Discussion of Peter Fonagy et al.'s “The Developmental Roots of Borderline Personality Disorder in Early Attachment Relationships: A Theory and Some Evidence”

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Discussion of Peter Fonagyet al.'s “The DevelopmentalRoots of Borderline PersonalityDisorder in Early AttachmentRelationships: A Theory andSome Evidence”Melvin R. Lansky M.D. a ba Los Angeles Psychoanalytic Instituteb UCLA Medical SchoolPublished online: 01 Jul 2008.

To cite this article: Melvin R. Lansky M.D. (2003) Discussion of Peter Fonagyet al.'s “The Developmental Roots of Borderline Personality Disorder in EarlyAttachment Relationships: A Theory and Some Evidence”, PsychoanalyticInquiry: A Topical Journal for Mental Health Professionals, 23:3, 460-472, DOI:10.1080/07351692309349043

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Discussion of Peter Fonagy et al.’s“The Developmental Roots ofBorderline Personality Disorder inEarly Attachment Relationships:A Theory and Some Evidence”

M E L V I N R . L A N S K Y , M.D.

I

IAM GREATLY HONORED TO HAVE THE OPPORTUNITY TO DISCUSS PETER

Fonagy’s paper. It is in some ways a daunting paper. An astonishingamount is put into a relatively short work that touches on borderlineetiology, phenomenology, psychopathology, dynamics, and treatment,all with the backdrop of copious research into attachment behavior inthese disorders. The very quantity of references and the immense scopeof the paper make it an intimidating, even overwhelming paper, since itrequires more than a bit of pluck to challenge a work that appears to beso closely tied to well designed and replicable research on attachmentbehavior. Another reason that the paper is daunting is that it appears tobe at the vanguard in the psychoanalytic quest for scientific respect-ability. The paper locates itself at a point of immense sensitivity and ofintense meaning for psychoanalysis today. It speaks to criticisms of thepsychoanalytic community from without and from within about scien-tific respectability. It is an attempt at synthesis of psychoanalytic and

460

Melvin R. Lansky, M.D. is Training and Supervising Analyst, Los Angeles Psycho-analytic Institute; Clinical Professor of Psychiatry, UCLA Medical School.

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psychodynamic wisdom with research from other sciences of behavior,of development, and of the workings of the mind. It responds to whatFonagy has in another context (Franz Alexander Lecture, Los Angeles,2001) labeled as old criticisms: our terms are not operational; we don’thave outcome studies; it is hard to put psychoanalytic assertions asverifiable or, more important, falsifiable; it is hard to add onto psycho-analytic research. And new criticisms: we are not in concert with newbrain and cognitive sciences.

Let me say at the outset that I assume neither that psychoanalysisshould set the empirical sciences as ideals nor that it should aspire toembrace the epistemologic standards of the natural sciences so as to beamong them. I assume, rather, that psychoanalysis might profitably drawfrom those sciences and be informed by them. I join those who applauda disciplined endeavor that points to bridging data from the psychoana-lytic situation with that from the empirical sciences so that psychoanaly-sis is not seen as entirely a matter of simple hermaneutics, belief systems,intuitions, or opportunities for postmodern defiance.

The paper, and Fonagy’s work generally, located as they are at whatis, for us, an intensely charged boundary of synthesis, feel as thoughthey add to us and sustain us in the area in which we most need help. Ithink that this is a truly laudable agenda and a truly substantial accom-plishment, but I do have some questions about the theory, the relationof the theory to the evidence from which it is said to arise, and the lineof support for that theory that Fonagy adduces. Although the project andthe paper itself have many merits, I am going to take a somewhatskeptical stance toward some of its assumptions and even quarrel a bitwith a few of them.

II

Let us look at the theory. It is an integrative theory about a fixationthat originates in attachment difficulties in the earliest caregiver–infant dyad and results in a deficiency of mentation, that deficiencybeing linked to the most important pathological features of borderlinepersonality disorder. In hopes of carrying the line of thinking further,I will raise for consideration some points about integrative theory;about fixation; about the dyad as the unit of fixation; and aboutdeficiency of mentation.

