferior polar opposite(Gabbard, 1990). Developmentally, individuals with Paranoid Personality Disorderare likely to have grown up in an atmosphere charged with criticism, blame, andhostility, and to have identiﬁed with a critical parent. Identiﬁcation with suchcritical parents suppresses these individuals’ feelings of inadequacy and ensuresthe continuing importance of the mode of criticalness in the development andfunctioning of the personality. Through their identiﬁcations paranoid individualslearn hypervigilance, suspiciousness, and blaming. Hypervigilance and suspicious-210 Diagnosis and Treatment of DSM-5 Personality Disorders

ness prevent self-criticism, while blaming—considered an identiﬁcation with
the aggressor—serves to erase possible experience of humiliation (Kellerman &Burry, 1989).
Paranoid individuals focus on seeing imperfection in the world around them.
This externalization permits a denial of any personal imperfection. Essentially,
paranoid individuals feel inferior, weak, and ineffective; thus, grandiosity and
specialness are allowed to be understood as a compensatory defense againstfeelings of inferiority (Gabbard, 1990).
The primary defense mechanisms of this disorder are, then, projection and
projective identiﬁcation. In addition to externalizing threats with projection,projective identiﬁcation additionally serves to control others in the environmentby binding them to paranoid individuals in pathological ways. This need to control
others reﬂects low self-esteem, which is at the heart of the Paranoid Personality
Disorder. Basically, it sensitizes these individuals to concerns about all passivesurrender to all impulses and to all persons (Shapiro, 1965). Finally, rationalization,reaction formation, and displacement are secondary defense mechanisms.
In short, the need to criticize the world and external objects allows paranoid
individuals to maintain an anxiety-free existence in the face of personalimperfections and a grave sense of inadequacy. Profound inferiority feelings areprojected onto the “inferior” world, which is then related to in a consistentlycritical manner. The self can be then viewed as “good” and “badness” split offand projected outward.
According to Beck (2015), individuals with paranoid personality are distrustfulof others in most circumstances. They are identiﬁable by their characteristic core,conditional, and instrumental beliefs. Their core beliefs include: “Other people can’t
be trusted,” “Others have ulterior motives (or bad intentions) toward me,” and“Others are deceptive, and are out to hurt or undermine me.” Their conditional
belief is that, if they are not careful, others will abuse, manipulate, or take
advantage of them, and that if others act friendly it is only because they have anulterior motive. Their instrumental belief is to be on guard, look for hidden meaning,
trust no one, and don’t get taken in. Underlying these various beliefs are theirbeliefs about self and the world.
These individuals typically view themselves as righteous and mistreated by
others. They tend to view others as devious, treacherous, manipulative, and dis -
crim inatory. They may believe that others form secret coalitions against them.
Based on belief that others are against them, these individuals are driven to behypervigilant and on guard. Their strategy is to be wary, vigilant, and counter -
attack. When they confront their “adversaries,” they often provoke the hostilitythat they believed already existed (Renton & Mankiewicz, 2015).Paranoid Personality Disorder 211

From a more behavioral perspective, Turkat (1990) contends there is no single
formulation for this disorder. However, hypersensitivity to criticism is charac -
teristic. Such individuals receive early training to be frightened at what othersthink of them. These individuals also learn that they are different than others,and that they must not make mistakes. As a result of these two beliefs, paranoidindividuals become overly concerned about the evaluations of others, constrainedto conform to parental expectations, and hypersensitive to others’ evaluation. This,of course, often interferes with acceptance by their peers. Eventually, they arehumiliated and ostracized by their peers, in part because they lack the interpersonalskills necessary to overcome this ostracism. Consequently, they excessively engagein ruminating about their isolation and mistreatment by others. From this, theyconclude that the reason for this rejection and persecution is because they arespecial and others are jealous of them. Accordingly, they act in ways to avoidnegative evaluations from others, but these attempts lead them to act differently,which invites social criticism. In their isolation they brood about theirpredicament, which engenders persecutory and grandiose thoughts, which furthermaintain their social isolation. Accordingly, these individuals are caught in a viciouscycle that perpetuates the disorder (Turkat, 1990).
According to Benjamin (2003a), persons diagnosed with Paranoid PersonalityDisorder were likely to have experienced sadistic, controlling, and degradingparenting. Typically abused children themselves, parents of paranoid-disorderedindividuals believed that children are basically evil or bad, require containment,and deserve retribution. Family loyalty was a basic value, and sharing family secretswith others was not tolerated. The adult consequences of such harsh upbringingis that paranoid-disordered individuals expect attack and abuse even from thoseclose to them. As children they were harshly punished for dependency, and evenattached when they were sick, hurt, or cried. As a result, they learned not to cry,not to ask for help even if injured or sick, and not to trust anyone. Subsequently,as adults they tend to avoid intimacy unless they can control their partner. Oftenthese individuals were subjected to covert as well as overt invidious compar-isons within the family, and later among peers. They learned that mistakes andhurts were seldom forgotten and that grudges were long-lasting. Not surprisingly,paranoid individuals are exquisitely sensitive and angry about exclusion, slights,and even whispering. They tend to be keenly aware of any inequalities inpunish  ments or privileges, and they are likely to sustain grudges for long periods.
Furthermore, as children they were rewarded for competence in helping the family,while “staying out of the way.” While they were given permission and supportto do well, they were degraded and humiliated for venturing out of an assignedarea. They came to believe that being a good and lovable person was outsidetheir reach. Subsequently, as adults they can function competently and212 Diagnosis and Treatment of DSM-5 Personality Disorders

independently but are interpersonally withdrawn. Their expectation of not being
acknowledged inspires fear, resentment, and alienation. Finally, they con stantly
fear that others will attack, blame, or hurt them, while they continue to wishthat others will afﬁrm and understand them. Not expecting to be afﬁrmed, theyangrily withdraw and tightly control themselves and, if they perceive attack, willreﬂexively counterattack.
In a marked departure from other formulations of Paranoid Personality Disorder,Millon (Millon & Davis, 1996) and Millon and Everly (1985) conceive of theParanoid Personality Disorder as a severe form of character pathology. Morespeciﬁcally, Millon and Everly describe it as syndromal continuation of three lesssevere personality disorders: Narcissistic, Antisocial, or Compulsive. Based on theirclinical research, individuals with paranoid personalities develop in one of thesethree syndromal patterns based on their unique biogenic and environmentalhistories. The narcissistic variation of the paranoid disorder is largely shaped byparental overvaluation and indulgence. As a result, these individuals fail toadequately learn interpersonal responsibility, cooperation, and interpersonal skills.They are often perceived by others as selﬁsh and egotistical. Furthermore, lackof parental controls can give rise to grandiose fantasies of success, power, beauty,or brilliance. As a result they tend to be rejected and humiliated by their peers.These interpersonal rebuffs are followed by increased fantasy and isolation fromwhich a propensity for paranoia emerges.
The antisocial variant of the paranoid personality exhibits high levels of
activation and impulsive high-energy temperaments. The principal environmentaldeterminant seems to be harsh parental treatment. Consequently, they developa deep, abiding mistrust of others and manifest a strong self-directedness andarrogance. Because of their tendency to reject both parental and social controls,they also develop an aggressive, impulsive, hedonistic lifestyle. Anticipating theattacks of others, paranoid-antisocial individuals react irrationally and vindictively.Since they are unable to cope directly with perceived threats, they often eruptin overt hostility.
Individuals with the paranoid-compulsive pattern have developmental histories
quite similar to the Obsessive-Compulsive Personality Disorder. However, theyexhibit more irrationally rigid and inﬂexible behavior (Millon & Everly, 1985).These three versions of the paranoid disorder appear to be self-perpetuated bytheir own rigidity and suspiciousness. By ascribing slanderous and malevolentmotives to others, paranoid individuals remain in a defensive and vindictive posturemost of the time. Furthermore, keeping distance from others fosters themaintenance of their illusion of superiority, which allows a self-fulﬁlling pattern:as they expect others to be hostile and malevolent, others often become so.Paranoid Personality Disorder 213

The following integrative formulation provides a biopsychosocial explanation 
for how this personality is likely to have developed and how it is maintained.
Biologically, a low threshold for limbic system stimulation and deﬁciencies in
inhibitory centers seem to inﬂuence the behavior of the paranoid personality.The underlying temperament can best be understood in terms of the subtypes ofthe paranoid disorder. Each of three subtypes are brieﬂy described in terms 
of their underlying temperament, and correlative parental and environmental
factors. In the narcissistic type, a hyperresponsive temperament and precocious-ness, parental overvaluation and indulgence, as well as the individual’s sense of
grandiosity and self-importance, probably result in deﬁcits in social interest and
limited interpersonal skills. The antisocial type of the paranoid personality is likelyto possess a hyperresponsive temperament. This, plus harsh parental treatment,
probably contributes to the impulsive, hedonistic, and aggressive style of this type.
In the compulsive type, the underlying temperament may have been anhedonic.This, as well as parental rigidity and overcontrol, largely accounts for the develop -
ment of this type. Finally, a less common variant is the paranoid-passive aggressivetype. As infants, the individuals usually demonstrated the “difﬁcult child”temperament, and later temperament characterized by affective irritability. This,plus parental inconsistency, probably accounts in large part for the developmentof this type (Millon, 1981).
Psychologically, paranoid individuals view themselves, others, the world, and
life’s purpose in terms of the following themes. They tend to view themselvesby some variant of the theme “I’m special and different. I’m alone and no one
likes me because I’m better than others.” Life and the world are viewed by some
variant of the theme “Life is unfair, unpredictable and demanding. It can andwill sneak up and harm you when you are least expecting it.” As such, they are
likely to conclude: “Therefore, be wary, counterattack, trust no one, and excuse
yourself from failure by blaming others.” The most common defensive mechanismassociated with the paranoid disorder is projection.
noted for this disorder. For all the subtypes the parental injunction appears to be:
“You’re different. Don’t make mistakes.” Paranoid Personality-Disorderedindividuals tend to have perfectionistic parents who expose these children tospecialness training. This, plus the parental style that has been articulated for thesubtypes of the disorder and parental criticism leads to an attitude of social isolationand hypervigilant behavior. To make sense of the apparent contradiction betweenbeing special and being ridiculed, the children creatively conclude that the reason
they are special and that no one likes them is because they are better than other
people. This explanation serves the purpose of reducing their anxiety and allowingthem to develop some sense of self and belonging.214 Diagnosis and Treatment of DSM-5 Personality Disorders

This paranoid pattern is conﬁrmed, reinforced, and perpetuated by the
following individual and systems factors: a sense of specialness, rigidity, attributingmalevolence to others, blaming others, and misinterpreting motives of others leadsto social alienation and isolation, which further conﬁrms the individual’spersecutory stance (Sperry, 2015; Sperry & Mosak, 1996).
Table 10.2  summarizes the characteristics of this disorder.Paranoid Personality Disorder 215
TABLE 10.2 Characteristics of Paranoid Personality Disorder
Triggering Event(s) Close interpersonal relationships and/or personal queries
Behavioral Appearance Guarded and defensive
Resists external inﬂuenceHypervigilant and chronically tense
Interpersonal Behavior Distrustful and suspicious of others
Reluctance to conﬁdeBears grudges and blamesCounterattacks for perceived slightsHypersensitive to slights and criticism
Cognitive Style Tends to disregard evidence to the contrary
Quick to rationalize and hold to preconceptions
Affective Style Restricted affect, but easily provoked
Aloof and humorlessJealous and envious
Temperament Narcissistic type: active, hyperresponsive
Compulsive type: irritablePassive-Aggressive type: affective irritability
Attachment Style FearfulParental Injunction “You’re different. Keep alert. Don’t make mistakes.”Self-View “I’m so special and different. I’m alone and no one likes
me, because I’m better than others.”
World-View “Life is unfair, unpredictable, and demanding. It will
sneak up and harm you. Therefore, be wary, counter -
attack, trust no one, and excuse yourself from failure byblaming others.”
Maladaptive Schemas Abuse/mistrust; defectivenessOptimal Diagnostic Suspects, without sufﬁcient basis, that others are
Criterion exploiting, harming, or deceiving him or her

Assessment of Paranoid Personality Disorder
logical testing are important adjuncts to the patient’s self-report in the clinical
interview. This section brieﬂy describes some characteristic observations that the
clinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e., MMPI-2 and MCMI-IV) and projective (i.e.,Rorschach and TAT) tests are also described.
Interviewing Paranoid Personality-Disordered individuals is a delicate challenge.Rapport with them is hampered by their pervasive belief that others will harmand exploit them. Therefore, they screen all questions for conspiratorial contentand hidden meaning, and assume that any kindness shown by the clinician is a
clever maneuver to take advantage of their weakness. Similarly, they cannot allow
themselves to relax in the interview, fearful that easing up would make them toovulnerable, and so they justify their suspiciousness and hypervigilance. They caneasily confront others, but will not tolerate being confronted. Smooth transitionsfrom topic to topic are essential. Any abruptness may be experienced as an unjusti -
ﬁed attempt to trap them, which could lead to anger, counterattack, or
termination of the interview (Ackley et al., 2011; Othmer & Othmer, 2002).
The Minnesota Multiphase Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-IV), the Rorschach Psychodiagnostic Test, and theThematic Apperception Test (TAT) can be useful in diagnosing the CompulsivePersonality Disorder as well as the Obsessive Compulsive Personality style (Groth-Marnat, 2009).
On the MMPI-2, an elevation on the 6 scale (Paranoia) is common. However,
since these individuals tend to be hyperalert about being perceived as paranoid,
this scale may be greatly elevated (Graham, 2012). These individuals are easilyirritated at the MMPI’s forced choice format as well as the self-disclosure requiredof many of the items (Meyer, 1995). Scales 3 (Hysteria) and 1 (Hypochondriasis)and K (Correction) tend to be high in these individuals, reﬂecting their use of
denial and projection, their inclination to focus on somatic concerns, and their
need to present a facade of adequacy (Graham, 2012).
On the MCMI-IV, elevation on scale 6B (Sadistic) and P (Paranoid) are
expected (Millon et al., 2015). Since this personality pattern often overlaps withthe antisocial, the narcissistic, and the passive aggressive, elevations are likely on216 Diagnosis and Treatment of DSM-5 Personality Disorders

scales 6A (Antisocial), 5 (Narcissistic), and 8A (Negativistic-passive aggressive)
(Choca & Denburg, 1997).
On the Rorschach, these individuals produce records that are generally
constricted, but characterized by more P (Popular) and A (Animal) responses thanC (Pure color) and M (Human Movement) responses. These individuals typically
resent ambiguous stimuli and so respond to the test with condescending criticism
and ﬂipping of cards, and a focus on D (Detail) responses. Occasionally they rejectcards or refuse to continue with the examination (Meyer, 1995).
On the TAT, suspiciousness may characterize their stories. This is particularly
likely to occur on cards 9, G, F, 11, and 16 (Bellak, 1997).
Included in the differential diagnosis of this disorder are the following personality
disorders: Antisocial, Narcissistic, and Obsessive Compulsive. The most commonsymptom disorders associated with the Paranoid Personality Disorder are
Generalized Anxiety Disorder, Panic Disorder, and Delusional Disorder. If aBipolar Disorder is present, an irritable manic presentation is likely. Decom -
pensation into schizophrenic reaction is also likely. When this occurs, the paranoidand catatonic subtypes are most likely to be present (Sperry, 2015).
Until recently, the prognosis for treatment of the Paranoid Personality Disorder
was considered guarded. Today, more optimism prevails in achieving speciﬁc
treatment goals, such as increasing the benignness of perception and interpretationof reality, and increasing trusting behavior. Several psychotherapeutic andpsychoeducation interventions are useful in accomplishing these goals. Medicationmay be useful in decreasing anxiety associated with loss of control. To date, nocontrolled treatment outcomes studies have been completed for the ParanoidPersonality Disorder (Crits-Christoph & Barber, 2002).
Psychodynamically Oriented Psychotherapy
Patients with paranoid personalities tend to be individuals who lead reasonably
adaptive and productive lives and, not surprisingly, are responsive to psycho -
dynamic psychotherapy. Meissner (1978) contends, however, that their treatmentis not easy but requires empathy, patience, and a great deal of sensitivity to theirvulnerabilities. Meissner contends that the treatment process must be slowly paced,with limited, long-term goals. Three treatment principles characterize suchtreatment (Meissner, 1978, 1986).Paranoid Personality Disorder 217

First, a meaningful therapeutic alliance must be established and maintained.
The therapeutic alliance requires the patient have a certain degree of trust in theclinician, which is considerably difﬁcult for paranoid patients. The clinician’sempathic responsiveness and willingness to serve as a container for a range ofnegative affects is essential. The clinician must avoid responding defensively, norchallenge the patient’s perception of events or of the clinician. Instead, the clinicianasks for more details and empathizes with the patient’s perceptions and affects.Most importantly, the clinician must resist the countertransference tendency tobe rid of indescribable projection by deﬂecting them back to the patient withpredictive interpretations (Epstein, 1984). In short, the patient must come to viewthe clinician as a benign, disinterested, but friendly, helper (Salzman, 1980).
Second, the essential treatment strategy is to convert paranoid manifestations
into depression and work through the underlying mourning. Gradual
undermining of paranoid defenses and attitudes leads to the emergence of adepressive core in which the patient’s inner sense of weakness, defectiveness,vulnerability, and powerlessness comes into focus. This is accomplished throughthe techniques of counterprojection and “creative doubt” (Meissner, 1986).Depressive elements are worked through in the transference, which allows themto begin the process of mourning their frustrated learning and disappointments
with early objects.
Third, the clinician must respect the patient’s fragile and threatened sense of
autonomy and work toward building and reinforcing it in the therapeutic
relationship. A commitment to openness, honesty, and conﬁdentiality means that
all decisions must be explored with the patient, and the ultimate choice must bethe patient’s. This even applies to decisions about medication, if when and if theyare indicated (Meissner, 1989).
Since these patients tend to be resistant, provocative and contentious,
countertransference issues cannot be underestimated. Behind their defensivenessand arrogance are narcissistic vulnerability, core feelings of shame and humiliation,
and passive longing for dependence. Thus, these patients attempt to counter their
anxieties by “turning the tables” and making the clinician feel vulnerable,humiliated, and helpless. Clinicians may react with annoyance, impatience, con -
frontation and argumentation. Or, they may experience frustration, discourage -
ment and victimization. These reactions must be monitored, their impact on
therapy analyzed, and efforts to rebalance the therapeutic alliance initiated(Meissner, 1989). Examples of these kinds of exchanges can be found in Williams
(2010).
Metacognition-oriented therapy provides another treatment for personality
disorders based on individual narrative and interpretation. Its goal is to pro gressively
promote awareness of problems in subjective experience and schemas driving social
behavior (Salvatore, Russo, Russo, Popolo, & Dimaggio, 2012). Therapists elicit
patients’ autobiographies, or narrative episodes, to identify the inﬂuences and218 Diagnosis and Treatment of DSM-5 Personality Disorders

theories behind their problems. This also includes work intended to develop the
skills to understand the minds of others. The authors present a case study of aneight-month, ongoing course of metacognition-oriented treatment with a 31-year-old female law student diagnosed with Paranoid Personality Disorder anddelusional disorder.
A similar type of psychotherapy used for Paranoid Personality Disorder is based
on Dialogical Self Theory (DST), which examines the inner dialog betweendifferent parts, or voices, of the self (Dimaggio, Catania, Salvatore, Carcione, &
Nicolo, 2006).
Brief Psychodynamic Psychotherapy
Long-term psychodynamically oriented psychotherapy involves two or more
sessions per week for three or more years. However, since Paranoid Personality-
Disordered individuals do not easily engage in the therapeutic process, they may
have reluctance to such intensive long-term work. On the other hand, receptivityfor treatment has increased during crisis period, usually the experience of acuteanxiety or depression. Shorter-term therapy that is more crisis-oriented might bea preferable way of beginning treatment. Such crisis-focused short-term therapycould be a prelude to longer-term treatment.
Malan (1976) and Balint, Ornstein, and Blaint (1972) describe short-term
psychotherapy with acute paranoid difﬁculties. While these treatments were
effective with reactive paranoid presentations, it may not be for the enduringpresentations, more typical of the Paranoid Personality Disorder. Currently,
there are no published reports of completed successful treatments of Paranoid
Personality Disorder in the context of brief dynamic psychotherapy.
model of psychodynamically oriented treatment that has been used for personality
disorders. It consists of a narrative reformulation and the sequential diagrammatic
reformulation (SDR). Patients receive 24 weekly sessions and four follow-upsessions spread out over a six-month period. Following the ﬁrst three assessment
the origins of their distress and identiﬁes target problems and procedures. Kellettand Hardy (2014) conducted a mixed-methods single-case study with a 36-year-old male diagnosed with Paranoid Personality Disorder. The six target complaint
measures were as follows: suspiciousness; hypervigilance; dissociation; conspiracy;questioning; and anxiety. Cognitive Analytic Therapy ends with a “goodbye letter”
jointly formulated by the patient and therapist to summarize achievements,
prepare for future obstacles, and address any feelings of abandonment related to
the termination of therapy. Results showed that ﬁve out of the six measuresidentiﬁed at the onset of treatment were extinguished during the treatment phase.The patient also attributed his changes to the CAT method.Paranoid Personality Disorder 219

Cognitive Therapy Approach . Beck et al.(2004) provide an extended dis cussion
of the Cognitive Therapy approach with Paranoid Personality-Disordered
individuals. The initial phase of treatment can be exceedingly stressful for paranoidindividuals in that participating in treatment requires self-disclosure, trustinganother, and acknowledging weakness, all of which they experience as being quitedangerous. This stress can be reduced by focusing initially on less sensitive issuesor by discussing issues directly, i.e., talking about how “some individuals”experience and react to such situations, or by beginning with a more problem-solving approach and behaviorally focused interventions on presenting problems.
Such strategies, as well as giving the individual more than the usual amount ofcontrol over scheduling appointments or the content of sessions, can facilitate
development of a collaborative working relationship wherein they will feel lessdistrustful, coerced, and vigilant. Trust can be engendered by explicitly acknow -
ledging and accepting the individual’s difﬁculty in trusting the therapist. As thisbecomes evident and gradually demonstrated through trustworthiness and actions,it provides the evidence on which trust can be based.
A guided discovery approach when working on treatment goals will reveal
the manner in which their paranoid pattern contributes to their problems,facilitating collaborative work on their distrust of others, feelings of vulnerability,and desire for retribution, rather than the therapist insisting that these issues bedirectly addressed. As treatment progresses to working on speciﬁc goals, emphasisshould shift to increasing the individual’s sense of self-efﬁcacy before attemptingto modify interpersonal behaviors, automatic thoughts, or schemas. Developingan increased awareness of another’s point of view, and learning a more assertiveapproach to interpersonal conﬂict, are other common treatment goals with theseindividuals. The use of traditional cognitive behavioral techniques such as assertivecommunication training and behavioral rehearsal are commonly employed toreverse the provocation of hostile reactions from others that previously conﬁrmedthe paranoid individual’s view of self and others. In instances where hypervigilanceand ideas of reference are particularly resistant, the information-processing socialskills intervention strategy described by Turkat and Maisto (1985) can beexceptionally useful.
The treatment goals are to decrease sensitivity to criticism, and modify social
behavior. Social skills training consists of instructional role-playing, behavioralrehearsal, and videotaped feedback. The patient is taught to attend to moreappropriate social stimuli; to interpret that information more accurately; to attack,criticize, or single out the patient; and to receive others’ feedback in a non defensive
way and utilize it constructively (Turkat, 1990). Turkat and Maisto (1985)present a detailed case report illustrating these treatment strategies.
Williams (1988) provides a detailed case report of time-limited cognitive therapy
with a substance-depressed college student who also met criteria for Paranoid220 Diagnosis and Treatment of DSM-5 Personality Disorders

Personality Disorder. The patient was distressed about poor interpersonal relations
and drug use, and was quite intelligent and motivated for therapy. Noteworthyabout Williams’ treatment protocol is that only 11 sessions were available andneeded to achieve three treatment goals: reduce depressive symptoms, less threat -
ening perceptions of the world, and other people; and increase skills in beingmore relaxed and comfortable with others. Cognitive restructuring and progressivemuscle relaxation were the principal intervention strategies. The six-monthfollow-up showed that all gains had been maintained. Williams concludes thatbrief cognitive therapy may be particularly well suited for the Paranoid PersonalityDisorder. Renton and Mankiewicz (2015) identify three key treatment goals forthe treatment of any Cluster A disorder: elicit trust in therapy by exploringambivalence and respecting the individual’s independence and boundaries; explorethe inﬂuence of unhelpful beliefs about others in key social contexts while develop -
ing alternative, functional beliefs; and experiment with new social behaviors notbased on suspicion and mistrust. They provide a case study of a 27-year-old femaleaccountant diagnosed with Paranoid Personality Disorder.
In short, the Cognitive Therapy approach to working with paranoid individuals
focuses considerable effort on carefully developing a work collaborativerelationship, and increasing the individual’s sense of self-efﬁcacy early in treatment.It utilizes cognitive techniques and behavioral experiments to directly challengethe individual’s remaining paranoid beliefs late in therapy.
Schema Therapy . Schema Therapy is an elaboration of cognitive therapy that
has been developed by Young (1999; Young et al., 2003) speciﬁcally for personalitydisorders, and other difﬁcult individual and couples problems. Schema Therapyinvolves identifying maladaptive schemas and planning speciﬁc strategies andinterventions. Four main strategies are cognitive, experiential, behavioral, and thetherapeutic relationship itself. Cognitive restructuring, modiﬁcation of mal adaptive
schemas, is an important cognitive strategy, but is combined with imagery exercises,empathic confrontation, homework assignments, and “limited reparent ing,” i.e.,
a form of corrective emotional experience (Young, 1999; Young et al., 2003).
Maladaptive schemas typically associated with Paranoid Personality Disorder
include: mistrust/abuse —the belief that others will abuse, humiliate, cheat, lie,
manipulate, or take advantage; defectiveness —the belief that one is defective, bad,
unwanted, or inferior in important respects; and approval-seeking (Bernstein,
2002).
For Benjamin (2003a), psychotherapeutic interventions with Paranoid Personality-Disordered individuals can be planned and evaluated in terms of whether theyenhance collaboration, facilitate learning about maladaptive patterns and their roots,block these patterns, enhance the will to change, and effectively encourage newpatterns.Paranoid Personality Disorder 221

Benjamin notes that the major treatment problem with paranoid individuals
is establishing a collaborative therapeutic relationship. To the extent thatcollaboration occurs, paranoia disappears. Accustomed to being abused andhumiliated, paranoid individuals view therapists as critical and judgmental, lookfor “slip-ups,” and want them to leave. Patience and kindness without hints ofcoercion, criticism, or appeasement are essential for a considerable period duringthe early stages of therapy. Benjamin provides an excerpt from a session with awoman hospitalized with delusional disorder, suspicious type, that illustrates theeffectiveness of this kind of respectful, caring curiosity.
As treatment proceeds, they must learn that their expectations of attack and
abusive control stem from past experiences. As such, they can begin appreciatingthat these expectations are not always appropriate in the present, and that hostilitybegets hostility. Furthermore, they must come to understand that their defensesof control, avoidance, and anticipatory relation will elicit attack and alienationin others. Benjamin advocates the use of “verbal holding” as an antidote to theiroriginal abuse. Accurate empathy, genuine afﬁrmation of accomplishments, andunderstanding constitute verbal holding. At the same time, therapists need to gentlybut ﬁrmly confront provocations. Since confrontation is likely to be threateningto them, therapists must carefully balance afﬁrmation with confrontation. Thegoal here is for proactive criticism, and these individuals to learn the meaning offeedback and that their feelings of vulnerability and fearfulness do not “prove”that others, including therapists, are attacking them.
Benjamin’s discussion of blocking maladaptive patterns in paranoid individuals
includes strategies for dealing with various crises, such as aborting or redirectingrageful outbursts at therapists, dealing with homicidal threats, and abuse of theirchildren. She believes that the therapist’s honesty, caring, calmness, attentiveness,and clear commitment to resolving conﬂicts are extremely useful to paranoidindividuals in crisis. Benjamin ﬁnds that the wish to relinquish patterns of alien -
ation, hostile control, carrying grudges, and fearfulness do not develop until  these
individuals feel safe to do otherwise. As therapy proceeds, they are helped to lessentheir enmeshment with early controlling, attacking ﬁgures. As they can see thatthey are acting like a hated parent, they may become interested in becomingdifferent.
Once safer bases are established with signiﬁcant others and/or with their
therapist, they can begin channeling their anger in a direction that encouragesseparation from earlier destructive patterns and beliefs. Finally, to the extent thattherapeutic collaboration develops, considerably new learning about trust, givingand receiving positive and negative feedback from and to others, and thinkingmore benignly about people and life circumstances, has already taken place. Asthese are mastered, any residual learning that remains by the last stage of therapyis relatively easy to implement. For paranoid individuals at the last stage oftreatment, excursions into the social world further the idea that friendly approacheselicit friendly reaction which can be slightly frightening but also exhilarating.222 Diagnosis and Treatment of DSM-5 Personality Disorders

Because of their hypersensitivity, suspiciousness, and tendency to misinterpret
comments of others, Paranoid Personality-Disordered individuals tend to avoidgroup therapy and other forms of group treatment. Similarly, the paranoidtendency to be accusatory, self-righteous, obstinate, hostile, and evasive has beena contraindication to heterogeneous intensive group therapy (Frances et al., 1984;Vinogradov & Yalom, 1989; Yalom, 1985).
On the other hand, higher functioning paranoid patients who can maintain a
degree of self-awareness and are able to tolerate a group confrontation of theirparanoid distortion, may derive considerable beneﬁt from participation in anestablished group that is sufﬁciently cohesive and tolerant of divergent opinions(Meissner, 1989). Rutan et al. (2014) provide an example of a patient sharingabout, but not acting upon, his paranoid fantasies about the group facilitator’svacation being a covert attempt to get away from him. The patient connectedthis abandonment fantasy to being the only child in his family to be given up foradoption.
There is relatively little published literature on therapy with the paranoidpersonality, per se. Nonetheless, either treatment modality can be used alone orconcurrently with individual therapy. Meissner (1989) indicates that familytherapy might be combined sometime during the course of long-term individualpsychotherapy. Family therapy might be indicated for the paranoid adolescentwhose family dynamics and interaction patterns interfere with or contribute tothe patient’s difﬁculties.
Harbir (1981) details some general principles for couples therapy for the
paranoid personality. He notes that paranoid features often lead to severe maritaldysfunction. The paranoid partner’s hypersensitivity, joyless intensity, hyper -
vigilance, extreme mistrust, and jealousy cause considerable suffering for theirpartner. Nevertheless, the nonparanoid partner also causes suffering, because theiractions often exacerbate the paranoid condition. Typically, nonparanoid spousesreact passively and secretively when accused or criticized. The more theywithdraw and are evasive, the more their paranoid partner becomes suspiciousand mistrustful. Therefore, the clinician who is treating a married paranoid patientin individual therapy should consider concurrent couples therapy or, at least, aconjoint session with the nonparanoid partner to modify the marital interactionpattern that seems to be maintaining the psychopathology.
The goal of marital therapy is to enhance the positive growth of the couple
by reducing the personality pathology of either or both partners. Harbir (1981)reports that paranoid patients can progress in couples therapy despite the inevitableissues of trust and conﬁdentiality. The clinician needs to be constantly aware ofParanoid Personality Disorder 223

the paranoid partner’s close monitoring of the clinician’s behavior. These patients
invariably become angry if they perceive the clinician taking sides, or becomejealous of the clinician’s relationship with their partner. Thus, the clinician, justas in individual psychotherapy, must be open and forthright about the speciﬁctherapeutic process and their rationale. Once a therapeutic alliance has beenestablished, the clinician can support the nonparanoid spouse to confront andchallenge the constant mistrust of the paranoid partner. An angry response canbe expected at ﬁrst, but the paranoia will start decreasing. Obviously, suchconfrontation is only prescribed when the patient has adequate impulsive controland has not been violent. Harbir describes a detailed case example of conjointcouples therapy involving a paranoid spouse. The treatment involves two stagesand illustrates Harbir’s therapy approach.
Benjamin (2003a) also comments on the role of family in the treatment of
this disorder. Damage caused by the controlling and attacking ﬁgures found inearly life may be challenged by the rehabilitative presence of a spouse or childinvolved in sessions. The paranoid individual may come to see that their hostilebehavior resembles that of their abuser, which can spark a desire to be different.She discusses the implications of child abuse by the paranoid individual at length,including the unintended effect of mandatory reporting laws that can lead topremature termination of treatment.
Currently, there are no psychotropic medications speciﬁcally indicated for treatingthis personality disorder (Silk & Feurino, 2012). Nevertheless, medications areused that target speciﬁc troubling symptoms associated with the disorder, suchas depression, anxiety, or sleep problems. Generally, these medications are usedas an adjunct to psychotherapy and skills training. Because troubling symptomsoften respond to medications sooner than most psychological interventions,medications are usually prescribed at the onset of treatment. Since antipsychoticmedications are somewhat effective in paranoid schizophrenia, it was hoped thatthese medications would likewise be useful in the treatment of this personalitydisorder. Unfortunately, evidence does not support this hope. Furthermore,there is little research evidence to provide guidelines for the use of suchmedications (Silk & Feurino, 2012).
There are sufﬁcient data to suggest that the Paranoid Personality Disorder is nolonger untreatable, as was previously believed, but can be successfully treated.Although treatment with psychodynamic and cognitive-behavioral approaches isconsidered long term, there has been at least one report of successful time-limitedtreatment (Williams, 1988). Currently, there is little published data on integrating224 Diagnosis and Treatment of DSM-5 Personality Disorders

and tailoring treatment with this disorder. Nevertheless, clinical experience shows
that an integrative treatment approach probably can maximize therapeuticoutcomes while decreasing the length of treatment.
Conceptualizing Paranoid Personality Disorder as having temperament and
characterological dimensions, it appears that the dynamic approaches areparticularly effective with the characterological dimensions, but less effective withthe temperament/style dimension. It seems that cognitive restructuring and thebehavioral-information processing approach (Turkat & Maisto, 1985) areparticularly effective with modifying the paranoid’s cognitive style of hyper -
vigilance. The cognitive-behavioral approach is also useful with constrictedaffects. The interpersonal approach (Benjamin, 2003a) seems particularly effectivein reducing blame and hypersensitivity to criticism. Thus, integrating dynamic,cognitive-behavioral, and interpersonal approaches could have a synergistic effect on changing both temperamental and characterological dimensions of thisdisorder. It also appears that combining treatment modalities should increasetreatment efﬁcacy and cost-effectiveness, especially for the more severepresentations of this disorder. The most obvious combined treatment involvesthe concurrent or sequential use of family, marital, or group therapy withindividual psychotherapy. Also quite promising is the combination of medication,i.e., pimozide or serotonin reuptake inhibitors when they are indicated, withindividual psychotherapy.Paranoid Personality Disorder 225

11
SCHIZOID PERSONALITY 
DISORDER
Individuals with schizoid personalities tend to be reclusive and have little desire
or capacity for interpersonal relationships, primarily because they derive littlepleasure from such relationships. Yet, they can perform well if left alone. Forinstance, they can be effective nightwatchmen and security guards. Nevertheless,they have little emotional range, they daydream excessively, and appear to behumorless and aloof (Hopwood & Thomas, 2012).
of this disorder. It includes sections on its description, case conceptualization,assessment, and treatment interventions. It begins with background informationon the disorder as well as a DSM-5 description and a prototypic description ofthis disorder. The section on case conceptualization provides ﬁve commonclinical formulations of this disorder: psychodynamic, biosocial, cognitive-behavioral, interpersonal, and an integrative conceptualization of this disorder.Several treatment approaches, modalities, and intervention strategies are also des -
cribed. These include individual psychotherapy, group therapy, marital andfamily therapy, medication, and integrative and combined treatment.
Description of the Schizoid Personality Disorder
Schizoid Personality Disorder can be recognized by the following descriptors and
characteristics: style vs. disorder, triggering event(s), behavioral style, interpersonal
style, cognitive style, affective style, attachment style, and optimal diagnosticcriterion.
Style vs. Disorder . The schizoid personality can be thought of as spanning
a continuum from healthy to pathological, with the dependent personality styleat the healthy end and the Schizoid Personality Disorder at the pathological end.

Schizoid Personality Disorder 227
TABLE 11.1 Comparison of Schizoid Personality Style and Disorder
Exhibit little need of companionship Neither desire nor enjoy close 
and are most comfortable alone relationships, including being part of a
family; have one or no close friends orconﬁdants other than ﬁrst-degreerelatives.
Tend to be self-contained, not requiring Nearly always choose solitary activities.
interaction with others in order to enjoy experiences or live their lives.
Even-tempered, dispassionate, calm, Rarely, if ever, claim or appear to
unﬂappable, and rarely sentimental. experience strong emotion, such as 
anger or joy.
Little driven by sexual needs, and, while Little if any desire to have sexual
they can enjoy sex, do not suffer in its experiences with another person.absence.
Tend to be unswayed by either praise Indifferent to the praise and criticism
or criticism and can conﬁdently come to of others; display constricted affects, terms with their own behavior. e.g., is aloof, cold, and rarely
reciprocates gestures or facial
expressions, such as smiles or nods.
Table 11.1  compares and contrasts differences between the dependent style and
the disorder.
Schizoid Personality Disorder—Mr. Y.—and the schizoid personality style—Mr. P.
CASE STUDY: SCHIZOID PERSONALITY DISORDER
Mr. Y. is a 20-year-old freshman who met with the director of the
Introductory Psychology course program to arrange an individual assignmentin lieu of participation in the small-group research project course requirement.
He told the course director that, because of a daily two-hour commute each
way, he “wouldn’t be available for the research project,” and that he “wasn’treally interested in psychology and was only taking the course because it
was required.” Upon further inquiry, Mr. Y. disclosed that he preferred to
commute and live at home with his mother, even though he had theﬁnancial resources to live on campus. He admitted he had no close friends
nor social contacts, and preferred being a “loner. “ He had graduated from

likely triggers or activates the characteristic maladaptive response of the SchizoidPersonality Disorder (Othmer & Othmer, 2002), as noted in behavioral,interpersonal, cognitive, and affective styles, is: “close interpersonal relationships.”
Behavioral Style . The behavioral pattern of schizoids can be described as
lethargic, inattentive, and occasionally eccentric. They exhibit slow andmonotonal speech and are generally nonspontaneous in both their behavior andspeech.
Interpersonal Style . Interpersonally, they appear to be content to remain
socially aloof and alone. These individuals prefer to engage in solitary pursuits,they are reserved and reclusive, and rarely respond to others’ feelings and actions.They tend to fade into the social backdrop and appear to others as “cold ﬁsh.”They do not involve themselves in group or team activity. In short, they appearinept and awkward in social situations.
Cognitive Style . Their style of perceiving, thinking and information
processing can be characterized as cognitively distracted. That is, their thinkinghigh school with a “B” average, but did not date or participate in
extracurricular activities, except the electronics club. He was a Computer
Science major, and “hacking” was his only hobby. Mr. Y’s affect wassomewhat ﬂattened and he appeared to have no sense of humor and failed
to respond to attempts by the course director to make contact through
humor. There was no indication of a thought or perceptual disorder. Thecourse director arranged for an individual project for the student.
CASE STUDY: SCHIZOID PERSONALITY STYLE
Mr. P. is a 28-year-old and six-year veteran of the US Department of theInterior. He has been a forest ranger since graduating from college. While
in school, he excelled in the classroom, but was considered a loner by others.
Unlike most of his classmates, he didn’t pledge a fraternity, feeling he reallyneeded to live in a place that was quiet and distraction-free. Mr. P. enjoyedhis work and has received commendations for it. A year ago, he was offered
a promotion to ﬁeld supervisor, which he turned down, since it would have
required him to have regular voice or face-to-face contact with up to 10 forestrangers who would report to him. Mr. P had befriended a college friend,with whom he roomed for three years and continues to have occasional
contact. He has never considered marriage or family, so he has little interest
in dating.228 Diagnosis and Treatment of DSM-5 Personality Disorders

and communication can easily become derailed through internal or external
distraction. This is noted in clinical interviews when these patients have difﬁcultyorganizing their thoughts, are vague, or wander into irrelevance such as the shoescertain people prefer (Millon, 1981). They appear to have little ability for intro -
spection, nor ability to articulate important aspects of interpersonal relationships.Their goals are vague and appear to be indecisive.
Affective Style . Their emotional or affective style is characterized as being
humorless, cold, aloof, and unemotional. They appear to be indifferent to praiseand criticism, and they lack spontaneity. Not surprisingly, their rapport and abilityto empathize with others are poor. In short, they have a constricted range ofaffective response.
Attachment Style . Individuals with a dismissing attachment style are charac -
terized by a sense of self that is worthy and positive, as well as a low and negativeevaluation of others, which typically manifests as mistrust of others. Because theybelieve they are emotionally self-sufﬁcient while others are emo tionally
unresponsive, they dismiss the need for friendship and contact with others. ThisDismissing Attachment Style is common in individuals with Schizoid PersonalityDisorder (Lyddon & Sherry, 2001).
Dependent Personality Disorder, one has been found to be the most useful indiagnosing this disorder. The belief is that, by beginning with this criterion, theclinician can test for the presence or absence of the criterion and more quicklydiagnose the personality disorder. The optimal criterion for this disorder is: neitherdesires nor enjoys close relationships, including being part of a family (Allnutt &Links, 1996).
Individuals with this personality disorder are characterized by an unremittingpattern of detachment from others and restricted emotional expression. They donot desire nor enjoy close relationships, including family relationships. Exceptfor ﬁrst-degree relatives, they are unlikely to have close friends or conﬁdants.These individuals typically choose solitary activities, and have little, if any, interestin sexual relations. Not surprisingly, they seem indifferent to the feedback,including criticism, of others. They experience little, if any, pleasure in mostactivities. Instead, they exhibit emotional coldness, detachment, or ﬂat affect(American Psychiatric Association, 2013).
A prototype is a brief description that captures the essence of how a particulardisorder commonly presents. Prototypic descriptions are useful and convenient,and clinicians commonly rely on them rather than lists of behavioral criteria andSchizoid Personality Disorder 229

core and instrumental beliefs (Westen, 2012). Here is a common prototypic
description of the Schizoid Personality Disorder: These individuals just want tobe left alone. Making and maintaining contact with others has little or no mean -
ing and is without pleasure, comfort, or emotion. Accordingly, they live alone,avoid dating, have no real friends, and have jobs that require little or no contact
with others. Others consider them awkward, distant, and overly formal in all social
contacts. In short, they come across to others as “cold ﬁsh.”
Prevalence of this disorder has been estimated at between 3.1 and 4.0 percent inthe general population (American Psychiatric Association, 2013). In clinical
settings, this disorder is the most infrequent in presenting for treatment, withestimates of 0.5 to 5.1 percent (Torgersen, 2012).
Conceptualizations of the Schizoid Personality Disorder
The inner world of schizoid individuals appears to be different than their outward
appearance. Akhtar (1987) describes them as overtly detached, asexual, self-sufﬁcient, and uninteresting, while covertly emotionally needy, exquisitely sensi -
tive and vulnerable, creative and acutely vigilant. These stark differences represent
a splitting or fragmentation of different self-representations that remain integrated.
The result is identity diffusion.
Balint (1968) and Nachmani (1984) believe that their difﬁculty relating to others
stems from a deﬁcit—inadequate mothering—rather than from an Oedipalconﬂict. In short, these individuals base their decision to be isolative on theconviction that, because they failed to receive maternal nurturance and supportas infants, they cannot expect or attempt to receive any emotional supplies fromsubsequent signiﬁcant ﬁgures. Fairburn (1954) views the isolation of schizoidindividuals as a defense against a conﬂict between a wish to relate to others anda fear that their neediness will harm others. Thus, they vacillate between a fearof driving others away by their neediness, and the fear that others will smotheror consume them. Consequently, all relationships are experienced as dangerousand must be avoided.
Kellerman and Burry (1989) view this isolation and social distancing as a way
of managing anxiety. Schizoid individuals are remote, cool, and aloof, but notnecessarily malicious toward others. Typically, schizoid individuals utilize thedefenses of repression, suppression, isolation of fantasy affect, displacement, and
compensation to ensure distance from others and avoid anxiety.230 Diagnosis and Treatment of DSM-5 Personality Disorders

Millon and Davis (1996) believe the schizoid personality is formed by an
interaction of biogenic and environmental factors. Millon and Everly (1985) suggest
that a proliferation of dopaminergic postsynaptic receptors in limbic and frontal
cortical regions account for the unusual cognitive activity and inhibited emotionalresponses of schizoid individuals. Along with this excessive parasympatheticnervous system, dampening could account for their apathy, ﬂattened affect, and
underresponsiveness. Finally, Millon and Everly note that an ectomorphic—thin
and frail—body type, which has been associated with shyness and introversion,is common among schizoid individuals.
Major environmental factors involve parental indifferences and fragmented
communication patterns. Families of schizoid individuals are typically characterizedby interpersonal reserve, formality, superﬁciality, and coldness. They tend to com -
municate in a fragmented, aborted, and circumstantial fashion. Not surprisingly,
individuals raised in such environments are likely to be vague, abortive, and cir -
cum stantial in all their communications. These disjointed communication patterns
tend to be confusing to others and foster misunderstanding, frustration, lack oftolerance, and hostility on the part of others. Schizoid individuals are prone tobe isolative and come to believe that others do not understand them. Furthermore,these individuals are usually incapable of correcting the problem.
Their schizoid disorder is perpetuated by social distancing, by having their
social isolation reinforced, and by their cognitive and social insensitivity. Theirinfrequent social activities limit their ability to grow, and their social isolation isfrequently reinforced by others who ostracize isolative individuals. Furthermore,
their social and cognitive insensitivity tends to oversimplify and make boring a
world that is so rich and diverse to others.
According to Beck (2015), individuals with schizoid personality are, for all prac -
tical purposes, detached from others. There are characteristic core, conditional,and instrumental beliefs noted in individuals with this disorder. Their core beliefs
are that they are misﬁts from life, that relationships take effort and are not worththe trouble, and that they are happier being alone. Their conditional beliefs are that
if they get too close to others, they will be teased or imposed on by others, and
there is no point in trying to connect with others. Their instrumental beliefs are
don’t get involved, say no to others’ demands, and leave social situations quickly.Underlying these various beliefs are their beliefs about self and the world.
They typically view themselves as loners and oddballs who don’t ﬁt in. They
tend to view others as demanding, hostile, and intrusive. Accordingly their basicstrategy is to keep their distance from others and avoid contact when others areSchizoid Personality Disorder 231

around. While they may make contact with others as part of their job or meet
basic needs, they typically avoid any form of intimacy (Renton & Mankiewicz,2015).
From the behavioral perspective, Turkat (1990) does not offer a formulation
for this disorder. However, it might be that parental indifference, emotionalreserve, and little opportunity to develop interpersonal skills contribute to thedevelopment of this disorder.
According to Benjamin (2003a), persons diagnosed with Schizoid PersonalityDisorder were likely to have been raised in a home that was orderly and formal.While these children’s physical and educational needs were met, there was littlewarmth, play, or social and emotional interaction within the family, or elsewhere,for that matter. The schizoid individual would have modeled social isolation andcolorless, unemotional functioning. Such identiﬁcation with withdrawn parents,leads schizoid individuals to expect little and give little. Though they may besocialized for work, they are not predisposed to intimate contact, and prefer fantasyand solitary advocating instead. In short, they have neither fears of, nor desiresfor, others. Underdeveloped in social awareness and skills, they can meet socialrole expectations and employees or even as parents. They may be married butdo not develop close, intimate relationships.
The following integrative formulation provides a biopsychosocial explanation forhow this personality is likely to have developed and how it is maintained. Bio -
logically, the schizoid personality was likely to have had a passive and anhedonicinfantile pattern and temperament. Millon (1981) suggested that this pattern results,in part, from increased dopaminergic postsynaptic limbic and frontal lobe receptoractivity. Constitutionally, the schizoid is likely to be characterized by an ecto -
morph body type (fragile and delicate) (Sheldon, Dupertius, & McDermott, 1954).
Psychologically, they view themselves, others, the world, and life’s purpose
in terms of the following themes. They view themselves by some variant of thetheme “I’m a misﬁt from life, so I don’t need anybody. I am indifferent toeverything.” For schizoid personalities, the world and others are viewed by somevariant of the theme “Life is a difﬁcult place and relating to people can be harmful.”As such, they are likely to conclude, “Therefore, trust nothing and keep a distancefrom others and you won’t get hurt.” Alexandra Adler (1956) further describesthese lifestyle dynamics. The most common defense mechanism utilized by themis intellectualization.
noted in them. Parenting style is usually characterized by indifference and232 Diagnosis and Treatment of DSM-5 Personality Disorders

impoverishment. It is as if the parental injunction was “You’re a misﬁt,” or “Who
are you, what do you want?” Their family pattern is characterized by fragmentedcommunications and rigid, unemotional responsiveness. Because of these condi -
tions, schizoids are grossly undersocialized and develop few if any interpersonalrelating and coping skills. This schizoid pattern is conﬁrmed, reinforced, andperpetuated by the following individual and systems factors: Believing themselvesto be misﬁts they shun social activity. This plus social insensitivity leads toreinforcement of social isolation and further conﬁrmation of the schizoid style(Sperry, 2015; Sperry & Mosak, 1996).
Table 11.2  summarizes the characteristic features of this disorder.Schizoid Personality Disorder 233
TABLE 11.2 Characteristics of Schizoid Personality Disorder
Triggering Event(s) Close interpersonal relationships
Behavioral Style Slow and monotonous speech
Lethargic and inattentiveNonspontaneous and indifferent
Interpersonal Style Minimal desire for relationships
Chooses solitude over social interactionLacks conﬁdantsFades into social backgroundIsolative and content to remain aloof
Cognitive Style Cognitively distracted, easily derailed, and tangential
Absent-mindedMinimally introspective
Affective Style Emotionally distant
Rarely responsive to another’s feelings
Temperament Passive and anhedonic infantile patternAttachment Style DismissingParental Injunction “Who are you, what do you want?”Self-View: “I’m a misﬁt from life, so I don’t need anybody.”
“I’m indifferent to everything.”
World-View “Life is a difﬁcult place and can be harmful. Therefore,
trust no one and keep distance from others and you won’tget hurt.”
Maladaptive Schemas Social isolation; emotional deprivation; defectiveness;
subjugation; undeveloped self
Optimal Diagnostic Neither desires nor enjoys close relationships, including 
Criterion being part of a family

Assessment of Schizoid Personality Disorder
Interviewing the Schizoid Personality-Disordered individual can seem like anexercise in futility, given their pervasive emotional withdrawal. They express littleor no emotionality even when talking about anxious or depressed feelings. Moreintelligent individuals with this disorder may complain about anhedonia and mayeven use the label “depression,” but seldom report associated sadness or guilt.Since emotional warmth is absent, it is difﬁcult to judge whether problems orconcerns are central to them. Typically, they have one-word or short phraseanswers to all questions. Neither open-ended questions, structured questions, nor
other interview strategies will change the ﬂow of information or expression ofaffect. Unlike paranoid individuals, this restricted verbal and emotional expression
is not due to self-protectiveness, but rather to emotional and mental emptiness.Rapport usually reﬂects a willingness to reveal symptoms, problems, and innermostfeelings. Since these patients are so impoverished, rapport and engagement mayseem impossible with these patients. Long periods of silence are not uncommon.If these patients return for sessions, it usually means they are “connecting” insofaras they know how. Thus, the clinician’s persistence, patience, and tolerance forlimited verbal interchange may have a therapeutic effect (Ackley et al., 2011;Othmer & Othmer, 2002).
The Minnesota Multiphase Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-IV), the Rorschach Psychodiagnostic Test, and theThematic Apperception Test (TAT) can be useful in diagnosing the SchizoidPersonality Disorder as well as the schizoid personality style or trait. On the MMPI-2, a normal proﬁle is common for reasonably well-integrated Schizoid individuals.In such instances O (Social Introversion) may be elevated (Lachar, 1974). As theseindividuals become distressed, a rise in F (Frequency), 2 (Depression), and 8(Schizophrenia) are likely. Occasionally, a 1–8 (Hypochondriasis-Schizophrenia)“nomadic” proﬁle is noted wherein interpersonal attraction is limited (Graham,2012).234 Diagnosis and Treatment of DSM-5 Personality Disorders

On the MCMI-IV, an elevation on scale 1 (Schizoid) with low scores on 4A
(Histrionic), 5 (Narcissistic), and N (Bipolar-Manic), are likely (Millon et al., 2015).
On the Rorschach, a high percentage of A (Animal) and few C (Color)
responses are likely. The overall record tends to be constricted and certain blotsmay be rejected. Reaction time to many of the cards may be slow. There maybe a higher Experience Potential than Experience Actual, and their M (HumanMovement) production will be high relative to the overall quality of the protocol(Exner, 1986).
On the TAT, constricted response along with a blindness of theme is common.
So also is an impoverished portrayal of story characters (Bellak, 1997).
disorders: Avoidant, Schizotypal, and Dependent. The most common symptomdisorders likely to be associated with this disorder are: Depersonalization Disorder,Bipolar Disorders, Obsessive-Compulsive Disorder, Somatic Symptom Disorder,Schizophreniform, and Disorganized and Catatonic Schizophrenias.
Schizoid personalities rarely volunteer for treatment unless decompensation is
present. However, they may accept treatment if someone, like a family member,demands it. Treatment goals are focused on symptom alleviation rather than onrestructuring of personality. Common treatment strategies include crisismanagement and a consistent and supportive therapeutic interaction. Medications,particularly the antipsychotics, have not been shown to be useful with this disorder(Silk & Feurino, 2012).
Some form of individual psychotherapy is indicated for the majority of the schizoidpatients. Whether the clinician chooses an active confrontative approach, orcognitive restructuring and social skills training approach, or one that is moresupportive, depends on a number of factors, including a patient’s psychological-mindedness, resilience, and treatment expectations, the clinician’s therapeuticrepertoire, and resources for treatment.
This section brieﬂy describes the psychodynamic, cognitive-behavioral, and
interpersonal approaches to individual therapy.
Because the dynamic understanding of both the schizoid and schizotypal person -
ality are inherently similar, Gabbard (1990, 1994) proposes that their treatmentSchizoid Personality Disorder 235

is similar. Schizoid patients can be treated effectively with dynamically oriented
psychotherapy, both expressive and supportive, depending on their level offunctioning and treatment readiness (Gabbard, 1994). The basis for dynamictreatment is not interpretation of conﬂict, but rather internalization of a thera -
peutic relationship (Stone, 1985).
Essentially, the clinician’s task is to meet the patient’s frozen internal object
relations by providing a correct emotional experience. The schizoid’s style ofrelatedness results from inadequacies in early relationships with parental ﬁgures.As a result, these patients go through life distancing themselves from others.Therapy must therefore provide a new relationship for internalization (Gabbard,1994). Thylstrup and Hesse (2009) suggest that the schizoid individual’s outwardemotional detachment from others actually conceals a deep inner longing forcloseness. This ambivalence can be addressed within the context of therapy;however, because these patients are unable to adequately articulate their emotionalneeds, therapists tend to lose interest in them easily. Therapists must pay particularattention to countertransference with these patients, to avoid further alienation.Questions such as “Do I feel like canceling appointments with my socially isolatedpatient, thinking it won’t hurt him or her?” and “Do I ﬁnd myself wonderingif this patient has any problems at all, in spite of clear evidence that he does?”are useful guidelines. The authors present a case study of a 40-year-old un employed
male.
Kavaler-Adler (2004) presents the treatment of this disorder from an object-
relations perspective. In this course of psychoanalysis, the schizoid individual istaken through a period of “developmental mourning” in order to grieve the lossof normal development in the separation-individuation process and understandhow traumatic early childhood experiences inﬂuence current interpersonalproblems. The schizoid patient may then work to confront and give up the regretassociated with this. She presents a detailed case example of psychoanalysis witha female writer.
Supportive Therapy . Since their basic mode of functioning is non-relational,
they ﬁnd the task of therapy very challenging and difﬁcult. Not surprisingly, theyrespond to the challenge with silence and emotional distancing. Clinicians needto adopt a permissive, accepting attitude, and must be exceedingly patient withthese individuals. It is more helpful to understand silence as a nonverbal form ofrelating rather than as treatment resistance. By listening with a third ear, theclinician can learn much about these patients. Through projective identiﬁcationthey will evoke certain responses in that clinician that contain valuable diagnosticinformation regarding the patient’s inner world (Gabbard, 1989). Dealingeffectively with countertransference issues is critical in working with schizoidpatients. Accepting silent nonrelatedness is foreign to the clinician’s psychologicalpredisposition and training. Thus, when silence is prolonged, the clinician mustguard against acting out and projecting their own self- and object representationsinto the patient. Accepting the silence, and refraining from interpreting it,236 Diagnosis and Treatment of DSM-5 Personality Disorders

legitimizes the patient’s private, noncommunicative core self. And, it may be the
only viable technique for building a therapeutic alliance (Gabbard, 1989).
The proper pace and depth of therapy is controversial. Bonime (1959)
advocates an active, confrontative approach, while Gabbard (1990) and othersmaintain that a more restrained approach is more respecting and less threatening
for these patients.
Supportive techniques can be utilized to encourage the lower functioning
schizoid to become more active. For example, the patient is ﬁrst urged to engage
in activities where others are present, but where the patient’s participation is
minimal, for example, at a sports event. If some level of comfort is achieved,further involvement may be encouraged. Involvement in a computer club, traveltour, or aerobics class risks them attending a sports event, but less than a social
gathering or dance class. Kantor (1992) advocates the techniques of “productive
substitution” and “modiﬁcation total push” with these therapeutic tasks. Inproductive substitution the clinician suggests gratifying replacements for what ismissing from the patient’s life. Thus, relationships with peers in a therapy groupsubstitutes for the unmarried patient. Using modiﬁed total push, the clinician urgesthe patient to become more socially active. Suggestions are presented tentatively,to test the patient’s limits. Problems encountered are brought back into therapy
and discussed. Treatment goals and outcomes may be quite limited: the patient
may eventually work, albeit in isolation, i.e., as a nightwatchman, may have oneor two social friends, and possibly even a long-term relationship with someone
who is willing to remain distant companions (Kantor, 1992).
Long-Term vs. Short-Term Dynamic Therapy . Decisions about the type
and frequency of dynamic therapy should be based on the patient’s level offunctioning and motivation and readiness for treatment. Higher functioning
schizoid patients who exhibit some depressive symptoms, or some capacity for
empathy and emotional warmth, tend to have better outcomes in dynamicpsychotherapy (Stone, 1983).
Those patients who are highly motivated for exploratory psychotherapy can
make dramatic gains in intense, long-term treatment of two to three sessions perweek over several years. On the other hand, long-term supportive psychotherapyis indicated for the majority of schizoid patients who present with major ego deﬁcits
and personal eccentricities. The goal of such treatment is improved adaptive
functioning in day-to-day living. The frequency of sessions is one to two timesper week for the majority of patients (Stone, 1989). Gamache and Diguer (2012)
provide a case study of a 34-year-old male with schizoid personality treated for
one year using psychodynamic psychotherapy.
Short-term dynamic therapy is indicated for crisis issues and situational
difﬁculties related to job or personal life. It may also serve as follow-up for a
previous course of long-term psychotherapy. Not surprisingly, there are no
reports of short-term dynamic individual treatment as curative intervention.Schizoid Personality Disorder 237

