Psychiatry & Psychotherapy Podcast - Disorganized Attachment: Fear without Solution

Episode Date: July 25, 2020

When people dissociate, it means they feel disconnected from their body. They feel fear and dread, sometimes feeling completely frozen. As mental health professionals, understanding disorganized attachment gives us appreciation and understanding for the necessity of empathy, attunement and deeply understanding the experience of another. In this episode, Dr. Puder is joined by Dr. Annabel Kuhn to discuss disorganized attachment.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

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Welcome back to the podcast. I am here with Annabel Kuhn. She is a fourth-year medical student who has done some digging with me over the past about six months on a topic of disorganized attachment. This is going to kind of build upon my Therapeutic Alliance attachment episode, but it will also stand alone. If you don't know what disorganized attachment is, we're going to get into that. We're going to talk about why it's an important construct, what it looks like at different ages. what the risk factors are that lead to disorganized attachment. We're going to talk about the parents of kids with disorganized attachment.

We're going to talk about genetics. And the exciting thing is that I have never dug so deep into this topic until we worked together on this. We looked at two books that were out there. And then we looked at pretty much every article that's been written since. And some of our articles are like 2019. So there's no way that you won't learn something about disorganized. I watched every YouTube video on disorganized attachment.

This is probably the deepest dive that I've seen out there. So please welcome Annabel. Thanks for having me. Yeah, it's been a lot of digging, as you said. And I've learned a lot, and I hope everyone listening learns a lot too. I think it's a really interesting topic. Yeah. So maybe I'll start out a little bit, and then we'll go back and forth, ask some questions, talk about this.

But we're talking about about 15% of infants in middle class families, 34% in low-income families have this thing that's called disorganized attachment. And I think that the biggest kind of one-liner for disorganized attachment is fear without solution. So these kids will have this intense fear in the midst of something stressful, but they don't have a solution to utilize an attachment to move out of the stress. Okay. So disorganized attachment is associated with future dissociative symptoms in adolescence and adulthood.

And it's one of the clear connections that we have between like what's going on at one year of life and dissociative symptoms and adolescent and early adulthood. Yeah. And I think there's a lot of studies that say disorganized attachment can cause or like be what happens before somebody like maybe diagnosed with like borderline personality disorder or something or there's other studies that say maybe major oppressive. But the clearest like thing that we have found is that disorganized attachment is like very much linked to like dissociative symptoms. So dissociation is kind of like that not feeling connected to your body, feeling maybe intense fear, feeling kind of frozen, like just kind of dread. It's sometimes mixed up with

panic attacks, often have patients who come in with maybe a history of trauma, and then they'll have these like panic attacks, but they're not like just purely panic. That's also like got this traumatic sort of dissociative vibe from it. And I think a lot of, a lot of people when they hear panic attacks, they don't think is this dissociation. But a lot of, lot of times it is more of a dissociation that they're describing in the midst of that. Okay. So what is disorganized attachment? In short, it's a category that's assigned to children who exhibit certain behaviors during what's called the strange situation procedure. And that sounds very strange. And it is a standardized

procedure that was created in the 1980s, maybe. 60s, I think, right? 1960, excuse me. Yes. Mary Ainsworth, you know, observing these infants, what happens to the infants when you leave them alone in a room and then when the mother comes back into the room? That's the question. Exactly.

And so the behavior that an infant exhibits, like when the mother comes back into the room, is the behavior that would classify an infant as having disorganized attachment. Yeah. So a normal infant was, you know, would be left in the room. room, there's some toys there, and then when the mother comes back into the room, will come towards the mother, maybe cry for 30 or so seconds, the mother consoles them, and they pop right back into joy. Okay.

But these children are best thought of as fear without solution. So the child is afraid of these situations, but is unable to get comfort for, from the caregiver and lacks an organized strategy to deal with the stress of separation. Right, exactly. Like, they may initially go towards the caregiver and then shy away or something like that. So it's like a, it's like they go towards, but then they stop, right? Right. Yeah.

And you can have a kid that, like, has these pauses sometimes when they're going back, they just like freeze. Yeah. Right. Mm-hmm. They can display contradictory behavior. Right. And they can sometimes display like unusual movements.

Like sometimes like they were, they could be seen like stumbling, but only when the parent is present or like what was described as underwater type of movements. Which I thought was interesting. And like trans like expressions. Right. Essentially they're describing something that looks kind of like an adult dissociation. you know, freezing, stilling, weird, weird movements. Sometimes I'll have patients in the intensive outpatient program who will have like psychogenic seizures.