DISCUSSION OF FONAGY ET AL.’S PAPER 461

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Integrative Theory

At this very important time when psychoanalysis is seeking, at timesdesperately, to add to its scientific credibility by synthesis with the studyof human development (our oldest area of synthesis with nonpsychoana-lytic methodologies), the cognitive sciences, attachment theory, andneuroscience, we are in need of a methodology of the integrative methoditself. Psychoanalysis has looked to child development in the works ofAnna Freud (1965), Margaret Mahler (1968), Robert Emde (1983),Daniel Stern (1985) to name just a few of the many contributors to thestudy of child development. The annual, The Psychoanalytic Study of theChild and the Hampstead Index (A. Freud, 1969), Mahler’s research onseparation and individuation, and Stern’s work stand among many, manyattempts at joining psychoanalytic insights with developmental observa-tions. More recently we have seen attempts at links of psychoanalyticthinking with cognitive science (Schore, 1994) and neuroscience (Solms,1997) join the synthetic projects. Fonagy’s and others’ research onattachment is another arena for potentially illuminating synthesis.

We are very badly in need of not just ad hoc synthetic efforts withrespectable sciences of behavior, brain, development, and attachmenttheory, but also of some serious “metatheorizing,” theorizing about theepistemological and scientific status of synthesis itself—some philoso-phy of integration, some metascience to help us evaluate our efforts atsynthesis per se. A skeptic has said that metaphysics is the finding of badreasons for what we wish to believe anyway. We run the same risk withintegrative efforts when we psychoanalysts very much want to believethat our clinical notions have the respectability of scientific credibility.It would be far beyond my allotted length of space to attempt a sketch ofa science of integration, but at the very least, this should include somekind of wariness that the synthesis be that between truly independentfindings, not the product of finding after-the-fact “evidence” for conclu-sions already embraced. There is also the risk that advocates of one oranother epoch of synthetic endeavor develop a facile “psychology”composed of values presumably derived from that synthesis that proves,in retrospect to be oversimplified if not outright incorrect. Cases in pointinclude all-too-simple notions of borderline psychopathology based onoversimplifications of Mahler’s “rapprochement crisis” (Masterson, 1978)or on Stern’s notion of “attunement.” Fonagy presumes that a theoryderived from the study of attachment behavior support his conclusions

462 MELVIN R. LANSKY

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about the mental life of the patient with borderline personality disorderand the treatment of that individual. I have considerable question aboutthe conclusions drawn about mentalization and about therapy actuallyresting on the developmental presuppositions put forward in the paper.Because of Fonagy’s style of citation and adduction of evidence, I cannotpursue his argument from beginning to end. I will comment on this stylelater, but it seems to me that he has simply stretched both his theoriesderived from the study of attachment and his views on the relation ofmentalization to the relation with the caregiver to his preexisting conclu-sions (some of them, quite plausible) regarding the caregiver–infant dyadand from Wilfred Bion’s theory of thinking and its relation to thecaregiver–infant bond—a theory curiously absent from Fonagy’s im-mense list of references. I have, therefore, serious reservations about theimplication that attachment theory research actually points to Fonagy’sconclusions in the way that he seems to think they do. I do have someconcern that Fonagy’s paper draws from a system of psychology derivedfrom Bion’s work. I will return to that point below.

Our notions regarding the task of synthesis per se will inevitably colorthe way in which we select what data we choose to include as central andunder what concepts those data are to be subsumed. I think that theseconsiderations powerfully affect the notions of fixation, of dyad, and ofdeficiency of mentation that are major synthetic foundations on whichthe argument of the paper stands.

