Tài liệu A Matter of Security The Application of Attachment Theory to Forensic Psychiatry and

A Matter of Security

other books in the series

Ethical Issues in Forensic Mental Health Research

Edited by Gwen Adshead and Christine Brown

ISBN 1 84310 031 2

Forensic Focus 21

Therapeutic Interventions for Forensic Mental Health Nurses

Edited by Alyson M. Kettles, Phil Woods and Mick Collins

ISBN 1 85302 949 1

Forensic Focus 19

Personality Disorder

Temperament or Trauma?

Heather Castillo

ISBN 1 84310 053 3

Forensic Focus 23

Violence and Mental Disorder

A Critical Aid to the Assessment and Management of Risk

Stephen Blumenthal and Tony Lavender

ISBN 1 84310 035 5

Forensic Focus 22

Forensic Psychotherapy

Crime, Psychodynamics and the Offender Patient

Edited by Christopher Cordess and Murray Cox

ISBN 1 85302 634 4 pb

ISBN 1 85302 240 3 two hardback volumes, slipcased

Forensic Focus 1

A Practical Guide to Forensic Psychotherapy

Edited by Estela V. Welldon and Cleo Van Velson

ISBN 1 85302 389 2

Forensic Focus 3

Forensic Focus Series

This series, edited by Gwen Adshead, takes the field of Forensic Psychotherapy as its focal point,

offering a forum for the presentation of theoretical and clinical issues. It embraces such

influential neighbouring disciplines as language, law, literature, criminology, ethics and

philosophy, as well as psychiatry and psychology, its established progenitors. Gwen Adshead is

Consultant Forensic Psychotherapist and Lecturer in Forensic Psychotherapy at Broadmoor

Hospital.

Forensic Focus 25

A Matter of Security

The Application of Attachment Theory

to Forensic Psychiatry and Psychotherapy

Edited by Friedemann Pfäfflin and Gwen Adshead

Jessica Kingsley Publishers

London and New York

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and Patents Act 1988.

First published in the United Kingdom in 2004

by Jessica Kingsley Publishers Ltd

116 Pentonville Road

London N1 9JB, England

and

29 West 35th Street, 10th fl.

New York, NY 10001-2299, USA

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Copyright © Jessica Kingsley Publishers 2004

Library of Congress Cataloging in Publication Data

A CIP catalog record for this book is available from the Library of Congress

British Library Cataloguing in Publication Data

A CIP catalogue record for this book is available from the British Library

ISBN 1 84310 177 7

Printed and Bound in Great Britain by

Athenaeum Press, Gateshead, Tyne and Wear

Contents

Foreword 7

Friedemann Pfäfflin, University of Ulm, and Gwen Adshead,

Broadmoor Hospital

Part I: Theory

1. The Developmental Roots of Violence in the Failure of

Mentalization 13

Peter Fonagy, University College London

2. Attachment Representation, Attachment Style or Attachment

Pattern? Usage of Terminology in Attachment Theory 57

Thomas Ross, University of Ulm

3. Fragmented Attachment Representations 85

Franziska Lamott, University of Ulm, Elisabeth Fremmer-Bombik,

Hospital for Child and Youth Psychiatry, Regensberg and

Friedemann Pfäfflin

Part II: Clinical Issues

4. The Link Between Childhood Trauma and Later Violent

Offending: The Application of Attachment Theory

in a Probation Setting 109

Paul Renn, Centre for Attachment-based Psychoanalytic

Psychotherapy

Part III: Institutional Issues

5. Three Degrees of Security: Attachment and Forensic

Institutions 147

Gwen Adshead

6. Forensic Mental Health Nursing: Care with Security

in Mind 167

Anne Aiyegbusi, Broadmoor Hospital

7. Finding a Secure Base: Attachment in Grendon Prison 193

Michael Parker, HMP Grendon, and Mark Morris, The Portman

Clinic

Part IV: Research Data

8. Attachment Representations and Factitious Illness by Proxy:

Relevance for Assessment of Parenting Capacity in Child

Maltreatment 211

Gwen Adshead and Kerry Bluglass, The Woodbourne Clinic

9. Violence and Attachment: Attachment Styles, Self-regulation

and Interpersonal Problems in a Prison Population 225

Thomas Ross and Friedemann Pfäfflin

10. Attachment Representations and Attachment Styles in

Traumatized Women 250

Franziska Lamott, Natalie Sammet, psychotherapist in private

practice, and Friedemann Pfäfflin

Conclusion: A Matter of Security 260

Gwen Adshead and Friedemann Pfäfflin

The Contributors 266

Subject Index 269

Author Index 276

Foreword

Attachment theory as developed by John Bowlby has since the 1960s stim￾ulated theorizing about the normal and psychopathological development of

children, women and men. In an unprecedented way it demonstrated how

psychological functioning depends on adequate emphatic interaction from

the very beginning of life. The quality of the interaction between the

newborn and his or her caregiver, the attachment patterns experienced, the

developing process of mentalization of these experiences and the resulting

attachment representations are crucial for how an adult will interact with

other persons and his or her environment.