Cognitive Therapy Approach . Beck et al. (2004) describe the Cognitive
Therapy approach to working with Schizoid Personality-Disordered individuals.Since schizoid individuals tend to have limited motivation for social interaction,a principal treatment goal is to establish or increase positions of social interaction,as well as reduce social isolation. These individuals enter treatment largely becauseof symptomatic Axis I disorders rather than to alter their manner of relating toothers. Thus, the initial goal of treatment is a collaborative focus on presentingproblems. As this occurs, the therapist can be commenting on the individual’srelational patterns, discussing its advantages and disadvantages, and how this patternaffects the presenting problem. The collaborative therapeutic relationship can itselfserve as a prototype for other interpersonal relationships, as well as a basis forincreasing the individual’s range and frequency of interactions outside sessions.
After rapport has been established, the therapist can point out the characteristic
interaction pattern as well as give feedback on how this impacts other persons.As these individuals develop a greater awareness and understanding of interpersonalrelating, they are guided in learning needed social skills and practicing them bothwithin and outside the sessions. Given their lack of expressiveness, routinely
soliciting feedback on their level of anxiety should reduce the likelihood ofpremature termination. Unlike work with other personality disorders whereconsiderable therapeutic leverage and motivation for change are available,relatively little of either is likely with schizoid individuals besides reason.Accordingly, Freeman et al. (1990) advise therapists to clearly present the rationalefor therapy, reasons for acting differently, the advantages and disadvantages ofchanging behavior, and the concrete gains possible. Presumably this strategy caninduce these individuals to change.
Beck et al. (2004) indicate that the following techniques are effective with
schizoid individuals. The Dysfunctional Thought Record is not only useful inchallenging dysfunctional automatic thoughts, but also in identifying a variety of
affects and their subtle graduation in intensity, as well as indicating the reactionsof others. Teaching social skills is best done directly through role-playing, in vivo
exposure, and homework assignments. Helping these individuals become more
attentive to, and experience, positive emotions can be facilitated by guided dis -
covery. For example, as these individuals are helped to recognize their over -
generalized view of others—”I don’t like people”—they can learn to be speciﬁcabout things they don’t like, as well as things they do like about others, after all.
As treatment needs termination, the matter of relapse prevention is discussed.
Beck et al. (1990) report that schizoid individuals are very likely to relapse into
an isolative lifestyle after termination. Thus they suggest maintaining contact withthese individuals through booster sessions. Finally, although treatment with theseindividuals can be difﬁcult, with persistence it is possible to improve their socialskills, frequency of social interaction, and decrease their “strangeness.” However,238 Diagnosis and Treatment of DSM-5 Personality Disorders

the therapist should anticipate that schizoid individuals are likely to retain some
distance and passivity in interpersonal relations after planned termination.
Renton and Mankiewicz (2015) echo the notion that these individuals rarely
present for treatment of their own accord, and, if doing so, it is likely to be short-lived and exclusively for the purpose of symptom relief or the resolution of speciﬁcproblems related to changes in their environment. Therapy rarely extends to theexamination and resolution of underlying cognitive factors, and ambivalence aboutchange may be present throughout treatment. If these individuals can acknowledgethe connection between their early experiences, maladaptive beliefs, and currentproblems, then they may be willing to reframe these beliefs.
that has been developed by Young (1999; Young et al., 2003) speciﬁcally forpersonality disorders, and other difﬁcult individual and couples problems. SchemaTherapy involves identifying maladaptive schemas and planning speciﬁc strategiesand interventions. Four main strategies are cognitive, experiential, behavioral, andthe therapeutic relationship itself. Cognitive restructuring, modiﬁcation ofmaladaptive schemas, is an important cognitive strategy, but is combined withimagery exercises, empathic confrontation, homework assignments, and “limitedreparenting,” i.e., a form of corrective emotional experience (Young, 1999; Younget al., 2003).
Maladaptive schemas typically associated with Schizoid Personality Disorder
include: social isolation —the belief that one is alienated, different from others, or
not part of any group; defectiveness —the belief that one is defective, bad, unwanted,
or inferior in important respects; emotional deprivation— the belief that one’s desire
for emotional support will not be met by others; subjugation— the belief that one’s
desires, needs, and feelings must be suppressed in order to meet the needs of othersand avoid retaliation or criticism; and undeveloped self— the belief that one must
be emotionally close with others at the expense of full individuation or normalsocial development (Bernstein, 2002).
Interpersonal Approaches
There is very little in the literature about treatment of this disorder from aninterpersonal perspective. For example, Benjamin (2003a) provides no discussionof treatment goals or strategies for the Schizoid Personality Disorder. She notesthat these individuals are socially withdrawn, do not desire social connections,and do not suffer from anger, fear, or depression. As such, they have little reasonto present for treatment.
Schizoid patients can proﬁt from group therapy, particularly dynamic group therapy(Azima, 1983). Group therapy offers these patients a socialization experience,Schizoid Personality Disorder 239

involving exposure to and feedback from others in a safe, controlled environment.
It is an environment in which new parenting can occur. Here group memberscan function as a reconstructed family and provide a corrective emotionalexperience that can counterbalance the schizoid’s negative and frightening internalobjects (Appel, 1974). As their worst fears are not realized and they feel accepted,these patients gradually become more comfortable with others. Giles andWienclaw (2008) note that the timing of group therapy is important to consider.They suggest that it is ﬁrst better to develop a strong therapeutic alliance betweenthe patient and the individual therapist before initiating group treatment, as theseindividuals generally avoid social contact.
From an object relations perspective, Leszcz (1989) contends that the group
functions as a holding environment which provides an opportunity for these
patients to be initially involved in a “nonrelated” way while slowly building 
trust. They do not have to leave their cocoon of self-sufﬁciency, but can observehow others relate in the groups, how feelings make a difference, how to deal with others related in the groups, and how to deal with negative emotions.The wise group leader will permit this non-related position until this patient isbetter able to tolerate the ambiguities of the group.
From a systems perspective, Bogdanoff and Elbaum (1978) maintain that the
schizoid’s isolation is not simply due to a fragile ego, but is also a function of the
group’s need to maintain that isolation. So, while the schizoid patient may provokethe group to make the schizoid talk, at other times the group effectively silences
the schizoid by ragefulness or blaming that frightens the schizoid. Essentially, the
schizoid is caught in an interpersonal trap—which they call a “role lock.” Onthe other hand, successful group interaction can occur only when the role lockis broken. If the group is avoiding the schizoid, the therapeutic task is to focus
the group’s attention on the role lock. The aim is for group members to reveal
their contribution of the lock and to relieve pressure on the locked member, andfor the locked member to reveal how he or she sees the group process to isolate
himself or herself.
From an interpersonal perspective, Yalom (1995) discusses other useful
interventions for dealing with role lock. The schizoid is helped to differentiateresponses to different group members, to take seriously feelings in the here-and-now, to become more aware of their speciﬁc avoidance strategies, and to becomemore aware of their bodily response. Yalom insists that these goals and strategiesare preferable to cathartic methods, which can drive the schizoid from the group.He cautions that this process is slow and that patience is essential for the clinician.
Finally, there seems to be a consensus of sorts, that heterogeneous groups are
preferable to homogeneous groups (Bogdanoff & Elbaum, 1978; Leszcz, 1989;Slavik, Sperry, & Carlson, 1992). Spotnitz (1975) suggests that the schizoid patientshould be referred to a group that is homogeneous in terms of global functioning,but heterogeneous in terms of personality types.240 Diagnosis and Treatment of DSM-5 Personality Disorders

Schizoid patients, particularly males, do not marry, and seldom become self-
supporting. They may reside with and become dependent on their families. Thiscan result in a vicious cycle in which limited motivation for social contacts and
a job or career leads to interferences and bitterness on the part of the family,
which is followed by lowered self-esteem, and an even greater reluctance to leavehome (Stone, 1989).
Clinicians working with the schizoid patient still living at home often confront
family tension, impatience, and discord arising from differences between parentalexpectations and the patient’s capacities and motivation. Family therapy can bequite effective in addressing these expectational differences, discord, andimpatience (Anderson, 1983). Shapiro (1982) describes how the family therapistcan function to contain such displaced and projected affects and impulses, andacknowledge, bear, work through, and redirect them. Family treatment can alsohelp family members reestablish more functional communication patterns betweenschizoid patients and their families.
McCormack (1989) describes a common marital constellation in which
schizoid individuals marry borderline individuals. In discussing the treatment ofthe schizoid spouse, McCormack indicates that the core of the schizoid’s difﬁcultyis an overwhelming fear of attachments. Insecurity arises from escalating aggres -
sion, because frustration of their dependency needs leads to marital dissatisfactionand discord. Schizoid spouses experience their love as lethal and then abortawareness of these feelings and dependency needs as a defense against them. Thus,they develop and maintain relationships in which they are never fully involved.
The treatment of the schizoid spouse emphasizes clariﬁcation and careful
interpretation and deemphasizes confrontation. Exploration should involve theirnarcissistic vulnerability, legitimization of their needs, acknowledgment of thepotential risks and gains attached to pursuing them, and the schizoid compromise.
McCormack describes the “schizoid compromise” as a means of maintaining
relationships that require limited emotional involvement, at the cost of limitingpersonality development. The clinician needs to acknowledge to these patientsthat this compromise has been adaptive, but is a stage through which they mustpass before facing their fear of genuine, healthy relationships.
Schizoid spouses tend to treat others as they fear being treated, which is frustrating
to those wanting an intimate relationship with them. In a conjoint session, theclinician helps both spouses to see that each suffers from difﬁculties that are bothsimilar to and different from their own and that, though these difﬁculties are fosteredin the marriage relationship, they also exist independent of it.
Couples therapy with the schizoid-borderline relationship may require referral
of one spouse for individual therapy, the use of medication, or hospitalization.Long-term couples treatment is usually necessary if the goal is to foster separationand autonomy, increased marital satisfaction, and harmony.Schizoid Personality Disorder 241

individuals with Schizoid Personality Disorder (Silk & Feurino, 2012). Becausesome controlled trials indicated that antipsychotics were useful in the treatment
of Schizotypal Personality Disorder (Koenigsberg, Woo-Ming, & Siever, 2002),
it was hoped that these medications might also be useful with this disorder.Unfortunately, that hope has not been realized. Nevertheless, antipsychotics arestill prescribed, but are only likely to be useful if some psychotic decompensationhas been noted (Sperry, 1995b). Furthermore, there is little research evidence toprovide guidelines for the use of medications with this personality disorder (Silk& Feurino, 2012).
Schizoid patients tend to avoid mental health professionals just as they avoidrelationships in general. When they do present for help, often at the urging oftheir family, they have a tendency to prematurely terminate therapy after a shorttime (Stone, 1989). This means there is only a small window of opportunity toengage these patients in the therapeutic process. Combining treatment modalitiesand integrating treatment approaches can facilitate both commitment to treatment
and positive treatment outcomes.
Gabbard (1994) advocates combining dynamic group therapy with dynamic
individual psychotherapy as the treatment of choice for the majority of schizoidpatients. However, he cautions that many of these patients will recoil at therecommendation for group therapy, even feeling betrayed by their clinician. Thus,Gabbard suggests that, prior to making a group referral, fantasies about the groupexperience need to be explored and worked through. Stone (1989) alsorecommends combining individuals and group modalities. However, he proposesa developmental approach in which the patient ﬁrst forms a stable dyadic
relationship with the clinician and then proceeds to group therapy with the same
clinician. In both instances, the combined treatment is concurrent.
As noted earlier, McCormack (1989) makes the case for combining marital
therapy with individual therapy, particularly when there is considerable splittingand projective identiﬁcation. Combining family therapy and individual therapy
has advantages, particularly if the schizoid patient is ﬁnancially dependent on the
family and/or resides with the family. Family can greatly inﬂuence the patient’scontinuation in individual and/or group treatment.
Armstrong (2002) describes schizoid personality features in substance abusers.
He echoes others when he suggests that these are individuals who want to relate,but whose social anxiety stands in the way of this. Substance abuse is one wayin which these individuals actively isolate themselves from others while medicatingtheir intense feelings. For these dually diagnosed individuals, the addition of242 Diagnosis and Treatment of DSM-5 Personality Disorders

treatments targeted at changing substance use behaviors, such as Motivational
Interviewing, may be helpful.
Slavik et al. (1992) advocate both combining treatment modalities and
integrating treatment approaches. They indicate the utility of concurrent indi -
vidual and group treatment. And they describe how an Adlerian approach canbe integrated with an object relations theory approach, social skills training,hypnosis, and psychodrama depending on the patient’s style, needs, and expec -
tations. These authors believe that the Schizoid Personality Disorder is eminentlytreatable, and that these patients are largely untreatable because clinicians have
not found sufﬁcient ways to engage and encourage them in the change process.Schizoid Personality Disorder 243

12
SCHIZOTYPAL PERSONALITY 
DISORDER
Individuals with schizotypal personalities share some features of the schizoid
personality. In addition, they are characterized by eccentric behavior and peculiarthought content. Typically, they describe strange intrapsychic experiences, thinkin odd and unusual ways, and are difﬁcult to engage. Yet, none of these featuresreach psychotic proportions. It has been suggested that the schizotypal personalityis one of the schizophrenic spectrum disorders, because schizophrenia occurs withincreased frequency in family members of the schizotypal individual (Kwapil &Barrantes-Vidal, 2012).
of this disorder. It includes sections on its description, case conceptualization,assessment, and treatment interventions. It begins with background informationon the disorder as well as a DSM-5 description and a prototypic description ofthis disorder. The section on case conceptualization provides ﬁve commonclinical formulations of this disorder: psychodynamic, biosocial, cognitive-behav -
ioral, interpersonal, and an integrative conceptualization of this disorder. Severaltreatment approaches, modalities, and intervention strategies are also described.These include individual psychotherapy, group therapy, marital and familytherapy, medication, and integrative and combined treatment.
Description of the Schizotypal Personality Disorder
The Schizotypal Personality Disorder can be recognized by the followingdescriptors and characteristics: style vs. disorder; triggering event(s); behavioralstyle; interpersonal styles; cognitive style; affective style; attachment style; andoptimal diagnostic criterion.
Style vs. Disorder . The schizotypal personality can be thought of as spanning
a continuum from healthy to pathological, wherein the schizotypal personality

Schizotypal Personality Disorder 245
TABLE 12.1 Comparison of Schizotypal Personality Style and Disorder
Tend to be tuned into and sustained Ideas of reference; suspicious or 
by their own feelings and beliefs. paranoid ideation; inappropriate or
constricted affect.
Keen observation of others, and are Excessive society anxiety, e.g., extreme
particularly sensitive to how others discomfort in social situations involvingreact to them. unfamiliar people.
Tend to be drawn to abstract and Odd beliefs or magical thinking,
speculative thinking. inﬂuencing behavior and inconsistent 
with subculture with norms, e.g., 
superstitiousness, belief in clairvoyance,telepathy, or “sixth sense.”
Receptive and interested in the occult, Unusual perceptual experiences, e.g.,
extrasensory, and the supernatural. illusions, sensing the presence of a force
or person not actually there (e.g., “I feltas if my dead mother were in the roomwith me”).
Tend to be indifferent to social convention, Odd or eccentric behavior or 
and lead interesting and odd unusual appearance, e.g., unkempt, unusual lifestyle. mannerisms, talks to self, speech.
Usually are self-directed and independent, No close friends or conﬁdants (or only
requiring few close relationships. one) other than ﬁrst-degree relatives.
style is closer to the healthy end and the schizotypal personality is on the
pathological end. Table 12.1  compares and contrasts the schizotypal personality
The following two case examples further illustrate the differences between the
Schizotypal Personality Disorder—Ms. R.—and the schizotypal personalitystyle—Ms. S.
CASE STUDY: SCHIZOTYPAL PERSONALITY DISORDER
Ms. R. was a 41-year-old single female who was referred to a community
mental health clinic by her mother because Ms. R. had no interests, friends,or outside activities and was considered by neighbors to be an “odd duck.”
Her father had recently retired, and because of a limited pension the parents
were having difﬁculty in making ends meet, since Ms. R. had been livingwith them for the past eight years after she had been laid off from anassembly-line job she had held for about 10 years. The patient readily

likely triggers or activates the characteristic maladaptive response of the SchizotypalPersonality Disorder (Othmer & Othmer, 2002), as noted in behavioral,interpersonal, cognitive, and Affective styles, is: “close interpersonal relationships.”
Behavioral Style . Behaviorally, schizotypals are noted for their eccentric,
erratic, and bizarre mode of functioning. Their speech is markedly peculiar withoutadmitted she preferred to be alone but denied that this was a problem for
her. She believed that her mother was concerned about her because of what
might happen to the patient after her parents’ deaths. Ms. R. was an onlychild who had graduated from high school with average grades, but had
never been involved in extracurricular activities while in school. She had never
dated, and mentioned she had a female friend whom she had not talkedwith in four years. Since moving back with her parents, she stayed in herroom preoccupied with books about astrology and charting her astrological
forecast. On examination, she was an alert, somewhat uncooperative female
appearing older than her stated age, with moderately disheveled hair andclothing. Her speech was monotonal and deliberate. She maintained pooreye contact with the examiner. Her thinking was vague and tangential, and
she expressed a belief that her fate lay in “the stars.” She denied speciﬁc
delusions or perceptual abnormalities. Ms. R’s affect was constricted, exceptfor one episode of anger when she thought the therapist was being critical.
CASE STUDY: SCHIZOTYPAL PERSONALITY STYLE
Ms. S. is a 37-year-old acquisitions editor for a large publisher. Her primaryresponsibility is to review proposals and manuscripts in science ﬁction andthe occult to determine if her company should publish them. She ﬁnds herjob fascinating and energizing, particularly since her boss has allowed her to
work from home four days out of ﬁve. She has great difﬁculty in working a
typical 9:00 to 5:00 workday, as she prefers to sleep days and work at night.When reviewing a submitted manuscript, she literally tries to put herself into
the plot by imagining herself as the heroine and enhances the effect by
donning appropriate clothing, burning incense, and playing suitablebackground music. She refers to Mark as her “soulmate” rather than aboyfriend. They do not actually date, since he lives in another city. But theyspend long hours on the phone and “let their spirits commune” the rest of
the time. Occasionally, they meet each other at various science ﬁction, UFO,
and Star Trek conventions.246 Diagnosis and Treatment of DSM-5 Personality Disorders

being incoherent. Occupationally, they are inadequate, either quitting or being
ﬁred from jobs after short periods of time. Typically, they become drifters, movingfrom job to job and town to town. They tend to avoid enduring responsibilitiesand in the process lose touch with a sense of social propriety.
Interpersonal Style . Interpersonally, they are loners with few, if any, friends.
Their solitary pursuits and social isolation may be the result of intense social anxiety,which may be expressed with apprehensiveness. This apprehensiveness doesn’tdiminish with familiarity, and is associated with paranoid features rather thannegative self-appraisal. If married, their style of superﬁcial and peripheral relatingoften leads to separation and divorce in a relatively short period of time. Theirlives tend to be marginal, and they gravitate toward jobs that are below theircapacity or demand little interaction with others.
Cognitive Style . The cognitive style of schizotypals is described as scattered
and ruminative, and is characterized by cognitive slippage. Presentations of super -
stitiousness, telepathy, and bizarre fantasies are characteristic. They may describevague ideas of reference and recurrent illusions of depersonalizing, derealizingexperiences without the experience of delusions of reference, or auditory or visualhallucinations.
Affective Style . Their affective style is described as cold, aloof, and unemo -
tional with constricted affect. They can be humorless and difﬁcult individuals toengage in conversation, probably because of their general suspicious andmistrustful nature. In addition, they are hypersensitive to real or imagined slights.
Attachment Style . Individuals with an “other-view” that is negative and a
“self-view” that vacillates between positive and negative exhibit a compositefearful-dismissing style of attachment. They tend to view themselves as specialand entitled, but are also mindful of their need for others who can potentiallyhurt them. Accordingly, they use others to meet their needs while being waryand dismissive of them. This fearful-dismissing attachment style is common inindividuals with Schizotypal Personality Disorder.
Optimal Diagnostic Criterion . Of all the stated DSM-IV-TR criteria for
the Schizotypal Personality Disorder, one criterion has been found to be the mostuseful in diagnosing this disorder. The belief is that, by beginning with thiscriterion, the clinician can test for the presence or absence of the criterion andquickly diagnose the personality disorder (Allnutt & Links, 1996). The “optimalcriterion” for this disorder is: “odd thinking and speech: behavior or appearancethat is odd, eccentric, or peculiar.”
Individuals with this personality disorder are characterized by an unremittingpattern of social and interpersonal deﬁcits with signiﬁcant discomfort and limitedcapacity for relationships, as well as by perceptual distortions and eccentricbehavior. They experience ideas of reference as well as unusual beliefs and thinkingSchizotypal Personality Disorder 247

that inﬂuence their behavior, and which is inconsistent with their subculture.
They also experience unusual perception, such as bodily illusions, and odd speechthinking. These individuals are prone to suspiciousness and paranoid ideation.They exhibit inappropriate or constricted emotions, and behavior that is odd,peculiar, or eccentric. With few exceptions, they lack close friends or conﬁdants,except for ﬁrst-degree relatives. When they are around others, they experienceexcessive social anxiety that is not diminished by familiarity and is associated withsuspicion and fears (American Psychiatric Association, 2013).
description of this disorder (American Psychiatric Association, 2013). It isdescribed as an impaired capacity for relationship and eccentricities in perception,cognition, and behavior associated with distorted self-image and incoherent goals involving suspiciousness and limited emotional expression. Characteristicdifﬁ culties are noted in identity, self-direction, empathy, and intimacy, as well
as suspi ciousness, withdrawal, restricted affect, eccentricity, unusual beliefs and
experi ences, or cognitive and perceptual dysregulation.
disorder commonly presents. Prototypic descriptions are useful and convenient,and clinicians commonly rely on them rather than lists of behavioral criteria andcore and instrumental beliefs (Westen, 2012). Here is a common prototypicdescription of the Schizotypal Personality Disorder: These individuals displaydisorganized behavior and speech and emotional blunting, but not the delusionsand hallucinations associated with the diagnosis of schizophrenia. Their charac -
teristic eccentric thinking and behavior, strange beliefs, and unusual perceptualexperiences are below the threshold of psychosis. These symptoms have an earlyonset and usually remain stable throughout life. It is also not un common for these
individuals to be misdiagnosed as having Asperger’s Disorder.
Prevalence of this disorder has been estimated at between 0.6 and 4.6 percent in the general population (American Psychiatric Association, 2013). In clinicalsettings, it is relatively infrequent, with estimates between 0.6 and 9.1 percent(Torgersen, 2012).
Conceptualizations of the Schizotypal Personality Disorder
Gunderson (1988) admits that little is known about the dynamics of the
Schizotypal Personality Disorder. Gabbard (1990), among other psychoanalytically248 Diagnosis and Treatment of DSM-5 Personality Disorders

oriented writers, believes that, except for a few symptoms suggestive of an attenu -
ated form of schizophrenia, the schizoid personality and the schizotypal personalityare inherently similar.
On the other hand, Kellerman and Burry (1989) believe that the dynamics of
the two disorders are quite different. They classify the Schizoid PersonalityDisorder as an emotion-controlled character type—along with the Paranoid andObsessive-Compulsive personality disorders—while they classify the SchizotypalPersonality Disorder as an emotion-avoidant character type—along with theBorderline and Avoidant personality disorders.
Kellerman and Burry believe that schizotypal individuals probably experienced
consistent object contact in early childhood. However, their parents failed toprovide sufﬁcient emotional closeness and warmth and were probably punitiveand critical. These factors probably account for the social hypersensitivity, whichserves as a defense against intense social anxiety noted in these individuals.Emotion is generally restricted, but when expressed tends to be inappropriate.These individuals typically utilize a wide variety of defense mechanisms, includingprojection to externalize fear and anger, preoccupation with magic thinking andintellectualization to reduce emotional overstimulation, and hysterical denial toscreen out undesirable social interactions in order to rationalize them.
The schizotypal personality is viewed by Millon and Everly (1985) as a syndromalcontinuation of the Schizoid and Avoidant personality disorders. Thus, theetiological and developmental determinants of the schizotypal disorder will besimilar, as in the schizoid and avoidant disorders, but in greater intensity orchronicity. Biogenic factors in the schizotypal schizoid variant include a geneticpredisposition at least as reported in one study (Torgerson, 1984). Millon andEverly suggest that schizotypal-schizoid individuals have shown a passive infantilereaction pattern which probably initiated a sequence of impoverished infantilestimulation and consequent parental indifference. Further, they point out that adampening of the ascending reticular activity system of the limbic system mayresult in the autostimulation and fantasy of these individuals. Environmentally, acold and formal family environment combined with fragmented parental com -
munication probably interacts with biogenic factors to produce this personalitypattern and disorder. The background of schizotypal-avoidant individuals issomewhat different. Genetically, these individuals are more likely to exhibit a“slow-to-warm-up” temperament (Thomas & Chess, 1977). These individualstend to be apprehensive, tense, and do not adapt quickly to new situations. Suchbehavior can precipitate parental tension and derogation, which further aggravatesthis temperament. Socially, the developmental histories of these individualstypically show parental deprecation as well as peer and sibling humiliation, whichresults in interpersonal mistrust and lowered self-esteem. Continuation of theseSchizotypal Personality Disorder 249

derogating and humiliating attitudes eventually leads to self-criticism and self-
deprecation.
The schizotypal personality is self-perpetuated by social isolation, over -
protection, and self-insulation. While social isolation and overprotectiveness haveimmediate beneﬁts, in the long run they are counter-productive as they deprive
these individuals of opportunities to develop social skills, besides fostering
dependency. Furthermore, their tendency toward self-insulation serves to fosterand further perpetuate the spiral of cognitive and social deterioration that typiﬁes
this disorder (Millon & Davis, 1996).
According to Beck (2015), individuals with schizotypal personality are odd and
different from others. There are characteristic core, conditional, and instrumental
beliefs noted in individuals with this disorder. Their core belief is that the world
is uncaring and life is full of powerful forces that cannot be explained. Theirconditional belief is that if they get close to normal people, they will be rejected;
if others view them as different, they will be left alone; and if they use their specialgifts, the powers will protect them. Their instrumental belief is that being different
is protective. Underlying these various beliefs are their beliefs about self and theworld. They tend to view themselves as different, special, gifted, or supernaturally
attuned. They typically view others as unfriendly and hostile, untrustworthy, and
unable to understand their specialness. Accordingly, their basic strategy is tocultivate unusual appearance or mannerisms, keep a distance from others, and
use their special gifts or magical powers to protect themselves (Renton &
Mankiewicz, 2015).
From a behavioral perspective, Turkat (1990) describes the Schizotypal
Personality Disorder, but is unable to provide behavioral formulation for it. Instead,
he notes that these individuals tend to be quite diverse in terms of behavioral
presentation. This is consistent with the observation that the schizotypalpersonality is a decompensation of either the avoidant personality or the schizoid
personality (Millon & Davis, 2000; Millon & Everly, 1985).
According to Benjamin (2003a), persons diagnosed with Schizotypal Personality
Disorder likely had parents who punished them for allegedly inappropriatecustomary talking, while their parents did the same. Thus, the absent father severely
reprimands the child for not staying home. Essentially, such a parent modeled
“mindreading,” suggesting that, even though not present, he “knew” somethingvitally important about the child. The adult consequence of this schizotypalmodeling is that the individual imitates this pattern of “knowing” through special250 Diagnosis and Treatment of DSM-5 Personality Disorders

means, such as telepathy, mindreading, or “sixth” sense. Parents were also likely
to place inappropriate reliance on children for performance of household dutieswith undue threat and duress. Thus, these children learned that proper behaviorand obedience could avert bad outcomes. The adult consequence is theparadoxical tendency to submit to rituals that bring control. Severe abuse, ofteninvolving invasion of these children’s personal boundaries is common.Furthermore, it also is likely that strong injunctions against leaving the home forpeer play or other reasons were levied by the parents. Such prohibitions interferedwith the development of social feelings and skills, and reinforced social isolationas well as fantasy and autism. Finally, there is a fear of being attacked and controlledby humiliation. These individuals are prone to hostile withdrawal and self-neglect. Furthermore, they believe they can magically inﬂuence—from a distance—circumstances and individuals through telepathy or ritual. Although they maybe aware of their aggressive feelings, they usually constrain them.
The following integrative formulation provides a biopsychosocial explanation forhow the Schizotypal Personality Disorder is likely to develop and be maintained.Because this disorder is a syndromal extension or deterioration of the Schizoidor the Avoidant personality disorders (Millon, 1981), the biological and tempera -
mental features of both of these subtypes should be consulted. The schizoid subtype
of a schizotypal personality is characterized with a passive infantile pattern,probably resulting from low autonomic nervous system reactivity and parentalindifference that led to impoverished infantile stimulation. On the other hand,
the avoidant subtype is characterized by the fearful infantile temperamentalpattern (Millon, 1981). This probably resulted from the child’s high autonomic
nervous system reactivity combined with parental criticism and deprecation that
was further reinforced by sibling and peer deprecation. Both subtypes of the
schizotypal personality have been noted to have impaired eye-tracking motions,which is a characteristic shared with schizophrenic individuals.
Psychologically, the schizotypals view themselves, others, the world, and life’s
purpose in terms of the following themes. They tend to view themselves by somevariant of the theme: “I’m on a different wavelength than others.” Theycommonly experience being selﬂess, that is, they experience feeling empty,estranged, and disconnected or dissociated from the rest of life. Their world-viewis some variant of the theme “Life is strange and unusual, and others have specialmagical intentions.” As such, they are likely to conclude: “Therefore, observecaution while being curious about these special magical intentions of others.”The most common defense mechanism utilized by them is undoing, the effortto neutralize “evil” deeds and thoughts by their eccentric, peculiar beliefs andactions.Schizotypal Personality Disorder 251

noted for the Schizotypal Personality Disorder. The parenting patterns mentionedpreviously—the cold indifference of the schizoid subtype or the deprecating andderogatory parenting style and family environment of the avoidant subtype—arenoted. In both cases, the level of functioning in the family of origin then wouldbe noted in the Schizoid Personality Disorder or the Avoidant PersonalityDisorder. Fragmented parental communications are a feature common to bothsubtypes of the Schizotypal Personality Disorder. The parental injunction is likelyto have been: “You’re a strange bird” (Sperry, 2015; Sperry & Mosak, 1996).
Table 12.2  summarizes the characteristics of this disorder.
Assessment of Schizotypal Personality Disorder
plan for personality disorders. Observation, collateral information, and psycho -252 Diagnosis and Treatment of DSM-5 Personality Disorders
TABLE 12.2 Characteristics of Schizotypal Personality Disorder
Behavioral Style Eccentric and peculiar behaviors
Odd speech but not incoherentDepersonalization and/or dissociation
Interpersonal Style May relate to others with similar unusual interests
Suspicious of others not in their like-minded groupIndifferent to social convention
Cognitive Style Tangential and scattered thought processing
Magical thinking and superstitious
Affective Style Inappropriate or constricted affect
Hypersensitive
Temperament Schizoid types: passive infantile pattern
Avoidance type: fearful infantile pattern
Attachment Style Fearful and dismissingParental Injunction “You’re a strange bird.”Self-View “I’m on a different wavelength than others.”World-View “Life is strange and unusual, and others have special
magic intentions. Therefore, observe caution while beingcurious.”
Maladaptive Schemas Alienation; abandonment; dependence; vulnerability to
harm
Optimal Diagnostic Thinking, speech, behavior, or appearance that is odd, 
Criterion eccentric, or peculiar

interview. This section brieﬂy describes some characteristic observations that theclinician makes and the nature of the rapport likely to develop in initial encounterswith speciﬁc personality-disordered individuals. Characteristic response patternson various objective (i.e., MMPI-2 and MCMI-IV) and projective (i.e.,Rorschach) tests are also described.
Interviewing Schizotypal Personality-Disordered individuals usually elicitssurprising statements and peculiar ideas. Rapport is hampered as long as they feelthe clinician cannot appreciate their experiences. To the extent the clinician isempathic and indicates understanding, they will be more willing to share theirsecret and autistic world. Unlike the schizoid, these individuals establish rapporteasily and are usually willing to respond to all types of questions. The clinicianwill frequently need to ask for clariﬁcation of the impressions and constructions.Empathic listening together with continuation techniques usually sufﬁces inencouraging them to explain their experience. On the other hand, doubtingquestions or confronting their views will cause them to recoil. More intelligentindividuals with this disorder may query the clinicians, wanting to know whetherthe clinician had had experiences similar to theirs. Handling this situation is morea matter of rapport than an issue of formulating questions more effectively(Ackley et al., 2011; Othmer & Othmer, 2002).
The Minnesota Multiphase Personality Inventory (MMPI-2), the Millon ClinicalMultiaxial Inventory (MCMI-IV), and the Rorschach Psychodiagnostic Test canbe useful in diagnosing the Schizotypal Personality Disorder as well as theschizotypal personality style or trait.
On the MMPI-2 a 2–7-8 (Depression-Psychasthenia-Schizophrenia) code is
likely among these individuals (Edell, 1987). Scales F (Frequency) and O (SocialIntroversion) are also likely to be elevated (Graham, 2012).
On the MCMI-IV, elevations on S (Schizotypal), 2A (Avoidant), 7
(Compulsive), and 8A (Negativistic: passive aggressive) can be expected (Choca& Denburg, 1997; Millon et al., 2015).
On the Rorschach, it might be expected that these individuals would respond
much like those with Schizoid Personality Disorder. However, the response ofschizotypal individuals is more similar to schizophrenics and those with BorderlinePersonality Disorder than those with Schizoid Personality Disorder (Swiercinsky,1985).Schizotypal Personality Disorder 253

Included in the differential diagnosis of this disorder are three other personality
disorders: Schizoid, Avoidant, and Borderline. The most common symptomdisorders associated with Schizotypal Personality Disorder are the schizophrenias,particularly the Disorganized, Catatonic, and Residual types. Other disorders noted
are the Anxiety Disorders, the Somatic Symptom Disorders, and the Dissociative
Disorders.
Individuals with this disorder ﬁnd it difﬁcult to engage and remain in a
psychotherapeutic relationship. Typically, they are on medication and may bereferred for adjunctive psychotherapy. Accordingly, the focus of treatment is on
“management” rather than on “treatment.” Thus, instead of attempting person -
ality restructuring, the realistic treatment goal for the schizotypal personality is
to increase the individual’s ability to function more consistently, even though onthe periphery of society. Speciﬁcally, successful management will likely incorp -
orate psychoeducational or social skills training with supportive psychotherapeuticmethods. Reid (1989) noted that if these patients can remain in long-termtreatment, they may be able to increase their ability to function more consistentlyand with less disease. He reports that homogeneous groups can occasionally bea useful adjunct to individual treatment. In terms of medication, low-doseneuroleptics have been found to be useful for the schizotypal personality, evenin the absence of psychotic features. Yet, it should be noted that medicationcompliance is a particular problem with this disorder (Sperry, 2015).
Schizotypal Personality-Disordered individuals tend to be treated in ofﬁce, clinic,
and day treatment programs rather than in acute inpatient programs. They may
proﬁt from dynamically oriented psychotherapy, both expressive and supportive,depending on their level of functioning and treatment readiness. The basis for
dynamic treatment is not interpretation of conﬂict, but rather internalization ofa therapeutic relationship (Stone, 1985).
Essentially, the clinician’s task is to “melt” the patient’s frozen internal object
relations by providing a correct emotional experience. Their style of relatedness
results from inadequacies in early relationships with parental ﬁgures. As a resultthese patients go through life distancing themselves from others. Therapy must
therefore provide a new relationship for internalization (Gabbard, 2000).
There has been relatively little psychodynamic research about this personality
disorder, as noted by Perry, Presniak, and Olson (2013). They conducted a study254 Diagnosis and Treatment of DSM-5 Personality Disorders

that evaluated the defense mechanisms used by individuals with various personality
disorders during videotaped therapy sessions. With schizotypal individuals, therewas the least variance of defense mechanisms among the other disorders.Projection, splitting, passive aggression, and devaluation were the most commondefenses used. Defenses speciﬁc to Schizotypal Personality Disorder includedisplacement and fantasy. Individuals with this disorder prefer to deal with othersindirectly. Since their basic mode of functioning is nonrelational, they ﬁnd thetask of therapy very challenging and difﬁcult. Not surprisingly, they respond tothe challenge with silence and emotional distancing. Clinicians need to adopt apermissive, accepting attitude, and must be exceedingly patient with theseindividuals. It is more helpful to understand silence as a nonverbal form of relatingrather than as treatment resistance. By listening with a third ear, the clinician canlearn much about these patients. Through projective identiﬁcation they will evokecertain responses in the clinician that contain valuable diagnostic informationregarding the patient’s inner world (Gabbard, 1990). Dealing effectively withcountertransference issues is critical in working with schizotypal patients.Accepting silent nonrelatedness is foreign to the clinician’s psychological pre -
disposition and training. Thus, when silence is prolonged, the clinician must guardagainst acting out and projecting their own self- and object representations intothe patient. Accepting the silence, and refraining from interpreting it, legitimizesthe patient’s private, noncommunicative core self. It may be the only viabletechnique for building a therapeutic alliance (Gabbard, 1990).
and frequency of dynamic therapy should be based on the patient’s level offunctioning and motivation and readiness for treatment. Higher functioningschizotypal patients who exhibit some depressive symptoms, or some capacity for
empathy and emotional warmth, tend to have better outcomes in dynamic
psychotherapy (Stone, 1983). Similarly, patients with better ego functioning interms of judgment, reality testing, and cognitive slippage tend to do better than
those with poorer ego functioning.
make dramatic gains in intense, long-term treatment of two to three sessions perweek over several years. On the other hand, long-term supportive psychotherapyis indicated for the majority of schizotypal patients who present with major egodeﬁcits and personal eccentricities. The goal of such treatment is improved adaptivefunctioning in day-to-day living (Stone, 1989). Mehlum et al. (1991) describeda long-term day treatment program for Schizotypal Personality-Disorderedindividuals based on psychodynamic principles.
previous course of long-term psychotherapy. Not surprisingly, there are few case
reports of short-term dynamic individual treatment as curative intervention.Schizotypal Personality Disorder 255

Stone (1989) indicates that, for schizotypal patients who aspire to “ﬁt in” better
and feel less alienated, corrective experiences may be necessary. Such experiencesmight include referral to elocution lessons, or a Dale Carnegie course, oraccompanying the patient to a clothing store to assist in selecting appropriateapparel for a job interview. Stone has also found videotape feedback useful inpointing out the patient’s awkwardness of gait, or gestures. Turkat (1990)recommends that anxiety management and modiﬁcation of hypersensitivity andhypervigilance also may be necessary, depending on the case formulation.
Cognitive Therapy . Beck et al. (2004) brieﬂy describe the Cognitive
Therapy approach to working with Schizotypal Personality-Disordered indi-
viduals. Developing a collaborative working relationship is the starting point for treatment with these individuals. Since these individuals hold a number of
irrational beliefs about others, the importance of the therapeutic relationship should not be underestimated. Since these individuals desire social relationshipsand experi ence distress with social isolation, assisting them in increasing their social
support network is an initial treatment goal. Increasing social appropriateness isa related goal. Social skills training as well as the therapist modeling appropriatebehavior and speech are effective strategies. In combination with these behavioralstrategies, the clinician works collaboratively with the individual to identifyautomatic thoughts and underlying schemas about social interactions. Role-playing more appropriate behavior then becomes much more meaningful.
Perhaps the most critical aspect of treatment is helping the schizotypal
individual seek out objective evidence in the environment to evaluate their
thoughts, rather than relying on emotional responses. As they learn to disregardinappropriate thoughts, they are able to consider the consequences that respondingemotionally or behaviorally to such thoughts would have, and respond more
rationally. The individual’s eccentric and magical thoughts are perceived assymptoms, and predesigned coping statements, such as “There I go again. Even
though I have this thought, it doesn’t mean it’s true,” are practiced. In additionto guided discovery and direct disputation of maladaptive beliefs, indirect strategiessuch as encouraging the schizotypal individual to keep track of the predictionsthey make and the accuracy of these predictions is an effective but less threateningintervention. In addition to focusing on automatic thoughts and schemas, efforts
to change the schizotypal’s cognitive style are helpful. Since the communication
patterns of these individuals tends to be circumstantial and idiosyncratic,collaborative experiments can be set up to modify this style. Furthermore, Becket al. (1990) note that, provided the therapist has realistic treatment expectations,
much can be accomplished, and the collaborative work can be a positive
experience, as these individuals are able to control portions of their inappropriatebehaviors and thoughts.256 Diagnosis and Treatment of DSM-5 Personality Disorders

Freeman et al. (1990) are not optimistic about the cognitive treatment of
schizotypal individuals, indicating that behavioral interventions such as social skillstraining are initially useful. It is only after these individuals can be more sociallyappropriate—that is, they begin acting more like schizoid personalities—that theirautomatic thoughts and cognitive distortions are amenable to cognitive methods.
Renton and Mankiewicz (2015) agree that establishing a collaborative and
trusting therapeutic relationship is crucial to the successful treatment of theseindividuals. Typically, they present for help only when some external crisis forces
them to do so. Schizotypal patients often harbor suspicions about the therapist,
which may include magical thinking such as having their minds read against theirwill. Once trust is established and therapeutic goals have been identiﬁed, a numberof cognitive interventions can be attempted. Developmental conceptualizations
may be particularly useful in helping schizotypal individuals see how past events
shape the beliefs and rules they currently hold about the world. However, theseindividuals may resist deeper examination into the origins of their belief systemsand commonly terminate therapy once symptom relief is achieved or thepresenting situation is resolved.
that has been developed by Young (1999) speciﬁcally for personality disorders,
and other difﬁcult individual and couples problems. Schema Therapy involves
identifying maladaptive schemas and planning speciﬁc strategies and interventions.Four main strategies are cognitive, experiential, behavioral and the therapeutic
relationship itself. Cognitive restructuring, modiﬁcation of maladaptive schemas,
is an important cognitive strategy, but is combined with imagery exercises,empathic confrontation, homework assignments and “limited reparenting,” i.e.,a form of corrective emotional experience (Young, 1999).
Maladaptive schemas typically associated with Schizotypal Personality Disorder
include: abandonment— the belief that signiﬁcant others will not or cannot provide
reliable and stable support; alienation —the belief that one must meet the needs
of others at the expense of one’s own gratiﬁcation; vulnerability to harm— the
exaggerated fear that imminent catastrophe will strike at any time and that onewill be unable to prevent it; and dependence —the belief that one is unable to
competently deal with everyday responsibilities without considerable help fromothers (Bernstein, 2002).
For Benjamin (2003a) psychotherapeutic interventions with SchizotypalPersonality-Disordered individuals can be planned and evaluated in terms ofwhether they enhance collaboration, facilitate learning about maladaptive patterns,and their roots block these patterns, enhance the will to change, and effectivelyencourage new patterns.Schizotypal Personality Disorder 257

The therapist facilitates collaboration by deferring to the schizotypal individual’s
sensitivities. For example, at the beginning of therapy, the therapist may need tobe quite tolerant about cancelled appointments and control over the course ofsessions. If not allowed to maintain distance and control in this manner, theseindividuals will quickly terminate. Gradually the therapist should be able to engagethese individuals through empathic listening, accurate mirroring, and constancy.As treatment progresses, they may develop sufﬁcient trust and insight to relinquishcontrol by magic and ritual. Unlike parents, clinicians require no caregivingthemselves. And, unlike the parents of schizotypals, therapists can be consistentin mainstreaming focus and supportive attention. Such an experience is, therefore,emotionally corrective.
During the course of treatment, schizotypal individuals need to learn that their
efforts to take responsibility for abusive situations when they were helpless servedto predispose them to magical thinking. Such early experiences led theseindividuals to assume they had inordinate power and inﬂuence. Next, they arehelped to recognize when and how they distort reality. At the same time, theyare taught new self-talk that can keep them grounded in the here-and-now. Later,they are helped to understand the contribution of early experiences and learningto their unrealistic thoughts. However, for reconstructive changes to occur theseindividuals must change their wish to magically protect their self and others whilemaintaining loyalty to early abusers. For example, interpreting suicidal or otherfantasies in relation to underlying wishes can lead to fuller awareness, allowingthe individual an opportunity for a new choice. Accurate mirroring and empathycan assist these individuals in mobilizing their will to recover and visualize betterways of viewing self, the world, and others. With these individuals, the therapistmust remain cautious. There is a fragile balance between allowing the patient tocontinue to participate in maladaptive behaviors in order to keep them in therapyand blocking them when they occur to promote change. Benjamin is doubtfulthat major changes in learning patterns will occur, believing that this disorder isgenetically mediated.
Clinical reports of group therapy with schizotypal patients have been limited.Nevertheless, there is sufﬁcient indication these patients may proﬁt fromsupportive group therapy (Mehlum et al., 1991; Stone, 1989).
A reasonable outcome or goal of group therapy is increased awareness that
others harbor fantasies and self-criticisms similar to schizotypals, and that othersmay ﬁnd them likable despite their conviction of unlikability. Group therapy mayimpact such social alienating tendencies as standofﬁshness and peculiarities ofspeech. An ongoing heterogeneous group may be able to tolerate some degreeof these tendencies. But, beyond the limits of tolerability, these behaviors mayso affect either the patient or other group members that therapeutic group process258 Diagnosis and Treatment of DSM-5 Personality Disorders

is molliﬁed. Obviously, appropriate selection of which schizotypal patients will
beneﬁt from being in a group is an important task of the group leaders (Stone,1989).
Clinical reports of marital or family therapy with schizotypal patients have notyet appeared. In general, schizotypal individuals tend to remain single. Becauseof their rejection sensitivity or insensitivity to others’ feelings, these patients arelikely to avoid committed relationships. Not surprisingly, schizotypals who domarry tend to have problems stemming either from insensitivity to the feelingsof their partner or from oversensitivity to the partner’s behavior. Therefore, incouples therapy, the clinician’s ﬁrst task is to assess the degree of and balancebetween these two tendencies. Typically, it is easier to assist a hypersensitive partnerto respond more appropriately than to help an insensitive partner become moreempathic (Stone, 1989).
Family therapy has been identiﬁed as a potentially beneﬁcial intervention for
adolescents with Schizoid Personality Disorder (Ryan, Macdonald, & Walker,2013). Because of the shared symptoms with schizophrenia and other schizo-phrenia spectrum disorders, family education interventions have been adapted toSchizo typal Personality Disorder that enlist family members to support patient
recovery. These include family education about the disorder, identiﬁcation ofrelapse signs and development of action plans, and communication training toreduce stress within the family.
Currently, there are no psychotropic medications speciﬁcally indicated for treatingthis personality disorder (Silk & Feurino, 2012). Nevertheless, medications areused that target speciﬁc troubling symptoms associated with the disorder, suchas depression, anxiety, or sleep problems. Generally, these medications are usedas an adjunct to psychotherapy and skills training. Because troubling symptomsoften respond to medications sooner than most psychological interventions,medications are usually prescribed at the onset of treatment. These include low-dose neuroleptics, which can be useful in decreasing anxiety associated with loss of control (Sperry, 1995b). In a randomized controlled trial, Risperdal(risperidone), an antipsychotic medication, has been shown to be effective withthis disorder (Koenigsberg, Woo-Ming, & Siever, 2002; Silk & Feurino, 2012).
Probably because of the impairing nature of this disorder, there is surprisinglylittle resistance to combining medication with psychological treatments, andSchizotypal Personality Disorder 259

tailoring treatment. Liebowitz et al. (1986) suggest beginning individual therapy
and medication, where indicated, concurrently. Stone (1992) advocates beginningwith medication or a behavioral intervention and adding a dimensionalpsychotherapy: a blending of supportive, exploratory, cognitive, and behavioralelements to match the concurrent needs and circumstances of the patient. This,of course, represents the epitome of integrated, tailored treatment.
Others have advocated social skills training as an adjunct to supportive
psychotherapy (Liebowitz et al., 1986) or combining group therapy withindividual dynamic psychotherapy (Gabbard, 1994). Mehlum et al. (1991) reporton the combining of several treatment modalities for Schizotypal and Borderlinepersonality-disordered patients: individual psychodynamic psychotherapy, grouptherapy, community meetings, art therapy, awareness group therapy, and milieutherapy. This unique prospective study of a day treatment program showed thatefﬁcacy of this combined treatment approach held up an average of three yearslater. Major changes were noted in symptom reduction. However, social adjust -
ments and employment were not as robust as with borderline patients. Nathansonand Jamison (2011) present a case study with a 21-year-old US combat infantry -
man diagnosed with Schizotypal Personality Disorder. His treatment involvedselectively reinforcing positive self-statements, social skills training, and anxietyreduction, as well as pharmacological interventions. Ryan, Macdonald, andWalker (2013) note that many individuals with schizophrenia spectrum disordersalso abuse cannabis, which can exacerbate psychotic symptoms. To address thisissue, they discuss Motivational Interviewing as an effective option.260 Diagnosis and Treatment of DSM-5 Personality Disorders

Romantic Love Conceptualized as an Attachment Process 
Cindy Hazan and Phillip Shaver 
University of Denver 
This article explores the possibility that romantic love is an attachment process--a biosocial process 
by which affectional bonds are formed between adult lovers, just as affectional bonds are formed 
earlier in life between human infants and their parents. Key components of attachment theory, 
developed by Bowlby, Ainsworth, and others to explain the development of affectional bonds in 
infancy, were translated into terms appropriate to adult romantic love. The translation centered on 
the three major styles of attachment in infancy--secure, avoidant, and anxious/ambivalent--and 
on the notion that continuity of relationship style is due in part to mental models (Bowlby's "inner 
working models") of self and social life. These models, and hence a person's attachment style, are 
seen as determined in part by childhood relationships with parents. Two questionnaire studies indi- 
cated that (a) relative prevalence of the three attachment styles is roughly the same in adulthood as 
in infancy, (b) the three kinds of adults differ predictably in the way they experience romantic love, 
and (c) attachment style is related in theoretically meaningful ways to mental models of self and social 
relationships and to relationship experiences with parents. Implications for theories of romantic love 
are discussed, as are measurement problems and other issues related to future tests of the attachment 
perspective. 
One of the landmarks of contemporary psychology is Bowl- 
by's (1969, 1973, 1980) three-volume exploration of attach- 
ment, separation, and loss, the processes by which affectional 
bonds are forged and broken. Bowlby's major purpose was to 
describe and explain how infants become emotionally attached 
to their primary caregivers and emotionally distressed when 
separated from them, although he also contended that "attach- 
ment behavior [characterizes] human beings from the cradle 
to the grave" (1979, p. 129). In recent years, laboratory and 
naturalistic studies of infants and children (summarized by 
Bretherton, 1985, and Maccoby, 1980) have provided consider- 
able support for attachment theory, which was proposed by 
Bowlby and elaborated by several other investigators. The pur- 
pose of this article is to explore the possibility that this theory, 
designed primarily with infants in mind, offers a valuable per- 
spective on adult romantic love. We will suggest that romantic 
love is an attachment process (a process of becoming attached), 
We are grateful to Donna Bradshaw for sharing her expertise in the 
areas of attachment theory and research, to Marry Meitus for allowing 
us to conduct Study 1 in the Rocky Mountain News, to Kathy Purcell 
for keypunching, to Rick Canfield for assistance in all phases of the 
project, and to Mary Ainsworth, John Bowlby, Harry Gollob, Lee Kirk- 
patrick, Roger Kobak, Anne Peplau, Harry Reis, Judith Schwartz, Ar- 
lene Skolnick, and Robert Sternberg for helpful comments on conven- 
tion presentations and earlier drafts of this article. 
Correspondence concerning this article should be addressed to Cindy 
Hazan or to Phillip Shaver, Department of Psychology, University of 
Denver, Denver, Colorado 80208-0204. experienced somewhat differently by different people because 
of variations in their attachment histories. 
For our purpose, which is to create a coherent framework for 
understanding love, loneliness, and grief at different points in 
the life cycle, attachment theory has several advantages over ex- 
isting approaches to love (Shaver, Hazan, & Bradshaw, in press). 
First, although many researchers (e.g., Rubin, 1973; Hatfield & 
Sprecher, 1985) have attempted to assess love with unidimen- 
sional scales, love appears to take multiple forms (e.g., Dion 
& Dion, 1985; Hendrick & Hendrick, 1986; Lee, 1973; Stock, 
Levitan, McLane, & Kelley, 1982; Sternberg, 1986; Tennov, 
1979). Attachment theory explains how at least some of these 
forms develop and how the same underlying dynamics, com- 
mon to all people, can be shaped by social experience to pro- 
duce different relationship styles. Second, although various au- 
thors have portrayed certain forms of love as healthy and others 
as unhealthy, or at least problematic (e.g., Hindy & Schwarz, 
1984; Tennov, 1979), they have not said how the healthy and 
unhealthy forms fit together in a single conceptual framework. 
Attachment theory not only provides such a framework, but 
it also explains how both healthy and unhealthy forms of love 
originate as reasonable adaptations to specific social circum- 
stances. The portrait of love offered by attachment theory in- 
cludes negative as well as positive emotions: for example, fear 
of intimacy (discussed by Hatlield, 1984), jealousy (e.g., Hindy 
& Schwarz, 1985), and emotional ups and downs (Tennov, 
1979) as well as caring (Rubin, 1973), intimacy (Sternberg,

1979) as well as caring (Rubin, 1973), intimacy (Sternberg, 
1986), and trust (Dion & Dion, 1985). Third, attachment the- 
ory deals with separation and loss and helps explain how loneli- 
ness and love are related (Shaver & Rubenstein, 1980; Parkes & 
Journal of Personality and Social Psychology, 1987, Vol. 52, No. 3, 511-524 
Colwfight 1987 by the American Psychological Association, Inc. 0022-3514/87/$00.75 
511

512 CINDY HAZAN AND PHILLIP SHAVER 
Weiss, 1983; Weiss, 1973). Finally, attachment theory links 
adult love with socioemotional processes evident in children 
and nonhuman primates; it places love within an evolutionary 
context (Wilson, 1981). (See Sternberg & Barnes, in press, for 
an anthology of recent approaches to the study of adult love.) 
Attachment Theory and Research 
Bowlby's attachment theory grew out of observations of the 
behavior of infants and young children who were separated 
from their primary caregiver (usually the mother) for various 
lengths of time. Bowlby noticed what primate researchers had 
also observed in the laboratory and the field: When a human 
or primate infant is separated from its mother, the infant goes 
through a predictable series of emotional reactions. The first is 
protest, which involves crying, active searching, and resistance 
to others' soothing efforts. The second is despair, which is a state 
of passivity and obvious sadness. And the third, discussed only 
with reference to humans, is detachment, an active, seemingly 
defensive disregard for and avoidance of the mother if she re- 
turns. Because of the remarkable similarities between human 
infants and other primate infants, Bowlby was led to consider 
the evolutionary significance of infant--careglver attachment 
and its maintenance in the face of separation. 
The attachment system, as Bowlby called the complex con- 
stellation of attachment feelings and behaviors, seems to have 
evolved to protect infants from danger by keeping them close 
to the mother. When very young, a human infant can do little 
more than cry, make eye contact, smile, and snuggle in to en- 
courage its mother to keep it near. Once mobile, however, it can 
actively pursue its mother and vocalize to her. Bowlby and other 
observers of both human and primate behavior have noticed 
that when an infant is healthy, alert, unafraid, and in the pres- 
ence of its mother, it seems interested in exploring and master- 
ing the environment and in establishing aifiliative contact with 
other family and community members. Researchers call this us- 
ing the mother as a secure base. 
Attachment theory can be summarized in three propositions, 
phrased clearly in the second volume of Bowlby's trilogy: 
The first [proposition] is that when an individual is confident that 
an attachment figure will be available to him whenever he desires 
it, that person will be much less prone to either intense or chronic 
fear than will an individual who for any reason has no such confi- 
dence. The second proposition concerns the sensitive period during 
which such confidence develops. It postulates that confidence in 
the availability of attachment figures, or lack of it, is built up slowly 
during the years of immaturity--infancy, childhood, and adoles- 
cence-and that wliatever expectations are developed during those 
years tend to persist relatively unchanged throughout the rest of 
life. The third proposition concerns the role of actual experience. 
It postulates that the varied expectation'g of the accessibility and 
responsiveness of attachment figures that individuals develop dur- 
ing the years of immaturity are tolerably accurate reflections of 
the experiences those individuals have actually had. (Bowlby, 1973, 
p. 235) 
The formation during early childhood of a smoothly func- 
tioning (i.e., secure) attachment relationship with a primary 
caregiver, although the norm in our society, is by no means 
guaranteed. Research by Ainsworth and others suggests that a 
mother's sensitivity and responsiveness to her infant's signals and needs during the first year of life are important prerequi- 
sites. Mothers who are slow or inconsistent in responding to 
their infant's cries or who regularly intrude on or interfere with 
their infant's desired activities (sometimes to force affection on 
the infant at a particular moment) produce infants who cry 
more than usual, explore less than usual (even in the mother's 
presence), mingle attachment behaviors with overt expressions 
of anger, and seem generally anxious. If, instead, the mother 
consistently rebuffs or rejects the infant's attempts to establish 
physical contact, the infant may learn to avoid her. On the basis 
of their observations, Ainsworth, Blehar, Waters, and Wall 
(1978) delineated three styles or types of attachment, often 
called secure, anxious/ambivalent, and avoidant. Infants in the 
anxious/ambivalent category frequently exhibit the behaviors 
Bowlby called protest, and the avoidant infants frequently ex- 
hibit the behaviors he called detachment. A major goal of this 
article is to apply this three-category system to the study of ro- 
mantic love. 
In their description of the three attachment styles, Ainsworth 
et al. (1978) referred to infants' expectations concerning their 
mothers' accessibility and responsiveness. This fits with Bowl-

mothers' accessibility and responsiveness. This fits with Bowl- 
by's claim that infants and children construct inner working 
models of themselves and their major social-interaction part- 
ners. Because the expectations incorporated in these models are 
some of the most important sources of continuity between early 
and later feelings and behaviors, they deserve special attention. 
According to Bowlby, working models (which we will also call 
mental models) and the behavior patterns influenced by them 
are central components of personality. The claim of cross-situa- 
tional and cross-age continuity is still controversial but is sup- 
ported by a growing list of longitudinal studies from infancy 
through the early elementary school years (Dontas, Maratos, 
Fafoutis, & Karangelis, 1985; Erickson, Sroufe, & Egeland, 
1985; Main, Kaplan, & Cassidy, 1985; Sroufe, 1983; Waters, 
Wippman, & Sroufe, 1979). This evidence for continuity adds 
plausibility to the notion that a person's adult style of romantic 
attachment is also affected by attachment history. 
Continuity, according to Bowlby (1973), is due primarily to 
the persistence of interrelated mental models of self and social 
life in the context of a fairly stable family setting: 
Confidence that an attachment figure is, apart from being accessi- 
ble, likely to be responsive can be seen to turn on at least two vari- 
ables: (a) whether or not the attachment figure is judged to be the 
sort of person who in general responds to calls for support and pro- 
tection; [and] (b) whether or not the self is judged to be the sort of 
person towards whom anyone, and the attachment figure in partic- 
ular, is likely to respond in a helpful way. Logically these variables 
are independent. In practice they are apt to be confounded. As a 
result, the model of the attachment figure and the model of the 
self are likely to develop so as to be complementary and mutually 
confirming. (Bowlby, 1973, p. 238) 
Love as Attachment 
So far, no one has'attempted to conceptualize the entire range 
of romantic love experiences in a way that parallels the typology 
developed by Ainsworth and her colleagues. Nor has anyone 
with an interest in romantic relationships pursued Bowlby's 
idea that continuity in relationship style is a matter of mental 
models of self and social life. Finally, no one has explored the

LOVE CONCEPTUALIZED AS AN ATTACHMENT PROCESS 513 
possibility that the specific characteristics of parent-child rela- 
tionships identified by Ainsworth et al. as the probable causes 
of differences in infant attachment styles are also among the 
determinants of adults' romantic attachment styles. These are 
the major aims of this article. 
We derived the following hypotheses by applying Bowlby's 
and Ainsworth's ideas and findings as literally as possible to the 
domain of adult love. 
Hypothesis 1 
Given the descriptions of the secure, avoidant, and anxious/ 
ambivalent styles, we expected roughly 60% of adults to classify 
themselves as secure and the remainder to split fairly evenly 
between the two insecure types, with perhaps a few more in the 
avoidant than in the anxious/ambivalent category. In a sum- 
mary of American studies of the three types of infants, Campos, 
Barrett, Lamb, Goldsmith, and Stenberg (1983) concluded that 
62% are secure, 23% are avoidant, and 15% are anxious/ambiv- 
alent. Given a diverse sample of American adults, we thought it 
reasonable to expect approximately the same proportions. 
Hypothesis 2 
Just as the feelings an infant presumably experiences in the 
relationship with his or her mother are thought to reflect the 
quality of attachment to her, we expected that different types of 
respondents--secure, avoidant, and anxious/ambivalent-- 
would experience their most important love relationships 
differently. We predicted that the most important love experi- 
ence of a secure adult would be characterized by trust, friend- 
ship, and positive emotions. For avoidant adults, love was ex- 
pected to be marked by fear of closeness and lack of trust. Anx- 
ious/ambivalent adults were expected to experience love as a 
preoccupying, almost painfully exciting struggle to merge with 
another person. This last style is similar to what Hindy and 
Schwarz (1984) called anxious romantic attachment and Ten- 
nov (1979) called limerence. 
Hypothes 3 
Respondents' working models of self and relationships were 
also expected to differ according to attachment style. Secure 
types should believe in enduring love, generally find others 
trustworthy, and have confidence that the self is likable. Avoid- 
ant types should be more doubtful of the existence or durability 
of romantic love and believe that they do not need a love partner 
in order to be happy. Anxious/ambivalent types should fall in 
love frequently and easily but have difficulty finding true love. 
They should also have more self-doubts than the other two types 
because, unlike avoidant respondents, they do not repress or 
attempt to hide feelings of insecurity. 
Hypothesis 4 
Because attachment style is thought to develop in infancy and 
childhood, we expected respondents of the three types to report 
different attachment histories. According to the theory, secure 
respondents should remember their mothers as dependably re- 
sponsive and caring; avoidant respondents should report that their mothers were generally cold and rejecting; and anxious/ 
ambivalent respondents should remember a mixture of positive 
and negative experiences with their mothers. As less research 
has been conducted with fathers, we tentatively expected the 
findings related to them to be roughly similar to the findings for 
mothers. 
Hypothesis 5 
Finally, because the attachment needs of insecure respon- 
dents are unlikely to be fully met, avoidant and anxious/ambiv- 
alent respondents should be especially vulnerable to loneliness. 
The avoidant types, however, may defend against or attempt to 
hide this vulnerable feeling and so report less loneliness than 
anxious/ambivalent respondents do. 
Study 1 
In an initial effort to test the attachment-theory approach to 
romantic love, we designed a "love quiz" to be printed in a local 
newspaper. As explained by Shaver and Rubenstein (1983), the 
newspaper questionnaire method has been used in a wide vari- 
ety of studies, always with results that approximate those from 
more expensive, more strictly representative surveys. The main 
difference between newspaper survey respondents and partici- 
pants in representative sample surveys is that the former have 
slightly higher education levels. Also, depending on the topic, 
newspaper surveys tend to draw more female than male respon- 
dents. Neither of these biases seemed to preclude a valuable ini- 
tial test of our ideas, and the gains in sample size and heteroge- 
neity appeared to outweigh the cost of mild unrepresentative- 
ness. 
A single-item measure of the three attachment styles was de- 
signed by translating Ainsworth et al?s (1978) descriptions of 
infants into terms appropriate to adult love. The love-experi- 
ence questionnaire, which we will describe in detail, was based 
on previous adult-love measures and extrapolations from the 
literature on infant-caregiver attachment. The measure of 
working models was based on the assumption that conscious

working models was based on the assumption that conscious 
beliefs about romantic love--concerning, for example, whether 
it lasts forever and whether it is easy or difficult to find--are 
colored by underlying, and perhaps not fully conscious, mental 
models. The measure of attachment history was a simple adjec- 
tive checklist used to describe childhood relationships with par- 
ents and the parents' relationship with each other. 
Method 
Subjects. Analyses reported here are based on the first 620 of over 
1,200 replies received within a week following publication of the ques- 
tionnaire. (The major findings were stable after the first few hundred, 
so additional replies were not keypunched.) Of these 620 replies, 205 
were from men and 415 were from women. The subjects ranged in age 
from 14 to 82, with a median age of 34 and a mean of 36. Average 
household income was $20,000 to $30,000; average education level was 
"some college" Just over half(51%) were Protestant, 22% were Catholic, 
3% were Jewish, 10% were atheist or agnostic, and 13% were "other." 
Ninety-one percent were "primarily heterosexual," 4% were "primarily 
homosexual," and 2% were "primarily bisexual" (3% chose not to an- 
swer). Forty-two percent were married at the time of the survey; 28%