They'll start like moving their body, groaning. These events, you know, a real seizure may last two minutes. These will last for 30 minutes to two hours. Oh, wow. You know, no real seizure that lasts two hours will leave the person normal, you know. So something that's going on two hours a day. It's probably more of a psychogenic seizure, but it's a dissociative episode. So they're having these sort of movements, slowed, underwater movements, trans-like expressions, apprehension towards the caregiver, hunched shoulders, fearful facial expressions.

When I hear that, I almost think about like all of these are kind of like, in the polyvigal theory, I talk about like this kind of dorsal vagal kind of like body posture. You know, where they're hunched over. They're kind of curled up in a ball. Interesting. Disoriented wandering, confused, dazed expressions, multiple rapid changes in affect. So they're not really connected to their surroundings. They're not really, you know, plain.

They're definitely not plain, right? Right, right. And it's very different from other types of attachment patterns. Like we talked about, like, the secure pattern. And there's also other patterns, like avoidant pattern, would be like when the infant shows a delayed inclination to approach the caregiver. And then there's the ambivalent or resistant pattern in which an infant displays anger or like passive, helpless distress to maintain the attention of the caregiver. Yeah. So the avoidant, they usually distract themselves with toys.

and they have stressed, their cortisol is elevated higher than a secure attachment child. In the avoidant pattern? In the avoidant. So they're distressed while playing with toys when the mother reenters the room. It's almost as if like I know that the most adaptive thing for me to do is just to, okay, I'm observing my mother, but I'm just going to regulate by toys. So they don't use the mother to help them regulate. Sure.

And, you know, women dating a very avoidant man will often feel very out of control when his coping mechanism is just to look stoic, distant, you know, disconnect, right? Interesting point, yeah. Yep. Okay. Ambivalent, resistant. That was the other one you mentioned. So these children are displaying anger. often at the caregiver, so they'll come up to the caregiver.

It'll take them a lot longer to be consoled, but they want to be consoled. Sure. Okay. So those two that we just described are different from disorganized attachment. Yeah. So, you know, initially it was only secure, avoidant, and ambivalent. And then historically, they were like, wait, there's this other type. And that's when they classified the disorganized attachment.

So like we sort of spoke about, disorganized attachment has different implications for later on in life. And so I guess we could sort of start by talking about what it looks like at four months old. So the strange situation procedure is typically done when the child's around a year old. So this is a study that sort of talks about what it might look like in a four month old. So before a person could even be classified as having a disorganized attachment pattern, what are they? what do they act like yeah so beatrice bebebe great researcher on this sort of early development really influenced my ideas on you know affective mirroring the power of you know sort of the dyad in psychotherapy and what she observed was that at four months um you could predict the attachment

pattern at 12 months and so we have these images of what some of these like disorganized future disorganized children, what their dyad look like at four months, right? So it's always a diet. So there's a back and forth going on between the mother and the infant. Right. And so, you know, in a normal child at four months, infant smiles, mother smiles. Infant's distress, mother looks concerned. Infant wants space.

Mother backs up, gives the child space. Infant wants engagement. Mother moves in to engage. So there's this mirroring. there's this back and forth. The child is being responded to. Whereas in this disorganized, future disorganized child, the child would maybe look angry and the mother's surprised. The child is looking away and wants space. The mother looms in. The child is happy and mother has an angry expression.

And so there's this mismatch going back and forth. And so there's things like less affectionate touch between the mother and child. The infant touches himself or herself less frequently. And the infant is more distressed. So there's more facial expression, voice distress. The infant is more angry, protesting, crying. there's this contradictory conflicting affects between both positive and negative in less than one second. So there's quick movements and contradictory affects.

And you have the mother looking away for longer periods and unpredictably, you know, responding or looming in, the mother not following the infant's emotions. The mother is positive when the infant is distressed. the mother has like the still face or the face is overly stable when the infant's trying to interact. So it's kind of sad talking about it actually thinking about dyads like this because it's tough. But this is what it looks like at four months of age. Right. So it seems like there's like a lot of disorganized attachment has a lot to do just like by the very

nature of it with the infant and the caretaker rather than just like the infant by himself or herself. It's interesting to keep in mind that these interactions are crucial. I'm glad that I had that I had read a bunch of this stuff before I had kids. Yeah. Honestly. And with the residents that I trained when they have kids, I always talk to them about Beatrice B.B. and the importance, you know. Well, we talk about this. in the psychotherapy training that I do at Loma Linda, but I really emphasize the importance of the first months of life. Right.