Fixation

I turn now to this very basic psychoanalytic concept that is at the centerof any truly psychodynamic understanding of psychopathology. Fromthe viewpoint of psychoanalysis, one views symptomatology as sub-tended between regression (a retreat from something that one fears) andfixation (an attachment to some earlier gratification or mental state thatarose from an overindulgence or deprivation, or some combination ofboth). In early formulations of classical psychoanalysis, in which theterm fixation was introduced, symptomatology is viewed as involvingregression from the fantasied dangers of castration to points of fixationdetermined developmentally and attached to erogenous zones—to oral,anal, phallic levels of functioning. Classical Kleinian psychoanalysis hasa dialectic of regression and fixation which privileges regression from


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the burdens of the depressive position to the fixation to omnipotence inthe paranoid-schizoid position, a fixation which usually includes a typeof fusion (by fantasies of omnipotent control and their confirmation bythe mechanism of projective identification) with a centrally importantother who represents an internal object. Kohutian psychoanalysis, too,has a theory of regression and fixation, the fixation to bonds providingselfobject function for the purposes of establishing personality cohesionand avoiding fragmentation. Within each theoretical framework, one“regresses” from something feared and to a point of fixation—somethingthat either gratifies or offers some secure gratification or state of mind.Fixation, then, is one pole of the dialectic that, psychodynamicallyspeaking, pinpoints our conceptions of psychopathology.

Fixation, though a central concept to many types of psychoanalyticdynamics, is a difficult concept to apply in practice. To posit a fixationas central in pathogenesis and in terms amenable to research verification,one must demonstrate that some failure occurred at a level of develop-ment at which the patient is now stuck and to which he or she returns intimes of anticipated or actual danger. Fonagy’s notion of deficiency ofmentation is presumed to result from environmental failure in combina-tion with biologic givens in the very earliest caregiver–infant relation-ship. It is in some ways an attractive hypothesis, albeit a speculative one,and his line of thinking is filled with clinically tempting bits of insight.But if we take the added step of asking what it would take in the way ofexperimental conditions to establish that the environmental failure tookplace in the dyad as opposed to continuously during development, wewind up with a surprising amount of methodological confusion. Howwould we, in fact, distinguish developmental arrests due solely to prob-lems in the early caregiver–infant dyad from developmental arrests thatare much more encompassing and cumulative? I have in mind here thesituation so commonly found in the study of the family of the borderlinepatient—that there is not only a high prevalence of affect intolerance,empathic failure, and self-preoccupation in a caregiver, but frequentchanges in caregivers due to widespread combinations of characterpathology in the family, that there is splitting within families involvingthe future “borderline” as delegate (Stierlin, 1973), scapegoat, blamedperson, go between, party to cross-generational coalitions and triangling(Bowen, 1966) or violation of generational boundaries when the futurepatient becomes the focus of marital schism or skew (Lidz, Fleck, andCornelison, 1965).


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We do not, in my view, know what it is that is decisively pathogenicabout the earliest dyadic environment of the future “borderline” patientand what is potentially pathogenic that might be amenable to ameliora-tive influence. So many borderline patients suffer not only from dysfunc-tion within a nurturant dyad, but also from a lack of, or even sanctionsagainst, subsequent corrective experiences or, indeed, to any meaningfulattachments outside of the dyad—to father, to siblings, extended family,or to those outside the family, that might offset or compensate for thepathogenic potential of the dyad. My own clinical experience withnonborderline siblings of borderline patients shows in these people a veryhigh prevalence of unmistakably ameliorative relationships—with fa-thers, grandparents, other siblings, teachers, coaches, friends, friends’parents in particular—relationships often actively sought out by theperson who, perhaps, might otherwise have been a “borderline” and thatseemed to offset some of the potentially pathogenic influences of theimmediate dyad.

To presume that attachment difficulties within the earliest dyad con-stitute in and of themselves a point of fixation that locates the pathogene-sis of borderline disorders is to presume that future ameliorative influ-ences are irrelevant. Since none of his data begins from measurabledisturbances in a dyad and proceeds to prospectively study selectedpopulations chosen to control for ameliorative experiences, I don’tbelieve that Fonagy’s data address this point at all, and I don’t believethat we can assume that appropriate data that go beyond the caregiver–in-fant dyad are not relevant.

In short, I believe that Fonagy may have begged the question ofrelevance of data by privileging data reflecting on the caregiver–infantdyad at the expense of data reflecting on the family system over time—data much more difficult to conceptualize and operationalize, but datathat is no less relevant to the task of synthesis bridging the world of theconsultation room to the world of replicable scientific investigation.