514 CINDY HAZAN AND PHILLIP SHAVER 
were divorced or widowed, 9% were "living with a lover" and 31% were 
dating. (Some checked more than one category.) 
Measures and procedure. The questionnaire appeared in the July 26, 
1985, issue of the Rocky Mountain News on the first and second pages 
of the Lifestyles section. Besides being highly visible there, it was re- 
ferred to in a banner headline at the top of the paper's front page: "Tell 
us about the love of your life; experts ask 95 questions about your most 
important romance" The instructions included the following sen- 
tences: "The questionnaire is designed to look at the most important 
love relationship you have ever had, why you got involved in it, and why 
it turned out the way it did .... It may be a past or a current relation- 
ship, but choose only the most important one?' Given that there was 
only enough room to ask about one relationship, we decided to have 
subjects focus on the one they considered most important. 
The questionnaire was divided into three parts. The first contained 
56 statements concerning the subject's most important relationship, for 
example, "I (considered/consider) one of my best friends" and 
"I (loved/love)~ so much that I often (felt/feel)jealous?' (The 
blank referred to the most important lover's name.) Responses were 
recorded by circling SD, D, A, or SA to indicate points along a strongly 
disagree to strongly agree continuum. The 56 statements, 4 each for 14 
a priori subscales, were adapted from previous love questionnaires 
(Dion & Dion, 1985; Hatfield & Sprecher, 1985; Hindy & Schwarz, 
1984; Lasswell & Lobsenz, 1980; Rubin, 1973; Steffen, McLaney, & 
Hustedt, 1984) or suggested by the literature on infant-caretaker attach- 
ment (e.g., Ainsworth et al., 1978). 
A principal-components analysis followed by equimax rotation was 
performed on the 56-item measure. Thirteen factors had eigenvalues 
greater than 1.0, and 12 corresponded to a priori scales. Items loading 
above .40 on 1 of the 12 predicted factors were analyzed for reliability, 
and items that reduced coefficient alpha were deleted. Table 1 provides 
the names of the 12 scales and a sample item, the number of items 
retained, and coefficient alpha for each. Alpha ranged from .64 to .84 
with a mean of.76, which seemed adequate for preliminary tests of the 
hypotheses. 
Part 2 of the questionnaire asked whether the described relationship 
was current or past (61% were current, 39% were past), what the sub- 
ject's relationship to that person was at the time of the survey, how long 
the relationship had lasted, how many times the subject had been in 
love, and whether he or she had experienced crushes before age 10. This 
part of the questionnaire also contained demographic questions• 
Part 3 dealt with attachment style and attachment history. It included 
sections dealing with the subject's childhood relationships with his or 
her mother and father and the parents' relationship with each other (the 
specific items will be discussed more fully in the Results and Discussion 
section). Also included were questions concerning how the subject typi- 
cally felt in relationships (the exact wording appears in Table 2) and 
what he or she believed concerning the typical course of romantic love• 
The questionnaire concluded with the open-ended question "Can you 
add anything that might help us understand romantic love?" and a re- 
quest for the subject's name and phone number if he or she was willing 
to be interviewed. (Over 60% of the subjects provided this information•) 
Subjects were asked to mail their reply forms to the Rocky Mountain 
News within a week. 
Results and Discussion 
Frequencies of the three attachment styles. Hypothesis 1 con- 
cerned whether newspaper readers could meaningfully classify 
themselves as avoidant, anxious/ambivalent, or secure in their 
most important romantic relationship, given fairly simple de- 
scriptions of the three attachment styles, and in particular 
whether the frequencies of the types would be similar to those 
found in studies of infants and young children. Table 2 shows Table 1 
Information on Love-Experience Scales 
No. of 
Scale name Sample item items a 
Happiness My relationship with ~ 4 .84 
(made/makes) me very 
happy. 
Friendship I (considered/consider) 4 .78 
one of my best 
friends. 
Trust I (felt/feel) complete trust in 4 .83 
Fear of closeness I sometimes (felt/feel) that 3 .64 
getting too close to 
could mean trouble. 
Acceptance I (was/am) well aware of 2 •67 
's imperfections but 
it (did/does) not lessen my 
love. 
Emotional I (felt/feel) almost as much 3 .81 
extremes pain as joy in my 
relationship with __ 
Jealousy 1 (loved/love)__ so 4 .82 
much that I often (felt/ 
feel) jealous. 
Obsessive Sometimes my thoughts 3 .70 
preoccupation (were/are) uncontrollably 
on 
Sexual attraction I (was/am) very physically 4 .80 
attracted to 
Desire for union Sometimes I (wished/wish) 3 .79

on 
Desire for union Sometimes I (wished/wish) 3 .79 
that and I were a 
single unit, a "we" without 
clear boundaries. 
Desire for More than anything, I 3 .70 
reciprocation (wanted/want) ~ to 
return my feelings. 
Love at first sight Once I noticed __, I was 4 .70 
hooked. 
how the alternatives were worded and provides the percentage 
of subjects endorsing each description. 
Just over half (56%) classified themselves as secure, whereas 
the other half split fairly evenly between the avoidant and anx- 
ious/ambivalent categories (25% and 19%, respectively). These 
figures are similar to proportions reported in American studies 
of infant-mother attachment (Campos et al., 1983, summa- 
rized the proportions obtained in these studies as 62% secure, 
23% avoidant, and 15% anxious/ambivalent). Our results sug- 
gest, but of course do not prove, that subjects' choices among 
the alternatives were nonrandom and may have been deter- 
mined by some of the same kinds of forces that affect the attach- 
ment styles of infants and children. The remainder of the results 
argue for the validity of subjects' self-classifications. 
Differences in love experiences. The second hypothesis pre- 
dicted that subjects with different self-designated attachment 
styles would differ in the way they characterized their most im- 
portant love relationship. Table 3 presents the mean subscale 
scores (each with a possible range of I to 4) for each attachment 
type, along with the F ratio from a one-way analysis of variance 
(ANOVA) on scores for each subscale. 
In line with the hypothesis, secure lovers described their most

LOVE CONCEPTUALIZED AS AN ATTACHMENT PROCESS 515 
Table 2 
Adult Attachment Types and Their Frequencies 
(Newspaper Sample) 
Question: Which of the following best describes your feelings? 
Answers and percentages." 
Secure (N = 319, 56% ): I find it relatively easy to get close to others 
and am comfortable depending on them and having them depend on 
me. I don't often worry about being abandoned or about someone 
getting too close to me. 
Avoidant (N = 145, 25% ): I am somewhat uncomfortable being close 
to others; I find it difficult to trust them completely, difficult to allow 
myself to depend on them. I am nervous when anyone gets too close, 
and often, love partners want me to be more intimate than I feel 
comfortable being. 
Anxious/Ambivalent (N = 110, 19% ): I find that others are reluctant 
to get as close as I would like. I often worry that my partner doesn't 
really love me or won't want to stay with me. I want to merge 
completely with another person, and this desire sometimes scares 
people away. 
Note. Twenty-one subjects failed to answer this question, and 25 
checked more than one answer alternative. 
important love experience as especially happy, friendly, and 
trusting. They emphasized being able to accept and support 
their partner despite the partner's faults. Moreover, their rela- 
tionships tended to endure longer: 10.02 years, on the average, 
compared with 4.86 years for the anxious/ambivalent subjects 
and 5.97 years for the avoidant subjects,/7(2, 568) = 15.89, 
p < .001. This was the case even though members of all three 
groups were 36 years old on the average. Only 6% of the secure 
group had been divorced, compared with 10% of the anxious/ 
ambivalent group and 12% of the avoidant group, F(2, 573) = 
3.36, p < .05. 
The avoidant lovers were characterized by fear of intimacy, 
emotional highs and lows, and jealousy. They never produced 
the highest mean on a positive love-experience dimension. The 
anxious/ambivalent subjects experienced love as involving ob- 
session, desire for reciprocation and union, emotional highs 
and lows, and extreme sexual attraction and jealousy. They pro- 
vided a close fit to Tennov's (1979) description of limerence and 
Hindy and Schwarz's (1984) conception of anxious romantic 
attachment, suggesting that the difference between what Tennov 
called love and limerence is the difference between secure and 
anxious/ambivalent attachment. 
Although the average love experiences of people in the three 
different attachment categories differed significantly, for most 
of the subscales all three types scored on the same side of the 
midpoint (2.50), emotional extremes and jealousy being the 
only exceptions. Thus, there appears to be a core experience 
of romantic love shared by all three types, with differences in 
emphasis and patterning between the types. The results also 
support the ideas that love is a multidimensional phenomenon 
and that individuals differ in more ways than the intensity of 
their love experiences. Especially noteworthy was the fact that 
the ordering of means for the different attachment styles 
differed for different dimensions. For the dimensions of happi- 
ness, friendship, trust, and fear of closeness, secure subjects 
differed significantly from avoidant and anxious/ambivalent subjects but these two insecure groups did not differ from each 
other. On the dimensions of obsessive preoccupation, sexual at- 
traction, desire for union, desire for reciprocation, and love at 
first sight, anxious/ambivalent subjects differed significantly 
from avoidant and secure subjects, who did not differ from each 
other. On the acceptance dimension, avoidant subjects (the least 
accepting) differed from anxious/ambivalent and secure sub- 
jects, and on emotional extremes and jealousy, all three groups 
were statistically distinct. This variety of patterns supports the 
claim that there are three different love styles, not simply three 
points along a love continuum. 
Differences in mental models. We attempted to assess what 
Bowlby (1969) called working models of relationships by using 
the items shown in Table 4. Each was either checked or not 
checked as describing how the subject generally "view[s] the 
course of romantic love over time" These dichotomous answers 
were analyzed by attachment style, using a one-way ANOVA. 
(Because the answers were scored as either 0 or 1, the means can 
be read as proportions.) 
In line with the third hypothesis, secure lovers said that ro- 
mantic feelings wax and wane but at times reach the intensity 
experienced at the start of the relationship and that in some 
relationships romantic love never fades. The avoidant lovers 
said the kind of head-over-heels romantic love depicted in 
novels and movies does not exist in real life, romantic love sel- 
dom lasts, and it is rare to find a person one can really fall in 
love with. The anxious/ambivalent subjects claimed that it is

love with. The anxious/ambivalent subjects claimed that it is 
easy to fall in love and that they frequently feel themselves be- 
ginning to fall, although (like the avoidant subjects) they rarely 
find what they would call real love. Like the secure subjects, 
the anxious/ambivalent subjects said they believe that romantic 
feelings wax and wane over the course of a relationship. 
Differences in attachment history. Attachment history with 
parents was assessed in two ways. Subjects were asked whether 
Table 3 
Love-Subscale Means for the Three Attachment 
Types (Newspaper Sample) 
Anxious/ 
Scale name Avoidant ambivalent Secure F(2, 571) 
Happiness 3.19a 3.31. 3.51b 14.21"** 
Friendship 3.18, 3.19, 3.50b 22.96*** 
Trust 3.1 la 3.13, 3.43b 16.21"** 
Fear of closeness 2.30. 2.15, 1.88b 22.65*** 
Acceptance 2.86, 3.03b 3.01 b 4.66** 
Emotional extremes 2.75. 3.05b 2.36¢ 27.54*** 
Jealousy 2.57a 2.88b 2.17c 43.91"** 
Obsessive 
preoccupation 3.01a 3.29b 3.01, 9.47*** 
Sexual attraction 3.27, 3.43b 3.27, 4.08* 
Desire for union 2.81 ~ 3.25b 2.69, 22.67*** 
Desire for 
reciprocation 3.24a 3.55b 3.22, 14.90"** 
Love at first sight 2.91~ 3.17 b 2.97, 6.00** 
Note. Within each row, means with different subscripts differ at the .05 
level of significance according to a Scheff~ test. 
* p < .05. 
** p < .01. 
*** p < .001.

516 CINDY HAZAN AND PHILLIP SHAVER 
Table 4 
Proportion of Respondents Who Endorsed Each Mental-Model 
Statement About Love (Newspaper Sample) 
Anxious/ 
Statement Avoidant ambivalent Secure F(2,571) 
I. The kind of head-over- 
heels romantic love 
depicted in novels and 
movies doesn't exist in 
real fife. .25~ .28a .13b 8.81"** 
2. Intense romantic love 
is common at the 
beginning of a 
relationship, but it 
rarely lasts forever. .41, .34~ .28b 3.83* 
3. Romantic feelings wax 
and wane over the 
course of a 
relationship, but at 
times they can be as 
intense as they were at 
the start. .60, .75b .79b 9.86*** 
4. In some relationships, 
romantic love really 
lasts; it doesn't fade 
with time. .41, .46a .59b 7.48*** 
5. Most of US could love 
many different people 
equally well; there is 
no "one true love" 
which is "meant to 
be" .39 .36 .40 ns 
6. It's easy to fall in love. 
I feel myself beginning 
to fall in love often. .04, .20b .09, 9.33*** 
7. It's rare to find 
someone you can 
really fall in love with. .66, .56, .43b 11.61"** 
level of significance according to a Scheff6 test. 
* p < .05. 
**p < .01. 
*** p < .001. 
they had ever been separated from either parent for "what 
seemed like a long time" and whether the parents ever separated 
or divorced. They were also asked to describe how each parent 
had generally behaved toward them during childhood (using 37 
adjectives, such as responsive, caring, critical, and intrusive, de- 
rived from a pilot study in which subjects answered open-ended 
questions about their childhood relationships with parents) and 
the parents' relationship with each other (using 12 similarly de- 
rived adjectives such as affectionate, unhappy, and argumenta- 
tive). 
There were no significant differences among the three attach- 
ment types in likelihood or duration of separation from parents 
during childhood, even when analyzed by reason for separation. 
In addition, parental divorce seemed unrelated to attachment 
type, even though quality of relationships with parents was as- 
sociated with type. The best predictors of adult attachment type 
were respondents' perceptions of the quality of their relation- 
ship with each parent and the parents' relationship with each 
other. A one-way ANOVA, with attachment style as the independent 
variable, on each of the 86 child-parent and parent-parent re- 
lationship variables yielded 51 Fs that were sitmificant at the 
.05 level, clearly more than expected by chance. (Thirty-seven 
of these were significant at the .01 level; 15 were significant at 
the .001 level.) Because many of the variables were correlated, 
which meant that many of the ANOVA results were redundant, 
a hierarchical discriminant-function analysis was performed to 
assess predictability of membership in the three attachment 
categories from a combination of attachment-history variables. 
Subjects with no missing data on the variables involved (N -- 
506) were included in the analysis. The 22 attachment-history 
variables shown in Table 5 (plus one with a correlation below 
.20) were retained as significant predictors of attachment type. 
Both discriminant functions (two being the maximum possible 
number given three target groups) were statistically significant, 
with a combined x2(46, N= 506) = 131.16, p < .001. After 
removal of the first function, x2(22, N = 506) was 40.94 (p < 
.01). The two functions accounted for 69.87% and 30.13%, re- 
spectively, of the between-groups variability. 
As shown in Figure 1, the first discriminant function sepa- 
rated secure subjects from the two kinds of insecure subjects. 
The second function separated avoidant from anxious/ambiva- 
lent subjects. Together, the two functions correctly classified 
56% of the avoidant subjects, 51% of the anxious/ambivalent 
subjects, and 58% of the secure subjects. (The incorrectly classi- 
fied subjects were distributed fairly evenly across the remaining 
categories.) 
Correlations of the 22 predictor variables with the two dis- 
Table 5 
Significant Correlations Between Attachment-History 
Variables and Discriminant Functions (Newspaper Sample) 
Function Function 
Variable 1 2 
Affectionate parental relationship .44* 
Respectful mother .43* .22 
Intrusive mother -.42* 
Caring father .41" 
Demanding mother -.40" 
Loving father .40* .25 
Humorous father .40* 
Confident mother .35" 
Unhappy parental relationship -.34* .24 
Accepting mother .33* 
Caring parental relationship .32* 
Responsible mother .31" 
Affectionate father .30* .26 
Sympathetic father .28* 
Strong mother .28* 
Disinterested mother -.28* 
Unresponsive father -.24* 
Unfair father -.20 .47* 
Humorous mother .43* 
Likable mother .38* 
Respected mother .30 .37* 
Rejecting mother -.27 -.30" 
Note. Correlations marked with an asterisk in the first column corre- 
lated more highly with Function 1 than with Function 2; the reverse is

lated more highly with Function 1 than with Function 2; the reverse is 
true in the second column.

LOVE CONCEPTUALIZED AS AN ATI'ACHMENT PROCESS 517 
t= 
_o 
3 
I: O E= 
E k. 
U 
"O e- 
o 
I * AnxlouslAmbivalent 
* Avoldant Secure * 
-.6 -.4 -.2 0 .2 .4 .6 
First discriminant function 
Figure 1. Plot of three group centroids on two discriminant functions 
derived from attachment-history variables (newspaper sanaple). 
criminant functions are shown in Table 5. The best discrimina- 
tors between secure and insecure subjects included (a) a rela- 
tionship between parents that was affectionate (r = .44), caring 
(.32), and not unhappy (-.34); (b) a mother who was respectful 
of the subject (.43), confident (.35), accepting (.33), responsible 
(.31), not intrusive (-.42), and not demanding (-.40), among 
other qualities; and (c) a father who was, among other things, 
earing (.41), loving (.40), humorous (.40), and affectionate (.30). 
The top discriminators between avoidant and anxious/ambiva- 
lent groups, with positively correlated variables being those 
named more frequently by anxious/ambivalent subjects, in- 
eluded (a) no parental relationship variables; (b) a mother who 
was relatively humorous (.43), likable (.38), respected (.37), and 
not rejecting (-.30); and (c) a father who was relatively un- 
fair (.47). 
These results can be summarized by saying that secure sub- 
jects, in comparison with insecure subjects, reported warmer 
relationships with both parents and between their two parents. 
Avoidant subjects, in comparison with anxious/ambivalent 
subjects, described their mothers as cold and rejecting. Anx- 
ious/ambivalent subjects saw their fathers as unfair. Both sets 
of correlations are compatible with expectations based on Ains- 
worth et al.'s (1978) studies ofinfant-caregiver attachment. 
Sex differences and similarities. There were a few significant 
sex differences on individual items. Most notably, respondents 
tended to describe their opposite-sex parent more favorably 
than their same-sex parent. For example, 62% of the women (vs. 
44% of the men) described their fathers as loving, t(563) = 4.16, 
p < .00 l, and 78% of the men (vs. 69% of the women) described 
their mothers as loving, t(614) = 2.36, p < .05. This same pat- 
tern was found for the adjectives affectionate and understand- 
ing. Moreover, on negative trait dimensions, respondents tended to judge their same-sex parent more harshly. For instance, 39% 
of the women, but only 27% of the men, described their mothers 
as critical, t(614) = 2.91, p < .01. When reporting about their 
fathers, on the other hand, 53% of the men chose critical com- 
pared with 39% of the women, t(563) = 3.06, p < .01. The same 
was true for demanding. There were no significant sex differ- 
ences in prevalence of the three attachment styles and only 
small differences on two of the love dimensions: Men agreed 
slightly more than women did with the sexual-attraction items 
(3.35 vs. 3.26), t(618) = 1.99, p < .05, and also reported greater 
desire for union (2.94 vs. 2.78), t(616) -- 2.45, p < .05. Overall, 
what stood out was the marked similarity of the results for men 
and women. 
Study 2 
Method 
Study 1 suffered from several limitations that made it desirable to 
conduct a conceptual replication. First, the newspaper sample might 
have been biased because of self-selection. This could have affected our 
estimate of the prevalence of each of the three attachment types and 
distorted other results in unanticipated and undetectable ways. It 
seemed wise, therefore, to test a non-self-selected college-student group 
in our second study, students being the usual subjects in social psycho- 
logical research. Second, Study I examined only limited aspects of sub- 
jects' mental models. An interesting part of Bowlby's (1969) analysis 
was the claim that these models involve complementary portrayals of 
self and relationships. In Study 1, because of space limitations imposed 
by newspaper editors, we neglected the self side of subjects' mental 
models; in Study 2 we focused on them. Third, because previous re- 
search on loneliness (e.g., Rubenstein & Shaver, 1982) has linked loneli- 
ness to attachment history without using the attachment-classification 
item designed for our research on romantic love, we decided to include 
in Study 2 brief measures of state and trait loneliness (Shave~ Furman, 
& Buhrmester, 1985). The hypotheses were the same as in Study 1, but 
Hypotheses 4 and 5 were especially important in Study 2 because new 
self-model items and measures of loneliness were included. 
Subjects. One hundred eight undergraduates (38 men and 70 women) 
who were enrolled in a course entitled Understanding Human Conflict 
completed the questionnaire as a class exercise. Approximately three 
fourths of the students were first-quarter freshmen; the mean age was 
18 years. 
Measures and procedure. As in Study 1, subjects were asked to de- 
scribe their most important love relationship in terms of 56 agree-<lis-

18 years. 
scribe their most important love relationship in terms of 56 agree-<lis- 
agree items. They also classified themselves by using the same attach- 
ment-style item. To measure additional aspects of subjects' mental 
models, we included several self-descriptive items and some new items 
concerning relationships with other people (see Table 8). State and trait 
loneliness were measured (in a separate questionnaire to be described) 
with two parallel 1 l-item scales similar to those described by Shaver et 
al. (1985). These were based in part on the revised UCLA Loneliness 
Scale (Russell, Peplau, & Cutrona, 1980). Each item was answered on 
a 5-point response scale; trait items referred to feelings experienced 
"during the past few years" and state items referred to "the past few 
weeks." Sample trait items included "During the past few years, I have 
lacked companionship" and "During the past few years, about how of- 
ten have you felt lonely?" 
Subjects received their questionnaires as part of a series of class exer- 
cises due at different points during the quarter. Each exercise was due a 
week before related issues were discussed in class. Confidentiality was 
assured by checking off the names of students who handed in the exer- 
cise on time and then analyzing all data by number rather than by name.

518 CINDY HAZAN AND PHILLIP SHAVER 
Table 6 
Types (Undergraduate Sample) 
Anxious/ 
Scale name Avoidant ambivalent Secure /7(2, 104) 
Happiness 3.06 3.26 3.30 ns 
Friendship 3.34a 3.39a 3.61b 3.30* 
Trust 3.25a 3.35b 3.57b 3.03* 
Fear of closeness 2.63, 2.45a 2.13b 4.48** 
Acceptance 2.96 3. l I 2.91 ns 
Emotional 
extremes 2.79~ 2.86a 2.33b 4.67** 
Jealousy 2.52, 3.26b 2.40a 13.24*** 
Obsessive 
preoccupation 3.03 3.09 3.09 ns 
Sexual attraction 3.05 3.31 3.23 ns 
Desire for union 2.83, 3.29b 2.92, 3.41" 
Desire for 
reciprocation 3.2 la 3.64b 3.18a 7.50*** 
Love at first sight 2.67~ 3.10b 2.83, 3.76* 
* p < .05. 
**p<.01. 
To decrease possible halo effects, the loneliness questionnaire was ad- 
ministered 4 weeks after the love-quiz exercise was completed. 
Frequencies of the three attachment styles. The proportions 
of each of the three attachment styles were highly similar in 
Study 2 to what they were in Study 1: secure, 56% (vs. 56% of 
newspaper respondents); avoidant, 23% (vs. 25%); and anxious/ 
ambivalent, 20% (vs. 19%). It seems unlikely, therefore, that the 
newspaper sample was biased in this respect. 
Differences in love experiences. The effects of attachment 
style on love experiences were also similar across the two stud- 
ies, as seen by comparing Tables 3 and 6. Even though only 8 
of the 12 subscales yielded significant mean differences with the 
smaller sample, nearly all exhibited the same pattern of means 
found in Study 1. Secure respondents characterized their love 
experiences as friendly, happy, and trusting, whereas avoidant 
subjects reported fear of closeness, and anxious/ambivalent 
subjects described relationships marked by jealousy, emotional 
highs and lows, and desire for reciprocation. 
Differences in mental models (old items). As seen by compar- 
ing Tables 4 and 7, the results for six of the seven mental-model 
items used in Study 1 were replicated in Study 2, the exception 
being Item 3. (In Study 1, avoidant subjects were distinguish- 
able by their denial that love can be rekindled after it wanes, 
but in Study 2 they were not.) However, only two of the items 
produced significant differences: Item 6 ("It's easy to fall in 
love..."; endorsed by 32% of the anxious/ambivalent, 15% of 
the secure, and none of the avoidant subjects) and Item 7 ("It's 
rare to find someone..."; endorsed by 80% of the avoidant, 
55% of the secure, and 41% of the anxious/ambivalent subjects). 
One possible reason for differences between the two sets of re- suits is that the college student subjects had less relationship 
experience; their average relationship had lasted about 1 year, 
compared with 8 years for the newspaper sample. Fewer of them 
were willing to say that Hollywood romance doesn't exist in real 
life (Item 1), more said that love doesn't fade over time (Item 
4), and so on. 
Differences in mental models (new items). Table 8 shows the 
proportion of each attachment group endorsing the new men- 
tal-model statements designed for Study 2. Attachment style 
had a significant effect on six of the eight, including all but one 
of the items concerning self. The secure subjects described 
themselves as easy to get to know and as liked by most people 
and endorsed the claim that other people are generally well-in- 
tentioned and good-hearted. The anxious/ambivalent subjects 
reported having more self-doubts, being misunderstood and un- 
derappreciated, and finding others less willing and able than 
they are to commit themselves to a relationship. The avoidant 
subjects generally fell between the extremes set by the secure 
and anxious/ambivalent subjects, and in most cases were closer 
Table 7 
Proportion of Respondents Who Endorsed Each Statement 
About Love (Undergraduate Sample) 
Anxious/ F Ratio 
Statement Avoidant ambivalent Secure (2, 104) 
1. The kind of head-over- 
real life. .16 .18 .12 ns 
rarely lasts forever. .40 .27 .17 ns 
course of a 
the start. .64 .68 .50 ns 
with time. .56 .59 .77 ns 
5. Most of us could love 
be?' .28 .36 .28 ns 
to fall in love often. .00, .32b .15,b 4.96** 
really fall in love with. .80a .4 lb .55b 4.10" 
Note. Within each row, means with different subscripts differ at the .05

level of significance according to a Seheff6 test. 
* p < .05. 
** p < .01.

LOVE CONCEPTUALIZED AS AN ATTACHMENT PROCESS 519 
Table 8 
Proportion of Respondents Who Endorsed Each New Mental- 
Model Item (Undergraduate Sample) 
Anxious/ 
Item Avoidant ambivalent Secure F(2, 104) 
1. I am easier to get to 
know than most 
people. .32a .32a .60b 4.39* 
2. I have more self-doubts 
than most people. .48a .64a .18b 9.96"** 
3. People almost always 
like me. .36, .41a .68b 5.19"* 
4. People often 
misunderstand me or 
fail to appreciate me. .36~ .50, .18b 4.56* 
5. Few people are as 
willing and able as I am 
to commit themselves 
to a long-term 
relationship. .24a .5% .23, 5.57** 
6. People are generally 
well-intentioned and 
good-hearted. .44. .32, .72b 6.99*** 
7. YOU have to watch out 
in dealing with most 
people; they will hurt, 
ignore, or reject you if 
it suits thcir purposes. .32 .32 .15 ns 
8. I am more independent 
and self-sufficient than 
most people; I can get 
along quite well by 
myself. .80 .59 .68 ns 
level of significance according to a Schefl'6 test. 
* p < .05. 
**p<.01. 
to the anxious/ambivalent than to the secure. Although the 
differences on the last two items did not reach significance, the 
means were ordered in theoretically meaningful ways. The two 
insecure groups more often said that one has to "watch out in 
dealing with most people" and more of the avoidant subjects 
(80%) than of the secure (68%) or anxious/ambivalent (59%) 
subjects agreed that "I can get along quite well by myself." 
Differences in attachment history. In an attempt to replicate 
the attachment-history findings of Study 1 using data from 
Study 2, we again performed a hierarchical discriminant-fune- 
tion analysis. Subjects with no missing data on the variables 
involved (N = 101) were included in the analysis. Once again, 
both functions proved to be statistically significant, with a com- 
bined x2(50, N = 101) = 128.30, p < .001. After removal of the 
first function, x2(24, N = 101) was 39.84 (p < .05). The two 
functions accounted for 75.31% and 24.69%, respectively, of the 
between-groups variability. As shown in the upper panel of Fig- 
ure 2, the first discriminant function separated anxious/ambiv- 
alent subjects from the other two attachment groups, a pattern 
different from that obtained in Study 1. The second function 
separated avoidant from secure subjects. Together, the two func- 
tions correctly classified 75.0% of the avoidant subjects, 90.5% of the anxious/ambivalent subjects, and 85.7% of the secure 
subjects. 
The new pattern was due primarily to the fact that avoidant 
subjects in Study 2 described their attachment histories as more 
similar to those of secure subjects on positive trait dimensions 
e- 
o 
c 
=1 tim ~m 
e- 
m 
c 
.~ o 
'I= 
O 
"O 
"O C 
O ' 
! 
-3 Secure t 
Avoidant Q 
Anxious/ 
Ambivalent 
-2 -1 0 1 2 
First discriminant function 3 
c 
_o 
o e- 
qo, 
c 
M 
c 
E 
u 
co 
"o 
c 
O 
o @ t~ 
o 
'7 
! 
-3 Secure t 
Anxious/ 
Ambivalen! 
t 
Avoidant 
-2 -1 0 1 2 3 
First dlscriminant function 
Figure 2. Plots of three group centroids on two discriminant functions 
derived from attachment-history variables. (The upper portion of the 
figure displays results for Study 2; the lower portion, results from news- 
paper respondents below 26 years of age.)

520 CINDY HAZAN AND PHILLIP SHAVER 
Table 9 
Variables and Discriminant Functions 
(Undergraduate Sample) 
Cold father 
Caring father 
Confident father 
Understanding mother 
Humorous father 
Warm father 
Respectful father 
Good-humored parental relationship 
Rejecting mother 
Confident mother 
Respectful mother 
Fair father 
Critical mother 
Disinterested mother 
Accepting mother 
Insecure mother 
Cold mother .25* 
-.24* 
-.23* 
-.22" 
-.21" 
-.18" 
-.17" 
-.16" 
-.42* 
.31" 
.21" 
.19" 
-.19" 
-.18" 
.17" 
-.17" 
-.16" 
Note. Correlations marked with asterisks in the first column correlated 
more highly with Function 1 than with Function 2; the reverse is true 
in the second column. 
than did avoidant subjects in Study 1. In Study 1, for example, 
only 12% of avoidant subjects said their mother had been ac- 
cepting; in Study 2 this figure jumped to 50%. For sympathetic, 
the figure jumped from 32% to 79%. The same kinds of differ- 
ences were evident in descriptions of the relationship with fa- 
ther and the parental relationship. For example, 29% of avoid- 
ant subjects in Study 1 described their parents' relationship as 
happy; the corresponding figure in Study 2 was 63%. For good- 
humored, the percentage increased from 19 to 54. This ten- 
dency toward more favorable descriptions on the part of Study 
2's avoidant subjects resulted in greater apparent similarity to 
the secure subjects; on several items, in fact, slightly more 
avoidant than secure subjects gave their parents favorable re- 
ports. This did not keep them, however, from also mentioning 
more negative descriptors, such as critical, rejecting, and disin- 
terested. These negative descriptors allowed the second discrim- 
inant function to distinguish between secure and avoidant 
groups. 
Correlations between the 17 significant predictor variables 
with coefficients above. 15 and the two discriminant functions 
are shown in Table 9. The best discriminators between anxious/ 
ambivalent subjects and secure subjects were (a) a relationship 
between parents that was perceived not to be good-humored 
(-. 16), (b) a mother who was not understanding (-.22), and (c) 
a father who was cold (.25), not caring (-.24), and not confident 
(-.23). In contrast to avoidant subjects, secure subjects de- 
scribed their mothers as respectful (.21), accepting (. 17), not 
rejecting (-.42), and not critical (-. 19), and their fathers as fair 
(.19). 
Why should avoidant subjects' attachment histories appear 
more similar to secure subjects" attachment histories in the 
younger (college student) sample? Central to avoidant attach- 
ment is defensiveness. Main et al. (1985) and Kobak and Sceery (in press) have shown that avoidant adults and college students 
tend to idealize their relationships with parents to avoid the neg- 
ative feelings associated with those relationships. Evidently, it is 
only with maturity and distance from parents that an avoidant 
person can begin to acknowledge severely negative aspects of 
his or her early relationships. To test the hypothesis that youth 
is an important factor, we performed a third discriminant-func- 
tion analysis, using data from the 100 youngest newspaper re- 
spondents (all under 26 years of age). The pattern of results 
proved to be highly similar to the results from Study 2, as seen 
by comparing the upper and lower panels of Figure 2. There 
were two statistically significant discriminant functions, and, as 
in Study 2, the first distinguished primarily between anxious/ 
ambivalent subjects and the other two groups. The second func- 
tion distinguished primarily between avoidant and secure sub- 
jects. 
As a further test of whether differences were due to younger 
avoidant subjects describing their attachment histories more fa- 
vorably than did older avoidant subjects, we compared the 
means on attachment variables for young (again, under 26 years 
of age) with those of older newspaper subjects who had classified 
themselves as avoidant. We found that more younger than older 
avoidant subjects described relationships with and between 
their parents in favorable terms. For example, more described 
their mothers as loving (.77 vs..57), t(5 l) = 2.15, p < .05. They 
were also significantly (p < .05) more likely to say their mothers 
were responsive, not intrusive, and not rejecting. The same pat- 
tern was found in their descriptions of their fathers. For exam- 
ple, 65% of the young avoidants but only 54% of the older group 
called their fathers loving, t(157) = 2.13, p < .05, and they de- 
scribed their fathers as significantly more good-humored. Thus, 
differences between discriminant-function analyses from the 
two studies seem to be due to age differences between the two 
samples and the tendency for young avoidant subjects to ideal- 
ize their attachment histories.

ize their attachment histories. 
Differences in state and trait loneliness. Finally, Table l0 re- 
ports mean trait- and state-loneliness scores (on 5-point scales) 
for each of the three attachment groups in Study 2. In line with 
Hypothesis 5, the highest scores were obtained by the anxious/ 
ambivalent subjects and the lowest scores by the secure subjects. 
These findings fit with other indications throughout the two 
studies that anxious/ambivalent adults yearn for a love relation- 
ship involving merger, reciprocation, and intense passion--a 
relationship for which they find too few willing partners. 
In an attempt to understand why avoidant subjects did not 
receive Wait-loneliness scores equal to those ofanxious/ambiva- 
Table 10 
Trait and State Loneliness as a Function of Adult Attachment 
Style (Undergraduate Sample) 
Loneliness Anxious/ 
type Avoidant ambivalent Secure F(2, 104) p 
Trait 2.30.b 2.59, 2.01 b 7.12 .001 
State 2.57~b 3.02~ 2.21b 6.43 .003 
level of significance according to a Scheff6 test.

LOVE CONCEPTUALIZED AS AN ATTACHMENT PROCESS 521 
lent subjects, we looked at individual items, including some ex- 
treme ones not included in the two scales. (The extra items were 
taken from the NYU Loneliness Scale; Rubenstein & Shaver, 
1982.) Two kinds of items were of special interest: one that bla- 
tantly emphasized being a lonely person (e.g., "I am a lonely 
person," "I always was a lonely person") and another that re- 
ferred to distance from others but without indicating that a 
lonely self was to blame (e.g., "During the past few years, no 
one has really known me well" "During the past few years, I 
have felt left out"). 
In an exploratory analysis, two items of each type were aver- 
aged and contrasted by means of planned comparisons. The 
comparison of anxious/ambivalent subjects and the other two 
groups on items that implicated a trait-lonely self produced 
F(I, 80) = 17.88, p < .001; the comparison of secure and inse- 
cure groups on the more ambiguous items produced F(I, 80) = 
7.05, p < .01. No other comparisons were significant. 
These exploratory analyses are compatible with findings re- 
ported by Kobak (1985). In his study, both avoidant and anx- 
ious/ambivalent subjects were rated by peers as less socially 
competent than secure subjects, but when asked to describe 
themselves, only the anxious/ambivalent subjects reported less 
social competence. 
Sex differences and similarities. In Study 2 there were no 
significant sex differences in any of the variables or patterns for 
which we had sufficient numbers of men to make comparisons. 
General Discussion 
Five hypotheses concerning adult love and loneliness were de- 
rived from attachment theory and research. The first was the 
simplest prediction we could make regarding the relative fre- 
quencies of the three attachment styles: that they would be 
about as common in adulthood as they are in infancy. The re- 
sults supported this hypothesis. Across both studies, approxi- 
mately 56% of the subjects classified themselves as secure, ap- 
proximately 24% as avoidant, and approximately 20% as anx- 
ious/ambivalent. Campos et al. (1983) estimated the figures for 
infancy as 62% secure, 23% avoidant, and 15% anxious/ambiv- 
alent. Of course, it is unlikely that our single-item measure of 
attachment style measures exactly the same thing that Ains- 
worth et al. (1978) coded from behavioral observations of in- 
fant-mother dyads, and it would be naive to think that a style 
adopted in infancy remains unchanged or unelaborated all 
through life. Still, the search for connections between attach- 
ment in childhood and attachment in adulthood must begin 
somewhere, and our simple measure and straightforward hy- 
pothesis fared surprisingly well in their initial tests. 
The second hypothesis predicted different kinds of love expe- 
riences for people in the three attachment-style categories. The 
data supported this hypothesis, indicating a unique constella- 
tion of emotions for each of the three attachment categories 
despite the existence of a general core experience of romantic 
love. The results were weaker in Study 2 than in Study l, partly 
because of sample size but also, perhaps, because of younger 
subjects' lack of relationship experience. 
The third hypothesis predicted that subjects' working models 
of self and relationships would be related to attachment style. 
The results supported this prediction, indicating that people with different attachment orientations entertain different be- 
liefs about the course of romantic love, the availability and trust- 
worthiness of love partners, and their own love-worthiness. 
These beliefs may be part of a cycle (a vicious cycle in the case 
of insecure people) in which experience affects beliefs about self 
and others and these beliefs in turn affect behavior and relation- 
ship outcomes (Wachtel, 1977). 
The fourth hypothesis, like the first, predicted straightfor- 
ward parallels between infant-mother interactions and adults' 
reports about their childhood relationships with parents. Sim- 
ple adjective checklists were used to assess remembered rela- 
tionships with parents and the parents' relationship with each 
other. Study 1 indicated that two discriminant functions based 
on attachment-history items could distinguish significantly be- 
tween members of the three attachment categories. The most 
powerful function discriminated between secure and insecure 
subjects; the second function discriminated mainly between the 
two insecure groups. These results fit well with Ainsworth et 
al's (1978) findings. 
The results were not so straightforward for Study 2, which 
involved a younger group of subjects. For them, the easiest at- 
tachment styles to distinguish, based on reports about child- 
hood experiences with parents, were anxious/ambivalent on the 
one hand and avoidant and secure on the other. A second func- 
tion discriminated mainly between the latter two groups. The

tion discriminated mainly between the latter two groups. The 
differences between Study 1 and Study 2 were interpreted in 
terms oftbe defensiveness of young avoidant subjects. An analy- 
sis distinguishing younger from older subjects in Study 1 sup- 
ported this interpretation. 
The fifth hypothesis predicted greater reported trait loneli- 
ness among insecure than secure subjects, especially among the 
anxious/ambivalents. This prediction was tested in Study 2 and 
was supported by measures of both trait and state loneliness. 
Additional analyses revealed that avoidant subjects admitted 
being distant from other people but did not report feeling lonely. 
It was impossible to evaluate their claims more deeply to see 
whether they are accurate or should be interpreted as additional 
examples of defensive avoidance. 
Overall, the results provide encouraging support for an at- 
tachment-theoretical perspective on romantic love, although a 
number of caveats are in order. 
Because the Study 1 and Study 2 questionnaires had to be 
brief (one due to the constraints of newspaper space, the other 
to limitations of a class-exercise format), we were able to in- 
quire about only a single romantic relationship---the one that 
each subject considered most important. To increase the 
chances of detecting features of relationship experience due to 
subjects' attachment styles, it would be better to ask about more 
than one relationship. Hindy and Schwarz (1984) questioned 
their subjects (all recent college graduates) about four relation- 
ships and treated these as items on an anxious-attachment mea- 
sure. They found correlations in the neighborhood of .40 be- 
tween each pair of relationships in terms of anxious attach- 
ment, suggesting both considerable continuity (due, we suspect, 
to subjects' attachment style) and considerable variation across 
relationships. Degree of security or anxiety in a relationship is, 
as one would expect, a joint function of attachment style and 
factors unique to particular partners and circumstances. This 
matter obviously deserves further study.

522 CINDY HAZAN AND PHILLIP SHAVER 
It may be useful to assess both partners in a relationship; so 
far, we and Hindy and Schwarz have relied on reports from only 
one. It should be possible, using methods like those of Gottruan 
(1979) and Gottman, Markman, and Notarius (1977), to exam- 
ine not only reports about relationship qualities but also ob- 
servable features of couple interaction in the laboratory. This 
is one way to extend measurement beyond the realm of self- 
report. 
In general, we have probably overemphasized the degree to 
which attachment style and attachment-related feelings are 
traits rather than products of unique person-situation interac- 
tions. Attachment researchers often vacillate between using the 
terms secure, avoidant, and anxious/ambivalent to describe re- 
lationships and using them to categorize people. We have fo- 
cused here on personal continuity, but we do not wish to deny 
that relationships are complex, powerful phenomena with 
causal effects beyond" those predictable from personality vari- 
ables alone. A secure person trying to build a relationship with 
an anxious/ambivaient person might be pushed to feel and act 
avoidant. An avoidant person might cause a secure partner to 
feel and act anxious, and so on. These kinds of interactions de- 
serve study in their own right. 
Our measures were limited in terms of number of items and 
simplicity of answer alternatives, and this should be corrected 
in future work. However, there are reasons to suspect that no 
amount of psychometric improvement will solve all the prob- 
lems associated with self-report assessment of attachment-re- 
lated variables. First of all, subjects may be unable to articulate 
exactly how they feel in love relationships. Second, subjects are 
unlikely to have anything like perfect memory for their love ex- 
periences or for the nature of their relationships with parents, 
especially those during the preschool years. Third, subjects are 
likely to be defensive and self-serving in their recall and descrip- 
tion of some of the events we wish to inquire about. 
One way around some of the problems with self-report mea- 
sures is to ask outsiders to describe subjects' relationship-rele- 
vant characteristics. Kobak and Sceery (in press) did so in a 
recent study of attachment styles of college freshmen. They had 
two acquaintances of each subject describe him or her by using 
a Q-sort procedure, and the two sets of results were averaged. 
Subjects' attachment styles were assessed by a long clinical in- 
terview designed by George, Kaplan, and Main (1984). The re- 
suits indicated that secure subjects were described by acquain- 
tances as more socially competent, charming, cheerful, and lik- 
able than their avoidant and anxious/ambivalent classmates. 
The two insecure groups differed in theoretically expected ways, 
the avoidant group being described as more hostile and defen- 
sive, for example, and the anxious/ambivalent group as more 
self-conscious and preoccupied with relationship issues. 
The attachment interview designed by George et al. (1984) is 
itself an important alternative to the kinds of self-report mea- 
sures we used because it includes assessments of defensiveness, 
apparently blocked memories of important relational episodes 
with parents, and preoccupation with attachment issues (on the 
part of anxious/ambivalent subjects). In fact, focusing on defen- 
siveness and information-processing style led Main et al. (1985) 
to conceptualize mental models somewhat differently than we 
did. Whereas we attempted to assess consciously held beliefs about self and relationships, Main et al. attempted to assess how 
information is processed and distorted. 
Even within the self-report domain, it should be possible to 
improve on our single-item measure of attachment style. Each 
of our answer alternatives included more than one issue or di- 
mension, for example, ease of getting close to others, feeling 
comfortable with caregiving and care receiving, fear of aban- 
donment. In principle, each such issue could be assessed sepa- 
rately, with a multi-item scale, and then attachment types could 
be derived by profile analysis. Besides being potentially more 
reliable, such a method would allow subjects to endorse parts 
of what is currently forced on them as a single alternative. 
Aside from measurement problems, the attachment ap- 
proach to romantic love must overcome important conceptual 
dilemmas. In our preliminary studies, we have chosen to over- 
look the fact that child-parent relationships differ in important 
ways from adult romantic relationships. One of the most impor- 
tant differences is that romantic love is usually a two-way street; 
both partners are sometimes anxious and security-seeking and 
at other times able providers of security and care. A second im- 
portant difference is that romantic love almost always involves

portant difference is that romantic love almost always involves 
sexual attraction (Tennov, 1979), whereas only the most specu- 
lative psychoanalysts have claimed that infants' attachments to 
the mother are sexual in nature. Bowlby (1979) and Ainsworth 
et al. (1978), taking their cue from ethology, have dealt with 
problems such as these by postulating distinct behavioral sys- 
tems. These include, among others, the attachment system, the 
caregiving system, and the mating or reproductive system. 
Adult romantic love seems to involve the integration of these 
three systems, with the form of the integration being influenced 
by attachment history (Shaver et al., in press). 
Another important issue has to do with continuity and 
change in attachment style. For theoretical reasons, we were in- 
terested in examining evidence for continuity of attachment 
style between childhood and adulthood, and we consider it im- 
portant that there is good evidence for continuity between ages 
1 and 6 and preliminary retrospective evidence for continuity 
in our own adult data. Nevertheless, it would be overly pessimis- 
tic-from the perspective of insecurely attached people--to 
conclude that continuity is the rule rather than the exception 
between early childhood and adulthood. The correlations we 
obtained between parent variables and current attachment type 
were statistically significant but not strong. They were higher in 
Study 2, where the average subject was 15 to 20 years younger 
than in Study 1. (Also, when we divided the newspaper sample 
into younger and older age groups in an analysis not reported 
here, correlations with parent variables were higher for the 
younger group.) It seems likely that continuity between child- 
hood and adult experiences decreases as one gets further into 
adulthood. (See Skolnick, in press, for relevant longitudinal evi- 
dence.) The average person participates in several important 
friendships and love relationships, each of which provides an 
opportunity to revise mental models of self and others. 
Main et al. (1985) reported that, despite an impressive associ- 
ation between adults' attachment history and the attachment 
styles of their own young children, some parents had freed 
themselves from the chain of cross-generational continuity. 
That is, some adults who reported being insecure in their rela- 
tionships with parents managed to produce children who were

LOVE CONCEPTUALIZED AS AN ATTACHMENT PROCESS 523 
securely attached at ages 1 and 6. Careful study of these cases 
suggested to Main et al. that the adults had mentally worked 
through their unpleasant experiences with parents and now had 
mental models of relationships more typical of secure subjects. 
The process by which an insecure person becomes increasingly 
secure, probably by participating in relationships that discon- 
firm negative features of experience-based mental models, 
offers an important avenue for future research. Our results sug- 
gest that younger avoidant adults are especially prone to defen- 
sive distortion of memories of relationships with and between 
parents. Older avoidant subjects presented a much less favor- 
able portrait of their parents. 
Because many social psychologists are likely to misread our 
approach as Freudian, it may be worthwhile to contrast Freud- 
ian conceptions of infant-to-adult continuity on the one hand 
with attachment theory's conception on the other. Unlike the 
Freudian conception, according to which the supposed irratio- 
nalities of adult love indicate regression to infancy or fixation 
at some earlier stage of psychosexual development, attachment 
theory includes the idea that social development involves the 
continual construction, revision, integration, and abstraction of 
mental models. This idea, which is similar to the notion of 
scripts and schemas in cognitive social psychology (e.g., Fiske 
& Taylor, 1984), is compatible with the possibility of change 
based on new information and experiences, although change 
may become more difficult with repeated, uncorrected use of 
habitual models or schemas. 
Freud argued his case beautifully, if not persuasively, by liken- 
ing the unconscious to the city of Rome, which has been rav- 
aged, revised, and rebuilt many times over the centuries. In the 
case of the unconscious, according to Freud, it is as if all the 
previous cities still exist, in their original form and on the same 
site. Bowlby's conception is more in line with actual archeology. 
The foundations and present shapes of mental models of self 
and social life still bear similarities and connections to their 
predecessors--some of the important historical landmarks, 
bridges, and crooked streets are still there. But few of the an- 
cient structures exist unaltered or in mental isolation, so simple 
regression and fixation are unlikely. 
The attachment-theory approach to romantic love suggests 
that love is a biological as well as a social process, based in the 
nervous system and serving one or more important functions. 
This view runs counter to the increasingly popular idea that 
romantic love is a historical-cultural invention, perhaps a cre- 
ation of courtly lovers in 13th-century Europe (e.g., Averill, 
1985; de Rougement, 1940). This is obviously a matter for seri- 
ous cross-cultural and historical research, but in the absence of 
strong evidence to the contrary, we hypothesize that romantic 
love has always and everywhere existed as a biological potential, 
although it has often been precluded as a basis for marriage. 
There are explicit records of romantic love in all of the great 
literate civilizations of early historic times, from Egypt and 
China to Greece and Rome (Mellen, 1981). 
Finally, we should make clear that by calling romantic love 
an attachment process we do not mean to imply that the early 
phase of romance is equivalent to being attached. Our idea, 
which requires further development, is that romantic love is a 
biological process designed by evolution to facilitate attach- 
ment between adult sexual partners who, at the time love evolved, were likely to become parents of an infant who would 
need their reliable care. 
The noticeable decrease in fascination and preoccupation as 
lovers move from the romantic (attaching) phase to what can 
become a decades-long period of secure attachment is evident 
not only in the case of romantic love but also in early childhood, 
when most secure children begin to take parental support for 
granted (barring unexpected separations). As Berscheid (1983) 
has shown in her analysis of the apparent unemotionality of 
many marriages, disruptions such as divorce and widowhood 
often "activate the attachment system" to use Bowlby's phrase, 
and reveal the strength of attachment bonds that were pre- 
viously invisible. Loneliness and grieving are often signs of the 
depth of broken attachments. 
In sum, love and loneliness are emotional processes that serve 
biological functions. Attachment theory portrays them in that 
light and urges us to go beyond simpler and less theoretically 
integrative models involving concepts such as attitude (e.g., Ru- 
bin, 1973) and physiological arousal (Berscheid & Walster, 
1974). For that reason, the attachment approach seems worth 
pursuing even if future study reveals (as it almost certainly will)

pursuing even if future study reveals (as it almost certainly will) 
that adult romantic love requires additions to or alterations in 
attachment theory. It would not be surprising to find that adult 
love is more complex than infant-caretaker attachment, despite 
fundamental similarities. 
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There are four attachment styles: Secured, Anxious-Preoccupied, Dismissive-Avoidant, and Fearful-Avoidant. in the article Attachment Styles Among Young Adults: A Test of a Four-Category Model, the definitions of the attachment styles as follows:

Secured attachment is characterized by the combination of a positive self model and a positive model of others. Secured individuals have an internalized sense of self-worth and are comfortable with intimacy in close relationships. Preoccupied attachment is characterized by a negative self model and a positive model of others. Preoccupied individuals anxiously seek to gain acceptance and validation from others, seeming to persist in the belief that they could attain safety, or security, if they could only get others to respond properly toward them. Fearful attachment is characterized by negative self and other models. Fearful individuals, like the preoccupied, are highly dependent on others acceptance and affirmation; however, because of their negative expectations, they avoid intimacy to avert the pain of loss or rejection. Dismissing attachment is characterized by a positive self model and a negative model of others. Dismissing individuals also avoid closeness because of negative expectations; however, they maintain a sense of self-worth by defensively denying the value of close relationships. secured subjects view themselves as relatively undistressed and others as supportive, that dismissive (avoidant) subjects view the self as undistressed and others as unsupportive, and that preoccupied subjects (corresponding to anxious-resistant children) view the self as distressed and others as supportive. interview method identified avoidant adults as people who denied experiencing subjective distress and downplayed the importance of attachment needs, the self-report method identified people who reported feeling subjective distress and discomfort when they become close to others. In the article, there are four cells. Cell I indicates a sense of worthiness (lovability) plus an expectation that other people are generally accepting and responsive. Because this cell corresponds conceptually to categories that investigators call securely attached, we labeled it secured. Cell II indicates a sense of unworthiness (unlovability) combined with a positive evaluation of others. This combination of characteristics would lead the person to strive for self-acceptance by gaining the acceptance of valued others. This pattern corresponds conceptually to Hazan and Shavers ambivalent group and to Mains enmeshed or preoccupied with attachment pattern and is referred to as preoccupied. Cell III indicates a sense of unworthiness (unlovability) combined with an expectation that others will be negatively disposed (untrustworthy and rejecting). By avoiding close involvement with others, this style enables people to protect themselves against anticipated rejection by others. We therefore labeled it fearful-avoidant. Finally, Cell IV indicates a sense of love-worthiness combined with a negative disposition toward other people. Such people protect themselves against disappointment by avoiding close relationships and maintaining a sense of independence and invulnerability. This style corresponds conceptually to the detached or dismissing of attachment attitude described by Main et al. (1985), so we labeled it dismissive avoidant. The dismissing and fearful styles are alike in that both reflect the avoidance of intimacy; they differ, however, in the persons need for others acceptance to maintain a positive self-regard. Similarly, the preoccupied and fearful groups are alike in that both exhibit strong dependency on others to maintain a positive self-regard, but they differ in their readiness to become involved in close relationships. Whereas the preoccupied cell implies a reaching out to others in an attempt to fulfill dependency needs, the fearful cell implies an avoidance of closeness to minimize eventual disappointment. self-concept measures were expected to differentiate groups with a positive model of the self (secured and dismissing) from those with a negative model of the self (preoccupied and fearful), whereas a sociability measure was expected to differentiate groups with a positive model of others (secured and preoccupied) from those with a negative model of others (fearful and dismissing). the groups were expected to differ from each other in their interpersonal problems. The groups with a negative image of self (preoccupied and fearful) were expected to exhibit problems with passivity and unassertiveness, whereas those with a negative image of others (fearful and dismissing) were expected to describe problems with socializing and intimacy. The fearful prototype is characterized by an avoidance of close relationships because of a fear of rejection, a sense of personal insecurity, and a distrust of others. the fearful group was rated significantly lower than the secured and preoccupied on self-disclosure, intimacy, level of romantic involvement, reliance on others, and use of others as a secure base when upset. They were also rated as uniquely low in self-confidence and as low on both balance-of-control scales. Continuous ratings of

reliance on others, and use of others as a secure base when upset. They were also rated as uniquely low in self-confidence and as low on both balance-of-control scales. Continuous ratings of the fearful prototype showed negative correlations with self-confidence. The secured and fearful ratings were negatively correlated, and the preoccupied and dismissing ratings were negatively correlated. Finally, the fearful group reported relatively more problems reflecting a lack of assertiveness and social inhibition (introversion). problems. Fearful subjects were most likely to report interpersonal problems in the overly passive region of the interpersonal space (the lower quadrants), whereas dismissing subjects were more likely to report problems related to a lack of warmth in social interactions.  the preoccupied group. Whereas their negative self-image and positive other-image were expected to reflect problems in being overly warm and passive (the lower right quadrant), their problems reflected a greater degree of warmth-dominance. preoccupied people are highly dependent on others to maintain positive self-regard, they attempt to achieve this aim though a controlling (overly dominating) interpersonal style. The preoccupied and fearful groups expressed higher mean levels of interpersonal distress than the other two groups. the expressive scale and negative with the introverted scale). The dismissing group showed its highest means on subscales reflecting excessive coldness, with the correlational analyses showing positive correlations with the cold and competitive subscales and negative correlations with the exploitable, nurturant, and expressive scales. The preoccupied group showed elevated means on the subscales in the warm-dominant quadrant, and the continuous preoccupied rating was most strongly associated with the overly expressive subscale. The preoccupied taxing was also positively correlated with the nurturant and autocratic scales and negatively correlated with the cold, introverted, and subassertive scales. Finally, the fearful group showed elevated means on those subscales located in the passive octants; the introverted subscale showed the highest mean. Correlational analyses also indicated that the fearful style was positively associated with problems of introversion, subassertiveness, and the tendency to be exploited and negatively correlated with problems related to being overly nurturant, expressive, autocratic, and competitive. the two groups with a negative model of the self (the preoccupied and fearful) showed similar responses to measures of personal insecurity, but they differed on measures indicating readiness to become intimate with and rely on other people. The two groups also showed diametrically opposite patterns of interpersonal problems: Whereas the problems of the preoccupied subjects were centered in the warm-dominant quadrant, those of the fearful subjects were centered in the cold-passive quadrant. Similarly, the two groups defined as avoidant of close relationships (the fearful and dismissing) both showed difficulties in becoming close to and relying on others, but they differed significantly on measures reflecting an internalized sense of self-worth. Only the fearful style was consistently associated with social insecurity and lack of assertiveness. two of the four attachment styles, the preoccupied and dismissing styles, were defined in terms of differing valences of self- and other-models. The present research has thus identified interpersonal patterns with discrepant valences between self- and other acceptance. In the preoccupied style, people blame themselves for perceived rejections by others and are thereby able to maintain a positive view of others. In the dismissing style, people downplay the importance of others whom they have experienced as rejecting and are thereby able to maintain high self-esteem.

Overall, if the view on the self is negative, and the view on others is negative - it is likely that the person is Fearful-Avoidant. if the view on the self is positive, and the view on others is positive - it is likely that the person is Secured. if the view on the self is positive, and the view on others is negative - it is likely that the person is Dismissive-Avoidant. if the view on the self is negative, and the view on others is positive - it is likely that the person is Anxious-Preoccupied. if anxiety is high, and avoidance is also high - it is likely that the person is Fearful-Avoidant. if anxiety is low, and avoidance is also low - it is likely that the person is Secured. if anxiety is low, and avoidance is high - it is likely that the person is Dismissive-Avoidant. if anxiety is high, and avoidance is low - it is likely that the person is Anxious-Preoccupied.

Also, in the article An Attachment Theory Perspective on Closeness and Intimacy by Nancy L. Collins and Brooke C. Feeney, these are the definitions of the attachment styles in relation to closeness and intimacy:

Secured Attachment Style: 
Secured adults are comfortable with intimacy and closeness, view themselves as being valued and worthy of care and affection from others, and they perceive that others are generally responsive. Secure individuals perceive attachment figures to be generally well-intentioned, trustworthy, good-hearted, and accessible. Thus, these individuals are able to depend on others and they are not worried about being abandoned or unloved. They tend to be involved in relationships characterized by frequent positive emotion and high levels of interdependence, commitment, trust, and satisfaction. They value intimate relationships, they are able to maintain close relationships without losing personal autonomy, and they are coherent and thoughtful in discussing relationship issues. Moreover, secure individuals report positive, warm, and responsive relationship histories, have high self-esteem and perceptions of personal competency, are generally positive and self-assured in their interactions with others, and have no serious interpersonal problems. They appear to maintain a healthy interdependence such that they effectively balance both intimacy and independence needs. Secured individuals exhibit their comfortable approach to relationship intimacy in a number of ways. They are willing to seek both emotional and instrumental forms of support from others in stressful situations. When in the caregiving role, they exhibit responsiveness and sensitivity to their partners needs, and there is an absence of compulsive over-caregiving and negativity. They are also less likely than insecure individuals to interpret a lack of support from their partner in pessimistic ways (e.g., by attributing negative intent to their partner) and to let an intervening negative event bias their perceptions of earlier relationship events. In addition, when their partner behaves in ways that are kind and caring, secure individuals are more likely to infer that their partner was motivated by altruistic rather than selfish concerns.