Taking this into account, it is not surprising that forensic psychothera￾pists and psychiatrists enthusiastically engage in attachment research, using

its achivements for a better understanding of their clients and for the

improvement of the care they offer, both as individual therapists and as pro￾tagonists of the systems of detention in secure psychiatric units and in

prisons, which have to offer a milieu of security for the sake of society as

well as staff and their clients. In both settings one finds an accumulation of

failed primary attachment processes that need remedy to interrupt the

‘circuit of misery, violence and anxiety’ which Sherlock Holmes (Conan

Doyle 1895) identified as one of our greatest problems, and which Murray

Cox, the founder of the Forensic Focus series, cited in his seminal work,

Mutative Metaphors in Psychotherapy. The Aeolian Mode (Cox and Alice

Theilgaard (1987), London: Jessica Kingsley Publishers.

This volume gathers a body of original work on attachment theory

applied to forensic psychiatry and psychotherapy, and also some previously

published seminal work from this field.

In the first section on theoretical issues, Peter Fonagy gives a survey of

research findings on the developmental roots of violence in the failure of

7

mentalization. He focuses on a time of violence which is predominantly

encountered in the lives of forensic psychiatry and psychotherapy patients,

and which is embodied as an act of overwhelming rage, and he suggests

‘that violent acts are only possible when a decoupling occurs between the

representations of subjective states of the self and actions’. Paradoxically, he

comes to the conclusion that ‘violence is a gesture of hope, a wish for a new

beginning, even if in reality it is usually just a tragic end’.

Thomas Ross examines the heterogeneous terminology used in attach￾ment theory and research. According to him, the terms ‘(attachment) repre￾sentation’, ‘(attachment) style’, and ‘(attachment) prototype’ are usually

used adequately and in accordance with the corresponding construct. They

denote an intrapsychic mode of handling interpersonal relationship experi￾ences (attachment representation) or relate to manifest behavioural corre￾lates of attachment (attachment style). When the focus is on testing clinical

hypotheses and the differentiation of manifest attachment behaviour (‘at￾tachment style’), the usage of ‘attachment type/prototype’ seems appropri￾ate. ‘(Attachment) pattern’ and ‘(attachment) organisation’ are applied in

inconsistent ways in the literature. The terms ‘attachment status’, ‘attach￾ment quality’, and ‘ attachment classification’ (as a result of a classification

process) are not really helpful, or rather useless, as they do not add informa￾tion beyond what is denoted by the above-mentioned terms. Furthermore,

they contain social connotations, which might lead to misunderstandings

when discussing human attachment. The same applies to the occasionally

used terms ‘attachment pathology’ and ‘attachment difficulty’. They imply

social judgments that are not empirically justified.

Drawing on incoherent narratives from the investigation of women who

have killed, Franziska Lamott, Elisabeth Fremmer-Bombik and Friedemann

Pfäfflin suggest classifying them as ‘fragmented attachment representa￾tions’ (FRAG), thus taking their specificity into account, instead of using the

category ‘cannot classify’ (CC).

In the second section, clinical issues are presented that reflect the appli￾cation of attachment theory to individual treatment. Paul Renn gives a lucid

report of the validity of attachment theory when applied to short-term

counseling in a probation setting, which may encourage other clinicians to

make use of it.

The third section deals with clinical and institutional aspects of attach￾ment theory within the framework of settings typical for forensic psychiatry

8 A MATTER OF SECURITY

and psychotherapy. Gwen Adshead emphasizes the need for psychiatric

secure institutions for forensic patients to truly provide a secure base for

dealing with intrapsychic as well as interactional conflicts. Anne Aiyegbusi

exemplifies the significance of attachment theory for the milieu of forensic

institutions, and especially for the work of nurses. Michael Parker and Mark

Morris draw on their experience of reflecting on attachment theory for

practical purposes in a prison setting.