The Dyad

Psychoanalysis as a field has from its beginnings to the present day hada strong tendency to privilege data from infant observation or fromobservations made on mothers with children and to regard with mistrustthe many cogent psychoanalytic studies of the family that bear on severepsychopathology. These family considerations became prominent about


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50 years ago with Adelaide Johnson’s notion of superego lacuna, con-flicts in a parent serving as a trigger for the child’s or adolescent’ssubsequent acting out of that parent’s repressed wishes (Johnson andSzurek, 1952). The pioneering work of analysts in the early 1950sinvestigated severe psychopathology as in part a result and in part anadaptation to a pathological family system. The earliest of these studiesfocused on schizophrenia (poorly diagnosed by today’s standards), onmarital tensions, and on adolescent behavior disorders, but the enduringfamily dynamisms described by these early investigators find theirapplication in a very wide variety of psychopathological difficulties inthe “identified patient,” personality disorders most prominently. Theinvestigators include Bateson et al. (1954), Lidz and Fleck (1965),Bowen (1966), Boszormeny-Nagy (Bosormeny-Nagy and Spark, 1973),Stierlin (1973), and Framo (1976), all of whom developed descriptiveterminology to describe the same phenomena found in the families ofdisturbed patients: marital schism (split, conflictual marriages with thepatient in the middle of a marital war) and skew (alterations of familydynamics to accommodate dysfunction in one spouse) and violation ofsexual and generational boundaries (Lidz and Fleck); future patient asdelegate (Stierlin); “trading of dissociations” (Wynne et al., 1958);multigenerational coalitions and triangling (Bowen); “invisible loyal-ties” across generation boundaries (Boszormenyi-Nagy); the return ofinternal objects (Framo); and fixation to dyads (Lansky, 1987). In a morestrictly psychoanalytic context, the work of Shapiro (1979), Zinner(Zinner and Shapiro, 1974), and Scharff and Scharff (1987) has used theconcepts of splitting and projective identification to account for thepathological effects of family systems. Most of these authors describenot only pathogenic family influences, but the toxifying effect of thefuture patient’s being unable to leave the emotional field. Wynne’s“rubber fence,” Bateson’s “tertiary injunction” prohibiting the victimfrom leaving the field, and Lidz and Fleck’s “prohibition of extrafamilialsocialization” are cases in point.

Fonagy’s work systematically omits any consideration of these im-portant and repeatedly verified observations in favor of exclusivelyprivileging the influence of the dyad. I doubt that this privileging willhold up if rigorous studies are employed that consider the pathogeniceffects of the entire family system in comparison with variables drawnfrom the caregiver–infant dyad in the absence of significant familialpathology.


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Yet another consideration that may apply to the privileging of the dyadin a theory drawing from empirical research is that the problem of whatconstitutes data is an easier problem to conceptualize and to operation-alize when the mother–child dyad is considered the unit to be studiedrather than the whole family. Imagine, for example, what data would bepertinent to the unit mother–father–child? There is much data that wouldinclude an absent party, or the discourse of one parent about the other,or the attitudes of one parent toward the other that do not easily lendthemselves to operationalizing. How would one compare the long-termimpact, for example, of a child’s hearing from his or her mother repeatedversions of, “Oh, wait till I tell Daddy, he’ll be so proud” as comparedto the same child hearing the mother’s complaints to others about thefather’s resented absences? It is not always easy to determine, so to speak,where the cameraman would stand to capture pertinent data about themother–father–child triad, much less for larger family constellations. Iemphasize this point because the difficulties conceptualizing and opera-tionalizing extradyadic data are so immense that they tend, I believe, toincline us to favor more easily operationalized dyadic data at the expenseof data pertinent to examination of the family system as a whole.

There is, then, in my view a strong dyadic bias contained in the paperand its choice of acceptable evidence that may arise from preestablishedtheories of fixation (those of psychoanalysis generally), from the Kle-inian/Bionian zeitgeist that further privilege the dyad, or from the com-parative ease of operationalizing dyadic as opposed to family systemsdata in research on attachment.