Anxious-Preoccupied Attachment Style:
Preoccupied (or anxious-ambivalent) individuals are comfortable with intimacy and closeness, but they view themselves as being somewhat unworthy of care and affection from others. They possess mental models of themselves as being misunderstood, under appreciated, and lacking in confidence; they tend to report inconsistent, unpredictable, and relatively unsupportive attachment histories. Anxious–ambivalent individuals place a great deal of importance on, and are therefore strongly motivated to form, intimate relationships with others. They seek others approval because they depend on other peoples acceptance for a sense of personal well-being and to maintain positive self regard; however, they experience a great deal of anxiety in their relationships with others because they are worried about being abandoned and unloved, and because they perceive significant others as being inconsistent, unreliable, and unwilling to commit to relationships. These perceptions and concerns appear to result in an over-dependence on close relationship partners, a tendency to desire extreme levels of intimacy, and a controlling (overdominating) interpersonal style. As a result, preoccupied/anxious individuals tend to be involved in relationships characterized by frequent negative affect and low levels of trust and satisfaction. They generally experience an approach-avoidance conflict in social situations as a result of their inconsistent experiences with attachment figures in the past—a conflict which typically results in extreme approach behaviors. Preoccupied individuals comfort with and desire for intimacy is reflected in their desire to seek support from others when feeling distressed. their willingness to disclose to others, and their positive feelings toward individuals who disclose to them. Preoccupied individuals report a use of touch to express affection similar to that of secures; however, they report a desire for more touch from relationship partners, and they are the most likely (of all attachment groups) to use touch in a care seeking capacity. that the support-seeking behavior of preoccupied individuals does not differ under conditions of high and low stress, which suggests that they may be less discriminating in their need and desire for support and intimacy and reflecting their chronic desire for a high level of intimacy and responsiveness from relationship partners. Although their caregiving behavior can be responsive with regard to the provision of instrumental support (in that they provide support in response to the partners need—more when its needed and less when its not), anxious individuals have been shown to provide emotional support to their partners irrespective of the partners need for it, again highlighting their desire for intimacy and closeness. They are also more likely than secure individuals to interpret an ambiguous support message in pessimistic ways (e.g., by perceiving their partner as insensitive and by attributing harmful intent to their partner) and to let an intervening negative event bias their perceptions of an earlier interaction. In addition, when their partner behaves in ways that are kind and caring, they appreciate this behavior but have doubts about their partners benevolent motivation. This type of thinking is likely to reflect a low sense of self-worth and a concern about rejection, and it is likely to impede intimacy by engendering suspicion, conflict, and ill feelings toward ones partner. Interestingly, preoccupied individuals also have been shown to differ from individuals with other attachment styles in the way in which they organize knowledge about conflictual romantic relationships. Probably because their relationship goals involve achieving a high level of intimacy and maximal responsiveness from their partners, they tend to view their conflict interactions in a more positive light than other individuals—noticing not only the negative side of conflict, but also its more positive, intimacy-promoting aspects.

Dismissing avoidant individuals are low in attachment-related anxiety but high in attachment-related avoidance. They perceive attachment figures as being generally unreliable, unavailable, and uncaring; however, they view themselves as being worthy and adequate individuals, and as being invulnerable to negative feelings. They maintain a positive self-image in spite of previous rejection from attachment figures by denying attachment needs, downplaying the importance of close relationships, placing much value on independence and self reliance, distancing themselves from others, and restricting expressions of emotionality. Therefore, dismissing avoidants tend to be compulsively self reliant, and their relationships tend to be characterized by low levels of commitment and interdependence. Although avoidant individuals report a high sense of self-worth, they lack clarity or credibility in discussing close relationships. The dialectic between intimacy and independence for both avoidant styles appears to be heavily pulled toward independence over intimacy, with the major difference being that dismissing avoidant individuals claim not to want or need intimacy, whereas fearful avoidant individuals admit that they want it but are concerned about rejection (see below). Consistent with this argument, Mashek and Sherman  found that the when adults were asked to rate their actual level of closeness and their desired level of closeness in their current relationship, individuals who were high in attachment-related avoidance but low in attachment related anxiety (the pattern associated with dismissing avoidance) wanted much less closeness than they currently had. In contrast, those who were high in avoidance and high in anxiety (the pattern associated with fearful avoidance) reported wanting much more closeness. Issues of closeness and distance (and struggles over this issue) are also salient for avoidant individuals who are characteristically uncomfortable with intimacy. Avoidant individuals discomfort with intimacy and closeness is apparent in their use of distancing strategies (as opposed to support-seeking strategies) when coping with stressful situations, their low levels of self-disclosure, their increases in negative emotion following the disclosure of others, and, compared to secure and preoccupied individuals, their lower likelihood of using touch to express affection or seek care from relationship partners, and their greater aversion to touch. Avoidant individuals also appear to be uncomfortable with intimate sexual contact as evidenced by their tendency to separate sex and love. Characteristic of avoidant individuals is their tendency to pull away from partners as their levels of distress increase. For example, that as the anxiety level of avoidant individuals rises, they show more resistance to touch from their partners. When in the caregiving role, they are generally unresponsive, controlling, insensitive, and unlikely to provide physical comfort. It is important to note, however, that these overt distancing strategies are characteristic of avoidant individuals primarily in situations in which the attachment system is activated (when the self or relationship partner is feeling alarmed or distressed). At lower levels of anxiety (when the attachment system is not activated), avoidant individuals do not distance themselves, and they do seek and provide support and establish intimacy with others. Thus, these individuals cannot be characterized as cold, distant, or aloof in general. It is distress or anxiety that appears to impede the establishment of proximity and intimacy in dyadic interactions involving avoidant individuals. It appears that distressed adult partners (similar to distressed infants in the developmental literature) present significant relationship problems for avoidant individuals. Because the proximity needs of avoidant individuals have been frequently frustrated and rarely satisfied, these individuals may overcompensate with proximity-seeking in nonthreatening circumstances. Although it may appear (on the basis of self reports and overt behaviors) that intimacy and closeness is not important to avoidant individuals, these individuals (similar to avoidant children in the strange situation) do exhibit physiological arousal when separated from their relationship partners in stressful situations, they are more likely than secure individuals to respond to physical separation from relationship partners with feelings of insecurity, and they appear to be somewhat more calmed than even secure individuals by supportive partner comments, which indicates that avoidant individuals do benefit from support and do have intimacy needs. that although dismissing adults attempt to avoid attachment-related emotions and are able to block emotional responses (or prevent them from surfacing) when asked to think about separation and loss, they show substantial arousal when made to focus on such thoughts. If

and are able to block emotional responses (or prevent them from surfacing) when asked to think about separation and loss, they show substantial arousal when made to focus on such thoughts. If dismissing-avoidant individuals are truly dismissing of attachment and intimacy, we would not expect them to react physiologically to the presence versus absence of a romantic partner or to be calmed by a partners conversational behavior when feeling stressed. With regard to cognitions about relationship events and behaviors that may have important implications for the closeness and intimacy experienced within the relationship, dismissing individuals are more optimistic than fearful or preoccupied individuals (but less optimistic than secure individuals) in their explanations for their partners transgressions—perhaps reflecting their positive views of themselves and their lack of dependence on relationship partners. However, relative to secure individuals, they are much more likely to draw negative inferences about their partners caring behavior (e.g., to believe that their partner was motivated by selfish rather than altruistic concerns; Collins et al., 2003) and to view their partners ambiguous support attempts as relatively unhelpful and unsupportive (Collins & Feeney, in press). Thus, dismissing individuals appear to draw inferences that protect them from the negative consequences of their partners transgressions, but may also undermine their ability to benefit from their partners kindness and goodwill.

Fearful-Avoidant Attachment Style:
fearful avoidant individuals are high in both attachment-related anxiety and avoidance. Like dismissing individuals, they perceive attachment figures as being generally unreliable, unavailable, and uncaring; however, they differ from dismissing individuals in their lower sense of self worth. Fearful individuals view themselves as being unlovable, emotionally distant, and mistrusting. They desire social contact and intimacy, but they avoid putting themselves in situations where they feel vulnerable to rejection. Thus, the approach-avoidance conflict they experience is typically resolved in favor of avoidance of close relationships. Fearful individuals tend to experience subjective distress and disturbed social relationships characterized by a hypersensitivity to social approval.	Because fearful individuals are high in both anxiety and avoidance, they have some characteristics in common with both preoccupied and dismissing individuals regarding their approach to intimacy. Their caregiving is characterized by low levels of physical contact, sensitivity, and responsiveness (similar to dismissing avoidants), but they also engage in relatively high levels of compulsive over-caregiving. The caregiving patterns of the two avoidant types (dismissing and fearful) support Bartholomew and Horowitzs (1991) hypothesis that the two styles are similar in their avoidance of intimacy, but differ in their need for others acceptance and approval and in their desire for intimate social contact. Fearful individuals are likely to be similar to dismissing avoidants in their use of distancing strategies when coping with stressful situations and in their low levels of self-disclosure. With regard to cognitions about relationship events and behaviors that may have important implications for the closeness and intimacy experienced within the relationship, fearful individuals (similar to preoccupied individuals) tend to make relationship-threatening attributions for their partners transgressions and (similar to dismissing individuals) tend to draw negative inferences about their partners caring behavior (Collins et al., 2003). In addition, when faced with a stressful laboratory task, fearful individuals are much more likely than secure individuals to view their partners support attempts as hurtful and unsupportive, especially when those attempts are somewhat ambiguous. Thus, fearful individuals tend to perceive their relationship experiences in ways that are likely to impede the continuance or establishment of intimacy.We suspect that fearful individuals cognitions about the hazards of relationships frequently override their emotional desires for intimate contact. However, in some situations in which they perceive rejection to be less likely (e.g., in situations in which the relationship partner is in need of support or care), their behavior is likely to be guided by their emotional desire for intimate contact. The compulsive caregiving they exhibit in some of these safer situations may reflect an overcompensation for their frequent lack of intimate contact with relationship partners.

Adult attachment researchers typically define four prototypic attachment styles derived from two underlying dimensions: anxiety and avoidance.
The anxiety dimension refers to one sense of self-worth and acceptance (versus rejection) by others, and this dimension appears to be closely linked to working models of the self. The avoidance dimension refers to the degree to which one approaches (versus avoids) intimacy and interdependence with others, and this dimension appears to be closely linked to working models of others. Secure adults are low in both attachment-related anxiety and avoidance, they are comfortable with intimacy, willing to rely on others for support, and confident that they are valued by others. Preoccupied adults are high in anxiety and low in avoidance, they have an exaggerated desire for closeness and dependence, coupled with a heightened concern about being rejected. Dismissing avoidant individuals are low in attachment-related anxiety but high in avoidance, they view close relationships as relatively and they value independence and self-reliance. Finally, fearful avoidant adults are high in both attachment anxiety and avoidance, although they desire close relationships and the approval of others, they avoid intimacy because they fear being rejected.

In addition, these are the items from questionnaires used to measure or determine attachment styles. each item is congruent to one of the attachment styles. if someone agree or confirm one or several of the items it means he belong to the listed attachment style of that item or items. these are the items and their attachment styles (4 attachment styles and 68 items in total):

1. It is relatively easy for me to become emotionally close to others. 
2. I am comfortable depending on others and having others depend on me.
3. I dont worry about being alone or having others not accept me. 
4. I find it relatively easy to get close to others.
5. I feel comfortable sharing my private thoughts and feelings with others. 
6. I am comfortable depending on others. 
7. I am confident that others will be there for me when I need them. 
8. I am confident that others find me to be a valuable person. 
9. I am comfortable developing close relationships with others. 
10. I am confident that most people are happy to have me as a friend. 
11. I find it easy to be emotionally close to others. 
12. I am comfortable with other people depending on me. 
13. I am comfortable having others share their feelings with me. 
14. I feel at ease in emotional relationships. 
15. I trust other people and I like it when other people can rely on me. 
16. I find it easy to get engaged in close relationships with other people. 
17. I feel at ease in intimate relationships. 
18. I think it is important that people can rely on each other. 
19. I trust that others will be there for me when I need them. 
20. I want to be completely emotionally intimate with others.
21. I dont worry excessively about others not accepting me. 
22. I dont worry excessively about being alone. 
23. I am comfortable having others depend on me. 
24. I am comfortable depending on others. 
25. I do not often worry about being abandoned. 
26. I know that others will be there when I need them. 
27. I am comfortable with my partner depending on me. 
28. I am confident that most people are happy to have me as a friend.

Anxious-Preoccupied Attachment Style: 
1. I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like.
2. I am uncomfortable being without close relationships, but I sometimes worry that others dont value me as much as I value them.
3. I often worry that romantic partners dont really love me.
4. I worry about having others not accept me.
5. I worry that others dont value me as much as I value them.
6. I worry that I wont measure up to other people.
7. I often worry about what others think of me.
8. I worry a lot about my relationships.
9. I want to merge completely with another person.
10. I sometimes feel that I force others to show more feeling and commitment than they would like.
11. I find that others are reluctant to get as close as I would like.
12. I often worry that my partner doesnt really care for me.
13. I worry that others will not care about me as much as I care about them.
14. I often wonder whether people like me.
15. I have the impression that usually I like others better than they like me.
16. It is important to me to know if others like me.
17. I am often worried that my partner does not really love me.
18. My desire to merge completely sometimes scares people away.
19. I worry that romantic partners wont care about me as much as I care about them.

Dismissive-Avoidant Attachment Style: 
1. I am comfortable without close emotional relationships.
2. It is very important to me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me.
3. I find it difficult to allow myself to depend on others.
4. I prefer not to show others how I feel deep down.
5. I find it difficult to depend on other people.
6. I dont feel the need to have close relationships.
7. I dont feel the need to have close emotional relationships.
8. I prefer that others are independent of me and I am independent of them.
9. I dont worry about being alone: I dont need other people that strongly.
10. I prefer not to have others depend on me.
11. I prefer not to depend on others.
12. I prefer not to have other people depend on me.
13. I try to avoid getting too close to my partner.

Fearful-Avoidant Attachment Style: 
1. I am somewhat uncomfortable getting close to others. 
2. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. 
3. I sometimes worry that I will be hurt if I allow myself to become too close to others. 
4. I would like to be open to others but I feel that I cant trust other people. 
5. I would like to have close relationships with other people but I find it difficult to fully trust them. 
6. I am afraid that I will be deceived when I get too close with others. 
7. I am wary to get engaged in close relationships because I am afraid to get hurt. 
8. I am nervous when anyone gets too close to me. 
9. I worry about being abandoned by those I am close to.

The Big Five five-factor personality traits are as follows:

- Extraversion (talktive, assertive, energetic, outgoing, gregariousness, sociable, excitement-seeking, adventurous, enthusiastic, outgoing, show-off, spunky, noisy, bossy), - the opposite is Introversion (solitary, reserved, quiet, withdrawn).

- Agreeableness (good-natured, cooperative, trustful, forgiving, straightforward, not demanding, altruitstic, not stubborn, modest, tender-minded, sympathetic, kind, appreciative, affectionate, soft-hearted, generous, helpful, pleasant, friendly, cooperative, gentle, unselfish, praising), the opposite is Antagonism (critical, rational, fault-finding, unfriendly, quarrelsome, hard-hearted, unkind, cruel).

- Conscientiousness (orderly, responsible, efficient, organized, competence, efficient, dutiful, not careless, achievement striving, self-discipline, not lazy, delberative, not impulsive, organized, thorough, planful, reliable, conscientious, precise, practical, deliberate, painstaking), the opposite is lack of direction (extravagant, careless, disorderly, frivolous, irresponsible, slipshop, forgetful).

- Neuroticism (stressed, anxious, neurotic, easily upset, sensitive, nervous, irritable, not contented, shy, impulsive, not self-confident, tense, worrying, moody, fearful, high-strung, self-pitying, temperamental, unstable, self-punishing, despondent), the opposite is emotional stability (calm, not neurotic, not easily upset, resilient, confident, stable, contented).

- Openness or Openness to experience (intellectual, imaginative, independant-minded, inventive, curious, artistic, wide interests, original, insightful, sophisticated, inventive, sharp-witted, ingenious, witty), the opposite is closedness to experience (cautious, narrow interests, simple, shallow).

NEO‐PI‐R measures the five personality domains in FFM. Each of these domains consists
of six facet scales with each facet scale containing eight items, resulting in a total of 30 facet
scales and 240 items. These items are rated on a 5‐point Likert‐type scale including Strongly

­Contents and Structure of  NEO-PI-339
Disagree (SD), Disagree (D), Neutral (N), Agree (A), to Strongly Agree (SA). These facet scales
and items are balanced to control for acquiescence effect.
The five domains and 30 facet scales are summarized below with a brief description
based on the Manual of the NEO‐PI‐R.

Neuroticism:
N: Neuroticism Tendency to experience of psychological distress
N1: Anxiety Experience of free‐floating anxiety
N2: Angry Hostility Experience of anger and related states
N3: Depression Feelings of guilt, sadness, despondency, and loneliness
N4: Self‐Consciousness Shyness or social anxiety
N5: Impulsiveness Act on cravings and urges rather than reining them in
N6: Vulnerability General susceptibility to stress

Extraversion:
E: Extraversion Quantity and intensity of energy directed outwards
E1: Warmth Interest in and friendliness towards others
E2: Gregariousness Preference for the company of others
E3: Assertiveness Social ascendancy and forcefulness of expression
E4: Activity Pace of living
E5: Excitement Seeking Need for environmental stimulation
E6: Positive Emotions Tendency to experience positive emotions

Openness:
O: Openness Active seeking and appreciation of experiences
O1: Fantasy Receptivity to the inner world of imagination
O2: Aesthetics Appreciation of art and beauty
O3: Feelings Openness to inner feelings and emotions
O4: Actions Openness to new experiences on a practical level
O5: Ideas Intellectual curiosity
O6: Values Readiness to reexamine own values and those of authority figures

Agreeableness:
A: Agreeableness Interactions one prefers from compassion to tough mindedness
A1: Trust Belief in the sincerity and good intentions of others
A2: Straightforwardness Frankness in expression
A3: Altruism Active concern for the welfare of others
A4: Compliance Response to interpersonal conflict
A5: Modesty Tendency to play down own achievements and be humble
A6: Tender‐Mindedness Attitude of sympathy for others

Conscientiousness:
C: Conscientiousness Organized, persistent, and motivated in goal directed behavior
C1: Competence Belief in own self‐efficacy
C2: Order Personal organization
C3: Dutifulness Emphasis on fulfilling moral and ethical obligations
C4: Achievement Striving Need for personal achievement and sense of direction
C5: Self‐Discipline Capacity to get job done on time
C6: Deliberation Tendency to think things through before acting or speaking

According to Drew Westen and Jonathan Shedler in their article An Empirically Derived Taxonomy for Personality Diagnosis, these are the personality types or disorders:

Anxious-Avoidant or Avoidant:
Individuals who match this prototype are chronically anxious. They tend to ruminate, dwelling on problems or replaying conversations in
their minds. They are more concerned with avoiding harm than pursuing desires, and their choices and actions are unduly influenced by
efforts to avoid perceived dangers. They are prone to feelings of shame and embarrassment. Individuals who match this prototype tend to
be shy and self-conscious in social situations and to feel like an outcast or outsider. They are often socially awkward and tend to avoid social
situations because of fear of embarrassment or humiliation. They tend to be inhibited and constricted and to have difficulty acknowledging
or expressing desires. They may adhere rigidly to daily routines, have trouble making decisions, or vacillate when faced with choices. Their
anxiety may find expression through a variety of channels, including panic attacks, hypochondriacal concerns (e.g., excessive worry about
normal aches and pains), or somatic symptoms in response to stress (e.g., headache, backache, abdominal pain, asthma).

Dependent-Victimized or Dependent:
Individuals who match this prototype tend to be needy and dependent, fear being alone, and fear rejection or abandonment. They tend
to be ingratiating or submissive, often consenting to things they find objectionable in an effort to maintain support or approval. They tend
to be passive and unassertive and to feel helpless and powerless. They tend to be indecisive, suggestible or easily influenced, and naïve or
innocent, seeming to know less about the ways of the world than would be expected. They tend to become attached to people who are
emotionally unavailable, and to create relationships in which they are in the role of caring for or rescuing the other person. Individuals
who match this prototype tend to get drawn into or remain in relationships in which they are emotionally or physically abused, or needlessly
put themselves in dangerous situations (e.g., walking alone or agreeing to meet strangers in unsafe places). They are insufficiently
concerned with meeting their own needs and tend to feel unworthy or undeserving. Individuals who match this prototype have trouble
acknowledging or expressing anger and instead become depressed, self-critical, or self-punitive. They tend to express anger in passive and
indirect ways (e.g., making mistakes, procrastinating, forgetting) that may provoke or trigger anger or mistreatment from others.

Schizoid-Schizotypal:
Individuals who match this prototype lack close relationships and appear to have little need for human company or contact, often seeming
detached or indifferent. They lack social skills and tend to be socially awkward or inappropriate. Their appearance or manner may be odd
or peculiar (e.g., their grooming, posture, eye contact, or speech rhythms may seem strange or  off ), and their verbal statements may be
incongruous with their accompanying emotion or non-verbal behavior. They have difficulty making sense of others’ behavior and appear
unable to describe important others in a way that conveys a sense of who they are as people. They likewise have little insight into their own
motives and behavior, and have difficulty giving a coherent account of their lives. Individuals who match this prototype appear to have a
limited or constricted range of emotions and tend to think in concrete terms, showing limited ability to appreciate metaphor, analogy, or
nuance. Consequently, they tend to elicit boredom in others. Despite their apparent emotional detachment, they often suffer emotionally:
They find little satisfaction or enjoyment in life’s activities, tend to feel life has no meaning, and feel like outcasts or outsiders. A subset of
individuals who match this prototype show substantial peculiarities in their thinking and perception. Their speech and thought processes
may be circumstantial, rambling, or digressive, their reasoning processes or perceptual experiences may seem odd and idiosyncratic, and
they may be suspicious of others, reading malevolent intent into others’ words and actions.

Antisocial-Psychopathic or Antisocial:
Individuals who match this prototype take advantage of others, tend to lie or deceive, and to be manipulative. They show a reckless
disregard for the rights, property, or safety of others. They lack empathy for other people’s needs and feelings. Individuals who match this
prototype experience little remorse for harm or injury they cause. They appear impervious to consequences and seem unable or unwilling
to modify their behavior in response to threats or consequences. They generally lack psychological insight and blame their difficulties on
other people or circumstances. They often appear to gain pleasure by being sadistic or aggressive toward others, and they may attempt to
dominate significant others through intimidation or violence. Individuals who match this prototype tend to be impulsive, to seek thrills,
novelty, and excitement, and to require high levels of stimulation. They tend to be unreliable and irresponsible and may fail to meet work
obligations or honor financial commitments. They may engage in antisocial behavior, including unlawful activities, substance abuse, or
interpersonal violence. They may repeatedly convince others of their commitment to change, leading others to think  this time is really different, 
only to revert to their previous maladaptive behavior.

Paranoid:
Individuals who match this prototype are chronically suspicious, expecting that others will harm, deceive, conspire against, or betray them.
They tend to blame their problems on other people or circumstances, and to attribute their difficulties to external factors. Rather than
recognizing their own role in interpersonal conflicts, they tend to feel misunderstood, mistreated, or victimized. Individuals who match this
prototype tend to be angry or hostile and prone to rage episodes. They tend to see their own unacceptable impulses in other people instead
of in themselves, and are therefore prone to misattribute hostility to other people. They tend to be controlling, to be oppositional, contrary,
or quick to disagree, and to hold grudges. They tend to elicit dislike or animosity and to lack close friendships and relationships. Individuals
who match this prototype tend to show disturbances in their thinking, above and beyond paranoid ideas. Their perceptions and reasoning
can be odd and idiosyncratic, and they may become irrational when strong emotions are stirred up, to the point of seeming delusional.

Narcissistic:
Individuals who match this prototype have an exaggerated sense of self-importance. They feel privileged and entitled, expect preferential
treatment, and seek to be the center of attention. They have fantasies of unlimited success, power, beauty, or talent, and tend to treat others
primarily as an audience to witness their importance or brilliance. They tend to believe they can only be appreciated by, or should only
associate with, people who are high-status, superior, or  special.  They have little empathy and seem unable to understand or respond to
others’ needs and feelings unless they coincide with their own. Individuals who match this prototype tend to be dismissive, haughty, and
arrogant. They tend to be critical, envious, competitive with others, and prone to get into power struggles. They attempt to avoid feeling
helpless or depressed by becoming angry instead, and tend to react to perceived slights or criticism with rage and humiliation. Their overt
grandiosity may mask underlying vulnerability: Individuals who match this prototype are invested in seeing and portraying themselves as
emotionally strong, untroubled, and emotionally in control, often despite clear evidence of underlying insecurity or distress. A substantial
subset of narcissistic individuals tend to feel inadequate or inferior, to feel that life has no meaning, and to be self-critical and intolerant of
their own human defects, holding themselves to unrealistic standards of perfection.

Borderline-Dysregulated or Borderline:
Individuals who match this prototype have emotions that can change rapidly and spiral out of control, leading to extremes of sadness,
anxiety, and rage. They tend to catastrophize, seeing problems as disastrous or unsolvable, and are often unable to soothe or comfort
themselves without the help of another person. They tend to become irrational when strong emotions are stirred up, showing a significant
decline from their usual level of functioning. Individuals who match this prototype lack a stable sense of self: Their attitudes, values, goals,
and feelings about themselves may seem unstable or ever-changing, and they are prone to painful feelings of emptiness. They similarly
have difficulty maintaining stable, balanced views of others: When upset, they have trouble perceiving positive and negative qualities in
the same person at the same time, seeing others in extreme, black-or-white terms. Consequently, their relationships tend to be unstable,
chaotic, and rapidly changing. They fear rejection and abandonment, fear being alone, and tend to become attached quickly and intensely.
They are prone to feeling misunderstood, mistreated, or victimized. They often elicit intense emotions in other people and may draw them
into roles or  scripts  that feel alien and unfamiliar (e.g., being uncharacteristically cruel, or making  heroic  efforts to rescue them). They
may likewise stir up conflict or animosity between other people. Individuals who match this prototype tend to act impulsively. Their work
life or living arrangements may be chaotic and unstable. They may act on self-destructive impulses, including self-mutilating behavior,
suicidal threats or gestures, and genuine suicidality, especially when an attachment relationship is disrupted or threatened.

Obsessional or Obsessive-Compulsive:
Individuals who match this prototype tend to see themselves as logical and rational, uninfluenced by emotion. They tend to think in abstract
and intellectualized terms, to become absorbed in details (often to the point of missing what is important), and prefer to operate as if
emotions were irrelevant or inconsequential. They tend to be excessively devoted to work and productivity to the detriment of leisure and
relationships. Individuals who match this prototype tend to be inhibited and constricted, and have difficulty acknowledging or expressing
wishes, impulses, or anger. They are invested in seeing and portraying themselves as emotionally strong, untroubled, and in control, despite
evidence of underlying insecurity, anxiety, or distress. They tend to deny or disavow their need for nurturance or comfort, often regarding
such needs as weakness. They tend to adhere rigidly to daily routines, becoming anxious or uncomfortable when they are altered, and
to be overly concerned with rules, procedures, order, organization, schedules, and so on. They may be preoccupied with concerns about
dirt, cleanliness, or contamination. Rationality and regimentation generally mask underlying feelings of anxiety or anger. Individuals who
match this prototype tend to be conflicted about anger, aggression, and authority. They tend to be self-critical, expecting themselves to be
 perfect,  and to be equally critical of others, whether overtly or covertly. They tend to be controlling, oppositional, and self-righteous or
moralistic. They are prone to being stingy and withholding (e.g., of time, money, affection). They are often conflicted about authority, struggling
with contradictory impulses to submit versus defy.

Hysteric-Histrionic or Histrionic:
Individuals who match this prototype are emotionally dramatic and prone to express emotion in exaggerated and theatrical ways. Their reactions
tend to be based on emotion rather than reflection, and their cognitive style tends to be glib, global, and impressionistic (e.g., missing
details, glossing over inconsistencies, mispronouncing names). Their beliefs and expectations seem cliché or stereotypical, as if taken
from storybooks or movies, and they seem naïve or innocent, seeming to know less about the ways of the world than would be expected.
Individuals who match this prototype tend to be sexually seductive or provocative. They use their physical attractiveness to an excessive
degree to gain attention and notice, and they behave in ways that seem to epitomize gender stereotypes. They may be flirtatious, preoccupied
with sexual conquest, prone to lead people on, or promiscuous. They tend to become involved in romantic or sexual  triangles  and
may be drawn to people who are already attached or sought by someone else. They appear to have difficulty directing both tender feelings
and sexual feelings toward the same person, tending to view others as either virtuous or sexy, but not both. Individuals who match this prototype
tend to be suggestible or easily influenced, and to idealize and identify with admired others to the point of taking on their attitudes
or mannerisms. They fantasize about ideal, perfect love, yet tend to choose sexual or romantic partners who are emotionally unavailable, or
who seem inappropriate (e.g., in terms of age or social or economic status). They may become attached quickly and intensely. Beneath the
surface, they often fear being alone, rejected, or abandoned.

Items from SWAP-200 Questionnaire:

Borderline Personality Disorder:
1. Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, rage, excitement, etc.
2. Tends to become irrational when strong emotions are stirred up; may show a noticeable decline from customary level of functioning.
3. Emotions tend to change rapidly and unpredictably.
4. Tends to fear she/he will be rejected or abandoned by those who are emotionally significant.
5. Tends to be overly needy or dependent; requires excessive reassurance or approval.
6. Tends to feel unhappy, depressed, or despondent.
7. Tends to feel she/he is inadequate, inferior, or a failure.
8. Tends to feel misunderstood, mistreated, or victimized.
9. Tends to make repeated suicidal threats or gestures, either as a “cry for help” or as an effort to manipulate others.
10. Tends to engage in self-mutilating behavior (e.g., self-cutting, self-burning, etc.).
11. Lacks a stable image of who she/he is or would like to become (e.g., attitudes, values, goals, and feelings about self may be unstable and changing).
12. Tends to see relationships as more intimate than they actually are.
13. Tends to feel empty or bored.

Narcissistic Personality Disorder:
1. Tends to be critical of others.
2. Tends to be competitive with others (whether consciously or unconsciously).
3. Tends to be arrogant, haughty, or dismissive.
4. Tends to believe she/he can only be appreciated by, or should only associate with, people who are high-status, superior, or special.
5. Tends to feel entitled; expects preferential treatment.
6. Seeks to be the center of attention.
7. Has fantasies of unlimited success, power, beauty, talent, brilliance, etc.
8. Is envious of others; assumes that others are envious of her/him.
9. Tends to think of herself/himself as special or unique.

Antisocial Personality Disorder:
1. Takes advantage of others; is out for number one; has minimal investment in moral values.
2. Tends to act impulsively, without regard for consequences.
3. Is deceitful; tends to lie or mislead.
4. Lacks empathy; tends to be callous, cold, or uncaring.
5. Tends to be unreliable and irresponsible (e.g., may fail to meet work obligations or honor financial commitments).
6. Has little empathy; seems unable or unwilling to understand or respond to others' needs or feelings.
7. Tends to break things or become physically assaultive when angry.
8. Tends to manipulate others’ feelings in order to get what she/he wants.
9. Lacks close friendships and relationships.
10. Tends to feel like an outsider or alien, as if she/he doesn’t truly belong.

Obsessive-Compulsive Personality Disorder:
1. Tends to be perfectionistic.
2. Tends to be overly concerned with rules, procedures, order, organization, schedules, etc.
3. Tends to be preoccupied with details, rules, and making lists.
4. Tends to be self-critical; sets unrealistically high standards for self and is intolerant of own human defects.
5. Tends to be overly controlling of others.
6. Tends to be conscientious and responsible.

Dependent Personality Disorder:
1. Tends to be overly needy or dependent; requires excessive reassurance or approval.
2. Tends to be ingratiating or submissive.
3. Tends to feel helpless, powerless, or at the mercy of forces outside his/her control.
5. Tends to be overly concerned with pleasing others; willing to compromise or sacrifice in order to avoid conflict.
6. Tends to feel she/he is inadequate, inferior, or a failure.

Avoidant Personality Disorder:
1. Tends to be shy or reserved in social situations.
2. Tends to avoid social situations because of fear of embarrassment or humiliation.
3. Tends to feel like an outsider or alien, as if she/he doesn’t truly belong.
4. Tends to be inhibited or constricted; has difficulty allowing self to acknowledge or express wishes, impulses, or anger.
5. Tends to feel she/he is inadequate, inferior, or a failure.

Schizotypal Personality Disorder:
1. Tends to have odd or peculiar thoughts, perceptions, or behaviors.
2. Appears to have peculiar mannerisms or behavior.
3. Tends to see relationships as more intimate than they actually are.
4. Tends to have fantasies that are bizarre or magical.
5. Tends to feel like an outsider or alien, as if she/he doesn’t truly belong.
6. Tends to feel misunderstood, mistreated, or victimized.
7. Has little empathy; seems unable or unwilling to understand or respond to others' needs or feelings.

Histrionic Personality Disorder:
1. Tends to be self-dramatizing, theatrical, exaggerated, or overstated.
2. Seeks to be the center of attention.
4. Emotions tend to change rapidly and unpredictably.
5. Tends to become attached quickly or intensely; develops feelings, expectations, etc., that are not warranted by the history or context of the relationship.
6. Tends to be overly suggestible or easily influenced.
7. Tends to be overly concerned with her/his physical attractiveness.

Paranoid Personality Disorder:
1. Tends to hold grudges; may dwell on insults or slights for long periods.
2. Tends to be critical of others.
3. Tends to be suspicious; tends to assume others will harm, deceive, conspire against, or betray her/him.
4. Tends to feel misunderstood, mistreated, or victimized.
5. Tends to expect others to reject, criticize, or betray her/him.
6. Tends to attribute her/his own unacceptable feelings or impulses to others (e.g., may assume that others are angry, envious, etc., when in fact she/he is).
7. Tends to react to criticism with feelings of rage or humiliation.

Schizoid Personality Disorder:
1. Tends to avoid social situations because of fear of embarrassment or humiliation.
2. Lacks close friendships and relationships.
3. Appears to have little need for companionship, and is genuinely indifferent to the presence or absence of others.
4. Tends to feel like an outsider or alien, as if she/he doesn’t truly belong.
5. Appears to have little or no interest in having sexual experiences with another person.

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 405According to the Diagnostic and Statistical
 Manual of Mental Disorders , fourth edition
 (DSM-IV;  American Psychiatric Association
 [APA], 1994), a personality disorder is char- acterized by pervasive and inflexible patterns
of inner experience and distorted perceptions that deviatesignificantly from behaviors most frequently found in most socialor cultural groups. Characteristic features of personality disorders
usually emerge during adolescence or early adulthood, tend to
remain stable over time, and often lead to serious distress orimpairment for the individual (APA, 1994, p. 630).
Over the years, etiological understandings of personality
disorders have evolved from an almost exclusive focus onthe internal characteristics of the person to a greater em-
phasis on developmental influences (Millon, 1994). Cen-
tral to many developmental approaches is the idea that for-mative experiences with primary caregivers and significantothers not only provide the foundation for a person’s basicsense of self but also influence the way he or she subse-quently navigates various life span developmental challenges
and issues (Kegan, 1982; Mahoney, 1991).
From a developmental perspective, one of the most impor-
tant developmental challenges is constructing an integratedpersonal identity balanced with a capacity to maintain healthyconnections with one’s social world (Mahoney, 1991). In thecase of most personality disorders, however, interpersonal
problems are often a defining feature of the disorder. As
Widiger and Frances (1985) pointed out:
An interpersonal nosology is particularly relevant to personality disor-
ders. Each personality disorder has a characteristic and dysfunctional
interpersonal style that is often a central feature of the disorder. There
is also some empirical support for the hypothesis that a personalitydisorder is essentially a disorder of interpersonal relatedness. (p. 620)Recently, attachment theory has become an important
conceptual framework for understanding the more or less
adaptive and maladaptive ways individuals may negotiate
various life span developmental challenges (Guidano, 1991;Lopez, 1995; Lyddon, 1995). Although attachment theoryhas been shown to be a viable conceptual framework fromwhich to understand many concerns that clients bring tocounseling, the counseling literature has not highlighted
how attachment concepts may be especially relevant to
understanding the core dimensions and unique symptomstructure of personality disorders.
The purpose of this article is to conceptualize personality
disorders in terms of attachment theory. Toward this end,Bowlby’s (1969) theory of attachment  and his interpreta-
tion of cognitive working models of self and others are first
discussed as a precursor to recent developments in the adultattachment literature. Second, using Bartholomew’s (1990)
model of adult attachment, each of the major types of person-ality disorders is (a) conceptualized as a developmental per-sonality style (Ivey, 1991; Ivey & Ivey, 1998) and (b) reviewed
in terms of the typical antecedent childhood attachment
experiences, working models of self and others, and“feedforward” (Mahoney, 1991) cognitions associated withthe personality style. Finally, several guidelines are offeredfor applying attachment theory to counseling those withproblematic developmental personality styles.
ATTACHMENT THEORY
The origins of attachment theory are associated with theextensive writings and research of John Bowlby (1969, 1973,
1980). Bowlby was initially trained in the psychoanalytic
method but eventually became concerned with the extent
William J. Lyddon  is a professor and the director of training of the counseling psychology doctoral program, and Alissa Sherry  is a doctoral student in the
counseling psychology program, both at the University of Southern Mississippi, Hattiesburg. Correspondence regarding this artic le should be sent to William J.
Lyddon, Counseling Psychology Program, University of Southern Mississippi, Hattiesburg, MS 39406-5025 (e-mail: William.Lyddon@u sm.edu).Developmental Personality Styles: An Attachment
Theory Conceptualization of Personality Disorders
William J. Lyddon and Alissa Sherry
Attachment theory, as a developmentally based theory of personality formation, provides a viable framework for understanding
the development and maintenance of personality disorders, or what A. E. Ivey and M. B. Ivey (1998) have referred to as “develop -
mental personality styles.” Using K. Bartholomew’s (1990) 4-dimensional model of adult attachment as an organizational frame-
work, 10 developmental personality styles are differentiated regarding their unique attachment experiences, working models of
self and other, and feedforward beliefs. Implications of an attachment theory framework for counseling clients with problematic
developmental personality styles are discussed.

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 406Lyddon and Sherry
to which his colleagues and teachers were preoccupied with
children’s fantasy life to the exclusion of what he perceived
were significant real-life events and environmental influ-
ences (Ainsworth & Bowlby, 1991). For example, he foundthat either prolonged experiences of mother–child separa-tion or deprivation of maternal care was more commonamong adolescents who had a history of stealing than amongadolescents who did not. He suggested that such experi-
ences were especially linked to children originally diagnosed
as “affectionless” (Bowlby, 1944).
On the basis of these initial observations, Bowlby (1969)
suggested that there were distinct qualities of the caregiver–child bond that come to regulate children’s emotional expe-rience and behavior. According to Bowlby (1969), infants are
equipped at birth with a biologically based behavioral and
motivational system that has evolved with the purpose ofpromoting proximity to a caregiver. From an evolutionaryperspective, the formation of close relationships serves toprovide safety and protection, ultimately increasing theinfant’s chances of survival. When an infant either becomes
separated from his or her caregiver or the bond is threatened
in some way, activation of this innate behavioral systemresults in characteristic proximity-seeking behaviors (e.g., cry-ing). The caregiver’s responses to these behaviors becomesystematically organized into a goal-directed partnershipbetween caregiver and child.
Some of the most important empirical studies designed to
identify and classify attachment behaviors are associated withMary Ainsworth and her colleagues (Ainsworth & Bell, 1969;Ainsworth, Blehar, Waters, & Wall, 1978; Ainsworth & Wittig,1969; Bell & Ainsworth, 1972). Ainsworth used a laboratoryprocedure known as the “Strange Situation Protocol.” Within
a controlled setting, a 1-year-old infant is briefly separated
from his or her primary caregiver, visited by a stranger, andthen reunited with the caregiver. Throughout the procedure,the child’s behaviors are rated along several dimensions:maintaining proximity (clinging), reestablishing proximity(reaching/following), protesting separation (crying), and dem-
onstrating pleasure in reunion (smiling/physical contact).
Ainsworth’s (Ainsworth et al., 1978) research with the
Strange Situation Protocol helped to establish four com-monly accepted child–caregiver attachment patterns: secure,anxious–ambivalent, avoidant, and disorganized. Securely
attached infants explore their environment, looking back at
their caregiver periodically (Ainsworth, 1985). They show
some distress when separated but are easily comforted uponreunion as evidenced by smiling, vocalization, waving, andseeking contact. These infants seem to experience their at-tachment figure as available and responsive. The child–caregiver relationship is characterized as a secure base to
which the child feels safe to return for comfort when ex-
ploration becomes particularly anxiety provoking or un-comfortable. Anxious-ambivalent  infants typically do not
explore their environment and choose instead to cling totheir caregivers (Ainsworth, 1985). They display extremeagitation upon separation. Upon reunion, these infants seek
contact while arching away from the caregiver, resisting allefforts to be comforted. These infants seem to perceive the
attachment figure as either inconsistently available or un-
responsive when needed. Caregivers are presumably unre-
liable sources of comfort during times of stress, leaving theinfant anxious about whether their bids for security will bemet. Avoidant  infants display a pervasive indifference be-
fore and after separation (Ainsworth, 1985). These chil-dren avoid their caregiver upon his or her return. In these
relationships, the infants’ bids for comfort and protection
have presumably been rebuffed or rejected. The child’s re-action to the caregiver seems to represent a knowledge thatany attempt to be comforted will be met with this undesir-able rejection, thus encouraging little responsiveness fromthe child. In several studies, it was noted that many infants did
not fall into any of the original three categories previously
described. Main, Kaplan, and Cassidy (1985) proposed afourth attachment pattern, disorganized attachment,  to describe
infants who displayed a pronounced mixture of am bivalent
and avoidant patterns of behavior.
According to Bowlby (1969), it is the extent to which
the caregiver is consistently accessible and responsive to
the infant’s bids for comfort and security that determinesthe quality and type of attachment the child will have forthe caregiver. The caregiver–child relationship is centralto the infant’s comfort and security. The child’s experi-ence of a positive, responsive relationship with a caregiver
or important others is a necessary precursor for healthy
exploration and adjustment. Persistent threats to the bal ance

of this goal-directed partnership lead to less adaptive ways
of the child relating within the child–caregiver rela tionship
and ultimately in the way the child is able to relate to theoutside world.
A central tenet of attachment theory is that along with
these distinct patterns of proximity-seeking behavior orresponding to the caregiver, infants develop correspondingworking models  or cognitive expectations about the accessi-
bility and responsiveness of their caregiver as well as theirown ability to elicit need-meeting responses from their
caregiver (Bowlby, 1973). Bowlby highlighted the distinc-
tion between working models of self and of others. A work-ing model of self is an evolving schema of how childrenview themselves based on their role in the attachment rela-tionship. One’s internal working model of self is a set ofbeliefs about one’s worthiness and competence as an indi-
vidual. Working models of others are believed to derive from
the original working models of primary caregivers and arethought to eventually generalize to a broader base of ex-pectations about others and the world. The two represen-tations of self and other mirror each other as the individualnavigates through life and its unfolding challenges.
SOURCES OF ATTACHMENT CONTINUITY
Specific attitudes and feelings toward attachment that per-sist into later periods, including adulthood, are not the ex-
clusive result of working models developed in early attach-
ment relationships. Instead, working models persist when

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 407Personality and Attachment
they encounter attachment strains of a quality and inten-
sity consistent with the child’s earliest attachment experi-
ences. Thus, it is the confirmation of early working models
in the form of later attachment experiences that contrib-ute to the persistence of these models. As Bowlby (1973)stated,
Environmental pressures are due largely to the fact that the family
environment in which a child lives and grows tends to remain rela-tively unchanged. This means that whatever family pressures ledto the development of a child to take the pathway he is now on arelikely to persist and so to maintain development on that same path-way. (p. 368)
A second source of continuity of attachment patterns is
the way in which the personality structure becomes self-confirmatory over time through the operation of assimilative,feedforward mechanisms (Lyddon, 1993b; Mahoney, 1991).
Feedforward processes actively anticipate and constrain
experiences to assimilate them into already held be liefs.
Such mechanisms serve to “fit” new experiences into existingcognitive constructions and are relatively inflexible to newinformation. As Bowlby (1973) noted,
Structured features of personality, once developed, have their own
means of self-regulation that tend also to maintain the current
direction of development. For example, present cognitive or be-havioral structures determine what is perceived and what is ig-nored, how a situation is construed, and what plan of action islikely to be constructed to deal with it. Current structures, more-over, determine what sorts of person and situation are sought after
and what sorts are shunned. In this way, an individual comes to
influence the selection of his/her own environment, and the wheelcomes full circle. (pp. 368–369)
It is important to note that securely attached individu-
als are characterized by a self-system that is relatively opento new information (or feedback). Working models of se-cure individuals reflect a relative balance betweenfeedforward (assimilative) and feedback (accommodative)
processes, and as a result, the secure self-system is rela-
tively flexible and open to new learning and change(Mikulincer, 1997). The self-systems of insecurely attachedindividuals , on the other hand, tend to be relatively closedto new information. Their working models tend to oper-ate primarily in an assimilative mode and have often fore-
closed around a few salient constructs or themes such as
dependence, mistrust, or personal worthlessness. In otherwords, their self-systems tend to be dominated byfeedforward processes and as a result are not as open tofeedback and new information (Mahoney, 1991). Suchworking models tend to assimilate most new information
under existing guidelines or rules, selectively attending to
information that confirms the rules and ignoring informa-tion that may disconfirm them. Working models of inse-cure attachment may therefore be viewed as highly de-veloped feedforward strategies that originate in formativeinsecure attachment experiences with significant others
and that tend to be relatively inflexible to new learning
and change.MODELS OF ADULT ATTACHMENT
Attachment researchers have extended their study of at-tachment to the developmental periods of adolescence andadulthood (Bartholomew & Horowitz, 1991; Collins &Read, 1990; Griffin & Bartholomew, 1994; Hazen & Shaver,
1990). One of the more popular and widely researched
models of adult attachment is that developed byBartholomew (1990). Drawing on Bowlby’s (1973) notionof working models of self and others, Bartholomew developeda four-category system of adult attachment that organizes aperson’s working models along two dimensions: (1) the dis-
tinction between self and others and (2) valence (positive
versus negative). As shown in Figure 1, the intersection ofthese dimensions leads to four prototypical styles of adultattachment: secure  (positive view of self and others), preoccu-
pied (negative view of self and others), dismissing  (positive
view of self, negative view of others), and fearful  (negative
view of self and others).
According to Bartholomew (1990), secure individuals
possess a sense of self-worth coupled with an expectationthat other people are generally trustworthy, accessible, andresponsive. Individuals displaying a preoccupied attachmentstyle possess a sense of personal unworthiness combined
with a positive evaluation of others. These individuals tend
to be very externally oriented in their self-definitions. Indi-viduals with a fearful attachment style exhibit a sense ofpersonal unworthiness combined with an expectation thatother people will be rejecting and untrustworthy. Theseindividuals trust neither their own internal cognitions or
feelings nor other people’s intentions. Finally, those with a
dismissing attachment style are characterized by a sense of
FIGURE 1
Bartholomew and Horowitz’s (1991) Model of Adult

FIGURE 1
Attachment
Note . From “Attachment Styles Among Young Adults: A Test of a Four-
Category Model,” by K. Bartholomew and L. M. Horowitz, 1991, Journal
of Personality and Social Psychology, 61,  p. 227. Copyright 1991 by
the American Psychological Association. Reprinted with permission.MODEL OF SELF
Positive Negative
(Low) (High)
Positive
(Low)
MODEL
OF OTHER(Avoidance)
Negative
(High)Cell I
SECURE
intimacy and autonomyCell II
Cell IV
Counter-dependentCell III
FEARFUL
Socially avoidant

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 408Lyddon and Sherry
self that is worthy and positive combined with a low evalu-
ation or mistrust of others. It is important to note that
Bartholomew (1990) specified that her model does not as-
sume that “all individuals are expected to exhibit a singleattachment style” (p. 162). She instead characterized theseattachment styles as conceptual prototypes and suggestedthat it is more appropriate to view adult attachmentmultidimensionally, with individuals exhibiting one or more
dimensions as predominant.
ATTACHMENT AND DEVELOPMENTAL PERSONALITY STYLES:
IMPLICATIONS FOR COUNSELING
Attachment theory, as a developmentally based model of
personality formation, also lends itself easily to a develop-mental conceptualization of clients’ presenting issues. Froma developmental perspective, “there is a developmental logicto any client thought, emotion, behavior, or meaning orga-
nization” (Ivey & Ivey, 1998, p. 340). Often the most ex-
treme client behavior makes sense once it is situated in thecontext of the client’s developmental history and the uniqueway in which that client makes meaning out of that history(Ivey, 1989).
From an attachment theory perspective, personality dis-
orders may be viewed as the outcome of insecure working
models that have become self-confirmatory and dominatedby feedforward processes. In these cases, working modelsof self and other have become relatively inflexible and closedto new information, and as a result, the person experiencessignificant distress in social, occupational, and relational
functioning. It is interesting that the various interpersonal
dysfunctions characterized by the major types of personal-ity disorders may be understood using the four-dimensionalmodel of self and others theorized by Bartholomew (1990).In particular, we propose that the insecure dimensions ofBartholomew’s model provide an attachment theory frame-
work from which to understand the organizational features
of the working models associated with those who are diag-nosed with personality disorders. There are 10 recognizedpersonality disorders in the DSM-IV  (APA, 1994; depen-
dent, obsessive-compulsive, histrionic, avoidant, paranoid,antisocial, narcissistic, schizotypal, schizoid, and borderline.
Although the DSM-IV  classification system of personality
disorders provides an excellent starting point for understand-ing how clients may repeat their developmental past in thepresent, it does not provide much information on problemdevelopment or problem solution. As Ivey (1991) noted, per-haps a more appropriate term for personality disorder would
be developmental personality style —a better concept to
express the unique way a person has learned to adapt to lifespan developmental challenges and gain protection from thepain of insecure attachments. Following from Ivey, andbecause this connotation is more consistent with the devel-opmental emphasis of this article, this is the term we use in
place of the more common psychiatric diagnostic term,
personality disorder . Using Bartholomew’s (1990) dimensions
of insecure attachment as an organizational scheme, we exam-ine each of the 10 major developmental personality styles
in terms of their developmental features, characteristic work-
ing models of self and others, and dominant feedforward
cognitive processes.
Preoccupied Attachment Dimension
The preoccupied attachment dimension is characterized by
a sense of personal unworthiness and a positive evaluationof others. Developmental personality styles that seem toexemplify this dimension of attachment include dependent,
obsessive-compulsive, and histrionic.
Dependent personality style . People with a dependent per-
sonality style usually lack assertiveness and self-confidence.Their interpersonal behavior is usually clinging, compliant,pleasing, and self-sacrificing. Developmentally, their familyhistory is often characterized by overprotective caregivers
who relay a message to them that they are not capable of
accomplishing things on their own (Bornstein, 1992). Overtime, these individuals begin to construct a view of them-selves as personally inadequate, exemplified by the corebelief that others are in their life to take care of them.Continual self-deprecation and avoidance of competitive
activities tend to perpetuate the self model of personal
inadequacy. Because current relationships are often char-acterized by extreme dependency, the potential to lose one’s
sense of self in relationships is always high. Feedforward cog-nitive processes include core beliefs such as “I am unable tofunction in the world without constant assistance from other
people,” “Others are here to look after my needs,” and “I can-
not survive without continual contact with anotherperson”(Sperry & Mosak, 1996, p. 287). These beliefs, coupledwith an ongoing dependent style of relating, tend to parallelthe negative self-view and positive other-view characteristicof preoccupied attachment.

Obsessive-compulsive personality style . Persons with an
obsessive-compulsive personality style often present asworkaholics and perfectionists. They are characterized as stub-born, possessive, and indecisive, but dependable. Their inter-personal relationships are marked by a domineering styletoward peers or subordinates coupled with a submissive or
passive style with superiors. They typically demand perfec-
tionism from others as they demand it from themselves.Such behaviors can usually be traced developmentally toparenting styles that demand achievement. Caregiver loveis often contingent on such achievement, and parent–childinteractions tend to be characterized by parental
overinvolvement (Ivey, 1991). As a consequence, the child
eventually internalizes extremely high perfectionistic stan-dards and develops a view of self that is reliable, compe-tent, and righteous (Ingram, 1982). However, the child alsocomes to believe that if something goes wrong, he or she isresponsible. Because the parental figures are often
perfectionistic as well, the individual’s view of others is
grounded in that perfectionism. However, these childrenare rarely able to live up to their parents’ expectations. There-fore, they ultimately develop a view of themselves that is

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 409Personality and Attachment
inherently negative because, although they see themselves
as reliable and competent, they continually fall short in the
eyes of the parental figure. The feedforward message that
perpetuates the self-system is “Always be prepared for theunpredictable demands of life” (Sperry & Mosak, 1996). Theirhypervigilance often magnifies things that may go wrong,reinforcing the belief that life is unpredictable and difficultto control.
Histrionic personality style.  A third developmental person-
ality style that is also relevant to the preoccupied dimensionof attachment is the histrionic personality style. Individualswith this personality style initially seem charming and excit-ing. However, they soon display characteristic lability,eccentricity, and the superficiality more typical of this
diagnosis. Their interpersonal behavior is marked by at ten-
tion getting, flirtatious, and even exhibitionistic behaviors.
Parenting styles experienced by these individuals are usu ally
enmeshed and engulfing and convey to the child the mes-sage: “If you do what I want, I will give you my attention.”Because at least one of the child’s parents often exhibits
histrionic features as well, lability, eccentricity, and super-
ficiality are modeled for the child. These parental charac-teristics may also contribute to minimal or inconsistentdisciplining, forcing the child to use extreme measures tobe noticed. Although failure to elicit need-meeting be-haviors from parental figures tends to contribute to a
negative self-view, the minimal attention the child does
receive often results in a positive view of others.Feedforward pro cesses that perpetuate the histrionic self-
system usually take the form of beliefs like “I need others tonotice me.” Although these beliefs lead the child to continu-ally seek external forms of gratification, the behaviors used
to get this attention are sometimes so extreme that others
may turn away (Sperry & Mosak, 1996). When this occurs,the child often experiences more anxiety and may developeven more elaborate attention-seeking strategies character-istic of histrionic personality style.
Preoccupied and Fearful Attachment Dimensions
Avoidant personality style . Individuals with an avoidant per-
sonality style often present with self–other working mod-
els that seem to incorporate both preoccupied and fearfulattachment dimensions. These individuals tend to have aself-view that is negative and an other-view that vacillatesbetween positive and negative. They often seem to be shyand to avoid people initially. However, this avoidance is
often based on the desire to be liked and accepted by oth-
ers, coupled with the fear of rejection and abandonment.These individuals do not have many friends, but when some-one does accept them and a friendship develops, they oftenbecome dependent on them. Their family history is charac-terized by either an engulfing or an avoidant parenting style
(Sperry & Mosak, 1996). With an engulfing parent, the child
may feel overwhelmed by the responsibility of such a highlevel of emotions within the relationship. The opportunityfor autonomy diminishes. As the child grows older, he orshe desires closeness with others but fears that such intimacy
may become engulfing. As a response, such interactions are
avoided. With an avoidant parenting style, the child develops
a fragile sense of self and ultimately fears the same type ofrejection from other people in their life. The assumption isthat it is better to avoid relationships than to risk being re-jected again. The feedforward cognitions associated with anavoidant personality style consist of beliefs like “Life is un-
fair, people reject and criticize me, but I want someone to
like me. Therefore, be vigilant, demand reassurance, and, if allelse fails, fantasize and daydream” (Sperry & Mosak, 1996, p.310). Because these individuals are rarely sufficiently reas-sured, their personality style is perpetuated by their ongoinganticipation of others’ rejection and criticism.
Fearful Attachment Dimension
Paranoid personality style . Those with a paranoid personality
style represent the prototype of Bartholomew’s (1990) fearful
dimension of adult attachment. These individuals are guarded
and defensively hypervigilant. They resist external influence,are chronically tense, and often present with restricted af-fect, possibly in an effort to control the outward expressionof emotions. In interpersonal relations hips they are often
distrustful, secretive, and blaming. Others tend to describe
them as constantly being on the counterattack, provoking
tension, or being argumentative and hypersensitive. Familyhistories of individuals with a paranoid personality style typi-cally include some form of active rejection and persecutionby caregivers coupled with a critical and vigilant approach toparenting. Caregivers also tend to be perfectionistic in their

expectations. The core message they relay to the child is
“You’re different, don’t make mistakes” (Sperry & Mosak,1996, p. 320). It is no surprise that the persecution and criti-calness that dominates the caregiver–child interaction resultsin negative working models of self and others and a pervasivemistrust in other people (Thompson-Pope & Turkat, 1993).
The feedforward cognitions that perpetuate the paranoid
system involve a pervasive suspicion of others. The view thatothers have malevolent motives often leads to increasedsocial isolation and alienation, further confirming to theperson that others cannot be trusted and should be blamedfor things that go wrong.
Fearful and Dismissing Attachment Dimensions
Three developmental personality styles seem to be most
associated with the fearful and dismissing dimensions of
insecure attachment: antisocial, narcissistic and schizotypal.
Antisocial personality style . These individuals present as
hostile, impulsively angry, and cunning. They are often thrill-seekers and risk-takers and view emotions such as warmthand intimacy as forms of weakness. Their relationships withothers are characteristically antagonistic and belligerent.
They distrust others and often exploit and manipulate oth-
ers for their own personal gain. The family history of indi-viduals with an antisocial personality style is often markedby parental hostility and probable abuse. These experiences

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 410Lyddon and Sherry
convey the message that “the end justifies the means” (Sperry
& Mosak, 1996, p. 301). Thus, much of their own vindictive
behavior is learned from their caregivers. Overall, there is
little affection and nurturance in the home and the child isforced to be self-reliant. The view of the self wavers be-tween a view that is negative and one that is positive. Thenegative view is very likely the result of messages trans-lated from the abuse and lack of nurturance in the home.
The message is “I must be unlovable because my parents do
not behave as if they love me.” Alternatively, a positive viewof self often develops, possibly as a defense in reaction tothis negative view, and may lead to a sense of personal en-titlement. The view of others is characterized by a consis-tent belief that others are not willing to love and care for
them. Initially created in the context of vindictive, abusive,
unloving interactions with their parents, this view is ulti-mately transferred to others in general and easily accountsfor the ability of those with antisocial personality style toexploit and use other people with little remorse or concernfor them. The primary feedforward cognitions include be-
liefs like “I need to be powerful and in control or people will
take advantage of me.” Because these individuals generallydevelop a worldview that life is hostile, they also come tobelieve that one must be cunning and break the rules to getwhat one wants (Sperry & Mosak, 1996). This worldviewand its associated behaviors generally turn others against
them, ultimately perpetuating the belief of these individu-
als that the world is a hostile place.
Narcissistic personality style . Individuals with a narcissistic
personality style are often characterized as conceited,boastful, and snobbish. They are often described as self-centered, pompous, impatient, arrogant, and thin-skinned. Their
interpersonal relationships are often exploitative and irrespon-
sible. They tend to lack empathy and use others to in dulge
themselves. Similar to an obsessive-compulsive personalitystyle, family histories of those with a narcissistic personalitystyle are often characterized by parental overevaluation andindulgence (Sperry & Mosak, 1996), with parental approval
and affection often tied to personal accomplishments rather
than the self (Ivey & Ivey, 1998). In general, the parentalinjunction they receive is “You are special, unique, and en-titled to extraordinary rights and privileges.” Because of thediscrepancy between their inflated view of themselves andtheir diminished view of others, they tend to have a negative
and disdainful working model of others. It is interesting that
working models of self tend to vacillate between positive andnegative appraisals. Although these individuals may behaveoutwardly with overzealous confidence, this is often a maskfor the intense insecurity they often feel. Their caregiversgive them the message that others owe them admiration and
privilege. As this view collides with a fragile view of self,
defense mechanisms that protect the fragile self-system arestrengthened and their narcissistic behavior becomes moreapparent to others. The primary feedforward processes asso-ciated with the narcissistic personality style include illusionsof specialness, a disdain for other’s views, and a sense of
entitlement. These views further distance the individual fromothers, thereby increasing self-absorption and reinforcing
narcissistic beliefs.
Schizotypal personality style . Individuals with a schizotypal
personality style also seem to fit within fearful and dismissingattachment dimensions. The behavior of these individuals isoften characterized as eccentric, erratic, and bizarre. They tendto isolate themselves socially and experience intense socialanxiety and apprehension, often coupled with paranoid think-
ing. The parenting style typical of their developmental histo-
ries is cold and derogatory. Ineffective and easily misinterpretedparental communications are common, typified by the mes-sage “You’re a strange bird” (Sperry & Mosak, 1996, p. 322).This parenting style leaves the individual feeling different,without a sense of self, empty, estranged, and depersonalized
(Millon, 1981). These developmental antecedents encourage
the person to become dependent on others while fearing thatothers have negative intentions. As a result, their view of oth-ers is predominantly negative. However, due to their “self-less”conceptions, the view of self vacillates between a positive, nega-tive, and almost nonexistent view, with the nonexistent view
serving as a defense for the intense confusion. The primary
feedforward process is the belief “Even though I need otherpeople, I am afraid to seek such relationships” (Sperry & Mosak,1996). This fear of involvement further insulates the person,reinforcing a sense of being different (Thompson-Pope &Turkat, 1993).