The fourth section reports attachment research data on specific forensic

patient samples. Gwen Adshead investigates the precursors of personality

disorders and identifies attachment shortcomings in childhood as a

prominent cause of the development of a personality disorder. Thomas Ross

and Friedemann Pfäfflin investigate attachment styles, self-regulation and

interpersonal problems in a group of 31 imprisoned offenders convicted of

at least one violent crime against another person and serving a prison

sentence of at least three years. Their data are compared with the data of two

comparison groups of non-violent men, prison service trainees and

members of a Christian congregation. Finally, Franziska Lamott, Natalie

Sammet and Friedemann Pfäfflin report comparative attachment data from

samples of women who have killed and been sentenced to either imprison￾ment or detention in a secure psychiatric hospital, and a group of women

who escaped domestic violence by taking refuge in a women’s shelter.

In a concluding chapter the editors reflect on the benefits that forensic

staff may draw from attachment theory, as well as from attachment research,

for their work. Providing a secure basis for patients as well as for staff seems

to be essential in order to deal with former deficits of attachment develop￾ment and to increase security for patients, staff, and society at large.

Friedemann Pfäfflin and Gwen Adshead

FOREWORD 9

Part I

Theory

CHAPTER 1

The Developmental Roots

of Violence in the Failure

of Mentalization1

Peter Fonagy

INTRODUCTION: THE NATURE OF VIOLENCE

This chapter will argue that interpersonal violence is difficult for us to con￾template, precisely because it is ultimately an act of humanity (Abrahamsen

1973). We wish to avoid that which is potentially a part of all of us. Both the

glamorization and the demonization of violence, strategies which are

familiar from the media, serve to distance us from an experience that may

not be far from any of us; they help us avoid having to understand violent

minds. It is as if contemplating these minds creates such intense fear and

helplessness that the mere act of thinking about them becomes impossible.

While failing to explore intrapsychic factors may help us to obscure the sim￾ilarities between our sense of ourselves and our sense of violent human

beings, it also blocks off any insight into how these individuals feel and

think. We must enter the violent person’s psychic reality, not just in order to

be able to offer treatment, but also to better anticipate the nature of the risks

they embody both to themselves and to society (Cox 1982). The attempt at

explanation does not amount to an exculpation, but understanding is the

first step in preventing violence. The answer to the riddle of how an individ￾13

ual can lose restraint over their propensity to injure others must lie in what is

ordinary rather than extraordinary: normal human development.

There are many ways of categorizing violent acts and it is unlikely that

any single set of ideas will be able to explain all the different types. One

approach has been to distinguish three types of violent acts. The first

consists of violence when it occurs as an act of overwhelming rage. At these

times it often appears disorganized as an act, propelled by massive affective

outflow or discharge. The second type of violent act appears as a gratifica￾tion of perverse or psychotic motives. In this context the act appears

somewhat more organized and there is a predatory character to the motive

state of the violent individual. The unfeeling, prototypically psychopathic

character of violent acts may be most obvious here. Finally, violent acts fre￾quently occur in part fulfilment of criminal motives. Such acts of violence

may be either organized or disorganized. While single acts of violence often

do not match any of these prototypes particularly well, some kind of

division of violent acts along these lines has to be accepted. This chapter is

mainly concerned with the first type of uncontrolled, affective, disorga￾nized violent act, regardless of the criminality of the motives.

There is an immense multidisciplinary literature on the subject of

violence. From these we know that poverty (Laub 1998), access to weapons

(Valois and McKewon 1998), exposure to media violence (American

Academy of Child and Adolescent Psychiatry 1999), academic failure

(Farrington 1989), impersonal schools (Walker, Irvin and Sprague 1997),

gangs (Bjerregaard and Lizotte 1995), rejection by peers (Elliot, Hamburg

and Williams 1998; Harpold and Band 1998), ineffective parenting (Wells

and Rankin 1988), lack of parental monitoring (Patterson, Reid and

Dishion 1992), exposure to domestic violence (Elliott et al. 1998), and

abuse or neglect (Smith and Thornberry 1995) are all associated factors.

Commonly in the history of violent individuals we find childhood hyper￾activity, attention or concentration deficit and impulsivity (Loeber and

Stouthamer-Loeber 1998), or adult psychiatric problems. Perhaps most

relevant for our purposes are recent studies that have found a link between

narcissism and violence, where violence can be seen as a response to a threat

to an exaggerated or grandiose self structure (Bushman and Baumeister

1999).

While such ‘facts’ of social violence paint a picture of the individual

most likely to be at risk, they do not capture the essential nature of the

14 A MATTER OF SECURITY