Deficiency of Mentation

I come now to what I see as a curious omission in this paper which is soreplete with citations to the literature, that is to say, the omission of anyreference to the work of Wilfred Bion (1977), work that has been centralto British psychoanalytic thinking for four decades. Bion’s (1962, 1977)work derives centrally and primarily from his theory of thinking (Lansky,1981, 1998). Bion posits the capacity to think, to process thought(whether by primary or secondary processes), to symbolize, and totransform via dreams, symbols, sublimations as due to what he calls alphafunction—that which has been supplied by the empathic responsivenessof the other (which Bion refers to as maternal “reverie”) to the infant’s


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inchoate and chaotic mental products—beta elements, Bion calls theseparticles that have not been subject to alpha function. Those aspects ofprimitive mental states which have not received maternal reverie remainchaotic, inchoate, unnameable and, in fact, unthinkable. In Bion’s enig-matic wording, the patient “has thoughts, but he can’t think them.” Thatwhich cannot be returned via maternal reverie cannot be thought ortransformed but can only be evacuated through projective identificationand repeated in chaotic behaviors in such a fashion that the future patientcan never really “think” them and consequently becomes doomed torepeat chaotic impulsive action over and over without the capacity tolearn from experience. The borderline patient’s use of projective identi-fication exerts a pressure on others either to collude with that patient’sinternal world in some (usually dysfunctional) way or to leave the scenealtogether.

Bion’s refinement of Melanie Klein’s notion of therapeutic techniquepoints the way toward analytic amelioration: the pressure exerted byprojective identification so that the other is pressed either to collude inan enactment or to leave the field is detected by the analyst in thecountertransference. One hopes that the analyst will neither enter intocollusion with the patient nor leave the emotional field, but rather supplythrough the use of analytic empathic reverie the very alpha function thatis needed to make the chaotic inchoate primitive mental states sym-bolizable, transformable—that is, thinkable. This, in brief, is the theoryof deficiency of mentation in relation to psychopathology that is the basisfor Bion’s theoretical and clinical contributions to psychoanalysis. It isthe very notion of deficiency of mentation that Fonagy has put forwardas the central feature of the psychopathology of those patients sufferingfrom borderline personality disorder. It raises for me the question ofwhether Fonagy’s theory does arise de novo from a consideration of hisdata or whether by conscious choice or otherwise the theory, Bionian atits heart, came first, and studies to support it, only after the fact. Whateverbe its origin, I have some comments on the relation of theory to thera-peutic technique that I will take up in the next section.

These considerations bear strongly on how we are to view the repeti-tive chaotic action and confused mental states that are such centralaccompaniments of borderline personality disorder. Are they basicallydisorders emanating from a deficiency of mentation or are there otherexplanations of the phenomenology of these disorders? I believe thatFonagy’s neglect of nuanced shame dynamics has biased his notions of


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deficiency of mentation and of therapeutic technique away from appre-ciating these central, though often hidden, dynamics.

III

There is much wisdom concerning the treatment of the borderline patientput forward at the end of the paper. Fonagy’s recommendations centeron the enhancement of reflective processes, understanding, and labelingof emotional states with a view to strengthening what he refers to as thesecondary representational system. I agree wholeheartedly with thisemphasis, and I would like to expand on this point. Central to thepsychotherapeutic treatment of patients with personality disorders is thefact that such patients have disconnected and shame-filled dissociatedstates of mind which are preludes to impulsive actions that are the mostvisible pathological feature of overdoses, slashings, domestic violence,blaming bouts in tension-ridden marriages, binge eating and drinking,and chaotic sexual behavior. These unlabeled emotional states, usuallyaccompaniments of disorganized fragmented states of mind, are prodro-mal; they trigger the more visible actions that are the hallmark of thecharacterological problems of severe personality disorders, includingborderline personality disorders and sources of presumed irresponsibleand destructive actions that result in instability of relationships and infailures and rejections.