Dismissing Attachment Dimension
Schizoid personality style . The dismissing dimension of
attachment seems to best characterize individuals with a
schizoid personality style. These individuals present in coun-
seling as nonspontaneous and inattentive. They have minimalinterest in other people, rarely respond to feelings oractions of others, and remain aloof and indifferent. Thedevelopmental histories of these individuals tend to becharacterized by experiences with caregivers who are rigid,
emotionally unresponsive, and undersocialized in interper-
sonal skills (Thompson-Pope & Turkat, 1993). Parentalbehaviors and interactions tend to convey to the child themessage “Who are you, what do you want?” These interac-tions lead to a view of the self that reinforces this differencefrom others while it decreases their immediate need for
interaction with others. This rigid, unresponsive developmen-
tal history helps to create the belief “Others are indifferentand the world is difficult, so why try to establish relation-ships?” These individuals are not bothered by their lack ofinterpersonal relationships and therefore can be conceptu-alized with a positive self-view. The primary feedforward
belief is “Relationships are unimportant and not necessary
because people are indifferent to each other anyway” (Sperry& Mosak, 1996).
Disorganized Attachment Dimension
Finally, individuals with a borderline personality style ex-
hibit a unique, unstable, and dynamic personality structurethat tends to shift among the various insecure attachment

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 411Personality and Attachment
dimensions, creating a disorganized profile. They frequently
shift from positive to negative views of self and others, with
little allegiance to any particular attachment dimension. As
a result, they often present as labile, resentful, impulsive,highly emotional, helpless, and empty. They are reactive totheir environment, and any self–other view can be drawnon at any time. Interpersonally, they may move very rap-idly between extreme closeness and extreme distance. These
shifts are behavioral manifestations of the cognitive beliefs
of these individuals that lead them to either idealize ordevalue others with whom they are involved in romanticor friendship relationships. These shifts often result in aseries of intense, unstable relationships. From a develop-mental perspective, Bowlby (1973) noted that some chil-
dren exhibit multiple, contradictory, and incompatible work-
ing models. Multiple models seem to be most common inchildren who are required to process experiences that arecontradictory, which causes them to exhibit confused pat-terns of relatedness (Lynch & Cicchetti, 1991). This mayexplain why no single dimension or combinaton of attach-
ment dimentions is adequate to conceptualize the border-
line personality style. Studies consistently note the chaoticdevelopmental histories of these individuals. Caregivers areoften overprotective, demanding, or inconsistent, provid-ing the child with little or no sense of stability or structurewith which to regulate emotions. Furthermore, physical orsexual abuse, or both, are often noted (Laporte & Guttman,
1996), and some researchers even speculate that because
of the inconsistent availability of caregivers during trau-
matic childhood events, the emotional neglect and absenceof surrogate adult attachment figures may be as powerfulas the actual childhood traumatic event in the develop-ment of the personality style (Sabo, 1997). As might beexpected, these experiences of individuals with borderline
personality style translate into a self–other view that is
dominated by inconsistency and a general inability to defineboth themselves and others as either positive or negative.Feedforward beliefs of these individuals such as “People aregreat; no they’re not” and “I am a good person; no I’m not,”
and the accompanying in consistent behaviors they exhibit of-
ten lead others to be either reactive or avoidant of them, which
tends to further perpetuate their disorganized self–other views.To summarize this section of the article, Table 1 highlights thekey relations among attachment dimensions, personality styles,working models of self and others, and feedforward beliefs.
APPLICATION OF THEORY TO COUNSELING
From an attachment theory perspective, developmental per-sonality styles may be viewed as the unique outcome ofa person’s attempts to negotiate and adapt to particular
developmental and environmental demands. In particular,
TABLE 1
Relations Among Attachment Dimensions, Personality Styles, Working Models of Self and Others, and
Feedforward Beliefs
Attachment Dimension
Preoccupied
Preoccupied and Fearful
FearfulFearful and Dismissing
Disorganized AttachmentDependentObsessive-compulsiveHistrionicAvoidantParanoidAntisocialNarcissisticSchizotypal
Schizoid
BorderlineInadequate, fragile
Extremely reliableInsignificant and unimportantInadequate and frightened
of rejection
Special, unique, and
different
Unlovable (sense of self as
entitled often develops asa defense)
Extremely fragile but
masked by overzealousconfidence
“Self-less,” nonexistent
Positive, unaffected
Positive and negativeOthers need to take care
of me
Others expect me to be
perfect
Others are a valuable
source of attention
Others are to be avoided
Others cannot be trustedOthers will never love or
care for me
Others expect greatness
from me
Others do not have good
intentions
Others are emotionally
unresponsive
Positive and negative“I am a weak, fragile
person and cannotsurvive without others.”
“I always have to be
prepared to demonstratemy competency.”
“I need the attention of
others to feel importantand worthwhile.”
“Even though people reject
me, I want someone tolike me.”
“I feel safer being alone
because others cannotbe trusted.”
“I need to be tough and
powerful so I will not behurt.”
“I am special, unique and
entitled to specialconsiderations.”
“I am a strange bird.”
“The world is unresponsive
so don’t even bother toestablish relationships.”
“If things don’t go my way,
I can’t tolerate it. Othersare great; no they’re not.”Personality Style Model of Self Model of Others Feedforward Belief

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 412Lyddon and Sherry
what seems to distinguish relatively adaptive and securely
attached individuals from insecurely attached individuals
with less adaptive developmental personality styles are the
qualitatively different feedforward beliefs that have cometo dominate their working models of self and others. As aresult, we suggest that attachment theory may inform thepractice of counseling in both general and specific ways.
Perhaps at the most general level, attachment theory is a
developmental theory that challenges counselors to appre-
ciate the way different developmental experiences withcaregivers contribute to the construction of clients’ quali-tatively different working models of self and others. Moreimportant, when applied to the realm of developmental per-sonality styles, attachment theory helps counselors understand
the potential functional value  of many of the symptoms and
problems associated with these styles. In other words, from anattachment theory perspective, individuals’ problematicworking models and feedforward beliefs associated with thedifferent personality styles may be construed as having beenadaptive in their original developmental contexts but are
now no longer viable in their current life contexts and
relationships. When seen this way, rather than viewed assenseless, irrational, or even pathological, clients’ present-ing symptoms may be thought of as “prote ctive actions”
(Ecker & Hulley, 1996, p. 17) that serve an important pur pose
(or adaptive function) in the client’s life.
Considering the previous discussion, an important impli-
cation for counselors working from an attachment theoryperspective involves the need to conduct a thorough life spandevelopmental assessment with a specific focus on (a) theclient’s attachment history with caregivers and significantothers and (b) the unique way the client derives meaning
from that history (Ivey, 1989; Lyddon & Alford, 1993). As
clients reveal the content of their personal stories, the coun-selor should look for recurring patterns regarding such coredevelopmental issues as trust, autonomy, identity, and inti-macy. In general, the relative security of clients’ attachmentexperiences and concomitant working models tends to be
related to the type of change that may be indicated in coun-
seling (Lyddon & Alford, 1993; Lyddon & Satterfield, 1994).For example, because securely attached clients are relativelycomfortable with their core assumptions about self and world,they tend to only require “first-order” (Lyddon, 1990) ad-justments in their personal systems. In these instances, the
client’s motivation for entering counseling is often related to
the effects of current adverse life situation or stressor (e.g.,problematic coworker, loss of job, end of an intimate rela-tionship).  As a result, the aim of counseling is to help theclient cope more effectively with the current stressor andreestablish a personal sense of equilibrium.
By way of contrast, insecurely attached clients most of-
ten require significant “second-order” (Lyddon, 1990)changes in their views of self and world. As is typical ofclients identified with problematic developmental personal-ity styles, the core beliefs of these clients about self and worldare no longer adaptive and their presenting problems and life
histories reveal more pervasive difficulties (e.g., patterns ofunproductive relationships, chronic low self-esteem, gener-
alized anxiety). In such cases, counseling tends to involve
the following:
(a) a developmentally focused reconstruction of the history and
patterning of the problem, (b) gradual elaboration of the client’s
tacit cognitive models of self and world that are no longer viable,
(c) full exploration of the feeling related to this newly accessedexperiential information, and (d) therapist support for the client’sconstruction of new meaning structures. (Lyddon, 1990, p. 125)
Regarding the assessment of client attachment themes and
dimensions, it is important to note that there are many re-liable and valid measures of adult attachment that may be
used as an adjunct to a developmentally focused counsel-
ing interview (cf. Bradford & Lyddon, 1994; Lyddon,Bradford, & Nelson, 1993).
Another important attachment theory implication for
counseling clients with problematic developmental person-ality styles involves the need to recognize the ways in which
their insecure working models of self and others are domi-
nated by feedforward beliefs and assumptions that confirmand perpetuate the problematic self-system structure. In-deed, this dominance by feedforward mechanisms—whichensure that the self-system remains relatively imperviousto new and potentially change-inducing information—is
perhaps the hallmark feature of the problematic develop-

mental personality style. As a result, it is incumbent on thecounselor to (a) collaborate with the client to discover thenature and content of  the client’s feedforward beliefs and(b) initiate counseling strategies that provide the client withthe opportunity to process new, self-relevant information
(feedback) that challenges or disconfirms ineffectual work-
ing models and necessitates a reworking of these modelstoward greater viability, flexibility, and adaptiveness. Inessence, the counselor works with the client to make theclient’s tacit working models explicit, emphasizing that intheir original developmental contexts these models had
adaptive value but that they are no longer adaptive in cur-
rent life circumstances and interpersonal relationships.
Although facilitating developmental changes in clients’
working models often involves providing clients with mul-tiple sources of self-relevant feedback (Lyddon, 1993a,1993b), the interpersonal issues that are often central to
developmental personality styles make interpersonal
forms of feedback a particularly powerful source of change.Several writers, for example, have stressed the importanceof counselors’ sensitivity to the way a client’s workingmodels of attachment are revealed in the relationships withtheir counselors (Liotti, 1991; Lyddon & Alford, 1993; Pistole,
1989; Safran & Segal, 1991). These authors have suggested
that the counseling relationship may be viewed as a mediumin which counselors can (a) directly experience and observetheir clients’ attachment patterns and (b) ultimately dis-confirm dysfunctional working models and attachmentpatterns (Kiesler, 1988; Liotti, 1991; Safran, 1990). In other
words, a counselor’s decision not to complement the client’s
problematic interpersonal patterns and concomitant

JOURNAL OF COUNSELING & DEVELOPMENT • FALL 2001 • VOLUME 79 413Personality and Attachment
feedforward beliefs provides the client with new interper-
sonal feedback, which may lead the client to rework his or
her cognitive models of self and others. The disconfirming
potential of counselor interpersonal feedback is describedby Safran:
[T]he therapist who refrains from responding to the hostile client
with hostility may be disconfirming the client’s belief that otherswill be hostile to him. The therapist who unhooks from the inter-personal pull to take charge of a client’s life disconfirms the client’s
perception of himself or herself as “a helpless person who must be
taken care of by others.” The therapist who values and accepts theclient even when the client is sad, disconfirms the client’s beliefthat they must always be happy in order to maintain relatedness toothers. (p. 112)
CONCLUDING REMARKS
In recent years, writers have been critical of the purported
atheoretical approach to diagnosis espoused by the DSM  (e.g.,
Faust & Miner, 1986). These critics point out that the DSM’ s
focus on behavioral manifestations and its adherence to amedical model that excludes theory largely eliminates pos-sible etiologies that could be investigated from various
alternative theoretical foundations. One of the underlying
assumptions of the DSM  is that syndromes seem to cluster
in a meaningful way, reflecting a common etiology, course,and treatment response. However, in reality, there is consid-erable heterogeneity among people diagnosed with the samedevelopmental personality style. Adherence to an atheoretical
medical approach to psychological discomfort might obscure
subtle differences that may be useful in understanding clientproblems and developing effective treatment solutions. Theoryand classification are reciprocally related, and withouttheory to guide a classification system, categories are freeto proliferate to an extent that ultimately minimizes their
utility (Follette & Houts, 1996). As we have suggested in
this article, we believe that attachment theory may fill theneed for more theory-based approaches to diagnosis andconceptualization of human discomfort, particularly in therealm of problematic developmental personality styles.
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© 2021 by Jonathan Shedler,  PhD
Key  Points
•Personality refers to an individual’s characteristic patterns of thought, feeling,
behavior, motivation, defense, interpersonal functioning, and ways of experien -
cing self and others.
•Clinical knowledge accrued over generations has given rise to a taxonomy of fa -
miliar personality syndromes.
•Personality syndromes exist on a continuum of functioning from healthy to se -
verely disturbed. There is no discontinuity between normal and pathological
personality.
•Understanding personality syndromes requires an understanding of underlying 
personality processes such as inner conflicts, defenses, and motives.
•A diagnostic prototype is provided for each personality syndrome, which
describes the syndrome in its “ideal” or pure  form.
•A practical diagnostic method based on pattern recognition is provided,
whereby clinicians consider the overall resemblance between patients and diag -
nostic prototypes.
•The personality constructs provide the broad strokes of clinical case formula -
tions. They can explain and contextualize presenting symptoms and disorders.
•Each personality syndrome is a distinct pathway to depression and requires a
different treatment  focus.
Introduction
Personality is not about what disorders you have  but about who you are. It refers to a 
person’s characteristic patterns of thought, feeling, behavior, motivation, defense, inter -
personal functioning, and ways of experiencing self and others. All people have person -
alities and personality styles.
OUP UNCORRECTED PROOF – FIRSTPROOFS, Sat Sep 04 2021, NEWGEN
med-9780197574393.indd   3med-9780197574393.indd   3 04-Sep-21   02:58:4304-Sep-21   02:58:43Shedler, J. (2021). The  personality syndromes. I n R. Feinstein (Ed.),  A Primer on Personalit y 
Disorders: Multi-Theoret ical Viewpoints. Oxford:  Oxford University Pres s.
1
The Personality Syndromes
Jonathan S hedler

4 Overview
While there are as many personalities as people, clinical knowledge accrued over 
generations has given rise to a taxonomy of familiar personality styles or types. Most 
people, whether healthy or troubled, fit somewhere in the taxonomy. Empirical re -
search over the past two decades has confirmed the major personality types and their 
core features.1– 5
Most clinical theorists do not view the personality types as inherently disordered. 
They are generally discussed in the clinical literature as personality types, styles, or 
syndromes—  n ot “disorders. ” Each exists on a continuum of functioning from healthy 
to severely disturbed. The term “disorder” is best regarded as a linguistic convenience for clinicians, denoting a degree of extremity or rigidity that causes significant dysfunc-
tion, limitation, or suffering. One can have, for example, a narcissistic personality style  
without having narcissistic personality disorder .
The same personality dynamics give rise to both strengths and weaknesses. A person 
with a healthy narcissistic personality style has the confidence to dream big dreams and 
pursue them; they can be visionaries, innovators, and founders. A person with a healthy 
obsessive-  co mpulsive style excels in areas requiring precise, analytic thinking; they may 
be successful engineers, scientists, or academics. A person with a healthy paranoid style looks beneath the surface and sees what others miss; they may be investigative journal -
ists or brilliant medical diagnosticians. Our best and worst qualities are often cut from 
the same psychological  cloth.
Many psychodynamically influenced clinicians accept the broad outlines of an orga-
nizing framework proposed by Otto Kernberg,6,7 which combines the concept of per -
sonality type with a “severity dimension” reflecting level of personality organization 
(healthy, neurotic, borderline, psychotic).8– 9 For example, we can speak of a patient 
with narcissistic personality organized at a neurotic level or at a borderline level. The approach presented here is consistent with this framework. (For discussion of levels of 
personality organization, see Chapter 2, Levels of Personality Organization: Theoretical Background and Clinical Applications.)
The recognition that personality styles exist on a continuum of functioning was un -
dercut by the Diagnostic and Statistical Manual of Mental Disorders
10 (DSM) beginning 
with the publication of DSM-  III.11 To shoehorn personality styles discussed in the clin -
ical literature into a categorical taxonomy of disorders, the framers of the DSM described 
them in pathological form, in some cases ratcheting up the severity to the point of cari -
cature.3,4 The DSM also disregarded the underlying personality processes at the core of 
the personality styles, such as internal conflict, defenses, and motives. It focused instead on outward behavior and readily observable symptoms. Thus, the DSM borrowed ter -
minology and concepts from the clinical, chiefly psychoanalytic literature (obsessive-  
compulsive, narcissistic, paranoid, and so on) but disconnected them from the larger 
body of clinical knowledge.
Clinicians who are expert in treating personality have a working knowledge of per -
sonality syndromes that is richer, deeper, and more complex than the depictions in the DSM
8,9,12,13 and in some cases diverges from it.3 This chapter provides an overview of 
the personality syndromes as understood by expert clinicians and verified by empirical 
research. The descriptions provided here go beyond overt behavior and symptoms and 
address the personality processes that underlie them. For many patients, they can pro -
vide roadmaps for effective treatment.
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The Personality Syndromes  5
Diagnosis as Pattern Recognition
Each personality syndrome discussed in this chapter is represented by a paragraph- 
length description called a diagnostic prototype, which describes the personality syn -
drome in its “ideal” or pure form.4,14– 15 These diagnostic prototypes are evidence 
based. They were derived empiricall y, based on a national sample of N = 1,201 patients 
described by their clinicians using the Shedler- Westen Assessment Procedure (S WAP). 
They reflect empirically observable characteristics of actual patients, not just theoretical 
conjecture.
Naturally occurring diagnostic groupings were identified using statistical clustering 
methods, which largely confirmed the personality syndromes described in the clinical 
literature. The S WAP items (descriptive statements) that best describe each personality 
syndrome were likewise identified empiricall y, then arranged as paragraphs to create the 
diagnostic prototypes.4 (The S WAP instrument is described in Chapter 4, Integrating 
Clinical and Empirical Approaches to Personality: The Shedler- Westen Assessment 
Procedure (S WAP). The instrument is available at https:// swapassessment.org.)
The diagnostic prototypes have the advantage of being empirically based and also pre-
serving the richness and complexity of accrued clinical knowledge. To make a personality 
diagnosis, a clinician rates the overall resemblance or match between a patient and a diag -
nostic prototype from 0 (no match) to 5 (very good match). Higher scores indicate more 
resemblance to the diagnostic prototype and more severity. The diagnostic prototypes are 
presented in Bo xes 1.1 to 1.10 and the rating scale is included with each prototype.
I
f categorical diagnosis is desired for compatibility with the DSM- 5 or International 
Classification of Diseases (ICD- 10) diagnostic system, scores of 4 and 5 indicate a per -
sonality disorder diagnosis, and a score of 3 indicates traits or features of a disorder. 
Thus, if a patient receives a score of 5 for narcissistic personality and 3 for obsessive- 
compulsive personalit y, the categorical (DSM format) diagnosis is narcissistic person -
ality disorder with obsessive- compulsive traits.
The premise of this approach is that a configuration or pattern of interrelated psy -
chological characteristics defines a personality syndrome, not the presence or absence 
of separate characteristics. Recognizing a personality syndrome is pattern recognition, 
much as recognizing a face depends on pattern recognition, not tabulating separate 
features.4,14,15
Prototype matching provides reliable and valid diagnoses and works with the cogni -
tive decision processes of clinicians, which rely on pattern recognition. It systematizes 
what expert clinicians already do in practice. In a consumer- preference stud y, psycholo-
gists and psychiatrists preferred this method of personality diagnosis to the DSM diag -
nostic system and to dimensional trait models of personalit y.16
Developin g a Treatment Focus
I
n recent years, many clinicians have been trained to focus on presenting problems and 
DSM Axis I disorders (such as depression or generalized anxiety) and view them as 
encapsulated conditions separate from personalit y. Treatments that target specific DSM 
disorders implicitly assume all patients with a given DSM diagnosis have the “same” 
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6 Overview
condition and will respond to the same interventions. Clinicians learn the hard way that 
things are rarely so simple.
Most often, the problems that bring people to mental health treatment are not 
encapsulated problems. They are woven into the fabric of their lives. They  are em- 
embedded in, and inseparable from, the person’s characteristic patterns of thinking, 
feeling, behaving, coping, defending, and relating to others: in other words, per- 
sonality. This is true whether or not the person has a diagnosable “personality 
disorder.” The patient needs the clinician to grasp something psychologically systemic 
about who they are, not just what disorders they have, to help them understand why 
they are repeatedly vulnerable to certain kinds of suffering and how to change it.
Meaningful and lasting change generally comes not from focusing on symptoms, but 
on the personality patterns that underlie them. Knowledge of personality styles 
provides a map of the personality terrain that expert clinicians navigate. Thus,  each 
personality syndrome is not just description, but shorthand for the broad strokes of a 
clinical case formulation that can provide a treatment focus and address the 
underlying causes of many patients’ suffering. The penultimate section of this chapter, 
Personality and Clinical Case Formulation, revisits this topic.
This section describes the major personality syndromes as understood by clinical 
theorists and confirmed by empirical research. The diagnostic prototypes and rating  
scales in Boxes 1.1 to 1.10 can be used for day- to- day clinical diagnosis.
Depressive Personality
Despite its omission from the DSM, depressive personality is the most common person-
ality syndrome seen in clinical practice.2 It is a personality syndrome in every sense of 
the term: an enduring pattern of psychological functioning evident by adolescence and 
encompassing the full spectrum of personality processes.
People with depressive personalities are chronically vulnerable to painful affect, espe-
cially feelings of inadequac y, sadness, guilt, and shame. They have difficulty re cognizing 
their needs, and when they do recognize them, they have difficulty expressing them. 
They are often conflicted ab out allowing themselves pleasure. They may seem driven by 
an unconscious wish to punish themselves, either by getting into situations destined to 
cause pain or depriving themselves of opportunities for enjoyment. A psychologically 
insightful observer might describe the person as their own worst enemy .
Where there is an enem y, there is often anger and aggression. One underlying psy-
chological theme in depressive personality is internal attacks against the self. The person 
is angr y, defends against experiencing anger, and instead directs it at themselves in the 
form of self-  criticism, self-  deprivation, and self-  punitiveness. The relevant S WAP item 
is, “Has trouble acknowledging or expressing anger toward others and instead becomes 
depressed, self-  critical, self-  punitive, etc .” In short, the person treats themselves like 
someone they despise.
Clinicians can easily miss the patient’s anger and aggression because people with 
depressive perso nalities tend to  be o vertly agreeable and put o thers’ needs first, 
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The Personality Syndromes  7
including the clinician’s needs. If psychotherapy is to bring about meaningful psycho -
logical change, anger must be recognized, experienced, and explored in the therapy 
relationship.
A second psychological theme involves separation, rejection, and loss. The person 
may be preoccupied with, and painfully vulnerable to, disruptions in interpersonal relationships. They fear being abandoned and left unprotected and uncared for. As a re -
sult, they avoid interpersonal conflict and have difficulty asserting themselves. Undue 
people-  p leasing and helpfulness protect against disapproval or rejection. In psycho -
therapy, they suppress legitimate criticisms and dissatisfactions for fear of hurting the 
clinician’s feelings or damaging the therapy relationship. Instead of communicating their 
needs and wants, they accept what is offered and make do. This can lead to a relation -
ship dynamic in which the clinician thinks things are going swimmingly and the patient 
does without, thereby recreating the patient’s dysfunctional relationship pattern in the 
therapy relationship.
This pattern may have roots in relational disruption or insufficient emotional availa -
bility of a caretaker in early development, leaving the person feeling emotionally empty and incomplete, and believing their deprivation was caused by their own badness. Some 
patients have a pervasive sense that someone or something essential to their well-  b eing 
has been lost and can never be recovered. These feelings can crystalize around, and be amplified by, subsequent experiences of loss. Rewards and pleasures that are realistically 
available may be experienced as a pale shadow of what was lost or could have been. Such 
patients may need the clinician’s help to mourn what has been lost before they can invest 
emotionally in what life can offer  n ow.
For some patients with depressive personalities, themes of unconscious anger and 
self- a ttack predominate. For others, themes of separation and loss predominate. These 
themes have been discussed in the clinical and research literature in terms of introjective 
(self-  cr itical) and anaclitic (dependent) depression.17,18 Both themes may be present in 
any blend.
Depressive personality is the most common personality style among people drawn to 
the mental health professions.19 Clinical practitioners have endless opportunity to care 
for others instead of themselves, be unduly helpful, and fault themselves for falling short 
of unrealistic, self-  im posed standards.
See Box 1.1 for the depressive personality prototype.
Anxious-  Avoidant Personality
The term “ Avoidant Personality Disorder” is used by the DSM and is more familiar to 
clinicians, but the hyphenated term “anxious-  a voidant” more accurately and telegraphi -
cally conveys the essence of this personality syndrome.
People with anxious-  a voidant personalities are, first and foremost, anxious. Anxiety 
pervades their experience of themselves and their world. They ruminate and dwell on perceived dangers and past mistakes. Their predominant emotions are anxiety, shame, 
and embarrassment. They defend against sources of anxiety by avoidance. The problem 
is that the sources of anxiety are everywhere, including within. Ultimately, avoidant responses become bars in a psychological prison, constricting and limiting freedom of 
thought, feeling, choice, and action. As a result, people with anxious-  a voidant personal -
ities lead constricted lives and tend to adhere to familiar routines. Despite their avoidant 
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8 Overview
defenses, anxiety still leaks out through a variety of channels, which can include somatic 
symptoms and concerns.
People with anxious-  av oidant personalities are fearfully avoidant not only of the ex -
ternal, interpersonal world but also their own internal world. The former is manifested 
in social avoidance, self-  con sciousness, and social awkwardness. The latter is manifested 
in inhibition and constriction of emotional life and desire. They are motivated to avoid perceived harm, not to pursue their desires.
The challenge in psychotherapy is that patients with anxious-  av oidant personality are 
avoidant in psychotherapy, too. They are likely to steer clear of difficult topics, change the subject when their thoughts lead in disturbing directions, and fend off the clinician’s 
efforts to explore psychological experience beyond the most familiar, well-  wo rn grooves. 
This creates a dilemma for clinicians: If they don’t confront avoidant defenses, therapy will accomplish little; if they do, the patient may quit or shut down. Effective treatment involves a balancing act of support and confrontation. The clinician should help and Box 1.1  Depressive Personality Prototype
Summary statement: Individuals with depressive personality are prone to feelings of 
depression and inadequacy, tend to be self-  cri tical or self-  pu nitive, and may be preoc -
cupied with concerns about abandonment or  loss.
Individuals who match this prototype tend to feel depressed or despondent and 
t
o feel inadequate, inferior, or a failure. They tend to find little pleasure or satisfac -
tion in life’s activities and to feel life has no meaning. They are insufficiently con -
cerned with meeting their own needs, disavowing or squelching their hopes and desires to protect against disappointment. They appear conflicted about experien -
cing pleasure, inhibiting feelings of excitement, joy, or pride. They may likewise be conflicted or inhibited about achievement or success (e.g., failing to reach their po -
tential or sabotaging themselves when success is at hand). Individuals who match 
this prototype are generally self-  cri tical, holding themselves to unrealistic stan -
dards and feeling guilty and blaming themselves for bad things that happen. They appear to want to “punish” themselves by creating situations that lead to unhap -
piness or avoiding opportunities for pleasure and gratification. They have trouble 
acknowledging or expressing anger and instead become depressed, self-  cri tical, or 
self- punitive. They often fear that they will be rejected or abandoned, are prone to 
painful feelings of emptiness, and may feel bereft or abjectly alone even in the pres -
ence of others. They may have a pervasive sense that someone or something neces -
sary for happiness has been lost forever (e.g., a relationship, youth, beauty, success).
5 very good match (patient exemplifies this disorder; prototypical case) Diagnosis
4 good match (patient has this disorder; diagnosis applies)
3 moderate match (patient has significant features of this disorder)Features
2 slight match (patient has minor features of this disorder)
1 no match (description does not apply)
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The Personality Syndromes  9
support the patient to put words to previously unarticulated feelings and fantasies. When 
they respond to situations (both inside and outside therapy) with fearful avoidance, they should be pressed for details about the presumed dangers (“ And what would happen then?”) so they can be examined in the light of day. When a secure working alliance is established, the clinician should encourage the patient to face feared situations and expe -
riences in incremental steps. See Box 1.2 for the anxious-  av oidant personality prototype.
Dependent‐Victimized Personality
The term “Dependent Personality Disorder” is used by DSM, but the hyphenated term 
“dependent-  vic timized” communicates a core feature of the personality syndrome: the 
tendency to put oneself in harm’s way. People with this personality syndrome are drawn 
t
o relationships in which they are mistreated, exploited, or abused.
People with dependent-  vic timized personalities are characterized by intense de -
pendency, leading them to subordinate their needs to those of others in order to main-tain desperately needed attachments. This leaves them vulnerable to mistreatment and exploitation. The person experiences the attachment relationship as essential to their Box 1.2  Anxious‐avoidant Personality Prototype
Summary statement: Individuals with anxious‐avoidant personality are chronically prone to anxiety, are socially anxious and avoidant, and attempt to manage anxiety 
in ways that limit and constrict their  lives.
Individuals who match this prototype are chronically anxious. They tend to 
ruminate, dwelling on problems or replaying conversations in their minds. They are more concerned with avoiding harm than pursuing desires, and their choices and actions are unduly influenced by efforts to avoid perceived dangers. They are prone to feelings of shame and embarrassment. Individuals who match this proto -
type tend to be shy and self‐conscious in social situations and to feel like an outcast or outsider. They are often socially awkward and tend to avoid social situations because of fear of embarrassment or humiliation. They tend to be inhibited and constricted and to have difficulty acknowledging or expressing desires. They may adhere rigidly to daily routines, have trouble making decisions, or vacillate when faced with choices. Their anxiety may find expression through a variety of chan -
nels, including panic attacks, hypochondriacal concerns (e.g., excessive worry about normal aches and pains), or somatic symptoms in response to stress (e.g., headache, backache, abdominal pain, asthma).
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10 Overview
existence and seems prepared to go to any length to preserve it, including a greeing 
to things they find objectionable and things that may be self-  dest ructive. Externally, 
they are ingratiating, passive, and submissive. Internally, they experience them-
selves as unworthy, undeserving, and bereft without the connection to and approval 
of the other person. In severe cases, existence outside the relationship, however self-  
destructive, may seem unimaginable. Because of an inner experience of deep unwor -
thiness, they may experience a person who demeans them as the only one who can 
understand  them.
Subservience leads to anger and resentment, but overt anger must be suppressed be -
c
ause it threatens the attachment relationship they perceive as their lifeline. Disavowed 
anger and aggression leak out in the form of passive-  ag gressive behavior, which tends 
to elicit further mistreatment from others. These relationship patterns can play out in 
the therapy relationship via transference and countertransference. The patient may 
feel dependent on the clinician while passive-  ag gressively thwarting all efforts to help. 
Clinicians may initially respond to the patient’s need with extra efforts to provide care, then find themselves becoming controlling or punitive after the patient has “helplessly” and repeatedly thwarted all their efforts. At this point, the therapy relationship comes to resemble the patient’s other dysfunctional attachments. Understanding these patterns and how they come about can open the door to new ways of relating. See Box 1.3 for the dependent‐victimized personality prototype.
Obsessive-  Compulsive Personality
Obsessive-  Compulsive personality is among the most familiar and easily recognized of 
the personality syndromes. On the surface, people with obsessive-  com pulsive person -
ality are conscientious, meticulous, regimented, and cerebral. They have little access to their emotional life and are more comfortable in the realm of thoughts and ideas than 
the realm of feelings. Ask a person with obsessive-  com pulsive personality what they feel, 
and they will likely tell you what they think , often at length, with careful weighing of pros 
and cons, arguments and counterarguments.
Their intellectualized discourse does not, however, lead to a decision or plan of ac -
tion. Instead, they may digress into minutia or get caught up in intellectualized abstrac -
tion. Their thought processes do not lead to emotional clarity because their unconscious function is to defend against feelings, impulses, and desires. When confronted with the need to make a personal choice, they are likely to vacillate and equivocate. For every pro, there is a con of equal and opposite weight.
Because they come across as robotic and emotionally inaccessible, one theorist 
described people with obsessive-  com pulsive personality style as “living machines. ”20 But 
defenses are proportionate to the impulses they defend against. Under the conscious sur -
face, the person with obsessive-  com pulsive personality is waging epic emotional battles.
At the core of obsessive-  com pulsive personality is a conflict between obedience and 
defiance.12 Obedience—  ob eying the rules, deference to authority—  is exp erienced as 
submission and humiliation. This leads to rage and the urge to defy and humiliate the other. Defiance leads to guilt and fear of punishment, which leads back to obedience. Mundane, everyday issues lose proportion. The decision to come early or late to an ap-pointment takes on the proportions of an epic battle between submission and defiance. 
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The Personality Syndromes  11
Acquiescing to another’s preference or insisting on one’s own can feel like being anni -
hilated or annihilating. Minor decisions become emotionally fraught. With so much at 
stake, fear, shame, and rage constantly threaten to break through.
The overtly observable features of obsessive-  compul sive personality derive from this 
conflict. Conscientiousness and orderliness derive from fear of authority and punish-ment. Defiance and rage “leak out” in the form of critical attitudes, controlling behavior, oppositionality, power struggles, stinginess, procrastination, and inevitable pockets of messiness and disorder. Intellectualization and emotional constriction serve to keep the conflict outside awareness.
People with obsessive-  compul sive personality benefit from exploratory, interpretive 
psychotherapy. They benefit from insight into their defenses against emotional life and 
their high cost vis-  à- vis their r elationships and capacity for spontaneity and joy. The Box 1.3  Dependent‐victimized Personality Prototype
Summary statement: Individuals with dependent‐victimized personality are highly dependent and fearful of being alone, tend to show insufficient concern for their own well‐being to the point of jeopardizing their welfare or safety, and have difficulty expressing anger directly.
Individuals who match this prototype tend to be needy and dependent, fear 
being a lo
ne, and fear rejection or abandonment. They tend to be ingratiating 
or submissive, often consenting to things they find objectionable in an effort to main 
tain support or approval. They tend to be pas
sive and unassertive and to 
feel helpless and powerless. They tend to be indecisive, suggestible or easily influ -
enced, and naïve or innocent, seeming to know less about the ways of the world than would be expected. They tend to become attached to people who are emo -
tionally unavailable, and to create relationships in which they are in the role of caring for or rescuing the other person. Individuals who match this prototype tend to get drawn into or remain in relationships in which they are emotionally or physically abused, or needlessly put themselves in dangerous situations (e.g., walking alone or agreeing to meet strangers in unsafe places). They are insuffi -
ciently concerned with meeting their own needs and tend to feel unworthy or undeserving. Individuals who match this prototype have trouble acknowledging or expressing anger and in
stead become depressed, self‐critical, or self‐punitive. 
They tend to exp
ress anger in passive and indirect ways (e.g., making mistakes, 
procrastinating, forgetting) 
that may provoke or trigger anger or mistreatment 
from others.
3 moderate match (patient has significant features of this disorder) Features
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12 Overview
clinician should be alert to the patient’s tendency to intellectualize and treat the clini -
cian’s comments as theories to ponder versus matters of immediate emotional import. 
For example, if the patient says the clinician’s observation makes sense, the clinician 
might ask whether it just “makes sense” or whether they recognize it in themselves and 
feel it to be true. In this way, the clinician can draw attention to the patient’s emotional 
life and the defenses that squelch it.
Obsessive- compulsive personality  is different from obsessive- compulsive disorder , 
which is a distinct phenomenon requiring different treatment. See Box 1.4 for the 
obsessive- compulsive personality prototype.
Box 1.4  Obsessive- compulsive Personality Prototype
Summary statement: Individuals with obsessive- compulsive personality are intellec -
tualized and overly “rational” in their approach to life, are emotionally constricted 
and rigid, and are critical of themselves and others and conflicted about anger, ag -
gression, and authority.
Individuals who match this prototype tend to see themselves as logical and ra -
tional, uninfluenced by emotion. They tend to think in abstract and intellectual -
ized terms, to become absorbed in details (often to the point of missing what is 
important), and prefer to operate as if emotions were irrelevant or inconsequen -
tial. They tend to be excessively devoted to work and productivity to the detriment 
of leisure and relationships. Individuals who match this prototype tend to be in -
hibited and constricted, and have difficulty acknowledging or expressing wishes, 
impulses, or anger. They are invested in seeing and portraying themselves as emo -
tionally strong, untroubled, and in control, despite evidence of underlying insecu -
rity, anxiety, or distress. They tend to deny or disavow their need for nurturance or 
comfort, often regarding such needs as weakness. They tend to adhere rigidly to 
daily routines, becoming anxious or uncomfortable when they are altered, and to 
be overly concerned with rules, procedures, order, organization, schedules, and so 
on. They may be preoccupied with concerns about dirt, cleanliness, or contamina -
tion. Rationality and regimentation generally mask underlying feelings of anxiety 
or anger. Individuals who match this prototype tend to be conflicted about anger, 
aggression, and authority. They tend to be self‐critical, expecting themselves to 
be “perfect, ” and to be equally critical of others, whether overtly or covertly. They 
tend to be controlling, oppositional, and self- righteous or moralistic. They are 
prone to being stingy and withholding (e.g., of time, money, affection). They are 
often conflicted about authority, struggling with contradictory impulses to submit 
versus defy.
5 very good match (patient exemplifies  this disorder; prototypical case) Diagnosis
3 moderate match (patient has significant features  of this disorder)Features
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The Personality Syndromes 13
Schizoid- Schizotypal Personality
The term “schizoid” is among the most confusing in the clinical literature, because dif -
ferent writers have used the same word to describe very different types of patients. Those 
impaired enough to be diagnosed with a DSM personality disorder have basic deficits in 
psychological capacities. They are characterized by impoverishments in interpersonal 
functioning, emotional life, and thought processes. The schizoid- schizotypal personality 
prototype presented here describes this deficit- based syndrome.
Psychoanalytic writers have also used the term “schizoid” to describe a very different 
and much healthier type of patient who does not suffer from such basic deficits, whose 
psychology is more conflict- based. These patients may have rich inner lives and deep 
capacity for empathy, even as they keep their distance from others. Their underlying psy -
chological conflict is between longing for closeness and fear of engulfment, impinge -
ment, or overstimulation. (For discussion of this healthier, conflict- based version of 
“schizoid personality, ” see Chapter 17, Some Thoughts About Schizoid Dynamics.)
With respect to the more impaired (deficit- based) patients, research does not support 
the DSM distinction between schizoid and schizotypal personality disorders. The fram -
ers of DSM attempted to sharpen the boundaries between these diagnostic categories 
by emphasizing subsyndromal positive symptoms of schizophrenia in one (schizotypal) 
and subsyndromal negative symptoms in the other (schizoid). However, the distinction 
does not hold up empirically. Research with the SW AP instrument consistently identi -
fied a single diagnostic grouping with features of both schizoid and schizotypal person -
ality disorders, hence the hyphenated term “schizoid- schizotypal. ”
Patients who match the schizoid- schizotypal prototype lack close relationships and 
appear indifferent to human company or contact. They lack social skills and tend to be 
socially awkward or inappropriate. They may seem odd or peculiar in appearance or 
manner; something about them seems “off. ” They tend to think in concrete terms and 
have little capacity to appreciate metaphor, analogy, or nuance. They have difficulty 
making sense of others’ behavior and likewise have little insight into their own. Despite 
apparent detachment, they suffer inwardly, often greatly, and experience themselves as 
outcasts and outsiders. A subset of schizoid- schizotypal patients shows substantial aber -
rations in thinking, reasoning, and perception, and their speech and thought processes 
may be digressive and circumstantial.
The schizoid- schizotypal grouping, identified empirically by statistical clustering 
methods, may not describe a homogeneous group of patients best understood in terms 
of personality. The patients share surface similarities, notably absence of close relation -
ships and deficits in interpersonal functioning. In some cases, this may reflect person -
ality. But other patients in this diagnostic cluster may have subclinical schizophrenic 
spectrum disorders and others may be on the autistic spectrum. Clinicians tempted 
to diagnose schizoid- schizotypal personality should consider carefully whether the 
patient’s difficulties might be better accounted for by factors other than personality 
per se.
Psychotherapy for deficit- based schizoid- schizotypal patients is largely supportive. 
Close interpersonal connections and emotional intimacy may not be attainable goals, 
but patients can work toward more harmonious and frictionless coexistence. Therapy 
should support ego functions (executive function) and assist patients with reasoning, 
interpreting events, interpreting others’ behavior, planning, judgment, and decision pro -
cesses. See Box 1.5 for the schizoid- schizotypal personality prototype.
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14 Overview
Antisocial‐Psychopathic Personality
The DSM diagnosis of Antisocial Personality Disorder emphasizes criminality but 
largely ignores the personality processes and motives that define a personality syn -
drome. The empirically derived diagnostic prototype describes personality processes 
and more closely resembles the historical concept of psychopathy.21– 23 The hyphenated 
term “antisocial- psychopathic” serves as a bridge between the DSM construct and the 
clinical personality syndrome.
People engage in antisocial and criminal behavior for many reasons unrelated to per -
sonality pathology. Not all people who engage in criminal behavior (or meet DSM cri -
teria for Antisocial Personality Disorder) have psychopathic personalities; not all people Box 1.5  Schizoid- schizotypal Personality Prototype
Summary statement: Individuals with schizoid- schizotypal personality are charac -
terized by pervasive impoverishment of, and peculiarities in, interpersonal relation -
ships, emotional experience, and thought processes .
Individuals who match this prototype lack close relationships and appear to 
have little need for human company or contact, often seeming detached or indif -
ferent. They lack social skills and tend to be socially awkward or inappropriate. 
Their appearance or manner may be odd or peculiar (e.g., their grooming, pos -
ture, eye contact, or speech rhythms may seem strange or “off ”), and their verbal 
statements may be incongruous with their accompanying emotion or non‐verbal 
behavior. They have difficulty making sense of others’ behavior and appear un -
able to describe important others in a way that conveys a sense of who they are as 
people. They likewise have little insight into their own motives and behavior, and 
have difficulty giving a coherent account of their lives. Individuals who match this 
prototype appear to have a limited or constricted range of emotions and tend to 
think in concrete terms, showing limited ability to appreciate metaphor, analogy, 
or nuance. Consequently, they tend to elicit boredom in others. Despite their ap -
parent emotional detachment, they often suffer emotionally: They find little sat -
isfaction or enjoyment in life’s activities, tend to feel life has no meaning, and 
feel like outcasts or outsiders. A subset of individuals who match this prototype 
show substantial peculiarities in their thinking and perception. Their speech and 
thought processes may be circumstantial, rambling, or digressive, their reasoning 
processes or perceptual experiences may seem odd and idiosyncratic, and they 
may be suspicious of others, reading malevolent intent into others’ words and 
actions.
3 moderate match (patient has significant features  of this disorder) Features
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The Personality Syndromes 15
with psychopathic personalities engage in criminality. In some walks of life, psycho -
pathic traits are rewarded. People with antisocial- psychopathic personality styles, given 
the right opportunities, may become business or political leaders, not criminals, and 
pursue their ruthless agenda with social approval and even admiration.
People with antisocial- psychopathic personality lack an internalized moral system. 
What is right is what they can get away with. They are out for personal gain, take advan -
tage of other people, and manipulate and deceive without guilt or inhibition. They show 
reckless disregard for others’ rights, property, or safety. They experience little remorse 
for the harm they cause. On the contrary, they take sadistic pleasure in dominating and 
exercising power over others.
People with antisocial- psychopathic personality experience little anxiety, and they 
show minimal autonomic reactivity in response to aversive events. Many have a high 
need for stimulation and seek thrills, novelty, and excitement. They push limits and act 
impulsively, because impulses are not checked by anxiety, empathy, or an internalized 
moral system. Non- impulsive variants of antisocial- psychopathic personality also exist 
but are less common. In these variants, sadistic aggression is planned, deliberate, and 
coldly emotionless, in a way that has been described as “reptilian. ”
People with antisocial- psychopathic personality are motivated by self- interest, sensa -
tion seeking, and desire for power and dominance. Others may puzzle over the person’s 
motive for manipulation or cruelty where there seems little to be gained. The reason is: 
because they can. Dominance and exerting power over another are their own rewards.
People with antisocial- psychopathic personalities have little interest in self- 
exploration and rarely come to treatment of their own accord. They come when they 
perceive some immediate personal advantage to doing so (for example, inducing the cli -
nician to intercede on their behalf, or to get out of legal or other trouble). They are expert 
at convincing others they have turned over a new leaf, only to revert to the same behavior 
once they have gotten out of trouble. They understand power, not empathy, and are likely 
to perceive the clinician’s sympathetic attention and compassion as a weakness to exploit. 
Prognosis is poor. Therapeutic leverage, to the extent there is any, comes from a position 
of power and dominance few clinicians are comfortable assuming. See Box 1.6 for the 
antisocial‐psychopathic personality prototype.
Narcissistic Personality
The hallmark of narcissistic personality is the coexistence of feelings of grandiosity and 
feelings of inadequacy and emptiness. Grandiosity defends against and masks under -
lying feelings of inadequacy (but see the section on Malignant Narcissism for a possible 
exception).
When narcissistic defenses are working, patients with narcissistic personalities feel 
special and superior. They have an exaggerated sense of self- importance, feel privileged 
and entitled, expect preferential treatment, and seek to be the center of attention. Their 
inner life is dominated by fantasies of limitless success, power, glory, beauty, or talent. 
They tend to treat others as an audience (to witness their magnificence) or as extensions 
of themselves.
Idealization and devaluation are central defenses. When they idealize someone to 
whom they are connected, they feel special and important by association. When they 
devalue someone, they feel superior. They are relatively oblivious to others’ actual 
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16 Overview
emotional experience unless it coincides with their own. Interpersonally, they have been 
described as having emotional transmitters but not receivers.
Grandiosity serves a defensive function, warding off and masking painful feelings of 
inadequacy, emptiness, smallness, anxiety, and rage. When narcissistic defenses fail, the 
person is at the mercy of these painful feelings and may lash out in rage or slump into 
depression and despair.
Deflated or depleted narcissists are less easily recognized than well- defended, gran -
diose narcissists (and not recognized at all by the DSM). However, they are common 
in clinical practice. Deflated narcissists are likely to be diagnosed with depressive dis -
orders and may present as ashamed, defeated, and beaten down. When clinicians gain 
access to their internal world, they find the patient is preoccupied with fantasies of glory 
and aggrieved at a world that has failed to recognize their unique worth or provide the 
rewards to which they feel entitled. Behind a depressive presentation, one sometimes 
finds a deflated narcissist.Box 1.6  Antisocial‐psychopathic Personality Prototype
Summary statement: Individuals with antisocial- psychopathic personality exploit 
others, experience little remorse for harm or injury caused to others, and have poor 
impulse control.
Individuals who match this prototype take advantage of others, tend to lie or 
deceive, and to be manipulative. They show a reckless disregard for the rights, 
property, or safety of others. They lack empathy for other people’s needs and feel -
ings. Individuals who match this prototype experience little remorse for harm or 
injury they cause. They appear impervious to consequences and seem unable or 
unwilling to modify their behavior in response to threats or consequences. They 
generally lack psychological insight and blame their difficulties on other people 
or circumstances. They often appear to gain pleasure by being sadistic or aggres -
sive toward others, and they may attempt to dominate significant others through 
intimidation or violence. Individuals who match this prototype tend to be impul -
sive, to seek thrills, novelty, and excitement, and to require high levels of stim -
ulation. They tend to be unreliable and irresponsible and may fail to meet work 
obligations or honor financial commitments. They may engage in antisocial be -
havior, including unlawful activities, substance abuse, or interpersonal violence. 
They may repeatedly convince others of their commitment to change, leading 
others to think “this time is really different, ” only to revert to their previous mala -
daptive behavior.
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The Personality Syndromes 17
Effective treatment involves a careful balancing act, with a judicious blend of empathy 
and confrontation. Patients with narcissistic personalities benefit from empathic un -
derstanding of their underlying pain, insecurity, and vulnerability when these feelings 
are accessible. With the clinician’s help, they can develop greater capacity to tolerate the 
feelings without resorting to grandiosity and devaluation. On the other hand, they ben -
efit from tactful but systematic confrontation of narcissistic defenses, and exploration 
of the considerable cost of these defenses vis- à- vis relationships and their ability to find 
meaning and fulfillment in their lives.
Countertransference reactions include feeling disengaged, deskilled, or competitive 
with the patient (when devalued), or tempted to join them in a mutual admiration so -
ciety (when idealized). The clinician’s countertransference provides a window into the 
patient’s relationship patterns and the responses they elicit from others. It is important 
to recognize and explore the relationship patterns as they arise in the therapy relation -
ship, instead of simply repeating the patterns with a new person. People with narcissistic 
personalities may be most receptive to psychotherapy in mid- life or later, when fantasies 
of extraordinary success and glory have failed to materialize and they are forced to con -
front life’s realistic limits. See Box 1.7 for the narcissistic personality prototype.
Malignant Narcissism
Malignant narcissism is a variant of narcissistic personality that has gained public atten -
tion in recent years. It is, in fact, the intersection of narcissistic personality and antisocial- 
psychopathic personality, blending the characteristics of both. Malignant narcissism has 
also been described by clinical theorists as narcissism suffused with sadistic aggression.6 
It is not sufficient for the malignant narcissist to feel important and special; it is necessary 
for someone else to be demeaned or vanquished. The syndrome could plausibly be called 
“psychopathic narcissism” or “narcissistic psychopathy, ” but malignant narcissism is the 
historically and clinically familiar term.
When psychopathic deception, exploitation, sadistic aggression, and externalization 
combine with narcissistic grandiosity and self- importance, the result can be especially 
destructive. When there is no internalized moral system to counteract grandiose striv -
ings, others’ needs, rights, and well- being become irrelevant. Other people are used and 
discarded without guilt or remorse. Harmful consequences and disastrous outcomes are 
always someone else’s fault.
Externalizing blame can have toxic effects on others and is often discussed by non- 
professionals as “gaslighting. ” The item in the SW AP assessment instrument that 
addresses externalization is: “Tends to blame own failures or shortcomings on other 
people or circumstances; attributes his or her difficulties to external factors rather than 
accepting responsibility for own conduct or choices. ” The psychological processes that 
give rise to gaslighting are straightforward. The underlying logic is something like, “The 
world exists for my aggrandizement and my personal benefit. I am not responsible for 
my actions or the harm they cause. You are responsible. ”
In extremis, people with severe malignant narcissism may appear to lose touch with 
reality. This comes about when external events starkly contradict their grandiose, de -
fensively constructed self- image. It is as though the person, forced to choose between 
revising their self- image and revising reality, opts to revise reality. They may demand that 
others in their orbit also accept their revised version of reality.
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18 Overview
In empirical research with the SW AP instrument, items addressing underlying in -
adequacy and inferiority did not emerge as descriptors of malignant narcissism.24 It is 
unclear whether underlying feelings of inadequacy are not a component of malignant 
narcissism or were not evident to the clinicians who provided the data. It seems likely 
that when personality dynamics are predominantly narcissistic, underlying inadequacy 
is present, even if not readily observable; when personality dynamics are fundamentally 
antisocial- psychopathic, it may not be.
Depending on the blend of narcissism and psychopathy, people with malignant nar -
cissism may or may not be amenable to psychotherapy. Where narcissism predominates 
and psychopathic traits are secondary, psychotherapy may be helpful, albeit difficult. 
When psychopathy predominates, prognosis is poor, for the same reasons it is poor for 
antisocial- psychopathic personality. There is little therapeutic leverage when patients 
lack an internalized value system or a basic capacity for mutuality.Box 1.7  Narcissistic Personality Prototype
Summary statement: Individuals with narcissistic personality are grandiose and 
entitled, dismissive and critical of others, and often show underlying signs of vulnera -
bility beneath a grandiose façade.
Individuals who match this prototype have an exaggerated sense of self‐impor -
tance. They feel privileged and entitled, expect preferential treatment, and seek to 
be the center of attention. They have fantasies of unlimited success, power, beauty, 
or talent, and tend to treat others primarily as an audience to witness their impor -
tance or brilliance. They tend to believe they can only be appreciated by, or should 
only associate with, people who are high‐status, superior, or “special. ” They have 
little empathy and seem unable to understand or respond to others’ needs and 
feelings unless they coincide with their own. Individuals who match this proto -
type tend to be dismissive, haughty, and arrogant. They tend to be critical, envious, 
competitive with others, and prone to get into power struggles. They attempt to 
avoid feeling helpless or depressed by becoming angry instead, and tend to react 
to perceived slights or criticism with rage and humiliation. Their overt grandi -
osity may mask underlying vulnerability: Individuals who match this prototype 
are invested in seeing and portraying themselves as emotionally strong, untrou -
bled, and emotionally in control, often despite clear evidence of underlying in -
security or distress. A substantial subset of narcissistic individuals tend to feel 
inadequate or inferior, to feel that life has no meaning, and to be self‐critical and 
intolerant of their own human defects, holding themselves to unrealistic stan -
dards of perfection.
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The Personality Syndromes 19
Paranoid Personality
Patients with paranoid personalities are chronically suspicious, angry, and hostile. They 
read malevolent intent into others’ words and actions and are quick to assume others 
mean them harm. They hold grudges, dwell on slights, and react to perceived threats 
with rage and aggression. They see their difficulties as externally caused and lack insight 
into their own role in shaping events.
At the core of paranoid personality is the defense of projection. People with para -
noid personalities are filled with aggression and rage, which they project onto others and 
(mis)perceive as originating from them. People with paranoid personalities experience 
the world as cold, hostile, and dangerous because they see their own hostility wherever 
they look.
Paranoid personality style is found at healthy and neurotic levels of personality 
organization but is more often seen at borderline levels of organization, at least in 
clinical populations. Often underappreciated in the clinical literature (and neglected 
in the DSM) is the extent of cognitive and perceptual disturbances in patients with 
paranoid personalities. They tend to show disturbances in thinking, above and be -
yond paranoid ideas. Their perceptions and reasoning can be odd and idiosyncratic, 
and they may become irrational in the face of strong emotion. While the role of cog -
nitive and perceptual disturbances has been historically underappreciated, it is per -
haps not surprising given the pervasiveness of paranoid projection, which necessarily 
requires some confusion about what is internal versus external and what is reality 
versus fantasy.
Clinicians’ strong emotional reactions to patients with paranoid personality give 
them a small taste of the fear and rage the patients experience chronically and seek to 
manage through externalization and projection. The clinician should assist the patient 
with reality testing when necessary, and help the patient recognize and find more adap -
tive ways to manage their anger and aggression. An overly friendly or sympathetic stance 
on the part of the clinician is likely to arouse the patient’s suspicion and intensify par -
anoid thinking. A matter- of- fact stance, even to the point of brusqueness, is generally 
more effective. See Box 1.8 for the paranoid personality prototype.
Hysteric- Histrionic Personality
The terms “hysteric” and “histrionic” evoke an era of patriarchy and gender inequality 
and are offensive to many, with reason. There is, however, a difference between the term 
and the phenomenon. Regardless of the label, a personality syndrome does exist. It is 
described repeatedly in the clinical literature and emerges in empirical research using 
statistical clustering methods. Objections to terminology should not blind us to the clin -
ical phenomenon. Nomenclature is beyond the scope of this chapter, which addresses 
clinical issues.
Before DSM- III introduced the diagnosis of histrionic personality disorder, the term 
“hysteric” was used to describe higher- functioning people with this personality style and 
“histrionic” was used for more disturbed patients (such as those in the borderline range 
of functioning). The hyphenated term “hysteric- histrionic” encompasses higher-  and 
lower- functioning variants of the personality syndrome and provides a bridge between 
the DSM construct and the extensive clinical literature.
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20 Overview
Hysteric- histrionic personality is a multifaceted syndrome encompassing the full 
spectrum of personality processes. On the surface, people with hysteric- histrionic per -
sonality styles exemplify gender stereotypes. They present as stereotypically feminine or 
masculine, like a leading lady or leading man in a stylized Hollywood movie. They are 
emotional and dramatic. They use their physical attractiveness and sexuality to gain at -
tention. They are flirtatious, seductive, and sexually provocative. They may lead people 
on and make romantic conquests. They tend to become involved in romantic triangles 
involving rivals. They can charm and captivate members of the other sex (when both are 
heterosexual) but may annoy or threaten members of the same sex. Their emotions can 
seem simultaneously intense and shallow. They can develop intense infatuations which 
they describe as love, and lose interest when a new prospect arrives.
For people with hysteric- histrionic personality, facts and reason take a backseat to 
emotion. Their reactions tend to be based on feelings, not reason. If you ask a person 
with hysteric- histrionic personality what they think, they are likely to tell you how they 
feel. Their cognitive style tends to be glib, global, and impressionistic; they miss details 
and gloss over inconsistencies.25 They come across as naïve and seem to know less about 
the ways of the world than might be expected. Their beliefs can seem cliché or stereo -
typical, as if taken from storybooks or movies. They tend to be suggestible. Their im -
pressionistic cognitive style is unrelated to intelligence and serves a defensive function. Box 1.8  Paranoid Personality Prototype
Summary statement: Individuals with paranoid personality are chronically suspi -
cious, angry and hostile, and may show disturbed thinking.
Individuals who match this prototype are chronically suspicious, expecting that 
others will harm, deceive, conspire against, or betray them. They tend to blame 
their problems on other people or circumstances, and to attribute their difficulties 
to external factors. Rather than recognizing their own role in interpersonal con -
flicts, they tend to feel misunderstood, mistreated, or victimized. Individuals who 
match this prototype tend to be angry or hostile and prone to rage episodes. They 
tend to see their own unacceptable impulses in other people instead of in them -
selves and are therefore prone to misattribute hostility to other people. They tend 
to be controlling, to be oppositional, contrary, or quick to disagree, and to hold 
grudges. They tend to elicit dislike or animosity and to lack close friendships and 
relationships. Individuals who match this prototype tend to show disturbances in 
their thinking above and beyond paranoid ideas. Their perceptions and reasoning 
can be odd and idiosyncratic, and they may become irrational when strong emo -
tions are stirred up, to the point of seeming delusional.
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The Personality Syndromes 21
People with hysteric- histrionic personality do not look too closely at details or connect 
too many dots, for fear of seeing and knowing too much.
At the core of hysteric- histrionic personality are conflicts around gender and power. 
Unconsciously, they see their own gender as weak, defective, or inferior. They see the 
other gender as powerful, exciting, and frightening, and they are unconsciously en -
vious. They use sexuality as a way to turn the tables and gain power over the other 
gender. Such use (or misuse) of sexuality helps to ward off feeling of weakness, power -
lessness, and fear. They may flaunt their sexuality in exhibitionistic ways to counteract 
underlying shame, fear, and envy. Genuine sexual intimacy and satisfaction are difficult 
for the same reasons; it is hard to experience deep connection while feeling shame -
fully defective or frightened by one’s partner. When underlying psychological conflicts 
cannot find expression in thoughts and words, they may find expression through so -
matic symptoms (conversion symptoms). Beneath the dramatic presentation and sexu -
alization is a fear of being abandoned and left uncared for, and a yearning to be cared for 
and protected. Their tragedy is that they long for a caring relationship but find sexual 
relationships instead.
Patients with hysteric- histrionic personalities respond well to psychotherapy and 
benefit from both its exploratory, interpretive aspects and its relational aspects. The de -
pendability of the therapist and safety of the therapeutic frame provide a context for self- 
exploration and insight into conflicts around gender, power, and sexuality. At the same 
time, the therapy relationship provides a new and different relationship template, one in 
which a therapist of the other gender is neither seductive nor seducible, and a therapist of 
the same gender is neither ineffectual nor competitive. Therapists should let the patient 
lead, allowing them to explore their needs, feelings, wishes, fears, and conflicts at their 
own pace. The patient does not need an authority figure explaining their experience to 
them; they benefit from exploring and explaining it to themselves. A didactic stance on 
the part of the therapist may reinforce feelings of defectiveness and powerlessness.
When both parties are heterosexual, high- functioning hysteric- histrionic patients 
may charm therapists of the other gender and annoy those of the same gender, at least in -
itially. It is helpful to remember the patient unavoidably brings their relationship patterns 
into the therapy relationship, and this is what makes it possible to explore the thoughts, 
feelings, and experiences that underlie them. More disturbed patients (in the border -
line range of functioning) with hysteric- histrionic personality may alarm and exasperate 
therapists with flagrant seductiveness or acting out in place of talking and reflecting. See 
Box 1.9 for the hysteric- histrionic personality prototype.
Borderline- Dysregulated Personality
The term “borderline” dates back to a time when psychiatric classification distinguished 
primarily between neurotic and psychotic disturbance based on intact versus impaired 
reality testing. Over time, clinical writers began describing patients on the “border, ” who 
seemed neither neurotic nor psychotic. The diagnostic construct has evolved, but the 
term “borderline” remains. The hyphenated term “borderline- dysregulated” retains the 
familiar term and highlights the emotional dysregulation that is a hallmark of the per -
sonality syndrome.
People with borderline- dysregulated personality have been described as “stably un -
s t a b l e .”26 There is a pattern of instability in emotional life, self- concept, and relationships. 
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22 Overview
Core features include affect dysregulation, splitting, identity diffusion, projection, pro -
jective identification, and insecure attachment.
People with borderline- dysregulated personality have difficulty regulating affect. 
Their emotions can change rapidly and unpredictably and spiral out of control, leading 
to extremes of despair, anxiety, agitation, and rage. They experience episodes of deep 
depression in which they lose access to any glimmer of hope. They are often filled with 
rage, and they are prone to destroy relationships with hateful, rage- filled outbursts. Poor 
impulse control is an ongoing problem and leads to ill- considered actions and self- 
destructive behavior.Box 1.9  Hysteric- histrionic Personality Prototype
Summary statement: Individuals with hysteric‐histrionic personality are emotion -
ally dramatic and cognitively impressionistic, sexually provocative, and interperson -
ally suggestible, idealizing of admired others, and paradoxically both intensely and 
superficially attached.
Individuals who match this prototype are emotionally dramatic and prone to 
express emotion in exaggerated and theatrical ways. Their reactions tend to be 
based on emotion rather than reflection, and their cognitive style tends to be 
glib, global, and impressionistic (e.g., missing details, glossing over inconsist -
encies, mispronouncing names). Their beliefs and expectations seem cliché or 
stereotypical, as if taken from storybooks or movies, and they seem naïve or in -
nocent, seeming to know less about the ways of the world than would be expected. 
Individuals who match this prototype tend to be sexually seductive or provocative. 
They use their physical attractiveness to an excessive degree to gain attention and 
notice, and they behave in ways that seem to epitomize gender stereotypes. They 
may be flirtatious, preoccupied with sexual conquest, prone to lead people on, 
or promiscuous. They tend to become involved in romantic or sexual “triangles” 
and may be drawn to people who are already attached or sought by someone else. 
They appear to have difficulty directing both tender feelings and sexual feelings 
toward the same person, tending to view others as either virtuous or sexy, but not 
both. Individuals who match this prototype tend to be suggestible or easily influ -
enced, and to idealize and identify with admired others to the point of taking on 
their attitudes or mannerisms. They fantasize about ideal, perfect love, yet tend 
to choose sexual or romantic partners who are emotionally unavailable or who 
seem inappropriate (e.g., in terms of age or social or economic status). They may 
become attached quickly and intensely. Beneath the surface, they often fear being 
alone, rejected, or abandoned.
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The Personality Syndromes 23
Splitting refers to compartmentalizing good and bad perceptions, feelings, and expe -
riences, leading the person to experience self and others as all good or all bad. (The term 
“dichotomous thinking” in dialectical behavioral therapy also refers to this phenom -
enon.) Splitting results in extreme, wildly fluctuating views of self and others, depending 
on which “compartment” the person is experiencing. When distressed, people with 
borderline- dysregulated personality lose the capacity to see others as complex, three- 
dimensional human beings. Instead, they become one- dimensional heroes, saviors, vic -
tims, villains, and abusers.
The person may see certain people as all good (“good objects”) and others as all bad 
(“bad objects”), or their experience of the same person may swing between contradic -
tory extremes. This leads to unstable and chaotic relationships. For example, a person 
with borderline- dysregulated personality may see the clinician as a savior, until they dis -
appoint. Then they may see the clinician as a “bad person” and attack them for their 
callousness or incompetence. Such shifts from idealization to devaluation are often pre -
cipitated by perceived criticism or rejection.
Splitting also refers to compartmentalized, contradictory experiences of self. The 
person may vacillate between experiencing themselves as a good person and as someone 
evil and rotten to the core. Self- concept depends on which of multiple, contradictory 
self- representations is being experienced. Shifts between different self- representations 
bring corresponding shifts in emotional state and keep the person on an emotional roll -
ercoaster. Affect dysregulation and splitting therefore go hand in hand.
Because disparate self- representations are not integrated into a coherent whole, 
people with borderline- dysregulated personality have difficulty maintaining a 
consistent, stable sense of self (“identity diffusion”). Their attitudes, values, and 
self- concept are unstable and changeable. They may shift with relationships, circum -
stances, or emotional state. The person may present in strikingly different ways on 
different occasions, often to the consternation of clinicians. If they are feeling good, 
they may be blithely unconcerned that they were recently suicidal. If depressed, 
they may feel no connection to any part of themselves they have ever experienced 
as positive.
Primitive forms of projection are a hallmark of borderline- dysregulated personality. 
Split, disavowed representations of self and others and the feelings associated with them 
are projected wholesale onto other people with conviction and certainty. The projec -
tions often involve intensely negative emotions like anger, spite, hate, envy, and disgust. 
The person regards their projections as facts, not perceptions. It can be disorienting and 
maddening to others, including clinicians, to be seen and treated repeatedly as someone 
they are not.
Projective identification takes the defense of projection a step further. In addition to 
projecting disavowed parts of themselves, the person works to induce and evoke the feel -
ings they have projected with such vehemence, so that the other person comes to feel 
and act in accord with the projection. Borderline- dysregulated patients are masterful in 
bringing this about, although they do not do it consciously. Clinicians describe experi -
ences of not being able to think their own thoughts or feel their own feelings, as if their 
minds have been colonized by something alien.27 Under the sway of projective identifi -
cations, clinicians may find themselves filled with hatred for their patient or impelled to 
cross professional boundaries to rescue them.
The transfer of thoughts and feelings from patient to clinician that occurs in projec -
tive identification is not mysterious or mystical. Observable behavior on the part of the 
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24 Overview
patient pulls, pushes, coaxes, and coerces the clinician into their assigned role, although 
the clinician may be unaware of this as it is occurring. Generally, countertransference 
comes first, and understanding emerges after the fact.
Borderline- dysregulated patients with a history of abuse are prone to enacting sce -
narios involving shifting roles of abuser, victim, and rescuer.27,28 Through processes 
of projection and projective identification, clinician and patient can inhabit any of the 
three roles. A common scenario begins with the patient in the role of victim and the 
clinician in the role of rescuer. As the patient’s needs and demands escalate, the clini -
cian overextends themselves to the point of feeling persecuted and victimized by the 
patient (for example, taking late night phone calls, allowing sessions to run overtime, 
not collecting fees). The clinician may become controlling and punitive as they try to 
reestablish boundaries, moving into the abuser role. Ideally, clinician and patient can 
examine the patient’s shifting experience of self and other and how these role relation -
ships are recreated in the therapy relationship, instead of just reenacting them with a 
new person.
Finally, people with borderline- dysregulated personality have insecure or disor -
ganized attachment styles and are hypersensitive to rejection. They are needy and 
dependent, become attached quickly and intensely, yet anticipate rejection and aban -
donment. They are desperate to be cared for, but their concept of “caring” involves un -
realistic levels of availability and attunement that no one can provide. When the other 
person inevitably falls short, they become enraged and lash out. This dynamic is cap -
tured by a pithy book title: I Hate You— Don’t Leave Me .29
A number of therapy models have been developed for borderline- dysregulated 
personality and are described in other chapters. Work with borderline- dysregulated 
patients can be fast, furious, chaotic, and confusing. One supervisor likened it 
to “tumbling helplessly in a clothes dryer, ” never knowing what is coming or from 
where. In the early stages of treatment, the clinician’s role may simply be to accept and 
tolerate the confusion, remain engaged with the patient, and maintain the treatment 
frame. A clear theoretical model provides direction and helps contain the clinician’s 
anxieties.
All therapy models emphasize attention to boundary issues, attention to what is hap -
pening in the therapy relationship, and active management of behaviors potentially de -
structive to the therapy and the therapy relationship. Because borderline- dysregulated 
patients are prone to crises, therapy can easily be derailed if crisis management rather 
than work on underlying psychological issues becomes the focus. Therapy models for 
borderline- dysregulated personality include regular consultation and support for thera -
pists, to help manage intense countertransference.
Borderline- dysregulated personality can be viewed as a personality syndrome in its 
own right (when no other personality syndrome is salient) or as a level of personality 
organization associated with any other personality syndrome. For example, a patient 
who matches the descriptions for narcissistic personality and borderline- dysregulated 
personality can be described as having narcissistic personality organized at a borderline 
level; a patient who matches the descriptions for paranoid personality and borderline- 
dysregulated personality can be described as having paranoid personality organized 
at a borderline level; and so on. This organizing framework brings considerable clarity 
to diagnostic formulations. See Box 1.10 for the borderline- dysregulated personality 
prototype.
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The Personality Syndromes 25
Personality and Clinical Case Formulation
It should be clear that personality syndromes are not merely descriptive constructs, like 
DSM diagnoses; they are explanatory. The descriptions of the personality syndromes 
explicate underlying psychological processes that leave people vulnerable to a range of 
mental health problems. Mental health problems do not arise in a vacuum. More often 
than not, they arise in the matrix of personality dynamics.
The personality syndrome descriptions provide the broad strokes of clinical case 
formulations. They can provide a treatment focus and direct the clinician’s attention to Box 1.10  Borderline- dysregulated Personality Prototype
Summary Statement: Individuals with borderline- dysregulated personality have im -
paired ability to regulate their emotions, have unstable perceptions of self and others 
that lead to intense and chaotic relationships, and are prone to act on impulses, in -
cluding self‐destructive impulses.
Individuals who match this prototype have emotions that can change rapidly 
and spiral out of control, leading to extremes of sadness, anxiety, and rage. They 
tend to “catastrophize, ” seeing problems as disastrous or unsolvable, and are often 
unable to soothe or comfort themselves without the help of another person. They 
tend to become irrational when strong emotions are stirred up, showing a signifi -
cant decline from their usual level of functioning. Individuals who match this pro -
totype lack a stable sense of self: Their attitudes, values, goals, and feelings about 
themselves may seem unstable or ever‐changing, and they are prone to painful 
feelings of emptiness. They similarly have difficulty maintaining stable, balanced 
views of others: When upset, they have trouble perceiving positive and negative 
qualities in the same person at the same time, seeing others in extreme, black‐or‐
white terms. Consequently, their relationships tend to be unstable, chaotic, and 
rapidly changing. They fear rejection and abandonment, fear being alone, and 
tend to become attached quickly and intensely. They are prone to feeling misun -
derstood, mistreated, or victimized. They often elicit intense emotions in other 
people and may draw them into roles or “scripts” that feel alien and unfamiliar 
(e.g., being uncharacteristically cruel, or making “heroic” efforts to rescue them). 
They may likewise stir up conflict or animosity between other people. Individuals 
who match this prototype tend to act impulsively. Their work life or living arrange -
ments may be chaotic and unstable. They may act on self‐destructive impulses, 
including self‐mutilating behavior, suicidal threats or gestures, and genuine su -
icidality, especially when an attachment relationship is disrupted or threatened.
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26 Overview
psychological processes underlying presenting symptoms and diagnoses. They are broad 
strokes because they are simplifications, especially when applied to people at higher 
(healthy and healthier neurotic) levels of functioning. People at higher levels of func -
tioning have greater psychological flexibility and commonly show a blend of personality 
styles. Even so, it is possible to recognize areas where specific personality dynamics (de -
pressive, obsessive- compulsive, narcissistic, and so on) prevail. “Purer” examples of per -
sonality styles are generally seen at lower levels of personality organization.
Clinical case formulations articulate cause and effect. For example, the person with 
depressive personality defends against anger, which finds indirect expression through 
self- criticism and self- punitiveness. The person with narcissistic personality inflates 
themselves to ward off underlying feelings of inadequacy and emptiness, but their de -
fensively constructed self- image cuts off authentic connection with self and others. The 
person with borderline- dysregulated personality cannot reconcile contradictory per -
ceptions and feeling states, and so vacillates between them. The person with paranoid 
personality sees their own projected hostility everywhere they look, and so experiences 
the world as cold and cruel.
Such statements describe cause- and- effect relationships that can form the nucleus 
of individualized, patient- specific case formulations that give treatment direction and 
focus. Without a coherent case formulation, treatment can devolve into a haphazard 
“spaghetti- on- the- wall” process, with the clinician trying one intervention after another, 
hoping something will “stick. ” It can also devolve into aimless, directionless “supportive 
therapy” in which the therapist has essentially given up on meaningful change. To recog -
nize a personality syndrome is to begin to articulate a clinical case formulation.
Personality Pathways to Depression
The most common mental health diagnoses, at least in North America, are depressive 
disorders. Many depressed patients experience only minimal relief from symptom- 
focused treatments, or experience relief but then relapse. Depression is often considered 
a chronic condition. In many cases, it may appear chronic because the personality pro -
cesses that give rise to it have never been addressed in psychotherapy.
Nearly all of the personality syndromes can be pathways to depression and require 
their own distinct treatment focus. I will briefly describe how several of the personality 
syndromes create vulnerability to depression and will touch even more briefly on some 
treatment implications. My purpose is to illustrate connections between personality 
processes and depression, not provide specific instructions for conducting treatment, 
which would require a book in its own right, or several.
Depressive personality refers to enduring personality dynamics, not mood state. 
People with depressive personalities may or may not experience clinical depression, 
and people with recurring or chronic depression may or may not have depressive per -
sonality styles.
Difficulty recognizing needs and desires can lead to clinical depression. It is difficult 
to meet your needs when you do not know what they are. Failure to meet basic emotional 
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The Personality Syndromes 27
needs leads to depletion and depression. Work in psychotherapy should focus not just on 
expressing unrecognized and unarticulated needs, but on recognizing the psychological 
processes that interfere with recognizing them. The clinician should be alert to subtle 
ways the patient steers away from needs and desires, and help them articulate the fears 
that lead them to steer away.
Anger directed at the self can lead to depression. Being berated, punished, and 
scorned causes pain, and this is equally true when the person doing the punishing is one -
self. To stop the self- torment, the person must recognize and consciously experience the 
anger they habitually disavow. This process cannot be merely academic or intellectual; 
the anger must be experienced in the “here and now” of the therapy relationship. The 
therapist should be alert to indirect indications of irritation or disappointment, or their 
absence where they might be expected, and actively invite them into the therapy rela -
tionship. “I’m sorry I was late” is not an invitation to explore disappointment or anger; “I 
notice you didn’t say how it felt when I was not here” is an invitation.
Patients who have not internalized a reliably available caretaker remain dependent on 
others for emotional care and are vulnerable to depression when left to rely on their own 
internal resources. They benefit from experiencing and internalizing a relationship with 
an attuned and reliably available therapist. Brief therapies with arbitrary session limits 
can be destructive. Instead of helping them repair early experiences of relational disrup -
tion or loss, they can force the patient to relive them.
Emotional well- being requires engagement in the world and at least a modicum of en -
joyment and pleasure. People with anxious- avoidant personality styles cut themselves 
off from emotional sustenance through fearful avoidance. Their living space can become 
too restricted to meet basic needs, leading to depletion and depression. To make matters 
worse, the person finds little respite from their anxieties even when they avoid feared 
situations, because perceived dangers are internal as well as external. The effort to keep 
anxieties at bay is emotionally depleting and exhausting.
Therapy must help the patient confront what they avoid, internally and externally. 
They remain vulnerable to depression so long as their lives remain too constricted to 
meet their emotional needs, and so long as they devote their energies to avoiding harm at 
the expense of pursuing desires.
Obsessive- Compulsive Personality
People with obsessive- compulsive personalities are engaged in an ongoing internal 
conflict, which they defend against by constricting and inhibiting emotional aware -
ness and expression. Unfortunately, it is impossible to selectively inhibit negative 
emotions. The defenses that inhibit shame, fear, and rage also inhibit spontaneity, 
joy, excitement, desire, and pleasure. Life becomes monotonized, routinized, and 
pleasureless.
Desires are forbidden, and when the person does pursue desire, it gives rise to so 
much guilt that they cannot enjoy it. Constant squelching of needs and desires, and 
excessive devotion to work and productivity at the expense of leisure and enjoyment, 
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28 Overview
lead to depletion and depression. Underlying shame, humiliation, and rage con -
stantly threaten to erupt, which can leave the person with a background feeling of 
impending doom.
Effective psychotherapy explores defenses against emotional life and allows the pa -
tient to discover through lived experience in the therapy relationship that emotion and 
desire can be met with acceptance and interest, not horror, and can be expressed without 
bringing about punishment, retaliation, or catastrophe.
People with narcissistic personality are inherently vulnerable to depression. One source 
of vulnerability is a chronic gap between grandiose expectations and what the world 
affords. Rewards that come the person’s way fall short of those to which they feel entitled 
and are therefore devalued. Instead of feeling satisfaction and pleasure, the person ends 
up feeling disappointed and aggrieved. The gap between expectation and reality never 
closes, leading to dejection, hopelessness, and despair.
There is likewise a chronic gap between self- expectations and capabilities. The nar -
cissistic person fantasizes about unlimited success, power, beauty, or talent. Instead of 
experiencing satisfaction and pride in legitimate accomplishments— which could pro -
vide a basis for realistic self- esteem— they perpetually feel they have fallen short.
Finally, their defensively constructed self- image represents a barrier to genuine inti -
macy and can cut them off from love and meaningful connection with others.
Effective psychotherapy can help these patients understand how they devalue life’s 
pleasures, devalue their own legitimate abilities, and cut themselves off from intimate 
connections that make life meaningful and make its hardships bearable (including the 
connection potentially available with the therapist). If they develop enough trust in the 
therapy relationship, they may allow themselves to reveal the parts of themselves they 
experience as shameful and inadequate and keep hidden away. They may then slowly 
internalize the therapist’s more accepting and benign view of their fundamental human -
ness. Ultimately, they must grieve the loss of the perfect person and perfect world of their 
fantasies, in order to live as they person they are in the world that is.
People with paranoid personality are vulnerable to depression because they experience 
the world as cold, cruel, and hostile. They feel embattled and surrounded by enemies and 
dangers on all sides. They experience the world as hostile because they project their anger 
and aggression and see their own hostility wherever they look. The chronic experience 
of being embattled, persecuted, and excluded leads to depressive states. Additionally, the 
person is deprived of meaningful attachments and emotional support because they keep 
others at a distance, and their hostility and suspicion make others want to keep their 
distance.
Psychotherapy may help the person recognize that the aggression they experience 
as external emanates from within, understand its sources and its role as protection 
against deeper injuries, and understand their own role in creating hostile and adversarial 
interactions.
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The Personality Syndromes 29
People with borderline- dysregulated personality experience episodes of dark, deep de -
pression. Their severe depressive states seem to encompass the entirety of their being. 
There can be a pervasive feeling that everything about them and everything about their 
world is dark and hopeless and always has been and always will be. The person may feel 
irreparably damaged, evil, or rotten to the core. Positive self- representations and experi -
ences seem inaccessible.
These severe depressive states are rooted in splitting. At healthier levels of person -
ality organization, good and bad self- representations and feeling states are integrated 
into a coherent whole and naturally modify and modulate one another. But when self- 
representations are split and compartmentalized, the current self- representation and 
feeling state is experienced as all there is . When painful feeling states are not modulated 
by other experiences, they are felt in their rawest form.
Other factors also contribute to severe depressive states. Identity diffusion, or diffi -
culty maintaining a coherent and stable sense of self, leads to painful feelings of emp -
tiness. Recurring relationship patterns in which the person relives experiences of 
helplessness and victimization lead to depression. Unstable relationships and rageful 
responses to others can leave them without emotional support when they need it most. 
Impulsive, ill- considered choices and actions can bring painful consequences.
Some therapy approaches emphasize management of dysregulated emotional states 
(for example, by learning and practicing self- regulation skills). Others address and work 
to change the underlying psychological processes that cause the dysregulated states. This 
requires creating a sturdy reflective space in which the patient’s intense emotional reac -
tions can be contained, examined, and understood.
The purpose of diagnosis is to provide more helpful treatment. When presenting com -
plaints and diagnoses are rooted in personality dynamics, as they often are, meaningful 
change means addressing personality dynamics. Because personality dynamics tend to 
fall into recognizable patterns, personality diagnosis is largely a matter of pattern recog -
nition. Clinicians who recognize these patterns have a tremendous advantage in navi -
gating the clinical landscape. For example, they will recognize underlying psychological 
processes that create vulnerability to suffering, the defenses they are likely to encounter, 
and the roles they themselves are likely to be cast in (via transference and countertrans -
ference) as treatment unfolds. Treating patients without an understanding of personality 
syndromes is like navigating without a map.
The eleven personality syndromes described in this chapter reflect not only clinical 
knowledge accrued over generations of practice experience but also the findings of em -
pirical research. The typology itself— the eleven diagnostic groupings or classifications— 
is derived via statistical clustering methods applied to large clinical samples. The core 
diagnostic features of the syndromes, summarized in the diagnostic prototypes, are also 
empirically derived. Clinicians who use this diagnostic system can be confident they are 
utilizing an evidence- based approach.
Perhaps most important, each personality syndrome provides the broad strokes 
of a clinical case formulation that therapist and patient, working together, can fill in, 
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30 Overview
elaborate upon, and revise as new understandings emerge. This kind of case formulation 
gives treatment direction and focus that can lead to meaningful and lasting change for 
many patients.
For additional resources for clinicians and researchers review Box 1.11
Conflict of Interest/ Disclosure: The authors of this chapter have no financial conflicts 
and nothing to disclose.
 1. Westen D, Shedler J. Revising and assessing axis II, Part I: developing a clinically and empiri -
cally valid assessment method. Am J Psychiatry . 1999 Feb;156(2):258– 272.
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Feb;156(2):273– 285.
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Am J Psychiatry . 2004 Aug;161(8):1350– 1365.
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diagnosis: bridging science and practice in conceptualizing personality. Am J Psychiatry . 2012 
Mar;169(3):273– 284.
 5. Shedler J. Integrating Clinical and Empirical Approaches to Personality: The Shedler- Westen 
Assessment Procedure (SW AP). (Chapter 4, this volume).
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University Press; 1984.
 7. Kernberg O. Borderline Conditions and Pathological Narcissism . Lanham, MD: Jason 
Aronson; 1975.
 8. McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical 
Process . 2nd ed. New Y ork, NY: Guilford Press; 2011.
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Psychodynamic Diagnostic Manual (PDM- 2). 2nd ed. New Y ork, NY: Guilford Press; 
2017:15– 67.Box 1.11  Resources for Clinicians and Researchers
 • swapassessment.org.
This is where to access the SW AP assessment instrument. Clinicians can 
complete an assessment online and receive a comprehensive assessment 
report with personality diagnoses, clinical case formulations, and treat -
ment recommendations. There is an extensive bibliography with links to 
downloadable reprints.
 • swapassessment.org/ prototypes.
This is a three- page quick reference guide (pdf file) containing all the diag -
nostic prototypes. It is available as a free reference resource to facilitate 
personality diagnosis in day- to- day clinical practice.
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The Personality Syndromes 31
 10. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. Washington DC: American 
Psychiatric Association; 2013.
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Psychiatric Association; 1980.
 12. MacKinnon R, Michels R. The Psychiatric Interview in Clinical Practice . Philadelphia, PA: 
WB Saunders; 1971.
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American Psychiatric Publishing; 2014.
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J Psychiatry . 2006 May;163(5):846– 856.
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toward DSM- V . J Pers Disord . 2000 Summer;14(2):109– 126.
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systems for personality diagnosis: a “consumer preference” study. J Nerv Ment Dis . 2008 
May;196(5):356– 374.
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sion. Clinical Psychology Review . 1992:12(5):527– 562.
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psychological dimensions of depression. J Consul Clin Psychol . 1982;150:113– 124.
 19. Hyde J. Fragile Narcissists or the Guilty Good? What Drives the Personality of the 
Psychotherapist?  Dissertation. Macquarie University; 2009.
 20. Reich W . Character Analysis . New Y ork, NY: Farrar, Straus & Giroux; 1972. Original work 
published 1933.
 21. Cleckley H. The Mask of Sanity . St. Louis, MO: Mosby; 1941.
 22. Hare RD. Psychopathy: Theory and Research . New Y ork, NY: Wiley; 1970.
 23. Meloy R, Shiva A. A psychoanalytic view of psychopathy. In: A Felthous, H Saß, eds. The 
International Handbook of Psychopathic Disorders and the Law . Hoboken, NJ: Wiley; 
2007:335– 346.
 24. Russ E, Shedler J, Bradley R, Westen D. Refining the construct of narcissistic personality dis -
order: diagnostic criteria and subtypes. Am J Psychiatry.  2008;165:1473– 1481.
 25. Shapiro D. Neurotic Styles . New Y ork, NY: Basic Books; 1965.
 26. Schmideberg M. The borderline patient. In: Arieti S, ed. American Handbook of Psychiatry . 
Vol. 1. New Y ork, NY: Basic Books; 1959:398– 416.
 27. Gabbard GO, Wilkinson SM. Management of Countertransference with Borderline Patients . 
Washington DC: American Psychiatric Press; 1994.
 28. Davies JM, Frawley MG. Dissociative processes and transference- countertransference par -
adigms in the psychoanalytically oriented treatment of adult survivors of childhood sexual 
abuse. Psychoanal Dialogues . 1992;2(1):5– 36.
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Personality . New Y ork, NY: Avon; 1991.
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The International Journal of Psychoanalysis
ISSN: 0020-7578 (Print) 1745-8315 (Online) Journal homepage: https://www.tandfonline.com/loi/ripa20
Superego: An attachment perspective
Jeremy Holmes
To cite this article:  Jeremy Holmes (2011) Superego: An attachment perspective, The
International Journal of Psychoanalysis, 92:5, 1221-1240, DOI: 10.1111/j.1745-8315.2011.00411.x
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School of Psychology, University of Exeter, EX4 4QG, UK –
j.a.holmes@btinternet.com
(Final version accepted 25 November 2010)
With the help of attachment theory and research, the paper attempts to broaden
and build on classical and current views on the superego. Attachment theory ’s epi-
genetic approach and the concept of the subliminal superego are described. The
superego, it is argued, is as much concerned with safety as sex. The superego is
‘heir ’, not just to the Oedipus complex or Klein ’s pre-oedipal constellation, but
also to the attachment relationship. Under favourable developmental conditions a
‘mature superego ’emerges, facilitating, in the presence of an internal secure base,
maturational boundary crossings towards adult sexuality. In the light of the above,
the paper reviews Lear ’s updating of Strachey ’s model of psychic change and
explores the concept of transgression in relation to the ‘professional superego ’, its
development and maturation. Theoretical arguments are illustrated with clinical
examples.
Keywords :Attachment, Mentalising, Psychoanalysis, Psychoanalytic psychotherapy,
Security, Superego, Transgression
According to Freud, minds are like cities – prototypically Rome – in which
ancient structures persist, overlaid with the accretions of modern civilization
(Freud, 1930). The same might be said of psychoanalytic metapsychology, in
which old and new ideas jostle, co-existing sometimes peacefully, sometimes
less so (Blass, 2010). Psychoanalysts tend to respond in a number of ways:
remaining steadfastly loyal to time-honoured concepts; allowing them to
pass gracefully into oblivion; replacing them with contemporary additions
to theory; rejuvenating old models.
The aims of this paper are:
•to review the superego from an attachment perspective
•to revisit the idea of the ‘benign superego ’, somewhat overshadowed in
recent formulations
•to reconsider Strachey ’s notion of the part played by the superego –
both analysand ’s and analyst ’s – in therapeutic action
•to look at transgression, and its role in analytic work.
Throughout, it will be argued that the superego is ‘heir ’, not just to the
oedipal relationship, but to attachment constellations of infancy and early
childhood.Int J Psychoanal (2011) 92:1221–1240 doi: 10.1111/j.1745-8315.2011.00411.x
Copyright ª2011 Institute of Psychoanalysis
Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and
350 Main Street, Malden, MA 02148, USA on behalf of the Institute of Psychoanalysis
/T_he International Journal of

Attachment theory and the superego
Attachment Theory ’s distinctive contributions to contemporary psychoana-
lytic discourse (c.f. Bowlby, 2005; Fonagy, Gergely & Target, 2008; Holmes,
2001, 2009; Slade, 2008) include:
•an account of divergent developmental tracks , starting in infancy,
characterized by secure, insecure avoidant, insecure-ambivalent and
insecure-disorganized epigenetic pathways
•exposition of a security-driven dynamic in which the object is a source
of safety in parallel with libidinal satisfaction
•vicissitudes of the security system in which, with sub-optimal care-giving,
full expression of relational needs are inhibited, distorted or dissociated
•resulting disruption of narrative capacity and restrictions on conscious
exploration and awareness, including sexual and aggressive feelings
•a reciprocal relationship between the attachment dynamic and exploration
in which, in the face of threat or stress, attachment feelings and behav-
iours are triggered, inhibiting exploration and play
•replication of the security dynamic in the transference in which the
analyst is experienced by the analysand in terms of the primary attach-ment relationship
•through her sensitivity, responsiveness, reliability and boundedness, the
analyst helps the client move from a position of insecure attachment to
one of ‘earned security ’.
I shall approach the theoretical discussion via some clinical material. The
aim is to illustrate, firstly, the role of the superego as part of the systemsunconscious and conscious. Secondly, to suggest that moral precepts flowingfrom the superego can be seen as defensive strategies (c.f. Gray, 1994),
helpful insofar as they ensure security, unhelpful in that they inhibit full
expression of emotional need. Thirdly, to show how the oedipal and securitydynamics interweave one with another
Case example 1
Alison came into once-weekly, sitting-up psychoanalytic psychotherapy, notostensibly for herself but because her son Tom, aged 14, was ‘‘going off the
rails ’’. Her elder child, his sister, aged 17, was everything a parent could wish
for: helpful, studious, intelligent, charming and popular. Tom, by contrast,had always been ‘‘difficult ’’, prone to tantrums as a baby, reluctant to go to
school, and now holing up in his room playing internet computer games,falling behind on his grades, and possibly, Alison thought, taking drugs. Ifonly he could be like his elder sister! Just getting Tom to school every
morning was an hour-long ordeal; he did no homework and no amount of
cajoling or Draconian measures seemed to work. He was becoming pale,thin and withdrawn and she feared for his future and his life. He had beenreferred to various counsellors and doctors but had refused to cooperate.She was now seeking help in her own right, hoping that she could be shownhow best to rescue her son and put him on the path leading, as it ‘should ’
in her eyes, to school, university and a good job.1222 J. Holmes
Int J Psychoanal (2011) 92 Copyright ª2011 Institute of Psychoanalysis

Alison ’s own childhood history was one of not-so-benign neglect: ‘‘My
mother ’s priorities were: number one herself, number two her horse, number
three the dogs. We came in a poor fourth. ’’An early memory was of being
locked out of the house by her mother after breakfast in charge ofher younger siblings and not allowed back until lunchtime. Meanwhile,her mother was out hunting and hobnobbing with her friends. At 12 Alisonwas sent to boarding school while her parents worked abroad. She saw themonce a year, spent holidays with her grandparents, and was expected to
make her way to the airport and back on her own. Somewhat shy, she dis-
covered academic prowess and put all her energies into her school-work.Arriving at university at age 18 to study mathematics, she had a heady andunsettling sense that she could do whatever she wanted. After graduatingshe worked in the financial sector and soon became a successful stock-broker. Sporty as well as clever, she loved skiing and in her late 20s, afterthe breakup of a relationship, toyed with the idea of ‘‘giving it all up ’’and
becoming, as she put it, ‘‘a ski bum ’’, but was discouraged by her father
who could not tolerate the idea of a clever daughter ‘‘throwing herself
away ’’. Emotionally self-sufficient, she was rather surprised when, in her
early 30s, she met an older man, a lawyer, who, in her words, ‘‘insisted ’’that
they get married.
The marriage was basically happy, especially when they had lived abroad
for two years, far from his controlling family. When she became pregnantwith her first child they returned home and settled into a comfortable life ofmiddle-class suburbia. She continued to work part-time but the principal
focus of her life was her children. The intrusions of her in-laws were the
main marital irritant – she particularly resented the fact that her husband ’s
mother had apparently vetoed through her husband their choice of namefor her son. He had remained unnamed for 8 weeks, and Tom was semi-randomly chosen at the last moment on the way to the Registrar of births.Now she felt that her husband was disengaged, did not see what danger hisson was in, and was leaving everything, including coming to therapy, to her.
At first Alison was nonplussed by her therapist ’s apparent refusal to give
her directions about how best to handle Tom, focusing instead on herfeel-
ings of frustration, exasperation and panic about the situation. ‘‘Why don ’t
you tell me what to do? I am at my wit ’s end, and you just sit there ’’– this
was likened to having been sent out into the garden to fend for herself andhaving to control a group of unruly younger sibling ⁄feelings. Were the thera-
pist to tell her what she should do (if that were indeed possible) would henot be just another mother-in-law trying to control her – insertingthe wrong name-of-the-father into her family?! Everything seemed at odds
he suggested: the conflicting parts of herself (her love for Tom at and her
fury at his unresponsiveness); herself and her husband; and herself andher therapist – (his seeming passivity and failure to give advice).
Alison was now in a ‘benign bind ’(Holmes, 2009) – she accepted the
therapist ’s professional integrity but chafed at his failure to conform to her
representation of what a therapist ⁄parent ’s role should be. How could ‘let-
ting be ’(Lear, 2009) and giving her and Tom and his father a chance to
work things out for themselves possibly be helpful? She was stuck: therapySuperego: An attachment perspective 1223
Copyright ª2011 Institute of Psychoanalysis Int J Psychoanal (2011) 92

was no real help yet, now she was embarked on it, she could not quite bring
herself to walk away.
Alison could see that her attempts to fit Tom into her achievement-
oriented mould were not working. Something new was needed. Perhaps
letting him make his own decisions about school and computer time andcareer did not necessarily correspond to the negligence she accused herselfof. Perhaps laisser-faire (he refused to let her test him on his French verbs!)
did not have to be construed as neglect, and was not necessarily a repetition
of her mother ’s self-preoccupied emotional and physical absence. Maybe
too, the therapist suggested, there was a rebellious, ‘drop-out ’part of herself
that had been swept aside when her father insisted that she chose the stock-market in preference to the ski-slopes. Perhaps a similar autonomy wasemerging in Tom, his passive rebelliousness chiming with a part of herselfshe had for too long disavowed. She began to see that Tom was a being inhis own right, making his own choices, not an extension of her; and that thebehaviour she found intolerable in him was not so far removed from a
thwarted part of herself.
The struggle against her need to be in control was not easy. Alison found
it almost impossible not to try to run Tom ’s life for him – not to get him
up in the morning, ask him if he had done his homework, check whether hehad contacted any friends, insist on a detailed itinerary on the rare occa-sions when he did go out. Her tongue, ever ready to issue ‘helpful ’directives
and reproaches, had constantly to be bitten. She saw that it would be betterto hand over a lot of the parenting to her husband, but could she be sure
he would do things the ‘right ’– i.e. her – way? She wanted to pursue her
own interests – work, seeing friends – but felt driven by feelings of distressand the overwhelming need to return Tom to a normal developmentalpathway. Without her omnipresence Tom might fade away – how could shepossibly enjoy herself with that at the back of her mind? There was aninsistent, demanding, critical part of herself over which she had little juris-diction, urging her to ‘do something ’rather than just ‘sit there ’.
Despite her inner turmoil, as time went on and she learned to hold back,
the struggle began to seem worthwhile. Things improved: Tom was getting
himself to school; his reports acknowledged that he was at least trying;he was beginning to go out and see friends. She could imagine a time whenhe would lead his own life, even find a career, albeit a to her an alien-seem-ing, non-academic one, and that she and her husband could one day enjoythemselves again as they used to.
Before discussing this case I make a brief diversion into aspects of the
superego.
Superego theory
A comprehensive account of superego theory is beyond the scope of thispaper. What follows is a brief summary, with an added attachment gloss.
One way of looking at the superego as an ‘agency ’– distinct from id in
not being a source of psychic energy, and the ego in not wielding an execu-
tive function – is to see its role as that of regulation . In Freud ’s (Freud,1224 J. Holmes

1917) earlier formulations there are two aspects to this. The first is that of
self-observation. The superego represents the self ’s reflexive capacity: in
order to regulate, one has first to observe. This facet has however been lar-gely eclipsed by the second – the superego as a repository of conscience andmoral values. Here, by means of guilt and the ego ideal, the superego exertscontrol over the subject, labelling affects and impulses as legitimate or ille-gitimate, and policing potential transgressions (Freud, 1921). The ego ’s task
is to finesse id-derived drives against superego prohibition. In pathology,
this regulatory role malfunctions: either outlets for drive discharge are
blocked, leading to obsessionality or somatization, or in depression –Freud ’s starting point for the topographical model – the ‘harshness ’of the
superego turns against itself, resulting in self-attacking affects and behav-iours.
Freud saw the origins of the superego in the oedipal constellation. The
superego is ‘heir ’to the Oedipus complex in that it represents an internaliza-
tion of paternal authority, regulating infantile desire for exclusive possession
of the mother. Freud emphasized that what was internalized did not
necessarily represent actual parental behaviours, but rather perceptions ofthem, inevitably tinged with the child ’s own feelings: nested within the
superego ’s‘harshness ’is the child ’s own projected aggression.
This idea was extended in Klein ’s idea of the pre-oedipal ‘archaic super-
ego ’in which the child ’s primitive guilt-feelings about his hatred for the
loved object is sequestered, first in an external ‘bad breast ’and then
re-introjected as a punitive internal object (Klein, 1948). This is clinically
relevant in that, while in normal development the punitive superego ’s
attacks are eventually mitigated in the depressive position, they may persistin the form of the self-injurious attacks often seen in people suffering fromborderline conditions (Kernberg, 2009).
The introjection of positive as well as negative regulatory aspects of
parental function is suggested in Freud ’s brief late paper on humour (Freud,
1927; Christie, 2009; Lemma, 2009). Here the superego is a comforting,friendly, older, wiser entity, a good parent who ‘‘speaks …kindly words of
comfort to the intimidated ego ’’(Freud, 1927, p. 166). Similarly, Sandler
asserts that: ‘‘Parental introjects serve not only to criticize and punish but
also to encourage and support …’’(Sandler and Rosenblatt, 1962, p. 141).
Shafer likewise emphasized the ‘‘loving and beloved ’’aspects of the super-
ego, underpinning ‘‘pride, fortitude, humour, and the effective transmission
of cultural ideals ’’(Shafer, 1960, p. 187).
This ‘benign superego ’can be seen either as the introjection of the
positive aspects of the parent under favourable developmental conditions ab
initio , or as a manifestation of an achieved depressive position in which
forgiveness and benignity become possible. Similarly, the positive impact ofpsychoanalysis on the superego can be seen in two ways. Firstly, under theinfluence of the positive experience of analysis, there is a move towards amore realistic, forgiving, tolerant superego (Strachey, 1934). A slightly differ-ent view would be that analysis fosters a gradual dissolution of the superego– where superego was, there ego shall be – as a mature and more robustego takes over its functions (Britton, 2006).Superego: An attachment perspective 1225

An attachment perspective focuses on three aspects of the above. Firstly,
reviving the observing, self-monitoring aspect of the superego links well withthe emerging concept of mentalizing (Fonagy et al ., 2008; Holmes, 2009)
and affect regulation. Both of these have been shown to be problematic inpeople with borderline conditions (Bateman and Fonagy, 2006). Secondly, itcan be argued that the superego is ‘heir ’not just to the oedipal constella-
tion, but also to the child ’s attachment relationship. A regulatory superego
is one in which one part of the mind (the superego) oversees and guides
another (the ego). This presupposes an internalized dyadic structure. In
the classical formulation this is the parent–child relationship, the role of theinternalized parent being to regulate the child ’s sexual and aggressive
impulses. From an attachment perspective, equally important is the mainte-nance of physical and emotional security. Here the dyad is thecare-seeker ⁄caregiver couple. The parent who says ‘no ’when the toddler
approaches an electric socket, or cuddles the child when frightened or ill,becomes an internal regulating function ensuring safety. The external
caregiver is then gradually superseded by an internalized care-providing
function, which can be seen as part of superego, helping the child maintainphysical and emotional integrity in the face of threat or stress. This couldbe construed as the ‘maternal ’counterpart of the ‘paternal ’oedipal ‘heir ’.
Thirdly, as will be discussed later, the positive aspects of the superegoembodied in the analyst ’s benign attitudes enable the analysand to weather
the inevitable turbulence integral to psychic change.
In the light of this discussion, let us now return to the case material
Case 1: Discussion
How does the idea of the superego help think about Alison ’s case? Alison
was clearly a person divided against herself: one part kept persisting withineffective mothering strategies; another recognized that this was not help-ful. Part of her desperately wanted to make everything right for Tom;
another felt furiously and impotently angry with him. Aware of how counter-
productive this was, she was nevertheless unable to stop her controlling andcritical ways with Tom. There did indeed appear to be an ‘agency ’within
her, of which she was at best only partially conscious, beyond her control,dictating her behaviour in unhelpful ways. However, her high arousal levels– the activation of her caregiving dynamic, triggered by Tom ’s evident dis-
tress – meant that she was unable full to mentalize the inner forces drivingher behaviour. Tom ’s distress activated her caregiving dynamic – she could
not rest until he was ‘safe ’. His unassuaged neediness had activated
her long-repressed feelings of and neglect and rageful protest about this.Her ‘superegoish ’feeling that Tom should and must go to school were the
conscious manifestations of this.
Thus her sense of ‘right and wrong ’, how a child should be brought up,
were shaped and dictated to by forces ‘within ’her, yet seemingly over which
she had little control. Her implicit guiding rules represented her own defen-sive strategies as a child, unconsciously transmitted to her own children,
successfully in the case of her daughter, but not so with Tom : ‘be self-1226 J. Holmes

sufficient ’;‘study hard to the limits of your ability ’;‘don ’t be a neglectful
mother as yours was ’;‘suppress subversive desires ’;‘don ’t tolerate laziness
or backsliding ’. These superego strictures of which she was only dimly
aware, and which she could only with extreme difficulty subject to criticalscrutiny, seemed to have a life of their own, beyond the reach of herconscious ego. They had served her fairly well and enabled her to surviveher own distant and rebuffing parenting. In her developmental historyAlison had traded exploration and libidinal satisfaction for security and
self-sufficiency. Intimacy and reciprocity were jettisoned for the sake of
financial and social independence.
Alison ’s superego ‘rules ’had ensured her freedom from dependence on
unreliable attachment figures and underpinned the rewards of worldlysuccess. In the structure of her superego the search for security and thevicissitudes of her sexuality were intertwined. If being a ‘ski-bum ’was a
surrogate for sexual freedom, her father ’s intervention ensured that she
remained on the ‘straight and narrow ’of her career path. Her superego was
also anti-libidinal in that the ‘marriage ’in the family was more between
Alison and her children – echoing that between her husband and his mother– than the parental couple themselves, just as her narcissistic mother was pri-marily in Alison ’s eyes ‘married ’to her horse! Despair, rage, and desolation
about all this were feelings to be avoided at all costs. Discussing Tom ’s misery
about the lack of a close parental couple was off-limits..
Psychoanalytic therapy seemed to help in a number of different ways. It
offered an environment based on acceptance rather than control, suggesting
that non-directiveness did not necessarily equate to abandonment. Rather
than affect-denying directions, the therapist offered acceptance, containmentand a degree of nonverbal soothing in response to Alison ’s expressed distress.
This secure-base responsiveness could be seen as the gradual installation ofthe Sandler ⁄Shaffer-like ‘benign superego ’in Alison ’s psyche, sustaining her
while she wrestled with her anger at the therapist ’s refusal to ‘help ’or tell
her what to do, thereby providing a ‘benign bind ’(see below) as a catalyst for
change (Lear, 1993). Therapy began to provide a language, clich/C216d perhaps,
but self-generated rather than imposed, for looking at and revising her own
habitual thought processes – ‘letting go ’,‘doing my own thing ’
,‘staying with
it’, verbal expression of a less constraining, more self-sensitive superego.
Alison ’s difficulty in holding back from controlling her son ’s life could be
seen as a reflection of her own superego-derived ‘paternal ’prohibition on (sex-
ual) freedom and the wish to find herself rather than fit with a predeterminedparental blueprint. To that extent her superego is indeed an oedipal heir.Equally powerful, if not more so, were Alison ’s caregiving maternal impulses,
both aroused and thwarted in an agonizing way by Tom ’s distress. She was in
a state of chronic attachment activation, wanting to make Tom safe, butunable to do so. Here the superego, I argue, was acting as an attachment ‘heir ’,
reflecting Alison ’s own lack of maternal care as a child, her strategies for sur-
viving this deprivation, and her desperate wish to make good this deficiencywith her own children. Here we see the transmission of the attachmentdynamic across the generations: ‘‘A child ’s superego is constructed not on the
model of the parents, but the parent ’s superego ’’(Freud, 1933, p.136).Superego: An attachment perspective 1227

The relational superego
It is being suggested that the superego as the font of a person ’s moral uni-
verse and a regulator of affect and behaviour is shaped as much by the
attachment dynamic as by an oedipal or pre-oedipal one, and that what is
‘permissible ’and ‘good ’is determined as much by the vicissitudes of the
need for security as by the rivalries and regulations of the oedipal triangle.Further, this attachment constellation may be as much out of reach of con-scious awareness as the oedipal and pre-oedipal aspects of the self, albeitnot so much due to repression as the arousal of attachment-related anxietywhich itself precludes reflection. This dynamic view is consistent with thepsychoanalytic conceptualization of the superego as a defensive structure
(Gray, 1994). Let us now turn to some empirical findings from the attach-
ment literature to buttress this viewpoint, before considering its limitationsand need for extension.
Attachment Theory can be used to reformulate Anna Freud ’s (1998)
theory of defenses in dynamic relational terms (Mikulincer et al ., 2009).
As development proceeds, the growing child negotiates an ever-shiftingbalance of exploration and security. Thanks to the sensitivity and masteryof the responsive parent, when faced with temporary abandonment,
secure children can tolerate and express feelings of fear and rage without
jeopardizing their secure base. Curiosity and exploration need not beinhibited because comfort and companionship can be relied upon to bethere when required (Heard and Lake, 1997). Bolstered by parentalsupport, the secure child is confident that her hopes and wishes will befulfilled, or, if not, disappointment is tolerable as a mere temporarysetback. The relationship between the internalized parent and the selfand its desires is essentially benign; defensiveness, with concomitant
unconsciousness and lack of narrative competence, is minimal. There is
an internal containing, regulating, facilitating presence, distinct from theautonomous ego, yet located within the self. This internal secure base,like the benign superego, or Freud ’s humorous parent, oversees the ego
in all its vicissitudes.
In the ‘organized ’forms of insecure attachment greater defensiveness
comes into play. The relationship between the self and the internalizedparent is a necessary compromise. The child wishes to explore and to experi-
ence feelings – including feelings of closeness – but to do so runs the risk of
rebuff and disapproval (this was what Alison found so difficult to do forTom). In the hyp oactivating ⁄avoidant pattern, awareness of feelings is
suppressed for safety ’s sake. The superego, as it were, says: ‘Don ’tfeelyour
feelings of fear and rage and desire; damp them down, even if in doing soyou are diminishing the richness of your inner world and may miss affectivethe signals you need to guide you towards good choices in life ’. Attachment-
related feelings are subject to repression no less than those dominated by
sexuality or aggression.
The hyp eractivating ⁄ambivalent pattern of defence similarly trades off
exploration for security. Here the price paid for security is regression. Thesuperego ’s message runs: ‘Succumb to your flooding emotions, indulge1228 J. Holmes

them, stay regressed and uncontained – that way someone will take notice,
even if it means your autonomy and self-efficacy are compromised ’.
In disorganized attachment, the superego is dangerously disengaged from
the self and its desires, unable to support or help the fragile ego. Either itstands apart, mimicking the behaviour of the frightened, withdrawn parent(Lyons-Ruth and Jacobvitz, 2008); or it intrudes, attacks and blames theself, heartlessly disregarding its needs or feelings. Either way, the self isdepleted and at risk. In this radical state of dissociation, the self cannot
‘hear ’injunctions for self-preservation, and is likely to ignore warnings to
avoid dangerous or self-defeating behaviours. In the absence of a guidinginternalized parent, it is on its own, doing its best to achieve a modicum ofsecurity and satisfaction, even if this entails self-soothing via deliberate self-harm or drug abuse. In these pathological states the relational superego iseither absent or abusive, sub-sections of the self forced to make do withouta regulating, coherence-creating, meaning-making, over-viewing part of theself.
These early relational experiences with parents lay the foundation for
moral behaviour. Avoidant children tend to be bullies; hyperactivatingchildren to be clingy and helpless; disorganized children to resort torole reversal in their relationship with theircare-givers (Lyons-Ruth andJacobvitz, 2008). Relational models are internalized, including preceptsabout how things ‘should ’be. The morality of the ego ideal reflects the han-
dling which preceded it. Secure children are natural mentalizers (Slade,2008). They see others as sentient beings and treat them accordingly while
insecure children may set up narcissistically derived ego ideals – doomed to
disappointment when confronted with reality – as defences against feelingsof abandonment, isolation or intrusion.
The attachment typology outlined above is consistent with Bowlby ’s
(2005) view that normal and pathological development should be seen asdistinct, self-maintaining pathways. Secure children experience cascading‘broaden and build ’experiences as they ascend the developmental ladder.
Insecure children by contrast may enter self-perpetuating vicious circles of
relational disturbance. This epigenetic perspective is robustly supported by
longitudinal prospective studies following children classified in the first yearof life and followed through into young adulthood (Grossman et al., 2005).
Prohibition and the superego
From this viewpoint, rather than being an universal developmental stage, the
‘archaic ’pre-oedipal superego model may apply particularly to developmen-
talpathology , especially the disorganized attachment patterns underlying
Borderline Personality Disorder. The clinical phenomena usually explainedby the ‘archaic superego ’include the negative therapeutic reaction, and vari-
ous forms of self-defeating behaviours (Kernberg, 2009). Healthy strategies ofself-protectiveness and seeking out good rather than bad experiences are inabeyance. The sufferer appears driven by hate, including self-hatred, ratherthan love. Attachment thinking suggests that the dynamic here is the over-
whelming need to have some sort of security, even if this means clinging to aSuperego: An attachment perspective 1229

‘bad ’object. Better a bad object than none at all: as Fairbairn (1954, p. 27)
puts it: ‘‘Better a bad me in a good world, than a good me in a bad world ’’.
From an attachment perspective evading bad experiences in the short run
is more important than achieving good ones. In man ’s evolutionary past, it
was better not to be eaten than to go hungry; better to avoid poison than toindulge one ’s appetite. Bitter fruit chewed spells death; eschewed, one lives
to love another day. Our taste buds can detect one part of bitterness pertwo million, while they are sensitive only to one part sugar per 200 (Ito
et al., 1998 quoted in Music, 2009). Thus we are ten thousand times better
at detecting danger than enjoying pleasure. To stay safe, we need to be goodat representing, and then avoiding or negotiating bad experiences. Themother who says ‘No ’as her toddler lurches into a busy road is pitting
‘external ’superego power against the capacity of the environment to cause
harm. As an internalized, prohibiting caregiver, superego plays an essentialrole in maintaining safety, even if this means missing out on, or at leastpostponing, pleasure. In disorganized and borderline states this process goes
awry.
In sum, the superego is not just ‘heir to the Oedipus complex ’but also to
the attachment relationship which an infant needs in order to surviveinto adult life. The benign superego in this model is the internalization of theprotective parent. Rather than being a ‘pure culture of death instinct ’
the superego ’s job is to keep death at bay. It is only in severe pathological
states that the superego perversely turns against itself, and becomes the verysource of danger and disorder which its primary role is to counteract.
The subliminal superego
Bowlby summarized his view on the superego as follows:
[There are] …rules for appraising action, thought and feeling that together are usu-
ally referred to as constituting the super-ego …applied automatically and outside
consciousness. …hard to change either because they are ingrained or because of
‘defensive exclusion ’.
(Bowlby, 1971, p. 54)
The psychoanalytic notion of ‘working through ’acknowledges the power
of ‘ingrainedness ’, and the time needed to unlearn defensive habits and to
acquire new, more appropriate and adaptive ways of dealing with intra- andinter-personal experience. Recent attachment-informed research howeversuggests that both ingrainedness and defensive exclusion can be over-ridden
by subliminal messages from the immediate environment.
In a series of studies, Mikulincer, Shaver and colleagues (Mikulincer and
Shaver, 2008; Mikulincer et al., 2009) have shown that dispositional attach-
ment styles influence responses to affect-laden tasks, but that these can bealtered by appropriate environmental ‘priming ’.
Their findings apply across a range of situations. In a visual exploration
study, subjects were asked to rate their liking for and interest in a Chineseideograph. In a comparable textual study, subjects were exposed to a trau-
matic story in which a child was killed in an automobile accident, and the1230 J. Holmes

levels of compassionate responses towards the parents were rated. Studies
looking at intimate relationships asked subjects to consider a relationshipproblem that had occurred in the previous week, and then to think abouthow such difficulties might be resolved. In each of these situations secureindividuals (previously rated) showed more ‘positive ’and exploratory
responses than their insecure counterparts. The experiments were thenrepeated, but subjects were now ‘primed ’either with positive or neutral
stimuli, either subliminal (flashing words like ‘love ’and ‘support ’onto a
screen so briefly that the subjects did not consciously register them) or
supraliminal (asking the subjects to think about a loving or supportiverelationship, or showing them a picture of a mother cradling a baby). Thegeneral outcome was that insecure subjects, when primed with positive, but
not neutral stimuli then behaved and thought in ways that were indistinguish-able from the secure counterparts .
These studies could be seen as tapping directly into individual ’s superego
function or moral dispositions, measuring compassion, concern for the other
and prejudice. They suggest that individuals ’moral perspectives are influ-
enced both by their attachment history andby the prevailing ambiance, and
that the latter ’s impact does not depend on conscious awareness. Compared
with secure subjects, insecure people are less likely to be compassionate andconcerned; more likely to be negatively judgemental and to adopt self-serving ethnocentric perspectives; but these tendencies can be over-ridden bypositive attachment messages from the environment. As we shall see below,these findings lend empirical support to the Strachey–Lear model of thera-
peutic action.
The maturation of the superego
The discussion so far suggests a number of modifications of classical super-
ego theory. Firstly, the internalized parent or parent–child relationship asrepresented by the superego is concerned not just with sexuality or with
primitive feelings of hatred but also with maintaining safety. Sex and secu-
rity are linked in that a secure child will feel free to explore sexual feelings,whereas an insecure one will either be inhibited or confuse sexuality withthe need for security (c.f. Holmes, 2009). Secondly, a mechanism wherebyinternalization of parental function occurs is suggested by the Mikulincerexperiments. Parents create a subliminal atmosphere which to a varyingextent elicits ‘good ’behaviours and discourages ‘bad ’ones. The balance
between love and security and neglect or aggression implicit in this atmo-
sphere will determine the character of a person ’s superego. Thirdly, the
developmental perspective suggests that, when environmental conditions areright, there can be a move from a pathology-headed epigenetic pathway to amore positive one. There is a potential maturational process within thesuperego from a ‘primitive ’archaic, black-and-white, talion law viewpoint
into a more nuanced, ‘new testament ’morality, more forgiving, more able to
see both sides of an argument. Benign transgression, without which adultsexuality would be impossible, is predicated on a sense of safety which
enables the mature individual to see that ‘rules are there to be broken ’.Superego: An attachment perspective 1231

Clinical implications
What is the relevance of this to the quotidian work of the psychoanalyst and
analytic psychotherapist? Can thinking about the superego lead to a deepen-
ing of our understanding of ‘therapeutic action ’(Gabbard and Westen, 2003)?
Here I follow Lear ’s (1993, 2003) updating of the classical Stracheyan view
(Strachey, 1934) of ‘mutative moments ’in psychoanalytic therapy, before con-
cluding with a consideration of the analyst ’s‘professional superego ’.
Strachey ’s (1934) classic paper started from the then prevailing view that
neurosis was the result of superego-mediated repression and inhibition. Theprincipal aim of therapy therefore was to help mitigate the harsh stricturesof the superego. As ‘heir to the Oedipus complex ’the superego represented
an anachronistic presence within the self, controlling the ego and prohibiting
oedipal desires and rivalries. The role of the analyst was in effect to say tothe adult ego: ‘It’s all right to experience strong feelings of desire and
aggression: the old prohibitions no longer apply ’. Strachey ’s insight was to
see that simply saying that would not necessarily produce change: the super-
ego would continue to defend itself and its right to control the ego. Sincethe superego is formed through idealization, identification, and internaliza-tion, Strachey argued that if it could, via positive transference, be persuaded
to absorb into itself a portion of the analyst ’s more lenient superego, able to
tolerate a necessary degree of transgression, it would then in turn adopt amore benign attitude towards the self as a whole. Tracking the tensionbetween therapeutically internalized benign superego and transferentialexpectations of censure were the main focus of ‘mutative interpretations ’.
Strachey used Freud ’s theory of hypnosis to support his argument. The
hypnotherapist gains sway over the subject ’s mind by infiltrating a portion
of the superego; similarly, in ‘falling in love ’, the beloved assumes the posi-
tion of the ego ideal; and in groups the leader similarly colonizes followers ’
superegos. In the Strachey model, the hypnotic power of the analyst is putto therapeutic use. Temporary submission to the analyst ’s influence rear-
ranges the balance of psychic forces. Consonant with this, and in contrastto Klein (1948), Anna Freud (1998) unashamedly saw the therapist ’s role as
in part pedagogic – the non-judgmental, accepting attitude of the analystteaching the patient to be more loving and lenient towards himself.
The Mikulincer findings suggest a possible mechanism for Strachey ’s idea
that psychic change entails analysands internalizing therapists ’‘benign
superego ’. The analyst, unbeknownst to the patient or even herself, trans-
mits a benign ‘prime ’– acceptance, attention, focus, security, reliability –
thereby enabling the patient to become less hard on himself, more able toexamine and accept his id-derived desires and rages.
But would that analytic work were so simple! While the above model
might explain for ‘flight into health ’and the benefits of supportive therapy,
it fails to take into account resistance and the sheer difficulty of achieving
psychic change. For example, Taylor (2009) describes a psychoanalytic ther-
apy research project with treatment-resistant depression-sufferers: after aninitial period of improvement seemingly related to being listened to andtaken seriously, the old depressive patterns reasserted themselves.1232 J. Holmes

Lear’s model of therapeutic change
This takes us to Lear ’s reworking of Strachey ’s‘mutative interpretation ’
(Lear, 2003). His three-stage model starts from the accommodation of
the analyst to the linguistic and intrapsychic world of the analysand as the
former begins to enter into and share the analysand ’s‘ideolect ’. Here the
analyst ’s benign superego is absorbed into the client ’s world (this could be
construed as the ‘supportive ’stage). Next, as Strachey suggested, there is a
discrepancy between the client ’s transferential expectations – negative or
positive – and the analyst ’s response. The analyst neither colludes nor
rejects, nor allows herself to be expelled, while consistently resisting pressureto conform to the dictates of the client ’s fantasy. At this disjunction or ‘rup-
ture ’point (c.f. Safran and Muran, 2000) the client is forced to mentalize
(c.f. Fonagy et al., 2008) – to subject her ‘automatic ’responses to scrutiny
and articulation, while remaining held within the analytic field. This opensup a ‘mutative moment ’: the unlearning–relearning process of psychic reor-
ganization that is the essence of therapeutic change.
In this third stage analyst and analysand together examine in slow motion
or ‘action replay ’moments that have spontaneously arisen between them.
Mentalizing is subsumed under the self-scrutinizing aspect of the superego,
one of the three components originally proposed by Freud – the capacity to
look at oneself and one ’s thoughts as though from the outside. For Lear
(2003) this capacity is essentially ‘ironic ’in the sense that an interpretation
is not simply a plain statement of analytic ‘truth ’(to which the analyst, but
not the analysand, is privy), but incorporates the capacity to subject that‘truth ’to ironic scrutiny. The benign superego is not merely a Strachean less
harsh, good parent vector, but one at a level of ‘higher psychical organisa-
tion ’endowed with the capacity to communicate and transfer that higher
level of self-understanding to the analysand. This includes the capacity to
take full depressive position (the depressive position could be seen as intrin-sically ironic in that it acknowledges the kernel of love within hatred, andhatred within love) responsibility for one ’s negativity. One owns one ’s
hatred, envy and destructiveness – rather than blaming the superego as theinner representative of less-than-perfect parents. Attachment suggests this isonly likely to be achieved under conditions of security. Maturation is notjust a matter of tempering hatred with love, but also of mastering the anxi-
ety that inhibits exploration, including exploratory self-understanding.
Case example 2
Fran, a single woman in her mid-40s suffered from Borderline Personality
Disorder. She presented with alcoholism, depression and a wish to find a
stable relationship (she had had numerous traumatic sexual experiences) and
a coherent direction in life. Due to her mother ’s mental illness, she had been
brought up in multiple foster homes in the early part of her childhood.When her mother was finally able to look after her she was sexually abusedby her step-father.
Four years into twice-weekly couch-based psychoanalytic psychotherapy,
her life pattern had stabilized; she had successfully completed a universitySuperego: An attachment perspective 1233

course, she was far less depressed and able to be more sociable and outgoing.
However, her drinking remained problematic and she continued to feel lonelyand isolated. She managed to stay sober for the day before her therapysessions, but usually drank afterwards and for the next night or two, until sheagain became abstinent for the time leading up to her next appointment.
During an extended analytic break she attended a three-week Buddhist
retreat. On her return she happily reported that she had been abstinent sincegoing to the retreat, and recounted an epiphanous moment that had arisen
during a meditation session there. She had suddenly had a powerful vision
of herself pouring, as she put it, ‘‘poison [i.e. alcohol] down my throat ’’. She
then thought: ‘‘That ’s not something that I would ever do to someone I
love. ’’She had returned home determined to be more nurturing and loving
of herself, and so far had been alcohol abstinent. The therapist suggestedthat she was perhaps unfavourably comparing what he had to offer – two50-minute sessions punctuating an otherwise bleak existence – with theall-encompassing love which she had experienced at the retreat. This led
her tearfully to acknowledge the horror of coming back from sessions to her
lonely apartment, and how drinking controlled this desperation.
She returned next week saying that she had once more been drinking. The
therapist pointed out how difficult it was for her to ‘bring ’her drinking self
to the sessions, in which, generally, she was sober, serious, and collaborative.What would it be like, he speculated, if the drunken part of herself were tocome into view?
Responding perhaps unconsciously to the unwitting sexual undertones of
the word ‘come ’, she replied: ‘‘Oh, I ’d probably ‘come on ’to you ’’.
The therapist said: ‘‘Hmmm, that would mean that whatever I did it
would be wrong. If I responded, I would be like your abusive step-fatherand the other men in your life; if I held back I would be like your absentunresponsive mother. It is as though your sexuality is forever condemned toloneliness or abuse; its only hope is to be lulled to oblivion with alcohol. ’’
She said: ‘‘Actually perhaps this is not really about my so-called sexuality;
maybe I just want to feel safe and accepted and validated – up to now the only
way I know to get anything even approximating to that is through drunken sex. ’’
Case 2: Discussion
Fran ’s experience at the retreat suggests that the subliminal positive mes-
sages implicit in a group religious experience produced beneficial effects. Inthe embracing atmosphere of the retreat she developed compassionate
feelings towards herself, just as in Strachey ’s model the analyst ’s‘benign
superego ’lodges in the patient ’s psyche. Psychoanalytic sessions similarly
benefit clients even when the therapist relentlessly focuses on the negative(c.f. Music, 2009), because the subliminal message is one of warmth, reliabil-ity and non-judgemental validation. But the impact of the retreat wasshort-lived. Similarly, the subliminal positive messages of therapy producebenefit only as for the duration of the treatment, or perhaps for the sessionitself. To go beyond supportive psychotherapy, the mutative ‘value-added ’of
psychoanalytic work requires a further ingredient.1234 J. Holmes