Let me add a bit about the natural history of disorganization andattempted repair in patients with borderline personality disorders. Somuch of what Fonagy and many others have identified as central to thepatient with such disorders, impulsive action, has a quite distinctivenatural history, one that can be addressed therapeutically only if thepatient can develop some sense of self-reflection into the chaoticallyconfused states of disconnection (about which they feel a sense ofunbearable shame) that are regularly found to be prodromal and to triggerthe more obvious manifestations of impulsive action (about which theymay eventually feel guilt). In a predisposed person, especially the shameprone borderline patient with a pronounced vulnerability to personalitydisorganization, impending intimacy or separation flood that vulnerableperson with shame (at the uncovering of vulnerabilities to exposure orseparation and the intense need of an all important other). The result isfragmentation or a dissociated experience in which the patient is flooded


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with a host of dysphoric affects, most prominently, shame. What we callimpulsive symptomatology is best seen as the most visible componentof a sequence of events aimed at restoring a tenuously held and recentlyendangered or lost sense of self and an optimal distance to supportiveothers (Lansky, 1989). This restoration is often accomplished by instill-ing in others a kind of terror in the face of destructive acts such asself-harming or violent actions or binge drinking, and blaming bouts indysfunctional marriages.

I have argued elsewhere (Lansky, 1997) that phenomena often inter-preted as manifestations of envy are, on careful scrutiny, regularlytriggered by such shame conflicts, i.e., the results of signal affect re-sponding to the felt immanent danger of shame producing disorganiza-tion. However tenuously, the impulsive and often envious action, byintimidation or by transmission of sheer terror, binds others to thepreviously disorganized person. That this repetitive pattern is in the longterm both unstable and costly, usually engendering failures and rejectionsin the long run, is precisely what is self-destructive and pathologicalabout borderline restitutive mechanisms that deploy impulsive action. Itis a central aspect of the effective therapy of such impulse-ridden patientsthat the therapy, by overcoming some of the shame associated withawareness of the propensity to disorganize and of the desperate need forpeople, allow the patient to reflect on and to acknowledge these prodro-mal mental states and especially the shame connected with the awarenessof them and the triggering effects of those shame conflicts on morevisible impulsive actions. It is not clear from any of the data that Fonagyhas presented—whether the difficulty in bringing these chaotic, shame-filled mental states to awareness results from a basic deficiency inmentation (that is to say, an interpretive reconstruction of the origin of acontemporaneous experience of disorganization and disruption) or alter-natively from the borderline patient’s being flooded with shame that isfelt to be unbearable (a more phenomenologic line of thinking, but onethat does not rule out exploration of the origins of the disruptive state ofmind) at seeing him or herself as desperately in need of people forcohesion and disorganized if such persons are not an optimal distance.Whether the shame dynamics or the deficit in mentation or some other,as yet unidentified factor be primary, the result is the same—the patient’sincreasing awareness (and toleration of that awareness) of these shame-filled, disorganized, chaotic mental states that trigger dysfunctionalsymptomatic action are indeed the starting point in the patient’s control


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over psychopathology that otherwise heads relentlessly toward disrup-tion of bonds and rejection by desperately needed others.

I close with an observation about Fonagy’s style of evidence adduc-tion, which I find extremely problematic. I found this paper, stimulatingas it is, quite difficult to discuss because of the enormous numbers ofimaginative leaps from presumed hard evidence to wishful inference atalmost every step in what amounts to be a very complex argument infavor of the theory advanced. There are 129 references in this relativelybrief text, enough to intimidate many readers who will not have read themand will not be referring to them to verify Fonagy’s conclusions. I foundvery few of the ones with which I am familiar to be convincing supportsof or additions to the line of thinking, and many so generally applied asto be totally irrelevant to the line of thinking. Of the many referencescited with which I am not familiar, not one was explored in the text in away that would convince me that evidence was adduced that actuallypointed to the theory he was advancing. Although I cannot make a finaljudgment in the absence of actually studying all of the references, I haveconcerns that the method of scholarship seems to have more of arhetorical than a truly scientific impact.

Despite these reservations and criticisms, I regard Fonagy’s essay asa significant contribution. His work generally and this paper in particularhave added a new dimension in regard to which psychoanalysis and theempirical sciences can mutually inform each other. I am honored to havehad the opportunity to offer my thoughts.

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Discussion of Peter Fonagy et al.'s “The Developmental Roots of Borderline Personality Disorder in Early Attachment Relationships: A Theory and Some Evidence”