Fran ’s borderline ‘archaic superego ’orchestrated her self-destructive
drinking and negative sexuality: hate towards the ‘bad ’depressed mother ⁄
breast turned against herself. From an attachment perspective it representedthe disorganized attachment of her infancy and childhood. Her overwhelm-ing anxiety was, to an extent, contained in a split-off ‘bad me ’; clinging to
drink provided a source of pseudo-security. The lack of an internalizedprotective benign parental superego meant that she failed to protect herselffrom danger, in part through failure to read warning signs, in part in a
perverse attack on the absent secure base.
The subliminal support of therapy sessions and of the retreat offered the
security that her childhood had lacked, but failed fully to engage with thisself-destructive aspect. The archaic superego remained sequestered. When,in the context of a benign superego, Fran could express her transferentialneediness openly towards the therapist, the disjunction between her expecta-tions of abuse or neglect and the equipoise of his response provided thetherapeutic leverage that had been lacking. By his neither reciprocating nor
rejecting Fran ’s advances, she was forced to think about and put into words
what she really wanted – a safe place, a secure base – to which she could
turn when feeling lonely and sad, rather than resorting to drink. This men-talizing ‘meta-self ’was the first step towards the instatement of a ‘better
self ’in place of the self-destructive superego.
Transgression and the therapeutic superego
A paradox of the superego is that, as heir to the Oedipus complex, it pro-
hibits ‘illicit ’sexuality, and yet a well-functioning superego must lower its
restrictions when the time is right so that mature sexuality can flourish, withits necessary admixture of assertiveness and healthy aggression. Thestructural link between the ‘heir to the Oedipus complex ’and ‘heir to the
Attachment relationship ’is that it is under conditions of security that such
lowering of transgressive boundaries becomes possible.
Strachey pointed to a similar paradox for the analyst. Change in therapy
flows from the mitigating effect of the therapist ’s benign ‘good parent ’
superego vis-/C224-vis the patient ’s transferential expectations of seduction or
rejection. But, he argues, giving transference interpretations is no easy task:
There is a …lurking difficulty in actual giving of the interpretation , for there seems
to be a constant temptation for the analyst to do something else instead. …the
giving of a mutative interpretation is a crucial act for the analyst …he is exposing
himself to great danger in doing so …. at the moment of interpretation the analyst is
…deliberately evoking a quantity of the patient ’s id-energy while it is …aimed
directly at himself. Such a moment must above all others put to test his relationswith his own unconscious impulses.
(Strachey, 1934, p. 140, author ’s italics)
An attachment perspective on the superego can help elucidate this ‘great
danger ’. If part of the superego ’s job is to police the boundaries of social
relations, transference interpretations are difficult because they are inherently
transgressive . That is, they flout the strictures of the ‘normal ’superego. ASuperego: An attachment perspective 1235

psychoanalytic conversation, especially when interpretive, disobeys the rules
of ‘civilized ’non-intimate social intercourse: don ’t make personal remarks;
don ’t discuss sex, rivalry, or aggression; don ’t refer directly to the relation-
ship of the interlocutors; be helpful, polite and tactful; if any of these taboosare involuntarily broken, make a joke of it or apologize.
In everyday life, these topics are unsafe because they potentially expose
the power relations between people. Where the relationship is inherentlyunequal, one party is in a position to exploit the other – physically, sexually,
financially. Secure intimate relationships between parents and children,
spouses – and therapists – are built on the possibility (and hope) of mutualadvantage and non-exploitation. Attachment theory holds that danger canbe negotiated with the help of a trusted other or ‘secure base ’, i.e. someone
who will not use the inherent inequality of the relationship for their ownends. Freud ’s‘fundamental rule ’is a message to patients that it is all right
to explore taboo territory, even if it means going against what their superegotells them. But therapists themselves also need to feel that what they are
doing is acceptable to their superego. This is why prolonged training is
needed to overcome the ‘ingrainedness ’of convention, and to instate a
professional ethic that values truth above triteness, and confrontation overcollusion.
In Fran ’s case all was fairly plain sailing, with the therapist facing the
challenge of the patient ’s sexual comment in a way that was neither seduc-
tive nor evasive, leading to further opening up and enhanced awareness ofthe conformist and rebellious aspects of her personality, embodied in her
drinking and non-drinking selves. However, as the final case illustrates, ana-
lysts will recognize that this smooth running cannot always be relied upon.
Case example 3
Joel, a 45 year-old, had given up his beloved dairy farm when a heifer crushedhim and injured his back. His insurance company threatened to withdraw his
injury pension, and he was referred for psychoanalytic therapy by his family
doctor, with whom he had a very close relationship, for help with depression,sense of persecution, feelings of hopelessness and suicidal ideas.
Joel, an only child born out of wedlock and stigmatized in his rural
community, had never known his father. His mother had managed subsis-tence-level farming to support herself and her son. A difficult woman, shewould retire to her room for days if offended. In his late teens Joel inheritedthe farm from his grandfather, making a great success of it until the
accident, and the fateful day when he had to sell his beloved cows. His
20 year-old son lived on the farm with him and his semi-estranged partner.
He was seen in once-weekly psychoanalytic psychotherapy, lying down.
Sessions were relentlessly dominated by his story of the insurance company ’s
wrong-doings. He presented himself as a passive victim of their persecution.Interpretations were made along the lines of: (a) the insurance company ’s
attitude as a repeat of his feelings of being bullied by his peers at schooland at home by his unpredictable mother, and (b) as a surrogate for an
unseen, unknown, abandoning father. Both fell rather flat.1236 J. Holmes

The therapist felt increasingly oppressed, hopeless, impotent and irritated.
In one session he found himself unleashing a vigorous ‘non-analytic ’
challenge, encouraging Joel to stand up to the insurance company ’s onslaught,
to see it for what it was – unfortunate but not a disaster – to find strength andput things into perspective. He was dimly aware of how bullying and persecu-tory were his comments and the way he was delivering them, but persuadedhimself that he was acting like the father the patient had never had, trying toput some ‘backbone ’into a collapsed child, rather than reinforcing Joel ’s sense
of helplessness and victimization. But in the very last minute of the session
Joel said: ‘‘So you are telling me I am a worthless waste of space ’’. Shocked,
the therapist tried to backtrack, but time had run out and, as Joel departed,he was left feeling worried and guilty, and rang his family physician to tell herwhat had happened, warning of Joel ’s suicidal potential.
Meanwhile, self-supervising, the therapist suddenly saw the insurance
company incident, reinforced by his own onslaught, as a ‘re-tramatization ’,
both of the precipitating loss of his dairy herd, and of the childhood vacu-
ous neglect created by Joel ’s father ’s absence and his mother ’s depressions.
His feelings switched instantly from annoyance to compassion. Arriving forthe next session, Joel clumsily tried to hug the therapist as though to makeamends, before lying on the couch and saying that he was feeling much bet-ter and had written letters taking the fight to the insurance company. Inresponse to the therapist ’s acknowledgement of his unwarranted attack and
proffering the ‘re-traumatization ’interpretation, Joel spoke movingly about
his cows, how attuned he had been to them, their condition and illnesses,
and how important it was that his milk yields had been so high – unlike
most farmers he milked three times a day rather than the usual twice, bothfor their comfort and his pride. This in turn deepened the therapist ’s com-
passion, as he realized that Joel ’s relationship with his cows and their milk
represented the nourishment, both literal and metaphorical, that had beenso lacking in his childhood and his consequent despair at its traumatic loss.The accident and now the insurance company ’s refusal represented the ulti-
mate ‘no ’on the part of the ‘archaic superego ’, prohibiting mother–child
intimacy and love. Following this incident, Joel became less ‘concrete ’, more
open to, and initiating of, metaphorical and playful conversation, andreported increased closeness with his son, who was beginning to undertakesome of the farming jobs that had lain fallow during the years since theaccident.
Case 3: Discussion
The therapist ’s attack in this case constituted an enactment as opposed to
an interpretation, the therapist semi-unwittingly embodying aspects of thepatient ’s split-off rage and disappointment at his ill-treatment. The irony
was that, once mentalized, this seemed to have more beneficial effects thanthe conventional interpretations previously offered. It exemplified perhapsSymington ’s (1983) idea of the analyst ’s occasional necessary ‘act of
freedom ’in which she goes ‘off piste ’but in a way that communicates
pre-interpretive spontaneity and engagement to the client.Superego: An attachment perspective 1237

In enactment there is a double danger: the therapist transgresses not just
conventional mores, but also the rules laid down by his professional super-ego. In his challenge to Joel the therapist was caught up in a force-field overwhich he had only minimal control – he just decided to ‘go for it ’, knowing
that what he was doing was in some way wrong, while at the same timeneeding to follow his instinct that this might somehow lead to an escapefrom the impasse. Confident that this was boundary-crossing not boundary-breaking (c.f. Gabbard, 1989), he trusted the setting to hold both himself
and the patient. His ‘attack ’was transgressive in the way that barriers are
breached in dreams or in theatre, i.e. within a context that clearly demar-cates fantasy from reality. Therapists, although immersing themselves inrole-responsive enactments – ‘‘Nature subdued to what it works in, like the
dyer ’s hand ’’(Shakespeare, 1974, Sonnet 111) – can still be still guided by a
wider trust, secure in the benignity of a mature superego (c.f. Stern, 2009).
Conclusions and summary
A key part of the superego ’s role is to manage boundaries. The ‘archaic
superego ’uses crude symmetrizing categories of ‘good ’and bad ’. The
mature superego uses more differentiated, forgiving, subtle criteria injudging what is permissible and impermissible. The progression from theseprimitive to more mature states depends on an internalized parent–childrelationship that maintains safety, which in turn allows for exploration
including sexual exploration.
Values are gradually acquired and internalized throughout life. The
environmental ambiance transmits these values which, under favourable cir-cumstances, become instated in the maturing superego. Psychic changemeans negotiating the disjunction between new and old value-systems. Intherapy this proceeds by mentalizing the conflict between transferentialexpectations and the analyst ’s actual behaviours. Training as an analyst
means unlearning conventional social mores and, within the confines of the
consulting room, incorporating a new ‘professional superego ’. In the course
of professional maturation, this too becomes gradually modified and sophis-ticated, so that occasional boundary-crossings can be tolerated in the serviceof a greater good. For both analysand and therapist a degree of existentialcommitment is needed in order to brave these transgressions. A secureattachment history instantiated in the superego makes such benign leaps inthe dark more likely to succeed.
To return, finally, to the question implicit in the genesis of this paper: is
the superego still an essential part of the psychoanalytic theoretical arma-
mentarium? If seen as a quasi-physical locus within the mind, then theanswer must be no: as Stern (2009, p. 3) neatly puts it: ‘‘The era of psychic
geography is dead ’’. But if we think of the superego as a regulating function
(‘system superego ’, Barnett [2007]), concerned with observations, ideals and
prohibitions then, equally, Roth (2001, p. 3) was not far wrong in her claimthat: ‘‘Everyone has a superego ’’. Perhaps clinical change parallels theoreti-
cal development here. The movement from rigid structure to fluid function-
ing is synonymous with the movement from insecure to secure attachment1238 J. Holmes

patterns. I have tried to illustrate how this mutation might happen in the
course of attachment-informed psychoanalytic treatment, and pari passu ,i n
the evolution of our theories.
Acknowledgements
I am grateful to Catalina Bronstein, Sebastian Kraemer, Richard Mizen,
Kristin White and three anonymous reviewers for helpful comments and
suggestions on earlier versions of this paper.
Translations of summary
U¨ber-Ich: eine bindungstheoretische Perspektive. Der Beitrag versucht, mit Hilfe der Bindungstheo-
rie und –forschung klassische und aktuelle Sichtweisen des /C220ber-Ichs auszuarbeiten und zu erweitern.Beschrieben werden der epigenetische Ansatz der Bindungstheorie und das Konzept des subliminalen
/C220ber-Ichs. In den Zust/C228ndigkeitsbereich des /C220ber-Ichs, so die These, f/C228llt nicht nur die Sexualit/C228t, sondern
auch die Sicherheit. Das /C220ber-Ich ist der ,,Erbe ’’nicht allein des /C214dipuskomplexes oder der Kleinschen
pr/C228-çdipalen Konstellation, sondern auch der Bindungsbeziehung. Unter g/C252nstigen Entwicklungsbeding-ungen formiert sich ein ,,reifes /C220ber-Ich ’’, das dank einer inneren sicheren Basis die reifungsbedingte
/C220berschreitung der Grenze zur erwachsenen Sexualit/C228t erleichtert. In diesem Licht untersucht der BeitragLears Aktualisierung von Stracheys Modell der psychischen Ver/C228nderung sowie das Konzept derGrenzverletzung im Zusammenhang mit dem ,,professionellen /C220ber-Ich ’’, seiner Entwicklung und Reifung.
Klinische Beispiele illustrieren die theoretischen /C220berlegungen.
El superyo ´: una perspectiva desde el apego. Con la ayuda de la teor/C237a del apego y de la investigaci/C243n
en ese campo, este trabajo intenta ampliar y desarrollar puntos de vista cl/C181sicos y actuales acerca del
supery/C243. Se describen el enfoque epigen/C216tico de la teor/C237a del apego y el concepto de supery/C243 subliminal. Se
sostiene que el supery/C243 se interesa por la seguridad tanto como por el sexo. El supery/C243 es ‘heredero ’no
solo del complejo de Edipo o de la constelaci/C243n pre-ed/C237pica de Klein, sino tambi/C216n de la relaci/C243n de apego.Bajo condiciones evolutivas favorables, surge un ‘supery/C243 maduro ’que, en presencia de una base interna
segura, facilita el cruce de fronteras madurativas hacia la sexualidad adulta. A la luz de lo reci/C216n descrito,este ensayo examina la actualizaci/C243n realizada por Lear del modelo de cambio ps/C237quico de Strachey, yexplora el concepto de transgresi/C243n en relaci/C243n con el ‘supery/C243 profesional ’, su desarrollo y su maduraci/C243n.
Los argumentos te/C243ricos se ilustran con ejemplos cl/C237nicos.
Le surmoi: une perspective de l ’attachement. A partir de la th/C216orie de l ’attachement et de la recherche
dans ce domaine, l ’auteur de cet article tente d ’/C216largir les conceptions classiques et contemporaines du sur-
moi. Il d/C216crit l ’approche /C216pig/C216n/C216tique de la th/C216orie de l ’attachement et le concept d ’un surmoi subliminal. Il
souligne les deux faces du surmoi, l ’aspect protecteur et l ’aspect sexuel. Le surmoi est non seulement «l ’h/C216ri-
tier» du complexe d ’Oedipe ou de la constellation pr/C216-œdipienne kleinienne, mais /C216galement de la relation
d’attachement. Dans des conditions de d/C216veloppement favorables, on assiste /C224 l ’/C216mergence d ’un «surmoi
mature» qui, sur la base d ’une s/C216curit/C216 int/C216rieure, facilite le passage des fronti/C155res vers la sexualit/C216 adulte. A
la lumi/C155re de ce qui pr/C216c/C155de, l ’auteur reprend la mise /C224 jour par Lear du mod/C155le de changement psychique
de Strachey et explore le concept de transgression dans son rapport au d/C216veloppement et /C224 la maturation du
«surmoi professionnel». Ces arguments th/C216oriques sont illustr/C216s /C224 l ’aide d ’exemples cliniques.
Il superio nella prospettiva della teoria dell ’attaccamento. Facendo riferimento alla teoria dell ’
Attaccamento e alla ricerca ad essa relativa, questo lavoro intende rivisitare e approfondire le idee attualirelative al superio subliminale. In particolare, si avanza l ’ipotesi che il superio sia tanto motivato dal sesso
quanto da questioni di sicurezza. Esso sarebbe l ’‘erede ’non solo del complesso edipico o della costellazi-
one pre-edipica kleiniana, ma anche l ’erede del rapporto creatosi nel processo di attaccamento. Avanziamo
l’idea che in condizioni favorevoli dello sviluppo, emerga un ‘superio maturo ’che renderebbe pi/C156 agevole,
in presenza di una base sicura, il passaggio a una sessualit/C224 adulta. Alla luce di quanto sopra detto, illavoro intende discutere la revisione di Lear del modello del cambiamento psichico di Strachey ed esplorareil concetto di trasgressione in rapporto al ‘superio professionale ’e alla graduale maturazione di quest ’
ultimo. Queste nostre affermazioni teoriche vengono illustrate con esempi clinici.

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A r tic le
A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2  a jp.psychiatryo nline.o rg  2 7 3spective diagnostic criteria that cover the full spectrum of 
potentially relevant personality processes. We developed the Shedler-Westen Assessment Procedure (SWAP) (1, 2, 6–9) to provide mental health professionals with a clini-cally comprehensive item set for recording and quantify-ing their observations about a patient’s personality and to provide a set of potential diagnostic criteria to test empiri-cally. The instrument contains 200 personality-descriptive items or potential diagnostic criteria.
The SWAP-II, used in the present study, is the third-gen-
eration SWAP instrument. A guiding principle in its devel-opment was that items should be written in descriptively precise, jargon-free language useful to clinicians of any theoretical orientation. A second principle was that per-sonality processes that have been described repeatedly in the clinical literature constitute meaningful hypotheses to test as potential diagnostic criteria and should therefore be represented in the item set.
For example, clinical writings over the better part of a 
century have emphasized projection (i.e., misattribution of one’s own intentions to another person) as a central fea-ture of paranoid personality, but the construct had never been tested empirically as a potential diagnostic criterion. The concept was rendered in the SWAP in jargon-free lan-guage (“Tends to see own unacceptable feelings or im-pulses in other people instead of in him/herself”) and did indeed emerge empirically as a central feature of paranoid (A m  J P syc h ia try  2 0 1 2 ; 1 6 9 :2 7 3 –2 8 4 )an  em p irica lly  D e rive d  ta xo n o m y  fo r Pe rso n a lity  
D ia g n o sis: B rid g in g  Scie n ce  a n d  P ra ctice  in  
C o n ce p tu a lizin g  Pe rso n a lity
Drew Westen, Ph.D.
Jonathan Shedler, Ph.D.Bekh Bradley, Ph.D.Jared A. DeFife, Ph.D.O b je c tiv e : 	T he	a uthors 	d escribe 	a	s ystem 	
f
or	d
iagnosing 	p
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(
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dentify 	n
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atient 	s
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ach	p
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terviewers 	a
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C o n c lu sio n s: 	T
he	e
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elevant.
In 1999, we described a personality disorder taxonomy 
(1, 2) derived empirically via Q-factor analysis (3). The re-
search identified 11 diagnostic groupings, many of which resembled DSM-IV personality disorder diagnoses. The empirically derived taxonomy solved a number of prob-lems associated with personality disorder diagnosis: Co-morbidity among diagnoses was greatly reduced, clini-cians found the diagnostic system more useful than the DSM-IV system and more useful than dimensional trait models (4, 5), and the procedure empirically identified personality syndromes absent from DSM-IV (e.g., depres-sive) and refined the descriptions of others.
The 1999 patient sample was, however, restricted to 
patients with DSM-IV personality disorder diagnoses, and patients were not selected randomly. It was therefore not a representative sample drawn from clinical practice, and it excluded an unknown number of patients with po-tentially significant personality pathology that did not fit existing DSM-IV diagnostic categories. The present study addresses these limitations, rederiving a personality tax-onomy using an independent national sample of patients randomly selected from clinical practice.
D e scrib in g  Pe rso n a lity  Sy n d ro m e s
Developing empirically sound, clinically relevant de-
scriptions of personality syndromes requires testing pro-

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a N e M P i r i Ca llY D er iv e D ta x oNoM Y Fo r  P er SoNa litY D ia G NoSiS
2 7 4 	 ajp.psychiatryo nline.o rg  A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2similarity or “match” between a patient and the prototype, 
considering the prototype as a whole. This approach was 
designed to work with rather than against the naturally oc-curring cognitive decision-making processes of diagnosti-cians (29–32).
The prototype matching method preserves a configu-
rational or syndromal approach to personality diagnosis (33–35), consistent with all editions of DSM to date, while allowing dimensional assessment on a scale from 1 (no match) through 5 (very good match). Where categorical diagnosis is desired (e.g., to facilitate clinical communica-tion), ratings ≥4 indicate “caseness” and a rating of 3 in-
dicates “features” or subthreshold pathology. The method parallels diagnosis in many areas of medicine, where vari-ables such as blood pressure are measured on a continu-um but physicians refer to certain ranges as “borderline” or “high.”
The reliability of SWAP prototype diagnoses made by 
independent observers is high, with a median interrater reliability across personality disorders of 0.72 (28), com-parable to interrater reliability coefficients commonly ob-served for structured diagnostic interviews (mean kappa values between 0.69 and 0.84) (36, 37).
In this article, we present findings of research designed 
to rederive prototypes for personality disorder diagnosis using a large, clinically representative national sample and SWAP-II personality descriptors. We additionally present findings from a second, independent study examining the validity of personality diagnosis using these newly derived diagnoses.
M e th o d
We contacted a random national sample of 1,201 psychiatrists 
and psychologists with at least 5 years of posttraining practice 
experience, drawn from the membership registers of APA and the American Psychological Association (8, 27, 38). Because cli-nicians provided all data and no patient identifying information was disclosed to the investigators, clinicians rather than patients provided informed consent, as approved by the Emory Univer-sity Institutional Review Board. Participating clinicians received a $200 consulting fee. We asked clinicians to describe “an adult patient you are currently treating or evaluating who has enduring patterns of thoughts, feelings, motivation, or behavior—that is, personality patterns—that cause distress or dysfunction.” To ob-tain a broad range of personality pathology, we emphasized that patients need not have a DSM-IV personality disorder diagnosis.
Patients met the following additional inclusion criteria: ≥18 
years of age, not currently psychotic, and known reasonably well by the clinician (using the guideline of ≥6 clinical contact hours, 
but less than 2 years to minimize confounds due to treatment). To ensure random selection of patients, clinicians consulted their appointment calendars to select the last patient they saw during the previous week who met study criteria.
M e a su re s
th e  S h e d le r-W e s te n  as se ssm e n t P ro ce d u re – i i (S W aP -i i) . 
The SWAP-II has been described in detail elsewhere (2, 7, 8). The instrument consists of 200 personality-descriptive statements, each of which may describe a given patient well, somewhat, or not at all. Clinicians sort the statements into eight categories, personality disorder (2), irrespective of the theoretical ori-
entation of the clinician performing the assessment.
The initial SWAP item set (10) was drawn from a wide 
range of sources, including the clinical literature on per-sonality from the past 50 years (e.g., references 11–14), axis II diagnostic criteria from DSM-III through DSM-IV , selected DSM axis I items that could reflect aspects of per-sonality (e.g., depression and anxiety), empirical research on coping, defense, and affect regulation (e.g., references 15–18), research on interpersonal problems in patients with personality pathology (e.g., references 19, 20), re-search on personality traits in nonclinical populations (e.g., references 21–23), research on personality disorders conducted since the development of axis II (24), and pilot interviews in which observers watched videotaped inter-views of patients with personality pathology (7).
The SWAP item set was then revised through an iterative

The SWAP item set was then revised through an iterative 
process that incorporated the feedback of over 2,000 clini-cians of all theoretical orientations. The content of 21 of the 200 items was substantially changed from the SWAP-200 to the revised SWAP-II. The revisions were based on empirical considerations and were aimed at refining the psychometric properties of the item set. In brief, we de-leted items that failed to discriminate among patients (i.e., items that had minimal or no variance) and therefore con-tributed little or no incremental information, and we com-bined items that were empirically redundant (i.e., items that correlated >0.70). We also collected systematic written feedback from the users of the SWAP-200 and made text revisions to improve clarity of meaning where users indi-cated that they had difficulty scoring an item because its meaning seemed unclear or ambiguous. Among clinicians who have used the SWAP-II to describe a current patient, 84% “agreed” or “strongly agreed” with the statement “I was able to express the things I consider important about my patient’s personality”; less than 5% disagreed (7).
as sig n in g  D ia g n o se s in  D a y -to -D a y  
P ra ctice
We have proposed a prototype matching approach to 
personality diagnosis (9, 25–28). The  Appendix, below, 
describes the prototype matching diagnostic procedure. A premise of this approach is that a list of eight to nine criteria is often insufficient to define a multifaceted per-sonality syndrome in a way that clearly distinguishes it from other syndromes (contributing to the problem of comorbidity). Rather, it is the configuration or pattern 
the personality features form that identifies unique syn-dromes. From this perspective, recognizing a personality syndrome is fundamentally a process of pattern recogni-tion, much as face recognition depends on pattern rec-ognition, not tabulation of individual features. The SWAP items that describe a diagnosis are therefore arranged to form a narratively coherent paragraph, not presented as a list of features to tabulate. Diagnosticians rate the overall

W eSt e N,  S HeDl er , B r a Dl eY,  et  a l.
A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2   a
jp.psychiatryo nline.o rg  2 7 5treating clinicians. The findings are based on data from the first 
145 consecutive patients enrolled in the study. (We plan in future publications to report on the validity of the alternative diagnostic systems with respect to a range of criterion variables including  adaptive functioning assessed by multiple independent observ-ers; measures of implicit personality processes derived from in-direct measures, such as reaction time to experimental stimuli; and etiological variables such as salivary DNA, family history of psychiatric disorders, and developmental history.)
re su lts
The sample used to derive the SWAP-II personality pro-
totypes consisted of 1,201 patients, 73.1% of whom were 
seen in independent practice and the remainder in a range of settings from outpatient clinics to forensic units; 53.2% were female, and 82.7% were Caucasian; the mean age was 42.3 years (SD=12.3). Patients spanned all social classes. GAF scores spanned a broad range, from 10 to 93 (mean=57.9, SD=10.8). One-third of the sample had had at least one psychiatric hospitalization, one-fourth had a history of suicide attempts, and one in 10 had been ar-rested during the previous 5 years. Clinician respondents were highly experienced (with a mean of 19.8 years of practice experience [SD=9.2]). They were diverse in theo-retical orientation (e.g., biological, cognitive-behavioral, psychodynamic, integrative-eclectic, other), and no single theoretical orientation was endorsed by more than 25% of the sample.
D e riv in g  D ia g n o stic  P ro to ty p e s
We first selected patients who had a level of pathology 
indicative of what most investigators would consider a 
“disorder,” operationally defined as meeting DSM-IV cri-teria for at least one personality disorder and having a GAF score <70. Approximately 70% of the sample met these criteria. In this stratum, we obtained a hierarchical factor structure comprising three superordinate factors or broad personality spectra (which were also obtained in the full sample): 1) internalizing pathology, 2) externalizing pa-thology, and 3) borderline-dysregulated pathology (Figure 1). These factors accounted for 33% of the variance in the stratum.
We then conducted second-order factor analyses, fac-
toring patients within each broad spectrum (those with high loadings on one of the three superordinate factors) to identify specific diagnoses within each spectrum. This yielded four diagnoses within the internalizing spectrum (depressive, anxious-avoidant, dependent-victimized, and schizoid-schizotypal) and three within the externalizing spectrum (antisocial-psychopathic, narcissistic, and para-noid). The borderline-dysregulated superordinate factor was retained without further subdivision.
To identify personality syndromes that may have been 
missed in the analysis using the initial selection criteria, we performed a second factor analysis on patients with GAF scores ≥70. This analysis yielded two additional per-
sonality diagnoses, obsessional and hysteric-histrionic. from not descriptive of the patient (assigned a value of 0) to most 
descriptive (assigned a value of 7). Reliability and validity are high (8, 39, 40).
C lin ic a l d a ta  fo rm . The clinical data form is a clinician-report 
form that gathers data on demographic, diagnostic, etiological, 
and adaptive functioning variables. Data collected with the form concerning developmental history and life events have shown strong agreement (cross-method validity) with data collected from patients (41). Adaptive functioning variables assessed with the clinical data form (e.g., Global Assessment of Functioning Scale scores) have likewise shown high reliability and validity compared with ratings by independent observers (18, 41, 42).
ax
is i
i 
c rite rio n  c h e c k lis t. Clinicians completed a randomly 
ordered checklist of all criteria for all DSM-IV axis II disorders to indicate which criteria the patient met. We applied DSM-IV decision rules to generate DSM-IV diagnoses. This method pro-vides results that mirror those of structured diagnostic interviews (43–45).
D a ta  A n a ly sis
We applied Q-factor analysis to identify naturally occurring 
diagnostic groupings empirically—that is, groupings of patients with personality features similar to one another and distinct from those of patients in other groupings. The computational algo-rithms are identical to those of conventional factor analysis but are applied to cases rather than variables. Factor analysis identi-fies groups of similar variables that assess a common underlying factor. In contrast, Q-factor analysis identifies groups of similar people who share a common syndrome. The findings reported here are based on unweighted least squares factor extraction with promax rotation. We tested other potential factor solutions, which yielded similar results.

After identifying diagnostic groupings empirically, we cre-
ated psychometric scales to assess each disorder by selecting the SWAP-II items with the highest factor scores (i.e., the items that best described each diagnostic grouping). This resulted in a di-agnostic scale for each diagnosis comprising 15 to 24 items, with the number of items reflecting the complexity of the personal-ity syndrome. To create paragraph-format diagnostic prototypes useful for day-to-day diagnosis and appropriate for inclusion in a diagnostic manual, we organized the items thematically and edited the resulting descriptions for readability, redundancy, and narrative coherence. We also wrote a single-sentence summary statement (similar to the statements that begin the description of each disorder in DSM-IV but are not included in the diagnosis it-self) to convey telegraphically the core features of each diagnosis (see the Appendix).
We assessed the convergent and discriminant validity of the di-
agnostic scales and associated prototypes using an independent sample from an ongoing study designed to compare the validity of alternative approaches to personality disorder diagnosis (in-cluding SWAP-II prototypes, dimensional trait models, and the DSM-IV diagnostic system). Patients completed self-report per-sonality questionnaires and were evaluated by three indepen-dent research interviewers as well as their treating clinician. The research interviewers administered the Structured Clinical Inter-view for DSM-IV Axis II Disorders (46), the Clinical Diagnostic Interview (a systematic version of the kind of interviewing most skilled clinicians engage in during the initial hours of patient contact) (47), and the Longitudinal Interval Follow-Up Evalua-tion–Baseline Version (to assess adaptive functioning) (48). All as-sessors were blind to data provided by the others.
We examined the validity of the newly derived SWAP-II diag-
noses by comparing independent diagnostic assessments pro-vided by research interviewers who administered the Clinical Diagnostic Interview with assessments provided by the patients’

2 7 6 	 ajp.psychiatryo nline.o rg  A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2we had obtained a hierarchical factor structure, we need-
ed to differentiate the items that were most appropriate for describing each superordinate spectrum (items ap-plicable to all disorders within the spectrum) from those most appropriate for describing specific diagnoses within the spectrum (items more specific to an individual di-agnosis). Decisions about item inclusion and exclusion thresholds were based on psychometric considerations, taking into account item-scale correlations within and be-tween superordinate and subordinate factors. As a guiding principle, items were retained for a given diagnostic scale or prototype if they were among the top 20–25 items with the highest factor scores for the diagnosis; if the item-scale correlation was 0.30 or higher; and if inclusion of the item did not suppress the reliability of the scale (with the goal of maintaining Cronbach’s alpha values ≥0.70). Decisions 
that fell in gray areas were resolved conceptually—that is, items were retained if they were consistent with the broader themes of the factor. 
The Appendix, below, presents the diagnostic proto-
types for all personality syndromes, along with instruc-tions on how to make diagnoses in clinical practice. Table 1 lists the number of items constituting each diagnostic scale (subsumed in the corresponding paragraph-format prototype description) and its associated reliability. All diagnoses showed high (Cronbach’s alpha >0.70) to very high (Cronbach’s alpha >0.85) internal consistency or reli-ability.
Table 2 presents intercorrelations among the diagnostic 
scales. The results indicate excellent discriminant validity (i.e., minimal diagnostic comorbidity), with an average correlation between any two diagnostic scales of -0.04. 
The internalizing and externalizing clusters were highly distinct (the average correlation of internalizing disorders with disorders outside the internalizing spectrum was –0.17; the average correlation of externalizing disorders with those outside the externalizing spectrum was -0.18). 
Even within each spectrum, where diagnostic overlap is These factors accounted for 30% of the variance in the stratum. Finally, factor analysis of the full sample yielded an additional prototype representing optimal personality health or adaptive personality strengths. The factor analy-ses thus empirically identified a total of 10 distinct empiri-cally and clinically coherent personality diagnoses, plus an additional prototype representing optimal personality health. Figure 1 illustrates the hierarchical organization of the 10 personality diagnoses. (Factor analysis of the entire sample without stratification yielded similar diagnoses, although they tended to be less “clean” and sometimes mixed heterogeneous patients—for example, paranoid patients and higher-functioning individuals who were not paranoid but shared with paranoid patients prominent hostility and aggression.)
To develop scales and prototype descriptions for each 
diagnosis, we first listed the SWAP-II items that were most descriptive of each diagnosis in descending order of im-portance (by the magnitude of the factor score). Because FiG U r e  1 . H ie ra rc h ica l Stru ctu re  o f Pe rso n a lity  D ia g n o se s
Borderline-
Dysregulated
Spectrum
DysregulatedNeurotic
Styles
Hysteric-
HistrionicObsessionalInternalizing
Spectrum
Schizoid-
SchizotypalDepressive
Anxious-
AvoidantDependent-
VictimizedExternalizing
Spectrum
Antisocial-
PsychopathicParanoid
Narcissistic
taBl e  1 . N u m b e r o f it e m s a n d  as so cia te d  re lia b ility  C o e f-
fi cie n ts fo r D ia g n o stic Sca le s (N =1 ,2 0 1 )
Personality Spectrum and DiagnosisNumber of 
ItemsCronbach’s 
Alpha
Internalizing 20 0.85
 D
epressive 17 0.82
 A
nxious-avoidant 15 0.78
 D
ependent-victimized 16 0.78
 S
chizoid-schizotypal 19 0.77
Externalizing 21 0.87
 A
ntisocial-psychopathic 18 0.89
 N
arcissistic 21 0.72
 P
aranoid 15 0.79
Borderline-dysregulated 24 0.81
Neurotic styles
 O
bsessional 21 0.73
 H
ysteric-histrionic 20 0.72
Personality health 23 0.94

jp.psychiatryo nline.o rg  2 7 7(described in more detail below). These groupings provide 
an empirically based alternative to the DSM-IV approach of grouping personality disorders into “clusters” A, B, and C, which were derived post hoc and show high comorbid-ity within and across clusters. The factor structure is also “cleaner” than the structure we identified in 1999, which included a large internalizing factor (labeled “dysphoric”) that subsumed multiple subtypes.
C o n tin u itie s a n d  D isc o n tin u itie s W ith  D SM -IV
Although the 10 diagnoses maintain a fair amount of 
continuity with DSM-IV , the prototypes differ in key re-
spects from DSM-IV personality disorders. They are more clinically nuanced and include more items addressing in-ternal psychological processes. They all describe multifac-eted syndromes encompassing multiple domains of func-tioning (e.g., cognition, affectivity, interpersonal relations, impulse regulation, and affect regulation). The DSM-IV general criteria for personality disorders define them in terms of multiple domains of functioning, but most of the criterion sets for specific personality disorders do not ac-tually encompass these multiple domains. For example, the DSM-IV criteria for paranoid personality disorder are essentially redundant indicators of a single trait, chronic suspiciousness, and do not capture the complex person-ality syndrome recognized by most practitioners (which includes, for example, hostility and aggression, misattri-bution of hostile intentions to others, externalization of blame, and distortions in thinking and reasoning).
Similarly, the DSM-IV criteria for antisocial personal-
ity disorder emphasize criminality and behaviors that can be readily inquired about in structured interviews. Our empirically derived antisocial-psychopathic prototype is closer to Cleckley’s (50) conceptualization of psychopathy and the findings of subsequent empirical research on the psychopathy construct (51, 52).
Our expanded descriptions of personality syndromes 
solve a problem inherent in DSM-IV: it is psychometrically impossible for criterion sets of only eight or nine items to delineate distinct disorders and also retain fidelity to the clinical syndromes they are intended to describe (1). Cer-tain personality characteristics are central to more than one personality disorder (e.g., lack of empathy is charac-teristic of narcissistic and antisocial personality disorder; hostility is characteristic of paranoid, antisocial, and nar-cissistic personality disorders). As DSM is currently con-figured, including the same item in more than one crite-rion set gives rise to unacceptably high comorbidity, but arbitrarily excluding items from criterion sets results in clinically inaccurate descriptions.
Prototype matching resolves this problem because items 
can be included in multiple diagnostic prototypes without giving rise to artifactual comorbidity. For example, narcis-sistic, antisocial-psychopathic, and borderline-dysregulat-ed patients may all be characterized by deficits in empa-thy, but not in the same way. Narcissistic patients are often expected (because they are subordinate disorders within the same superordinate spectrum), the average correla-tions were 0.29 and 0.42 for the internalizing and external-izing spectra, respectively.
V a lid ity  A c ro ss In d e p e n d e n t O b se rv e rs a n d  
A sse ssm e n t M e th o d s
As an initial test of validity, we report data from 145 pa-
tients from a second, independent study of comparative 
approaches to personality disorder diagnosis. Eligible pa-tients were between ages 18 and 65 and were concurrently participating in psychotherapy; they were recruited from academic medical centers or through community clini-cians in two metropolitan areas. Exclusion criteria were active psychosis or a previous diagnosis of schizophrenia or schizoaffective disorder, any known organic impair-ment, and lack of fluency in English.
To determine whether two independent observers 
could diagnose patients similarly despite independent and nonoverlapping sources of assessment information, we compared diagnostic scores provided by an indepen-dent assessor after administering the Clinical Diagnostic Interview (40, 49) with scores provided by the patient’s treating clinician based on observations made over the course of treatment. Both assessors completed the SWAP-II and were blind to data provided by the other. The diag-noses were made in different assessment contexts based on unrelated data sources.
Table 3 presents the cross-method/cross-observer cor-
relations of SWAP-II diagnostic scores derived from re-search interviewers and from treating clinicians. Validity coefficients were good to very good, with a mean cross-observer correlation of 0.51. Discriminant validity coeffi-cients were desirably low, with a mean correlation of -0.01.

Once again, even correlations within the same superordi-nate diagnostic spectrum were relatively low, with an aver-age correlation among diagnoses of 0.18 and 0.22 within the internalizing and externalizing spectra, respectively. Correlations among disorders outside the same spectrum were negligible, with a mean of -0.06. The findings indi-
cate convergence among independent observers, with minimal comorbidity among diagnoses.
D iscu ssio n
We derived 10 prototypes for diagnosing personality pa-
thology. The prototypes are broadly consistent with con-ceptions of personality syndromes described in the clini-cal literature.
All 10 diagnoses replicate diagnostic groupings identi-
fied in our 1999 taxonomic research (2). This replication is noteworthy given that we used an independent sample with markedly different inclusion and exclusion criteria, a revised item set (The SWAP-II versus the SWAP-200), and a different factor-analytic procedure. A new finding is the hierarchical factor structure with superordinate internal-izing, externalizing, and borderline-dysregulated factors

2 7 8 	 ajp.psychiatryo nline.o rg  A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2spectrum are qualitatively distinct from stable internal-
izers or externalizers. Their perceptions of self and others are unstable and fluctuating, and they exhibit an impaired ability to regulate emotion (often oscillating between emotions characteristic of internalizing and externaliz-ing pathology, for example, depression, anxiety, and rage). They may best be described as “stably unstable” (53).
We additionally identified an obsessional personality 
syndrome and a hysteric-histrionic syndrome. We labeled them “neurotic styles” (54) because patients who match these prototypes may or may not show a level of dys-function that warrants the term disorder (we found these 
syndromes in previous research as well) (55). As with all personality syndromes, patients with these syndromes fall along a continuum of severity. Some experience severe dysfunction and have frank personality disorders, but on average they tend to cluster toward the less severe end of the continuum of personality pathology.
Identification of these two syndromes resolves two co-
nundrums that have existed since DSM-III. The first is oblivious to others’ needs, antisocial-psychopathic pa-tients may recognize others’ needs and exploit them, and borderline-dysregulated patients may have trouble recog-nizing others’ internal states when they are overwhelmed by their own emotions or because they are prone to seeing others in black-or-white terms. Clinical practitioners gen-erally do not confuse these configurations. The problem of “comorbidity” is not inherent in personality diagnosis but is an artifact of abbreviated criterion sets that do not cap-ture the complexity of real-life personality syndromes.
H ie ra rc h ic a l O rga n iza tio n  o f  P e rso n a lity  Sy n d ro m e s
Among patients with more severe personality pathology, 
we found three superordinate groupings or broad person-
ality spectra, reflecting internalizing, externalizing, and borderline-dysregulated pathology. Patients in the inter-nalizing spectrum are self-blaming and chronically prone to depression and anxiety. Patients in the externalizing spectrum blame others and are chronically prone to anger and aggression. Patients in the borderline-dysregulated taBl e  3 . C o rre la tio n s B e tw e e n  re se a rc h  in te rv ie w e rs a n d  tr e a tin g  C lin icia n s (N =1 4 5 )a
Ratings by Treating 
ClinicianRatings by Research Interviewer
DepressiveAnxious-
VictimizedSchizoid-
SchizotypalAntisocial-
Psychopathic Narcissistic ParanoidBorderline-
Dysregulated ObsessionalHysteric-
HistrionicPersonality 
Health
Depressive 0.56** 0.19 0.37** 0.08 –0.19 –0.08 –0.11 0.12 –0.01 –0.13 –0.10
Anxious-avoidant 0.46** 0.55** 0.36** 0.22 –0.30** –0.16 –0.13 0.04 0.03 –0.14 –0.09
Dependent-victimized 0.40** 0.06 0.56** –0.07 –0.27* –0.19 –0.34** –0.05 0.00 0.14 0.12
Schizoid-schizotypal –0.02 0.22 –0.13 0.48** –0.09 0.14 0.26* 0.01 0.19 –0.20 –0.16
Antisocial-psychopathic –0.33** –0.23* –0.36** –0.04 0.47** 0.12 0.27* 0.13 –0.16 –0.01 –0.14
Narcissistic –0.16 –0.14 –0.35** 0.07 0.15 0.48** 0.28* –0.04 0.15 –0.09 –0.11
Paranoid –0.26* –0.06 –0.32** 0.24* 0.21 0.30** 0.59** 0.14 –0.01 –0.14 –0.27*
Borderline-dysregulated 0.01 –0.12 –0.09 0.07 0.22 –0.09 0.22 0.45** –0.34** 0.04 –0.27*
Obsessional –0.08 0.20 –0.17 –0.05 –0.16 0.31** –0.08 –0.35** 0.50** –0.23* 0.21
Hysteric-histrionic –0.16 –0.28* 0.04 –0.16 0.08 –0.02 –0.09 0.02 –0.09 0.45** 0.02
Personality health 0.06 –0.11 0.17 –0.28* –0.11 –0.23* –0.35** –0.15 0.04 0.11 0.29**
a C orrelations in boldface (along the diagonal) represent convergent validity coefficients. Correlations off the diagonal represent discriminant 
validity coefficients. Average diagonal value, r=0.51; average off-diagonal value, r=–0.01. Shaded areas indicate correlations among disor-ders within the same superordinate (internalizing or externalizing) spectrum, which are generally expected to overlap.
*p<0.01. **p<0.001.t
aBl
e 
2 . in
te rco rre la tio n s am
o n g  Pe rso n a lity  D ia g n o se s (N =1 ,2 0 1 )a
Health
Depressive —
Anxious-avoidant 0.51 —
Dependent-victimized 0.53 0.40 —
Schizoid-schizotypal 0.10 0.28 –0.08 —
Antisocial-psychopathic –0.56 –0.53 –0.46 0.14 —
Narcissistic –0.36 –0.39 –0.55 –0.06 0.31 —
Paranoid –0.39 –0.24 –0.52 0.39 0.51 0.45 —
Borderline-dysregulated 0.01 –0.18 –0.04 0.00 0.28 –0.02 0.39 —
Obsessional –0.04 0.15 –0.13 0.12 –0.22 0.30 –0.01 –0.60 —
Hysteric-histrionic –0.24 –0.35 0.20 –0.32 0.10 –0.06 –0.23 0.25 –0.44 —
Personality health 0.01 –0.02 0.11 –0.53 –0.49 –0.19 –0.58 –0.55 0.21 –0.02 —

a S haded areas indicate correlations among disorders within the same superordinate (internalizing or externalizing) spectrum, which are gen-
erally expected to overlap.

jp.psychiatryo nline.o rg  2 7 9disorders (56) and with recent findings on adult psycho-
pathology obtained using very different research meth-ods, item sets, and data-analytic approaches (57, 58). The convergence across different methodological approaches suggests that internalizing and externalizing pathology are crucial personality constructs. These spectra have the ad-ditional advantage of facilitating understanding of the re-lation between axis I disorders and personality substrates (e.g., individuals with internalizing personality pathology are vulnerable to mood and anxiety disorders; those with externalizing personality pathology are prone to substance abuse and impulse disorders). Identification of a border-line-dysregulated spectrum is a unique finding of this re-search; its emergence likely reflects the use of a clinically rich item set capable of distinguishing patients with stably high negative emotionality from those with dysregulated emotions, impulses, and perceptions of self and others.
P e rso n a lity  H e a lth  P ro to ty p e
Factor analysis of the full sample yielded a prototype 
representing optimal personality health or adaptive per-
sonality strengths, which we also found in our 1999 study. This prototype provides a measure of personality health-sickness that cuts across all disorders. For example, a pa-tient with narcissistic personality pathology might match the personality health prototype to varying degrees, with important implications for adaptive functioning and prog-nosis. Degree of match with the health prototype can help clarify where a given patient falls along the continuum of functioning from neurotic style through personality disor-der (for example, in the case of obsessional and hysteric-histrionic personality). The factor has emerged repeatedly in previous research (1), and the items it comprises reflect broad consensus among clinicians of different theoretical orientations regarding the definition of healthy personali-ty functioning. Previous research has shown that inclusion of a personality health prototype substantially increases the predictive validity of personality diagnosis (27).
C o n c lu sio n s
The 10 empirically derived prototypes for personality 
diagnosis that we describe here are scientifically grounded and clinically relevant. The finding that treating clinicians and independent research interviewers can recognize the same personality configuration in a given patient is espe-cially encouraging because it indicates that clinicians can make accurate, quantifiable assessments of complex per-sonality syndromes in everyday practice.that obsessive-compulsive personality disorder is the only DSM personality disorder that tends to correlate positively with measures of healthy adaptive functioning. The sec-ond is that the framers of DSM-III had to “ratchet up” the level of pathology of both of these personality styles (pre-viously called obsessional and hysteric in both the clinical 
literature and earlier editions of DSM) to fit in a taxonomy of “disorders.” The result was an obsessive-compulsive personality diagnosis that often lacked congruence with clinical and empirical reality and a histrionic diagnosis that was empirically indistinguishable from borderline personality disorder.
The internalizing and externalizing spectra are consis-
tent with a rich literature on childhood and adolescent taBle 3 . C o rre la tio n s B e tw e e n  re se a rc h  in te rv ie w e rs a n d  tre a tin g  C lin icia n s (N =1 4 5 )a
Health
a Correlations in boldface (along the diagonal) represent convergent validity coefficients. Correlations off the diagonal represent discriminant

a Correlations in boldface (along the diagonal) represent convergent validity coefficients. Correlations off the diagonal represent discriminant 
*p<0.01. **p<0.001.taBle 2 . in te rco rre la tio n s am o n g  Pe rso n a lity  D ia g n o se s (N =1 ,2 0 1 )
a
Health
a Shaded areas indicate correlations among disorders within the same superordinate (internalizing or externalizing) spectrum, which are gen-

2 8 0 	 ajp.psychiatryo nline.o rg  A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2aP
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p irica lly  D e rive d  P ro to ty p e s fo r Pe rso n a lity  D iso rd e r D ia g n o sis B a se d  o n  th e  Sh e d le r-W e ste n  as
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P ro ce d u rea
For each diagnosis, please form an overall  impression of the type of person described, then rate the extent to 
which your patient matches or resembles the prototype.
5 Very good match (patient exemplifies  this disorder; prototypical case) Diagnosis
4 Good match (patient has this disorder; diagnosis applies)
3 Moderate match (patient has significant features  of this disorder) Features
2 Slight match (patient has minor features of this disorder)
1 No match (description does not apply)
Internalizing Spectrum
The internalizing spectrum subsumes four personality disorders: Depressive, Anxious-Avoidant, Dependent-Victimized, and Schizoid-Schizotypal. 
Individuals with disorders in the internalizing spectrum experience chronic painful emotions, especially depression and anxiety, tend to be emo-tionally inhibited and socially avoidant, and tend to blame themselves for their difficulties.
Individuals with disorders in the internalizing spectrum are chronically susceptible to a range of painful emotions, including depression, 
anxiety, guilt, shame, and embarrassment. They tend to be self-critical and to feel inadequate. They tend to be inhibited and constricted and have difficulty allowing themselves to express their wishes and impulses. They tend to be passive and unassertive, and to feel helpless, powerless, or at the mercy of forces outside their control. They tend to ruminate over problems. They have trouble acknowledging or ex-pressing anger and instead become depressed, self-critical, or self-punitive (turning their anger on themselves rather than getting angry at others). They often fear rejection or abandonment and may suffer from painful feelings of emptiness. They tend to be shy or self-conscious and may avoid social situations because of fear of embarrassment. They tend to feel like outcasts or outsiders and may lack close friend-ships and relationships.
Depressive PersonalitySummary statement: Individuals with Depressive Personality are prone to feelings of  depression and inadequacy, tend to be self-critical or self-
punitive, and may be preoccupied with concerns about abandonment or loss.
Individuals who match this prototype tend to feel depressed or despondent and to feel inadequate, inferior, or a failure. They tend to find 
little pleasure or satisfaction in life’s activities and to feel life has no meaning. They are insufficiently concerned with meeting their own needs, disavowing or squelching their hopes and desires to protect against disappointment. They appear conflicted about experiencing pleasure, inhibiting feelings of excitement, joy, or pride. They may likewise be conflicted or inhibited about achievement or success (e.g., failing to reach their potential or sabotaging themselves when success is at hand). Individuals who match this prototype are generally self-critical, holding themselves to unrealistic standards and feeling guilty and blaming themselves for bad things that happen. They appear to want to “punish” themselves by creating situations that lead to unhappiness or avoiding opportunities for pleasure and gratification. They have trouble acknowledging or expressing anger and instead become depressed, self-critical, or self-punitive. Individuals who match this prototype often fear that they will be rejected or abandoned, are prone to painful feeling of emptiness, and may feel bereft or abjectly alone even in the presence of others. They may have a pervasive sense that someone or something necessary for happiness has been lost forever (e.g., a relationship, youth, beauty, success).
Anxious-Avoidant PersonalitySummary statement: Individuals with Anxious-Avoidant Personality are chronically prone to anxiety, are socially anxious and avoidant, and 
attempt to manage anxiety in ways that limit and constrict their lives.

Individuals who match this prototype are chronically anxious. They tend to ruminate, dwelling on problems or replaying conversations in 
their minds. They are more concerned with avoiding harm than pursuing desires, and their choices and actions are unduly influenced by efforts to avoid perceived dangers. They are prone to feelings of shame and embarrassment. Individuals who match this prototype tend to be shy and self-conscious in social situations and to feel like an outcast or outsider. They are often socially awkward and tend to avoid social situations because of fear of embarrassment or humiliation. They tend to be inhibited and constricted and to have difficulty acknowledging or expressing desires. They may adhere rigidly to daily routines, have trouble making decisions, or vacillate when faced with choices. Their anxiety may find expression through a variety of channels, including panic attacks, hypochondriacal concerns (e.g., excessive worry about normal aches and pains), or somatic symptoms in response to stress (e.g., headache, backache, abdominal pain, asthma). 
Dependent-Victimized PersonalitySummary statement: Individuals with Dependent-Victimized Personality are highly dependent and fearful of  being alone, tend to show insuf-
ficient concern for their own well-being to the point of  jeopardizing their welfare or safety, and have difficulty expressing anger directly.
Individuals who match this prototype tend to be needy and dependent, fear being alone, and fear rejection or abandonment. They tend 
to be ingratiating or submissive, often consenting to things they find objectionable in an effort to maintain support or approval. They tend to be passive and unassertive and to feel helpless and powerless. They tend to be indecisive, suggestible or easily influenced, and naïve or innocent, seeming to know less about the ways of the world than would be expected. They tend to become attached to people who are emotionally unavailable, and to create relationships in which they are in the role of caring for or rescuing the other person. Individuals who match this prototype tend to get drawn into or remain in relationships in which they are emotionally or physically abused, or need-lessly put themselves in dangerous situations (e.g., walking alone or agreeing to meet strangers in unsafe places). They are insufficiently concerned with meeting their own needs and tend to feel unworthy or undeserving. Individuals who match this prototype have trouble acknowledging or expressing anger and instead become depressed, self-critical, or self-punitive. They tend to express anger in passive and indirect ways (e.g., making mistakes, procrastinating, forgetting) that may provoke or trigger anger or mistreatment from others. 
Schizoid-Schizotypal PersonalitySummary statement: Individuals with Schizoid-Schizotypal Personality are characterized by pervasive impoverishment of, and peculiarities in, 
interpersonal relationships, emotional experience, and thought processes.

jp.psychiatryo nline.o rg  2 8 1Individuals who match this prototype lack close relationships and appear to have little need for human company or contact, often seeming 
detached or indifferent. They lack social skills and tend to be socially awkward or inappropriate. Their appearance or manner may be odd or peculiar (e.g., their grooming, posture, eye contact, or speech rhythms may seem strange or “off”), and their verbal statements may be incongruous with their accompanying emotion or non-verbal behavior. They have difficulty making sense of others’ behavior and appear unable to describe important others in a way that conveys a sense of who they are as people. They likewise have little insight into their own motives and behavior, and have difficulty giving a coherent account of their lives. Individuals who match this prototype appear to have a limited or constricted range of emotions and tend to think in concrete terms, showing limited ability to appreciate metaphor, analogy, or nuance. Consequently, they tend to elicit boredom in others. Despite their apparent emotional detachment, they often suffer emotionally: They find little satisfaction or enjoyment in life’s activities, tend to feel life has no meaning, and feel like outcasts or outsiders. A subset of individuals who match this prototype show substantial peculiarities in their thinking and perception. Their speech and thought processes may be circumstantial, rambling, or digressive, their reasoning processes or perceptual experiences may seem odd and idiosyncratic, and they may be suspicious of others, reading malevolent intent into others’ words and actions. 
Externalizing Spectrum
The externalizing spectrum subsumes three personality disorders: Antisocial-Psychopathic, Paranoid, and Narcissistic. Individuals with disorders in the externalizing spectrum are angry or hostile, self-centered and lacking in empathy, and blame others for their difficulties.
Individuals with disorders in the Externalizing spectrum tend to be angry or hostile, whether expressed through overt aggression, rage 
episodes, or critical, controlling, or oppositional behavior. They tend to be suspicious of others, conflicted about authority, and prone to getting into power struggles. They tend to hold grudges and to react to perceived slights with rage and humiliation. They lack empathy for others’ needs and feelings, may feel privileged or entitled, and tend to have an exaggerated sense of self-importance. They tend to blame their failures on other people or circumstances. They have little psychological insight into their own motives and behavior and tend to feel mistreated or victimized rather than recognizing how their own behavior and attitudes affect other people. They tend to elicit dislike or animosity and to lack close friendships and relationships. 
Antisocial-Psychopathic PersonalitySummary statement: Individuals with Antisocial-Psychopathic Personality exploit others, experience little remorse for harm or injury caused to 
others, and have poor impulse control.
Individuals who match this prototype take advantage of others, tend to lie or deceive, and to be manipulative. They show a reckless 
disregard for the rights, property, or safety of others. They lack empathy for other people’s needs and feelings. Individuals who match this prototype experience little remorse for harm or injury they cause. They appear impervious to consequences and seem unable or unwilling to modify their behavior in response to threats or consequences. They generally lack psychological insight and blame their difficulties on other people or circumstances. They often appear to gain pleasure by being sadistic or aggressive toward others, and they may attempt to dominate significant others through intimidation or violence. Individuals who match this prototype tend to be impulsive, to seek thrills, novelty, and excitement, and to require high levels of stimulation. They tend to be unreliable and irresponsible and may fail to meet work obligations or honor financial commitments. They may engage in antisocial behavior, including unlawful activities, substance abuse, or interpersonal violence. They may repeatedly convince others of their commitment to change, leading others to think “this time is really dif-ferent,” only to revert to their previous maladaptive behavior.
Paranoid PersonalitySummary statement: Individuals with Paranoid Personality are chronically suspicious, angry and hostile, and may show disturbed thinking.Individuals who match this prototype are chronically suspicious, expecting that others will harm, deceive, conspire against, or betray them.

They tend to blame their problems on other people or circumstances, and to attribute their difficulties to external factors. Rather than recognizing their own role in interpersonal conflicts, they tend to feel misunderstood, mistreated, or victimized. Individuals who match this prototype tend to be angry or hostile and prone to rage episodes. They tend to see their own unacceptable impulses in other people instead of in themselves, and are therefore prone to misattribute hostility to other people. They tend to be controlling, to be oppositional, contrary, or quick to disagree, and to hold grudges. They tend to elicit dislike or animosity and to lack close friendships and relationships. Individuals who match this prototype tend to show disturbances in their thinking, above and beyond paranoid ideas. Their perceptions and reasoning can be odd and idiosyncratic, and they may become irrational when strong emotions are stirred up, to the point of seeming delusional. 
Narcissistic PersonalitySummary statement: Individuals with Narcissistic Personality are grandiose and entitled, dismissive and critical of  others, and often show under-
lying signs of  vulnerability beneath a grandiose façade.
Individuals who match this prototype have an exaggerated sense of self-importance. They feel privileged and entitled, expect preferential 
treatment, and seek to be the center of attention. They have fantasies of unlimited success, power, beauty, or talent, and tend to treat oth-ers primarily as an audience to witness their importance or brilliance. They tend to believe they can only be appreciated by, or should only associate with, people who are high-status, superior, or “special.” They have little empathy and seem unable to understand or respond to others’ needs and feelings unless they coincide with their own. Individuals who match this prototype tend to be dismissive, haughty, and arrogant. They tend to be critical, envious, competitive with others, and prone to get into power struggles. They attempt to avoid feeling helpless or depressed by becoming angry instead, and tend to react to perceived slights or criticism with rage and humiliation. Their overt grandiosity may mask underlying vulnerability: Individuals who match this prototype are invested in seeing and portraying themselves as emotionally strong, untroubled, and emotionally in control, often despite clear evidence of underlying insecurity or distress. A substantial subset of narcissistic individuals tend to feel inadequate or inferior, to feel that life has no meaning, and to be self-critical and intolerant of their own human defects, holding themselves to unrealistic standards of perfection. 
Borderline-Dysregulated Spectrum
Borderline-Dysregulated Personality
Summary Statement: Individuals with Borderline-Dysregulated Personality have impaired ability to regulate their emotions, have unstable per-
ceptions of  self  and others that lead to intense and chaotic relationships, and are prone to act on impulses, including self-destructive impulses.

2 8 2 	 ajp.psychiatryo nline.o rg  A m  J Psychiatry 1 6 9 :3 , M arch 2 0 1 2Individuals who match this prototype have emotions that can change rapidly and spiral out of control, leading to extremes of sadness, 
anxiety, and rage. They tend to “catastrophize,” seeing problems as disastrous or unsolvable, and are often unable to soothe or comfort themselves without the help of another person. They tend to become irrational when strong emotions are stirred up, showing a significant decline from their usual level of functioning. Individuals who match this prototype lack a stable sense of self: Their attitudes, values, goals, and feelings about themselves may seem unstable or ever-changing, and they are prone to painful feelings of emptiness. They similarly have difficulty maintaining stable, balanced views of others: When upset, they have trouble perceiving positive and negative qualities in the same person at the same time, seeing others in extreme, black-or-white terms. Consequently, their relationships tend to be unstable, chaotic, and rapidly changing. They fear rejection and abandonment, fear being alone, and tend to become attached quickly and intensely. They are prone to feeling misunderstood, mistreated, or victimized. They often elicit intense emotions in other people and may draw them into roles or “scripts” that feel alien and unfamiliar (e.g., being uncharacteristically cruel, or making “heroic” efforts to rescue them). They may likewise stir up conflict or animosity between other people. Individuals who match this prototype tend to act impulsively. Their work life or living arrangements may be chaotic and unstable. They may act on self-destructive impulses, including self-mutilating behavior, suicidal threats or gestures, and genuine suicidality, especially when an attachment relationship is disrupted or threatened.
Neurotic Styles
The neurotic styles grouping subsumes two personality syndromes: Obsessional and Hysteric-Histrionic. These syndromes generally do not entail the same level of  impairment or dysfunction as the other personality syndromes, and may therefore be considered character styles  rather than 
disorders . Their more extreme variants can, however, constitute bona fide personality disorders.
Obsessional Personality
Summary statement: Individuals with Obsessional Personality are intellectualized and overly “rational” in their approach to life, are emotionally 
constricted and rigid, and are critical of  themselves and others and conflicted about anger, aggression, and authority.
Individuals who match this prototype tend to see themselves as logical and rational, uninfluenced by emotion. They tend to think in ab-
stract and intellectualized terms, to become absorbed in details (often to the point of missing what is important), and prefer to operate as if emotions were irrelevant or inconsequential. They tend to be excessively devoted to work and productivity to the detriment of leisure and relationships. Individuals who match this prototype tend to be inhibited and constricted, and have difficulty acknowledging or expressing wishes, impulses, or anger. They are invested in seeing and portraying themselves as emotionally strong, untroubled, and in control, despite evidence of underlying insecurity, anxiety, or distress. They tend to deny or disavow their need for nurturance or comfort, often regard-ing such needs as weakness. They tend to adhere rigidly to daily routines, becoming anxious or uncomfortable when they are altered, and to be overly concerned with rules, procedures, order, organization, schedules, and so on. They may be preoccupied with concerns about dirt, cleanliness, or contamination. Rationality and regimentation generally mask underlying feelings of anxiety or anger. Individuals who match this prototype tend to be conflicted about anger, aggression, and authority. They tend to be self-critical, expecting themselves to be “perfect,” and to be equally critical of others, whether overtly or covertly. They tend to be controlling, oppositional, and self-righteous or moralistic. They are prone to being stingy and withholding (e.g., of time, money, affection). They are often conflicted about authority, strug-gling with contradictory impulses to submit versus defy. 
Hysteric-Histrionic Personality
Summary statement: Individuals with Hysteric-Histrionic Personality are emotionally dramatic and cognitively impressionistic, sexually provoca-
tive, and interpersonally suggestible, idealizing of  admired others, and paradoxically both intensely and superficially attached.
Individuals who match this prototype are emotionally dramatic and prone to express emotion in exaggerated and theatrical ways. Their re-

actions tend to be based on emotion rather than reflection, and their cognitive style tends to be glib, global, and impressionistic (e.g., miss-ing details, glossing over inconsistencies, mispronouncing names). Their beliefs and expectations seem cliché or stereotypical, as if taken from storybooks or movies, and they seem naïve or innocent, seeming to know less about the ways of the world than would be expected. Individuals who match this prototype tend to be sexually seductive or provocative. They use their physical attractiveness to an excessive degree to gain attention and notice, and they behave in ways that seem to epitomize gender stereotypes. They may be flirtatious, preoc-cupied with sexual conquest, prone to lead people on, or promiscuous. They tend to become involved in romantic or sexual “triangles” and may be drawn to people who are already attached or sought by someone else. They appear to have difficulty directing both tender feelings and sexual feelings toward the same person, tending to view others as either virtuous or sexy, but not both. Individuals who match this pro-totype tend to be suggestible or easily influenced, and to idealize and identify with admired others to the point of taking on their attitudes or mannerisms. They fantasize about ideal, perfect love, yet tend to choose sexual or romantic partners who are emotionally unavailable, or who seem inappropriate (e.g., in terms of age or social or economic status). They may become attached quickly and intensely. Beneath the surface, they often fear being alone, rejected, or abandoned. 
Personality Health
This prototype represents optimal personality health. Degree of  match with this prototype provides a measure of  adaptive psychological strengths. The more individuals match this prototype, the more they are able to engage in meaningful and mature relationships, find meaning and satisfaction in life’s pursuits, and make effective use of  their talents and abilities.
Individuals who match this prototype are capable of sustaining meaningful relationships characterized by genuine intimacy and caring. 
They are empathic and responsive to others’ needs and feelings and have the capacity to recognize alternative viewpoints, even when emotions are strong. They have moral and ethical standards, strive to live up to them, and tend to be conscientious and responsible. They appear comfortable in social situations, are able to assert themselves effectively and appropriately when necessary, tend to be energetic and outgoing, and tend to be liked by others. They tend to have satisfying sex lives. They are psychologically insightful and able to understand themselves and others in nuanced ways. They are capable of hearing and making effective use of information that is emotionally threaten-ing, and have generally come to terms with painful experiences from the past, finding meaning in the experiences and growing from them. Individuals who match this prototype tend to express emotion appropriate in quality and intensity to the situation at hand. They generally find contentment and happiness in life’s activities. They find meaning and fulfillment in guiding or nurturing others, in belonging and con-tributing to a larger community, and in the pursuit of long-term goals and ambitions. Individuals who match this prototype are able to use their talents, abilities, and energy effectively and productively. They enjoy challenges and take pleasure in accomplishing things. They are able to express themselves verbally, have a sense of humor, and tend to see things and approach problems in creative ways.
a A ll diagnoses fall on a continuum of functioning. More severe variants may be regarded as personality disorders  and less severe variants may 
be regarded as personality styles .

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alidity 	o
f	p
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ity	d
isorder 	a
ssessm ent 	u
sing 	a	s
ystem atic 	c
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ajp.2 0 1 1 .1 1 0 2 0 2 7 4 ). Fro m  th e  D e p artm e n ts o f P sych o lo g y an d  P sy-ch iatry an d  B e h avio ral Scie n ce , Em o ry U n ive rsity, A tlan ta; th e  D e -p artm e n t o f P sych iatry, U n ive rsity o f Co lo rad o  Sch o o l o f M e d icin e , D e nve r; an d  th e  A tlan ta VA  M e d ical Ce n te r, A tlan ta. A d d re ss co rre -sp o n d e n ce  to  D r. W e ste n  (d w e ste n @e m o ry.e d u ) o r D r. Sh e d le r ( jo n a-th an @sh e d le r.co m ).
Th e  au th o rs re p o rt n o  fin an cial re latio n sh ip s w ith  co m m e rcial in -
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Su p p o rte d  by N IM H  g ran ts R 0 1 -M H 6 2 3 7 7  an d  R 0 1 -M H 7 8 1 0 0 . 
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Clinical Guidance: Clinical Presentations of Personality Disorders
Clinicians more generally diagnose syndromes as a whole, rather than summing the 
individual symptoms in a checklist. Westen et al. used clinician input to construct archetypical vignettes and then assessed their validity for diagnosis as templates that clinicians could use to match patients. The syndromes fell into three major groups: in-ternalizing, externalizing, and borderline-dysregulated. Patients with higher levels of functioning also included hysterical-histrionic and obsessive types. The syndromes permit clearer distinctions between diagnoses, such as narcissistic personality dis-order and borderline personality disorder, that have a common symptom, e.g., loss of empathy, that leads to the misimpression of frequent comorbidity. In an editorial, Mi-chels (p. 241) praises the system as clinically astute but notes that occasional features are inconsistent, such as the schizoid-schizotypal syndrome, which includes both re-stricted affect and painful emotions. Because of the input from clinicians, other fea-tures, such as suggestibility in histrionic-hysterical patients, mirror clinicians’ tradi-tional teaching but are not fully validated by current research.

See discussions, st ats, and author pr ofiles f or this public ation at : https://www .researchgate.ne t/public ation/221825650
The Shedler-Westen Assessment Procedu re (SWAP): Evaluating Psychometric
Questions About Its Reliability, Validity, and Impact of Its Fixed Score
Distribution
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Geor gia Instit ute of T echnolog y
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The Shedler–Westen Assessment Procedure (e.g., SWAP-II; 
Shedler & Westen, 2004a, 2004b; Westen & Shedler, 2007) is a measure of personality and personality pathology designed for use by clinically trained mental health profes-sionals. Critics (Block, 2008; Widiger, 2002; Wood, Garb, Nezworski, & Koren, 2007) have raised a number of ques-tions about the reliability and validity of the procedure and, more specifically, about particular psychometric properties of the scales and scores derived from SWAP data. In this article, we evaluate the three primary psychometric ques-tions and criticisms of the SWAP identified in the literature, primarily pertaining to its performance as a tool for the dimensional assessment of personality pathology in research on the classification of personality pathology (psychiatric nosology).
Some critics (Wood et al., 2007) have questioned the 
validity of existing SWAP scales, raising legitimate concerns about the extent to which available research has examined their cross-method/cross-informant validity (Question 1). We address this critique through a review of the existing literature, including very recent research.
Others have questioned the reliability and psychometric 
soundness of SWAP score profiles and scale scores more generally. Thus, another critique (Question 2) is the argu-ment that the fixed score distribution of the instrument results in artifactually high correlations between SWAP-derived scale scores and personality pathology prototypes (Block, 2008) or artificially high estimates of reliability and validity (Wood et al., 2007). We address Question 2 
1Whitman College, Walla Walla, WA, USA
2UTC Power Corp, South Windsor, CT, USA
3University of Colorado, Aurora, CO, USA
4Emory University, Atlanta, GA, USA
Corresponding Author:
Pavel S. Blagov, PhD, Whitman College, 345 Boyer Avenue, Walla Walla, WA 99362-2067, USA Email: blagovp@whitman.eduThe Shedler-Westen Assessment  
Procedure (SWAP): Evaluating 
Psychometric Questions About Its Reliability, Validity, and Impact of  Its Fixed Score Distribution
Pavel S. Blagov1, Wu Bi2, Jonathan Shedler3, and Drew Westen4
Abstract
The Shedler-Westen Assessment Procedure (SWAP) is a personality assessment instrument designed for use by expert 
clinical assessors. Critics have raised questions about its psychometrics, most notably its validity across observers and situations, the impact of its fixed score distribution on research findings, and its test-retest reliability. We review empirical data addressing its validity, emphasizing the multitrait-multimethod approach to evaluating test validity. T o evaluate the hypothesis that the fixed, asymmetric score distribution artifactually inflates correlations between SWAP profiles, we conducted Monte Carlo simulations and also presented empirical data from a large patient sample. We observed a mean correlation of zero between simulated SWAP profiles, indicating that the score distribution does not impact the correlation coefficients. Empirical correlations between SWAP profiles of actual patients were small and similar to those obtained using Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) personality disorder scales that had no 
fixed score distributions, suggesting that the correlations were not a methodological artifact of the SWAP .  We report new test-retest reliability data (median coefficient > .85) for the SWAP’s trait and personality disorder dimensions. The SWAP appears to be reliable and valid. The data do not support its primary psychometric critiques.
Keywords
personality disorders, Shedler–Westen Assessment Procedure, SWAP-II, Q-sort, fixed distribution, test–retest reliability, 
validity

2  Assessment  XX(X)
conceptually as well as empirically in Studies 1 and 2 by 
examining hypothesized biases of the fixed-score distribu-tion on SWAP profile intercorrelations in simulated data as well as in a large sample of real patients.
In addition, Wood et al. (2007) have drawn attention to 
the fact that published data on the test–retest reliability of SWAP scores have been lacking, a legitimate concern we address (Question 3) in Study 3.
The Shedler–Westen Assessment Procedure
The SWAP is a psychometric system designed to provide a comprehensive assessment of personality and personality pathology (Shedler & Westen, 2004a, 2004b, 2007; Westen & Shedler, 1999a, 1999b). Unlike most personality assess-ment instruments, the SWAP is neither a self-report ques-tionnaire nor a rating form for lay informants. Rather, it is an instrument designed for use by trained mental health professionals in the context of either a thorough examina-tion of a patient using a systematic clinical research inter-view (Westen & Muderrisoglu, 2003, 2006; http://www.psychsystems.net/manuals) or in a professional assessment or ongoing therapeutic engagement (e.g., longitudinal knowledge of the patient over the course of psychother-apy). In this sense, it resembles the Psychopathy Checklist–Revised (PCL-R; Hare, 2003; Hare & Neumann, 2006), which can be scored by a forensic professional from a research interview, from all available data (including chart review), or both.
The premise of the SWAP approach is that a clinically 
trained informant who has examined a patient over time or completed a systematic clinical research interview resem-bling the narrative-based interviewing process used by cli-nicians of all theoretical orientations in practice (Westen, 1997; Clinical Diagnostic Interview, www.psychsystems.net/manuals) can make reliable and valid observations and inferences about psychological processes that may not be accessible via self-report or readily observable by nonex-perts (Westen & Weinberger, 2004). The SWAP instru-ments consist of 200 items, which the assessor sorts into eight categories, from not descriptive (0) to most descrip-tive (7) of the person. The procedure may be completed using paper cards with the items printed on them, an elec-tronic spreadsheet designed to facilitate the rating and sort-ing process, or Internet interface programmed to serve the same purpose.
The SWAP instruments (the original SWAP-200 and 
revised SWAP-II for adults, and the SWAP-200-A and revised SWAP-II-A for adolescents) have been used to develop an empirically based classification of personality disorders (PDs; Shedler & Westen, 2007; Westen & Shedler, 1999a, 1999b; Westen, Shedler, Bradley, & DeFife, in press; Westen, Waller, Shedler, & Blagov, in press), to refine cur-rent diagnostic constructs by identifying richer diagnostic criterion sets more faithful to the clinical syndromes observed in practice as well as in the lab (Blagov & Westen, 2008; Russ, Bradley, Shedler, & Westen, 2008; Shedler & Westen, 2004a; Zittel & Westen, 2005), to identify clinically important personality dimensions via factor analysis that are absent from other dimensional models of personality (Shedler & Westen, 2004b; Westen, Shedler, Bradley, & DeFife, in press), to link SWAP-assessed dimensions to eti-ological and outcome variables (including, e.g., genetic his-tory, psychosocial history variables, and treatment response to both psychotherapy and pharmacological interventions; Westen & Shedler, 2007), to develop dimensional prototype models for personality diagnosis as an alternative to the cat-egorical approach of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; Shedler & Westen, 2004a; Spitzer, First, Shedler, Westen, & Skodol, 2008; Westen, Shedler, & Bradley, 2006; Westen, Shedler, et al., in press), to explore subthreshold forms of personality pathology currently absent from the diagnostic manuals (Blagov, Bradley, & Westen, 2007), to assess subtypes of Axis I and Axis II disorders (e.g., DiLallo, Jones, & Westen, 2009; Russ et al., 2008), and to assess change in psychother -
apy (Lingiardi, Shedler, & Gazillo, 2006).
The SWAP, like all instruments based on the Q-sort

The SWAP, like all instruments based on the Q-sort 
method, uses a fixed score distribution. In other words, assessors rank-order items for their degree of applicability to the patient at hand rather than rating them, and they must assign each rank or score a specified number of times (e.g., limiting the highest ranking scale points, in the case of the SWAP, a rank of 5, 6, or 7, defined as most descriptive of the patient, to a small number of items, while assigning lower scores to a higher number of items). Prior Q-sort instruments, such as the California Adult Q-Sort (Block, 1978) have treated items as bipolar dimensions (very uncharacteristic to very characteristic) and have used quasi-normal score distributions in which middle scores indicate neutrality on the dimension (e.g., Block, 1978; Shedler & Block, 1990), and hence are the most common ranks that can be assigned using the fixed distribution. In contrast, SWAP items assess unipolar constructs, and the fixed score distribution is therefore asymmetric, ranging from 0 (not descriptive) to 7 (highly descriptive). Many items receive scores of 0 and progressively fewer items receive higher scores. In other words, SWAP items are descriptive of a person to a greater or lesser degree, but they are not defined as negatively descriptive.
The rationale for this approach has been discussed at 
length elsewhere (Westen & Shedler, 2007), but three con-siderations were most important in establishing the distribu-tion. First, empirically, virtually all psychopathology items from all scales are asymmetrically distributed in nature, with most patients showing little or no evidence of them and increasingly fewer individuals showing extreme scores. Thus, most people receive a score of 0 to 5 on the Beck 

Blagov et al.  3
Depression Inventory (e.g., Beck, Brown, & Steer, 1996) or 
the PCL-R and a 0 on most of the items; progressively fewer receive scores above 25 on either instrument. Second, empirically, when we tested the first iteration of the SWAP by asking experienced clinicians to 
rate a patient in their 
care using a traditional Likert-type scale, this asymmetrical distribution was in fact what we obtained (Shedler & Westen, 1998). Finally, the meaning of many personality statements is unclear if they are defined as bipolar traits, such that a low score is ambiguous. For example, the oppo-site of having emotions that spiral out of control could be having emotions that are flat or having relatively normal affect experience and regulation. Similarly, the opposite of being chronically anxious could mean being unable to experience anxiety or having normal anxiety levels. The asymmetric distribution resolves that problem by having coders make fine-grained distinctions among items that are descriptive of the patient to varying degrees but not those that are not descriptive. This also saves coders considerable time, as they do not have to spend most of their time consid-ering the exact placement of items of little relevance to a given patient, to maximize the utility of the instrument in everyday practice. The SWAP distribution requirements are thus as follows:
Critiques of the SWAP have focused on a number of 
concerns, of which three have been the most common and bear on the use of the SWAP method and SWAP-derived scores in nosological research on personality pathology: the ability of SWAP-based variables to predict cross-method/cross-informant criterion variables (Question 1), the extent to which the SWAP’s fixed-score distribution may bias estimates of the extent to which the personality descriptions of individuals match PD prototypes and inflate reliability and validity estimates (Question 2), and the lack of evidence for temporal stability of SWAP scale scores (Question 3). Below, we address Question 1 through literature review, Question 2 conceptually and empirically (Studies 1 and 2), and Question 3 empirically (Study 3).
Question 1: Do SWAP Scales Show Cross-
Method and Cross-Informant Validity?
The first critique (Wood et al., 2007) is based on the fact 
that much of the early research using the SWAP (e.g., Westen & Shedler, 1999a, 1999b) tended to rely on a single expert informant, the treating clinician, to provide both SWAP ratings and relevant criterion data (e.g., PD symp-tom ratings, adaptive functioning measures, and family history variables). This was indeed a legitimate concern.The first studies that bear on this critique were small-
sample studies finding very high correlations (in the range of r = .70-.80) between two independent clinical observers 
describing the same patient using the SWAP, one based on a systematic clinical interview and the other from the treating clinician, with each blind to the data and scoring of the other. These data resemble data on interrater reliability in that the scores being compared are based on observations generated by different evaluators describing the same patient; however, they also differ from interrater reliability estimates in that interrater reliability is traditionally based on comparing observations by different judges of the same or a similar sample of behavior, whereas the correlations obtained in these studies were based on different observers evaluating completely different samples of behavior by the same target individual (e.g., data from a single cross-sectional interview and data from longitudinal observation of the patient in treatment over months). These correlations can thus be interpreted as yielding evidence for validity to the extent that one informant, usually the one who com-pleted a formal clinical-research assessment of the patient blind to all available data, is held as the predictor rater, whereas the other informant, usually the treating clinician, whose observations are based on detailed observation of and interaction with the patient over time, is held as the cri-terion rater.
For example, in a sample of 24 outpatients, personality

For example, in a sample of 24 outpatients, personality 
syndromes calculated from independent interviewer ratings had a median correlation of .80 with the same SWAP dimensions calculated from the treating clinicians’ assess-ments of the patients. Equally relevant to assessing their validity was the impressive discriminant validity of the SWAP dimensions when tested against DSM-IV constructs, personality prototypes derived empirically, and personality traits (Westen & Muderrisoglu, 2003, 2006). These find-ings have just been replicated in a large-sample study, in which 145 patients were evaluated independently by a sys-tematic clinical research interview (based on a single cross-sectional encounter with the patient, as is the norm in PD research) and by the treating clinician (based on all avail-able longitudinal data from ongoing treatment), with each coder blind to the data from the other. Convergent validity correlations averaged .50 and discriminant validity correla-tions hovered around 0.0 (Westen, Shedler, et al., in press).
In a sample of 30 inpatients at a maximum-security foren-
sic hospital conducted by an independent research team,  
12 SWAP-based PD scales derived from researchers’ ratings of attachment interviews and chart records correlated highly with interpersonal circumplex ratings of patients’ personali-ties provided by their nurses as well as whether the patients had committed violent offenses (Marin-Avellan, McGauley, Campbell, & Fonagy, 2005). This work has recently been extended to a larger sample of 90 participants (Marin-Avellan, 2010).
Score 0 1 2 3 4 5 6 7
Frequency 100 22 18 16 14 12 19 8

4  Assessment  XX(X)
In a study of 47 outpatients (Bradley, Hilsenroth, 
Guarnaccia, & Westen, 2007), SWAP dimensions of 
Borderline, Antisocial, and Obsessive–Compulsive PDs based on ratings by treating clinicians showed a strong pat-tern of concurrent and discriminant validity with relevant dimensions of the Personality Assessment Inventory (PAI; Morey, 1991), a self-report measure of personality pathol-ogy completed by the patients. Correlations between SWAP dimensions and conceptually overlapping PAI scales ranged from .31 to .46, showing cross-method and cross-informant validity levels similar to those found in the literature using other established self-report instruments (e.g., Clifton, Turkheimer, & Oltmanns, 2005). Evidence of discriminant validity was strong, with no correlations even trending toward significance between the two near-neighbor disor-ders (BPD and APD) from the SWAP and the PAI and sig-nificant negative correlations in the range of r = −.35-.40 
between both disorders as assessed by the SWAP and Obsessive–Compulsive PD as assessed by the PAI.
Yet another team (Smith, Hilsenroth, & Bornstein, 2009) 
reported cross-method/cross-informant evidence for the validity of the SWAP-200 dependency scales evaluated against DSM-IV PD diagnoses by clinicians and self-report 
using an interpersonal circumplex measure in a sample of 85 patients. Whereas the studies by Westen and Muderrisoglu (2003, 2006) and Westen and colleagues (Westen, Shedler, et al., in press; Westen, Waller, et al., in press) offer increasingly strong evidence for cross-infor-mant validity, the studies by Bradley et al. (2007), Marin-Avellan et al. (2005), and Smith et al. (2009) offer evidence from three different, independent, research teams, both for cross-informant and for cross-method validity of specific SWAP scales.
In a sample of 91 highly psychopathic (PCL-R > 39) 
male inmates at medium- and high-security units, Blagov et al. (2011) used the SWAP in conjunction with videotaped clinical interviews to derive two psychopathy subtypes empirically. The primary psychopathy subtype was distin-guished by malevolent narcissistic features and high levels of superficial, seductive, and deceitful charm, whereas the secondary psychopathy subtype was emotionally dys-regulated, impulsive, and hostile, akin to Borderline PD (American Psychiatric Association; 2000). The extent to which participants’ SWAP profiles matched the empirical primary and secondary psychopathy prototypes evidenced good convergent validity with PCL-R factor scores obtained by an independent set of raters, with self-report measures of personality and psychopathology completed by the partici-pants, and with observer-report measures of psychopathy-related interpersonal behavior and impulsivity. The participants’ degrees of match to the two SWAP-based psy-chopathy prototypes evidenced excellent discriminant validity with regard to the external validation measures. For example, primary psychopathy correlated with PCL-R Factor 1 (from an independent team of assessors; r = .45), a 
self-report measure of extraversion (r = .41), a self-report 
measure of positive emotionality (r = .60), a self-report 
scale of active temperament (r = .42), a self-report measure 
of neuroticism (r = −.37), a self-report measure of fearful 
temperament (r  = −.50), and a self-report scale of internalized 
anger (r = −.35). Secondary psychopathy had no significant 
correlations with PCL-R Factor 1, extraversion, active tem -
perament, and neuroticism. It correlated significantly with PCL-R Factor 2 (r = .27), records of antisocial and violent 
behavior during childhood and childhood abuse (r  = .40-.44), 
self-report anger expression (r = .45) and internalized anger 
(r = .42), positive affectivity (inversely, r = −.60), socializa-
tion (r = -.55), observer-report aggression (r = .57) and 
inattention/hyperactivity (r = .36), and self-report indices of 
negative emotionality (r  = .42-.52). Thus, two SWAP-II 
scales capturing psychopathy subtypes evidenced strong cross-method and cross-informant validity.
Published data thus suggest that the first critique of the 
SWAP, namely regarding the cross-informant/cross-method validity of its scales, requires revision. Multiple research groups have now shown in multiple samples strong evidence for validity using multitrait–multimethod designs. Similar findings have emerged whether the SWAP studies used dimensional DSM-IV PD scales, empirically derived SWAP

trait scales, or empirically derived personality configurations or PD prototypes, with highly similar estimates of validity regardless of which kind of scales were used and how the scales were computed (e.g., Q-correlations vs. traditional unit-weighted scales, a point to which we return in addressing Question 2). At this point, few studies are being conducted using a single clinical informant, in part because of the wide-spread currency of this criticism and in part because the goals of the original studies that relied on large samples of patients as described by individual clinicians participating in practice networks were taxonomic, required prohibitively large sam-ples for cross-informant research, and have largely been ful-filled (Westen, Shedler, et al., in press; Westen, Waller, et al., in press). The validity evidence for cross-informant/cross-method data, has, however, generally been of similar magni-tude to previously published validity data using a single informant, the treating clinician, suggesting that the use of a single informant did not in fact impose substantial bias.
Of note, researchers have generally not held self-report 
personality instruments and structured interviews that rely heavily or exclusively on patient self-reports to this same standard, often accepting at face value correlations between self-reported personality pathology and self-reports of other variables interpreted as demonstrating validity. In general, personality researchers would do well to return to evaluat-ing validity using a multitrait/multimethod matrix approach that includes cross-correlations across informants.

Blagov et al.  5
Question 2: Does the Asymmetrical 
Fixed Distribution Generate Biases and Artifactually Inflated Estimates of  Validity and Reliability?
The SWAP score distribution has been challenged by pro-
ponents of other models of personality assessment, notably the five-factor model (Widiger, 2002; Widiger & Samuel, 2005; Wood et al., 2007). Two related critiques have received the most attention. The first is that the asymmetri-cal distribution of the SWAP may artifactually inflate cor-relations between individual SWAP profiles and criterion prototypes used to generate scale scores (Block, 2008). These correlations are also known as Q-scores (i.e., correla-tions between a given patient’s 200-item profile and an empirically derived, aggregated 200-item profile, e.g., of BPD or APD). Block points out that the fixed distribution forces a large number of items (100 items or 50%) into the “not descriptive” category (items that receive a rank of 0), and he argues that the sheer number of items ranked 0 would inflate Q-scores even though they are not “highly descriptive” items (i.e., items receiving ranks of 4, 5, 6, or 7).
Westen and Shedler (2007) have addressed this and sim-
ilar concerns elsewhere; however, because of the persis-tence of this critique, it is worth briefly addressing it here conceptually before addressing it empirically. Conceptually, the assertion that the score distribution induces spuriously high correlations is mathematically untenable. Because of the fixed distribution, the items in a SWAP profile always have a mean of 1.69 and a standard deviation of 2.18. This is also true of empirically derived SWAP-based prototypes of personality pathology that have previously been used to compute Q-scores. Thus, in computing a correlation between a SWAP profile and a prototype (or between two SWAP profiles), items with scores from 0 to 3 deviate mini-mally from the mean item score and therefore can have only minimal impact on the magnitude of the correlation coeffi-cient. In effect, the top 44 items (those receiving scores from 4 to 7, which are 2 or 3 to 5 standard deviations higher than the mean) “drive” the magnitude of the correlation coefficient (because no item can be substantially lower than the mean, rendering items with low scores largely irrelevant to the magnitude of the correlation). This is consistent with the unipolar nature of the items, where items receiving a high ranking are especially descriptive of the patient. The large number of items with scores of 0 mathematically has minimal impact on the magnitude of a Pearson correlation coefficient, given its computation, which is derived from deviation of each score from the mean. Thus, should fea-tures of some kind of personality pathology that is not cen-tral to understanding the patient be present among even items ranked 1 to 3 (but not among items ranked 4-7), the deviation from the mean of 1.69 will have minimal impact on the magnitude of Q-correlations. For items receiving a 0, the impact is trivial.
Were this critique valid, there would also be a substantial 
discontinuity between the results of SWAP research relying on Q-correlations (a scaling method derived from Block, 1978) to measure personality constellations, such as PDs and research using factor-analytically derived SWAP trait scales, which are traditional unit-weighted item scales. That has not in fact been the case with the SWAP-200 (Shedler & Westen, 2004a, 2004b), the SWAP-200-A for adoles-cents (Westen, Dutra, & Shedler, 2005), or the SWAP-II (Westen, Waller, et al., in press). Unit-weighted trait scales have produced similar patterns of convergent and discrimi-nant validity as PD scales derived from Q-correlations.
In any case, whether this criticism about the application 
of Q-scores to a given patient has merit conceptually or mathematically, it is no longer relevant, given recent changes in the scaling of SWAP scores for both DSM-IV and empirically derived personality syndromes (Westen, Shedler, et al., in press), whether for purposes of clinical assessment or research. In developing SWAP-II scales to measure DSM-IV dimensional diagnoses, we tested multi-
ple methods for generating scales and discovered that Q-correlations were actually less valid than traditional scales ranging from 16 to 24 items, depressing correlations between SWAP PD scales and measures of Axis II pathol-ogy while inflating estimates of comorbidity—precisely the opposite of the criticism suggested by Wood et al. (2007), Block (2008), and others. The differences were not enormous, but they were substantial enough that we have turned to more conventional scaling techniques that take the average of items relevant to the construct, rather than correlating a patient’s 200-item profile with a 200-item aggregate profile except where the latter proves empirically more predictive or useful. Thus, this first version of the criticism, even if it were true, is now essentially moot.

Critics have, however, expressed concerns about other 
possible undesirable effects of the asymmetrical fixed dis-tribution of the SWAP (Block, 2008; Wood et al., 2007), particularly as it is or has been used for research purposes, notably on estimates of reliability and validity. These cri-tiques are similar to the ones addressed above, resting on the large number of items receiving a ranking of 0 and oth-erwise low scores in the asymmetrical distribution. Block argued that “all SWAP-II intercorrelations are appreciably heightened because of the inevitable and appreciable over-lap of heavily weighted and inapplicable descriptors” so that “the chance correlation between SWAP Q-sorts begins at a surprising, unwittingly high level” (Block, 2008,  
p. 114). Were this true, of course, it would inflate estimates of discriminant validity as much as convergent validity (because all correlations would increase) and hence would not have any net effect on estimates of validity or reliability 

6  Assessment  XX(X)
to a psychometrician appropriately attending to correla-
tions both on and off the diagonal.
In the previous section, we addressed why, conceptually 
and mathematically, low-ranking items are, in fact, not weighted heavily and have minimal impact on correlations between SWAP profiles. Furthermore, it has been known in the Q-sort literature for some time that “the exact distribu-tion form has little effect on the kinds of analyses which are made of the data [because] correlation coefficients, and the factors obtained from them, are largely insensitive to changes in distribution shapes” (Nunnally, 1978, p. 616). Nevertheless, the critique merits an empirical evaluation, both because it has been raised frequently by critics and because it is possible for the fixed distribution to have some effect on correlation magnitudes if a subset of the items were consistently to receive low ratings (especially 0; Block, 2008) or receive very different mean ranks and stan-dard deviations (Nunnally & Bernstein, 1994). As described elsewhere, however, items with minimal variance or extremely low base rates have been deleted from the SWAP during its construction as part of a multi-year, iterative revi-sion process (Westen & Shedler, 2007).
Here, we present two studies that address this question. 
To evaluate the critique empirically, we considered the fol-lowing: (a) What is the average chance correlation among SWAP profiles? We addressed this in Study 1. In Study 2, we address two additional questions: (b) Do empirical data support the claim of high “baseline” correlations between pairs of SWAP profiles in an actual patient sample, and are these higher than the baseline correlations between, for example, profiles of patients assessed using DSM-IV crite-ria rated on a similar but unconstrained Likert-type rating scale? (c) What is the typical SWAP item score and its dis-persion? In other words, is it true that some SWAP items consistently receive scores of 0 across individuals and oth-ers consistently receive high scores, thereby “building in” a spurious correlation between score profiles?
Study 1 is a Monte Carlo simulation in which we exam-
ine the magnitude of correlations between simulated SWAP profiles created by generating random scores conforming to the fixed distribution requirement of the SWAP. If the asymmetric fixed distribution artifactually inflates correla-tions between SWAP profiles, we should observe positive correlations between the simulated SWAP profiles, and the Monte Carlo procedure will permit us to estimate the mag-nitude of the inflation. In Study 2, we examine empirically observed correlations among SWAP profiles of actual patients in a large national sample of patients assessed with the SWAP-II (Westen & Shedler, 2007), comparing them with correlations observed using unconstrained 6-point rat-ings (no fixed distribution) of Axis II diagnostic criteria. We also report central tendency and dispersion estimates for the individual SWAP-II items to explore whether cer -
tain items have score distributions that might bias estimates of reliability and validity.Study 1: Monte Carlo Simulation of 
Randomly Paired SWAP Profiles
We wrote a computer program to generate 10,000 random 
SWAP profiles, each of which conformed to the fixed dis-tribution requirements described above (e.g., with only 8 items allowed to receive a score of 7 and 100 items required to receive a score of 0). We then selected random pairs of SWAP profiles from this sample and calculated the  
correlations between the profile pairs, resulting in 5,000 correlation coefficients. We calculated the mean, median, standard deviation, standard error of the mean, and skew-ness of the 5,000 correlations. To generate a sampling dis-tribution of correlation coefficient means, we repeated this entire procedure 200 times.
The mean correlation coefficients were normally distrib-
uted (as expected under the central limit theorem), centered on a mean of M  = .001 (SD = .001, SEM < .001, Md = .001). 
The Shapiro–Wilk test of normality (SW = .992, df = 200, 
p = .395) was not significant. The distribution of the skew-
ness statistic (M  = .077, SD = .033, SEM = .002, Md = .079) 
was similarly approximately normal (SW = .993, df = 200, 
p = .463), indicating that the distributions of correlations had 
minimal skew. The standard error of skewness (a constant equal to .035 for this sample size) suggested a slight positive skew to the distribution of correlations, although the normal-ity plots for the mean and skewness were consistent with approximate normality with small deviations at the extremes.
The data thus show that in 200 samples of 5,000 SWAP

The data thus show that in 200 samples of 5,000 SWAP 
correlations, the mean correlation was 0 to 2 decimal places, with a negligible positive skew. The sample size we chose (5,000) was 5 to 10 times the size of the largest existing studies on personality pathology and roughly 50 times the size of the average study. In research with real participants, even in the largest-N studies, the slight deviation from normality in the sampling distribution would thus have no impact on research findings, and the mean and median correlations among simu-lated patient pairs of 0.0 do not support critics’ speculations.
Study 2: SWAP Profile 
Intercorrelations in a  Clinical Sample
The aim of the next study was to evaluate empirically the cri-
tique that the fixed distribution may inflate profile intercorrela-tions by examining (a) intercorrelations of SWAP-II profiles of real patients compared with intercorrelations among profiles using an alternative (DSM-based) measure; and (b) central ten-dencies and variability estimates of item scores across patients.
Method
We used data collected as part of a larger study whose meth-ods and overall sample characteristics have been detailed 

Blagov et al.  7
elsewhere (e.g., Shedler & Westen, 2007; Westen &
 
Shedler, 2007). In brief, we invited psychologists and psy-
chiatrists from a random national sample (30% response rate; N = 1,201) to serve as expert informants and offered 
them a $200 consultation fee to describe “an adult patient you are currently treating or evaluating who has enduring pattern of thoughts, feeling, motivation or behavior—that is, personality problems—that cause distress or dysfunc-tion.” We explicitly informed potential clinician-participants that patients did not need to have a PD diagnosis. Patients were required to be at least 18 years old, not in a psychotic episode, and well-known to the clinician (at least 6 hours but less than 2 years of clinical contact, to minimize effects of personality change with treatment). To limit selection biases, we directed observers to select the last patient they saw during the previous week who met study criteria. Of a subsample of clinicians recontacted with questions regarding the patient they selected, 96% reported follow-ing the procedure as specified. Each observer contributed data on only one patient to minimize rater-dependent variance.
The expert informants completed the SWAP-II along 
with additional measures of psychopathology, adaptive functioning, personal and family history, and other clini-cally relevant information. Among these materials and of relevance to the present study was an Axis II Criteria Rating Form (a randomly ordered list of DSM-IV diagnostic crite-
ria for all 10 PDs). Clinician-informants rated each diagnos-tic criterion on a scale from 1 to 6, with values greater than 3 indicating that the criterion was definitely met. The scale is similar in range to the 0 to 7 scale used in the SWAP, except that it does not have a fixed distribution and hence provides a useful psychometric comparison. By applying DSM-IV decision rules to the criterion data (coded as crite-rion present or absent), we were also able to assign categori-cal Axis II diagnoses to patients.
Results and Discussion
Intercorrelations Among  
SWAP-II Profiles in Real Patients
To evaluate SWAP profile intercorrelations among the 
patients, in a first analysis we included those individuals who met DSM-IV diagnostic criteria for at least one Axis II PD based on Axis II diagnostic criteria. To reduce true covariance due to the presence of overlapping personality features, we excluded pairs of patients with Axis II diagno-ses falling within the same Axis II diagnostic cluster (e.g., cluster A, which subsumes the comorbid diagnoses of para-noid, schizoid, and schizotypal PDs). We predicted that we would observe symmetrically distributed correlations with values ranging from negative to positive, with the average correlation positive and small in magnitude (because most individuals sampled from a clinical population with PD diagnoses share certain aspects of personality pathology features, such as negative affectivity, and because of non-negligible correlations between dimensional diagnoses across clusters in all prior research using structured inter-views, self-reports, the SWAP, and other instruments).
For comparison purposes, we also generated a distribu-
tion of correlations for the same patient subsample using an alternative DSM-based measure, the Axis II Criterion 
Rating Form, that did not have a fixed score distribution. We predicted that the distribution of the SWAP-II data would resemble that of the DSM-IV criterion ratings, except that the SWAP-II data would have a somewhat higher mean because the SWAP-II includes symptoms related to general neurotic features (e.g., tends to be anxious, tends to be depressed) that have been excluded from the DSM-IV to minimize comorbidity but are shared nearly universally among patients with PDs. Finally, we repeated these two analyses, except that this second time we used the entire sample of 1,201 patients (i.e., including those without a PD) and calculated all possible SWAP-II and DSM-IV Axis II profile intercorrelations (without restricting the possible pairings to nonoverlapping PD clusters). We expected that, in these latter analyses, both the SWAP-II and the DSM-IV Axis II Criterion Rating data would produce mean intercor-relations between random pairs of real patients that are small to moderate in magnitude and similar to one other.
The first analysis resulted in 89,128 unique correlations 
between pairs of SWAP-II profiles, which were distributed symmetrically around a mean of .07386 (SEM = .00055, 
Md = .07614) with SD = .16454. The skewness statistic 
(.00186) was smaller than its standard error (.00821), sug-gesting the absence of significant skewness. The correlations between Axis II criterion ratings were similarly distributed symmetrically around a mean of .01510 (SEM = .00065, 
Md = .01576) with SD = .19478. The skewness statistic

Md = .01576) with SD = .19478. The skewness statistic 
(.02315) was greater than twice the standard error (.00821), suggesting a small but statistically significant positive skew.
We interpret these results as follows. When we sampled 
pairs of patients who did not share PDs from the same Axis II cluster, the measure that was the basis of this selec-tion (the Axis II Criterion Rating Form) produced a roughly normal but positively skewed distribution of correlations that was centered slightly above zero. The SWAP-II pro-duced slightly larger correlations that on average were nev-ertheless small. As noted above, one of the meaningful ways in which the SWAP-II and the Axis II Criterion Ratings differ as measures of personality pathology is that the former measures general symptoms of distress and per-sonality dysfunction related to negative affectivity or neu-roticism that were not included among the DSM-IV criteria to reduce comorbidity; if a tendency to experience negative emotions such as depression were included among the PD criteria, they would have to be included among the criteria for multiple disorders because empirically they are related to several disorders (e.g., Shedler & Westen, 2004a, 2004b).

8  Assessment  XX(X)
In fact, in the present sample, the following SWAP-II 
items had the highest mean ranks across patients: Tends to 
feel unhappy, depressed, or despondent (M = 4.39); Tends 
to feel anxious (M = 4.12); Tends to fear s/he will be rejected 
or abandoned (M = 3.95); and Tends to feel he or she is 
inadequate, inferior, or a failure (M = 3.82). Thus, in light of 
the evidence from Study 1, and in the absence of substantial skewness, the shift in the mean of the SWAP-II distribution of correlations likely reflects the fact that patients sampled from a clinical population who are in treatment for person-ality pathology share a proclivity toward anxiety, depres-sion, rejection sensitivity, and low self-esteem. In the context of interrater reliability estimation, this covariance probably reflects the accurate perceptions of raters and their agreement rather than an artifactual bias having to do with the distributional properties of the measure. Indeed, it may reflect a likely strength of the SWAP-II, which was intended to measure the broad spectrum of personality pathology, relative to the roughly 80 items comprising the diagnostic criteria for the PDs in DSM-IV. In any case, if the marginal difference of .05 between data using the fixed distribution and the data using a nonfixed distribution is meaningful and replicable for whatever reasons, it affects convergent and discriminant validity alike and hence has no bearing on validity or on reliability as long as discriminant reliability estimates are obtained along with convergent reliability estimates, something we recommend in PD diagnosis given substantial comorbidities among disorders.
In examining the SWAP-II correlation data when the 
patients in each pair had not been preselected to eliminate patients from the same DSM diagnostic cluster, 720,600 correlations were distributed unimodally and symmetrically around a mean of M  = .152 (SD = .171, SEM < .001, Md = .152), 
with a skewness statistic of −.012 that was smaller in abso-lute value than its standard error of .003. The 713,415 DSM-IV Axis II Criterion Rating patient profile correlations were distributed around a virtually identical mean of M  = .143 
(SD = .202, SEM < .001, Md = .148) with a skewness of 
−133 that was in absolute value substantially larger than its standard error of .003. Although the two correlation means were significantly different from each other (p < .01) in this 
extraordinarily large sample, the 95% confidence interval = .009-.010 indicated that the real mean difference was negligible.
These data suggest that the SWAP-II (which has a fixed, 
asymmetric distribution of items) and the Axis II criterion rating form (which uses 6-point scale ratings and imposes no restrictions on the score distribution) produced similar distributions of random intercorrelations among patients with personality pathology not constrained to those with an Axis II PD. On average, nearly identical, small, positive correlations (.14 and .15) were observed with both instru-ments, suggesting that people who seek treatment for per-sonality problems have on average 2% shared variance in their personality profiles when assessed with either person-ality pathology measure.
Central Tendency and  
Variability of SWAP-II Ratings
We computed central tendency (means, medians, and 
modes) and variability (standard deviations) estimates for the SWAP-II items in the entire participant sample to examine the extent to which some items may tend to appear in extreme locales of the distribution and thus might unduly influence profile intercorrelations.
The overwhelming majority of SWAP-II items (196) 
had a modal score of 0, with the exception of the following four items: Item 35 (“Tends to feel anxious,” Mode = 7), Item 92 (“Is articulate, can express self well in words,” Mode = 7), Item 98 (“Tends to fear she or he will be rejected 
or abandoned,” Mode = 6), and Item 189 (“Tends to feel unhappy, depressed, or despondent,” Mode = 7). The scores given to each of the 200 items ranged from 0 to 7, showing that each item received scores from the full possible range. The average mean score was 1.69 (SD = 0.85). The median 
scores per item ranged from 0 to 5, with an average median of .98 (SD = 1.19), suggesting that the tendency was for the 
majority of the items to receive low scores. Item standard deviations ranged from 1.10 to 2.50 (M = 1.97, SD = 0.33).

majority of the items to receive low scores. Item standard deviations ranged from 1.10 to 2.50 (M = 1.97, SD = 0.33). 
These data suggest that, with the exception of a few items that tended to be highly descriptive of most patients, the majority of the items “hover” at the bottom of the score distribution and receive high rankings only when clinicians find those rankings appropriate. This does not support the claim (Block, 2008) that some select items might have undue influence because their range is restricted to the bot-tom of the distribution. Furthermore, with the exception of the same few items noted above, the variability of the means of the items’ ranks is constrained within the lower end of the fixed-score distribution and the standard deviations of the items’ ranks do not vary substantially. This reduces the concern that unequal item means and standard deviations may inflate profile correlations (Nunnally & Bernstein, 1994), although the effect of the four items that had much higher means needs to be evaluated in future research. The results can be seen in Table 1.
Question 3: Do SWAP Scales Have 
Reasonable Test–Retest Reliability?
As noted by Wood et al. (2007), evidence for test–retest 
reliability (temporal stability) of the SWAP has been lack-ing. Recently, an independent group (Cogan & Porcerelli, 2011) reported that, on reevaluation of 77 patients with the SWAP-200 after a 6-month retest interval, reliabilities averaged r = .81 for the instrument’s PD scales and r = .68 
for its empirically derived personality diagnostic syndromes. 

Blagov et al.  9
This study fills an important void in the literature; however, 
the question of temporal stability is a legitimate concern
 
for any instrument that cannot be adjudicated with a single study. Thus, in Study 3, we present the first data on the test–retest reliability of factor-analytically derived trait dimensions of the SWAP-II in a clinical sample, comple-menting the data provided by Cogan and Porcerelli, as well as data on PD scores, as reported by Cogan and Porcerelli.
Study 3: Test–Retest 
Reliability of the SWAP-II
The aim of the study was to address Question 3 by examin-
ing the test–retest reliability of the SWAP factors and PD scales, thus addressing a gap identified in the literature (Wood et al., 2007). As part of the project referenced in Study 2 above, we recontacted 139 participating informants who had provided SWAP-II data using the Internet approx-imately 2 to 4 months earlier and asked them to assess their patient again. At retest, 40 received the SWAP-II paper card-sort to complete, 40 received a username and pass-word to complete the instrument on the Internet, and 59 received the prior version of the instrument, the SWAP-200 (to provide preliminary data useful for imputation from one to the other). The response rate was 68% (N  = 27, paper, 
N = 29, Internet, and N = 38, SWAP-200; total N = 94). 
Retest data arrived 4 to 6 months following the initial assessment. The retest subsamples did not differ at p = .05 
in the discipline, gender, and years of experience of the observers, or in the gender, age, GAF (Global Assessment of Functioning), or time in treatment of the patients.
We correlated scores for the 14 factor-analytically 
derived SWAP-II trait scales (Westen, Waller, Shedler, & Blagov, in press) as well as 10 PD scales (based on the DSM-IV criteria as represented in SWAP-II items) at Time 1 and Time 2, which allowed us to assess not only test–retest reliability along the diagonal but also discriminant reliability estimates off the diagonal, something that has largely been lacking in the PD literature (Clark, 1992). To examine cross-method stability (paper vs. Internet), we calculated reliabil-ity matrices separately for observers who completed both assessments using the Internet and those who completed one paper and one web version, although with the small sample sizes we consider these analyses very preliminary. We used Fisher’s Z to test for any differences between web-to-paper 
and web-to-web correlations. We chose a study-wise alpha level of p  < .01, given the large number of tests for which we 
made no predictions. To maximize N  for retest analyses, we 
used simple algorithms to impute Time 2 SWAP-II profiles for patients whose clinicians had used the SWAP-II at Time 1 and the SWAP-200 at Time 2. Because the SWAP-II items correlated highly with corresponding SWAP-200 items, only those items that were completely new or substantially rewritten required imputation (16 items).
The clinician retest sample (N = 94) consisted of 81% psy-
chologists and 19% psychiatrists. Most self-identified theo-retically as integrative or eclectic (52%), cognitive–behavioral (18%), or psychodynamic (18%). Patients had a mean age of 42.4 years (SD = 13.0) and were roughly 65% male. The 
patients were receiving treatment primarily in private prac-tice (62%), outpatient clinics (20%), or inpatient settings (10%). The ethnic distribution was 74% Caucasian, 11% African American, 10% Hispanic, and 5% other ethnicities.
Table 2 contains the results for the factor-analytically 
derived scales. In Westen, Waller, et al. (in press), we derived 16 factors, which showed generally good internal consistency with a mean α of .73, although two (Boundary Disturbance and Sexual Conflict) were on the low side at .44 and .55, most likely because of a limited number of highly loading items (4 and 6, respectively.; We retained 14 of the 16 factors, eliminating Boundary Disturbance because of its low internal consistency and an eating disor-der factor that we interpreted primarily as an Axis I scale, but we report data on all 16 factors here). Retest correla-tions for the 16 SWAP-II factors (along the diagonal) ranged from .64 to .96 (all significant at p < .001), with a 
median retest r = .85. The only factor with a reliability coef-
ficient below .70 was Factor 13 (Boundary Disturbance), which had also shown relatively weak internal consistency. Correlations off the diagonal (between each factor at Time 1 and all other factors at Time 2) averaged near 0 and were distributed with a slight negative skew, M = −.04, SD = .26. 
Medians of the absolute values of the discriminant retest correlations for each factor were substantially lower than the test–retest correlations and ranged from r = .08 to .32

Medians of the absolute values of the discriminant retest correlations for each factor were substantially lower than the test–retest correlations and ranged from r = .08 to .32 
(for Obsessionality). Interestingly, cross-method (web-to-paper) retest reliability coefficients were slightly higher than same-method (web-to-web) coefficients, though not significantly, Md
r = .87 and .78, respectively. Thus, the two Table 1. Summary Statistics of Central Tendency and Variability 
Estimates of 200 SWAP-II Items in a Sample of 2,101 Adult Patients
Summary statistics for 200 items
Statistic NRange Minimum Maximum M SEM SD
Item M 200 4.04 0.3 4.34 1.69 0.06 0.85
Item Md 200 5 0 5 0.98 0.08 1.19
Item mode 200 7 0 7 0.14 0.07 0.95
Item SD 200 1.40 1.10 2.51 1.97 0.02 0.33
Item range 200 0 7 7 7 0 0
Item minimum 200 0 0 0 0 0 0
Item maximum 200 0 7 7 7 0 0

10  Assessment  XX(X)
Table 2. Test–Retest Correlations for 16 SWAP-II Scales (N = 94)
f1r f2r f3r f4r f5r f6r f7r f8r f9r f10r f11r f12r f13r f14r f15r f16r Mdabsa
f1 .96* - .38* - .56* .09 - .10 .26 .47* - .24 - .14 - .31* - .53* .55* .26 .07 .51* - .24 .26
f2 -
.43* .84* .20 -
.36* -
.01 -
.30* .01 -
.07 -
.30* -
.22 -
.10 -
.36* -
.01 .05 -
.31* -
.08 .20
f3 -
.51* .10 .84* .13 .40* -
.39* -
.27* .06 .17 .13 .35* -
.46* -
.22 -
.29* -
.28* -
.01 .27
f4 .06 -
.32* .11 .81* .42* -
.09 -
.16 .08 -
.09 -
.01 .23 .03 -
.17 -.39* .10 -
.10 .10
f5 .01 .04 .22 .20 .77* -
.48* .06 -
.18 -
.03 -
.06 -
.06 -
.14 -
.13 -
.38* .06 -
.20 .13
f6 .24 -
.37* -
.39* .02 -
.39* .87* -
.02 .17 .06 .09 -
.08 .26 .16 .18 .29* -
.02 .17
f7 .53* .07 -
.35* -
.20 -
.01 .01 .90* -
.32* -
.22 -.46* -
.73* .11 .46* .19 .43* -
.22 .22
f8 -
.28* -
.16 .20 .01 -
.18 .19 -
.30* .85* .09 .32* .39* -
.09 -
.19 -
.12 -
.25 .15 .19
f9 .01 -
.31* .08 .01 -
.01 .01 -
.14 -
.07 .70* .08 .23 .08 -
.04 .04 -
.19 .24 .08
f10 -
.27* -
.24 .07 .05 -
.04 .07 -
.43* .32* .24 .85* .45* -
.12 -
.24 -
.18 -
.21 .21 .21
f11 -
.54* -
.16 .42* .26 .02 -
.14 -
.68* .28* .34* .47* .86* -
.19 -
.33* -
.18 -
.49* .28* .28
f12 .57* -
.36* -
.46* .07 -
.25 .30* .05 -
.09 -
.06 -
.17 -
.18 .86* .10 .11 .12 -
.15 .15
f13 .31* -
.08 -
.32* -
.06 -
.22 .37* .40* -
.01 -
.14 -
.25 -
.39* .14 .64* .27* .26 -
.19 .25
f14 .14 .10 -
.36* -
.39* -
.47* .13 .29* -
.17 .06 -
.17 -
.30* .12 .26 .83* -
.17 .12 .17
f15 .54* -
.27* -
.35* .17 .01 .34* .34* -
.14 -
.31* -
.22 -.40* .19 .15 - .15 .92* - .18 .22
f16 -
.20 -
.04 -
.01 -
.14 -
.14 -
.01 -
.16 .14 .19 .16 .20 -
.13 -
.19 .13 -
.16 .87* .14
Mdabsa.28 .16 .32 .13 .14 .19 .27 .14 .14 .17 .30 .14 .19 .18 .25 .18 .85
Note. SWAP-II = Shedler–Westen Assessment Procedure–II; f1 = Psychopathy; f2 = Psychological health; f3 = Obsessionality; f4 = Schizotypy; f5 = 
Emotional avoidance; f6 = Emotionally dysregulated; f7 = Narcissism; f8 = Anxious somatization; f9 = Sexual conflict; f10 = Depression; f11 = Social anxiety/avoidance; f12 = Unstable commitments; f13 = Boundary confusion; f14 = Histrionic sexualization; f15 = Hostility; f16 = Eating disturbance; r = Retest.a. Median absolute value of the discriminant retest correlations.*p < .01 (two-tailed).
methods appear to be equivalent. Nor did the imputed 
scores produce divergent patterns from the web-to-web and web-to-paper; hence their inclusion in these analyses.
Table 3 reports the results for the SWAP DSM-IV PD 
scales, using the current scaling procedures, which do not rely on Q-correlations. Prior research using the SWAP has tended to report results using these scales or their equiva-lents in the earlier version of the instrument (the SWAP-200). As Table 3 shows, the retest correlations (along the diagonal) were very high and ranged from .86 to .96 (Md = .90). 
The discriminant (off the diagonal) test–retest correlations were somewhat higher and had a larger standard deviation (M = .08, SD = .49) than the equivalent correlations for the 
factors in Table 1. The absolute values of the discriminant retest correlations for the PD scales ranged from .01 to -.80, with a median of .37. Thus, the SWAP-II factors had similar test–retest reliabilities but lower artifactual “comorbidities” when compared with the SWAP-II PD scales, which makes sense given that the factors were empirically derived using factor analysis and hence do not suffer from the problem of comorbidity built into all measures of DSM-IV constructs.
In summary, we examined the test–retest reliability of 16 
SWAP-II factors and PD scales over a 4- to 6-month period in a subsample of 94 patients treated in a wide range of clinical settings. Within the limits of sample size, the results indicate substantial retest reliability. Whereas the 16 SWAP-II factors yielded high correlations with themselves over 4 to 6 months (Md
r = .85), the median correlation across factors was modest, providing evidence for discrimi-nant retest reliability, something that is too infrequently reported in studies of personality pathology measures where constructs are often overlapping. The SWAP-II PD scales were similarly reliable but more “comorbid,” underscoring the general consensus in the literature on PDs that the DSM-IV PDs show unrealistically high comorbidity estimates.
Three limitations are worth noting vis-à-vis the retest 
data. The first reflects the unintended oversampling of men that took place as a result of the timing of the retest study in relation to the overall study. Second, temporal stability beyond 4 to 6 months is unknown. We chose this follow-up interval to minimize personality change reflecting treatment as a potential confound. A third limitation is the reliance on a single informant, which means that part of the stability in the psychopathology factors may reflect rater effects, although this is an equal limitation of all retest reliability data on self-report scales.
Summary and Conclusions

We evaluated the three most prevalent psychometric cri-tiques in the literature concerning the SWAP. Regarding the validity critique (Question 1), the literature review found substantial evidence for cross-informant/cross-method validity of SWAP scales measuring dimensional DSM-IV diagnoses, empirically derived PDs, and traits, as well as preliminary data on primary and secondary 

Blagov et al.  11
p
sychopathy. Research underway with a sample of more 
than 200 patients is examining the relation between SWAP 
DSM-IV diagnoses, empirically derived PDs, and factor-analytically derived traits with a range of criterion vari-ables, from data from multiple independent interviewers and self-reports, to genotyping, to adaptive functioning, to longitudinal follow-up data at 18 months.
Regarding the distributional critiques (Question 2), the 
fixed, asymmetric distribution of the SWAP has been a par-ticular source of controversy. Although we have moved away from Q-correlations as a method of scaling, particu-larly for personality assessment in practice, neither concep-tually nor empirically does this critique appear to be well grounded. Study 1 demonstrated that the average intercor-relation between randomly generated SWAP profiles, con-forming to the asymmetric fixed distribution requirement, is zero to two decimal places. In Study 2, using real data from a national sample of N = 1,201 patients with personal-
ity pathology, the correlations between random pairs of patient profiles were essentially equal, on average, whether using the SWAP-II with its fixed distribution of scores (average r = .15) or a set of DSM-IV-based Axis II Criterion 
Ratings that did not have a fixed distribution (average r  = .14). 
These average values are not 0, but they do not likely reflect the fixed score distribution of the SWAP, given that they are essentially identical for 6-point unconstrained DSM-IV criterion ratings. They are more likely to reflect naturally occurring similarities in patients who seek therapy and who have personality pathology, as evidenced by the fact that four SWAP-II items (reflecting proneness to anxiety, depression, rejection sensitivity, and high verbal skills) were the only four items whose median score across 1,201 patients was not 0 (and was, in fact, high). Recently, in a sample of psychotherapy patients (Cogan & Porcerelli, 2011), the SWAP-200 scale scores of mismatched patients (i.e., pairs consisting of unrelated patients at Time 1 and Time 2, instead of the same patient at test and retest) cor-related at r = .02 (for PD scales) and r = −.05 (for Q-factor 
analysis-derived scales), also suggesting that reliability coefficients are not artificially inflated. The fact that, in Study 2, the mean and median ratings for 196 out of 200 items were close to 0 (and that the mean and variability esti-mates of the standard deviations were small) argues against Block’s (2008) concern that a sizeable proportion of items consistently receives low ratings whereas another sizable proportion consistently receives high ratings.
Regarding Question 3, that temporal stability data had 
been lacking, we reported the second test–retest study of the SWAP and the first evidence for test–retest reliability of SWAP traits derived by factor analysis (Study 3), demon-strating an average r = .85 in an adult clinical sample over a 
4- to 6-month period. The mean reliability was .90 for SWAP scales corresponding to DSM-IV personality disor -
ders. Research is needed on the retest reliability of these factors over a longer period, preferably in a population that is not undergoing treatment for personality pathology.
In sum, we evaluated three of the primary questions crit-
ics have raised about the validity and psychometrics of scales based on the SWAP. Although critics can and will no doubt generate other concerns about the SWAP, as they should about any psychometric instrument, the data reviewed and presented here did not support these critiques. Other con-cerns, however, need to be addressed, namely with respect to questions confronting all personality instruments, partic-ularly those that focus on psychopathology, such as the best approaches to scaling psychopathological constructs that have substantial but differing and relatively low base rates in the population. Like others who have been down this Table 3. Test–Retest Correlations for 10 DSM-IV PD Scales of the SWAP-II (N = 94)
1 2 3 4 5 6 7 8 9 10 Mdabsa
 1 Paranoid PD .92* - .04 .25* .59* .45* .35* .54* - .45* - .43* - .22 .25
 
2
 
Schizoid PD -
.12 .87* .71* -
.11 -
.37* -
.52* -
.32* .53* .01 .32* .11
 
3
 
Schizotypal PD .17 .75* .88* .09 -
.16 -
.28* -
.05 .24 -
.15 .25* .09
 4
 Antisocial PD .60* -
.12 .08 .96* .42* .50* .65* -
.57* -
.50* -
.45* .08
 
5
 
Borderline PD .39* -
.26* -
.09 .40* .89* .68* .21 -
.29* .03 -
.58* .03
 
6
 
Histrionic PD .33* -.51* -
.29* .53* .72* .90* .52* -
.59* -
.16 -
.62* .16
 
7
 
Narcissistic PD .63* -
.35* -
.08 .70* .22 .49* .94* -
.80* -
.66* -
.18* .08
 8
 A
voidant PD -
.55* .54* .28* -
.61* -
.36* -
.58* -
.78* .92* .62* .29 .36
 
9
 
Dependent PD -
.46* .05 -
.04 -
.44* .02 -
.10 -
.54* .56* .88* -
.13* .10
10
 Obsessiv
e–compulsive PD -
.25* .27* .16 -
.40* -
.58* -
.55* -
.16 .25* -
.11 .86* .16
Mdabsa .17 .04 .08 .09 .02 .10 .05 .29 .15 .18 .90

.04 -
.44* .02 -
.10 -
.13* .10
10
 Obsessiv
.40* -
.58* -
.55* -
.16 .25* -
Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders fourth edition; PD, personality disorder; SWAP-II = Shedler–Westen Assessment 
Procedure–II.a. Median absolute value of the discriminant retest correlations.*p < .01 (two-tailed).

12  Assessment  XX(X)
same path, we have attempted to identify an optimal if 
imperfect way of transcending the limits of traditional but readily interpretable metrics, such as T-scores, which can provide a distorted impression of profiles of disorders with different base rates (e.g., Borderline vs. Schizotypal PD). We are now using normalized T scores (Hsu, 1984), which have the advantage of equating percentiles associated with T scores across traits, disorders, or other personality 
constellations.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to 
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by National Institute of Mental Health grant MH60892-01 (to D.W.).
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