I've had guy friends who like don't get it. And they're like, I just don't get it. It's hard to interact. It's like, I don't know what to do. And so showing them some of these pictures talking about this, all of a sudden there's like something clicks in them of the importance of this early interaction. It's interesting. Yeah. You know, and I also think what would lead to a dyad not going well?

You know, if mothers hopped up on meth, you know, there's a lot of reasons that the mom could be really severely disconnected where you would have this sort of early issue with connecting. And we'll get into that. We'll talk about all these. Yep. Okay. Let's get into middle. childhood. Yeah. So middle childhood. So we took a look at one study from 2009 that talked about how children who are characterized as having disorganized attachment during infancy were described as exhibiting controlling behavior towards parental figures. And so the child is attempting to

assert authority over the parent. And that was seen at age eight. They called it exhibited. punitive and disorganized behavior at age eight, but only within families with clinical risk factors. That's really interesting to me. And they didn't really specify what those clinical risk factors were. They just said that they were referred for clinical home visiting because of concerns about the quality of the parent-infant relationship. So they didn't touch more on what exactly those risk factors were. It's interesting.

Well, someone had raised a red flag. Right. So you can imagine if you're like a social worker or someone who's working with, you know, mothers with kids and you kind of like notice there's something off there, right? It raises a red flag. Let's let's get a, let's get clinical home visit to see how that relationship is. And so these are the kids that had, they had punitive and disorganized behavior at age eight. if they had that risk factor with 12 months of age having the disorganized attachment classification. Right. Okay. Okay. Yeah, so tell me about this 2012 study on the callous unemotional traits. Sure.

So this 2012 study found that kids between ages 3 and 8 who demonstrated callous unemotional traits were significantly associated with disorganized attachment. patterns. Yeah, and this was boys, 55 boys specifically, age 3 to 9, who had been referred for conduct problems. And they assessed the attachment issues, not at one year of life, but using this Manchester Child Attachment Story Task, which looks at like their attachment themes. so in that age that they were referred.

So is that sort of like a strange situation procedure, like type of way to classify attachment patterns, just not at one year? It's another method of doing it. Obviously, you can't do the strange situation when they're nine years old. Sure. And so, you know, there's other measures that they look at

on how kids are attaching. Yeah. So they have like kids, you know, they have like, like, stories where they enact using dollhouses and play furniture and figurines and they can they have representatives of the child and the mother, the primary caregiver. And then you kind of look at attachment related solutions in the midst of the stories and, and the stories that the kid creates, you know? Right. Yeah. Okay. So they have this method. And what's interesting about this is

you get this, specifically the callous unemotional aspects of more of the antisocial conduct disorder kid is linked to that disorganized attachment. It's interesting. Yeah, the high levels of callous and unemotional traits were strongly associated with it. And boys. And the other thing that was very interesting about this was that what was not connected to this callous unemotional traits, it was not associated with avoidant representations,

which is what you might think initially, right? Oh, right, absolutely. You might think, oh, this is more of an avoidant child, but really it's more of the disorganized attachment. Right, which is interesting. And yeah, something you might not expect. Okay, so let's keep going. What does disorganized attachment look?

like during adolescence? So this is sort of where the dissociative symptoms come into play. Studies have repeatedly demonstrated the connection between dissociative disorders and disorganized attachment, and dissociation symptoms extend beyond adolescence and into adulthood, and we'll discuss that later. So I guess I'll talk a little bit about what dissociation is. We kind of mentioned it before, but it's characterized by a dissociation of consciousness. And like minor dissociative states are commonplace.

For example, like maybe someone's becoming so absorbed listening to this podcast right now, like on their drive that they're unaware of the passing landscape. And that's like a minor example of dissociation. But dissociative disorders in contrast involve like dissociation of someone's identity or memory and consciousness. Yeah. Like they may, you know, how did I end up in this? place. You know, you ever, I mean, I think that's normal to some degree, but then like, like, oh, I walked into this room. What did I walk into this room for? That might be normal. But imagine

ending up somewhere and then not remembering what happened in the last two hours or freezing and just feeling very disconnected from your body, like depersonalization, de-realization. Those are both dissociative things. Right. And so, um, considering. perceivably, children who exhibited, and like we talked about earlier, disorganized attachment behaviors kind of represent dissociation. And so it kind of makes sense, like the kids are unable to like go to the parent figure for comfort or reassurance. And it's maybe because the parent has like displayed frightening behavior at home. And the kid is aware of that. and they know that they can't exactly approach the parent for comfort.

Right. The very person that should be comforting them is also very scary and frightening to them. Right. Exactly. Yeah, so there's various studies that show that infant disorganization was associated with higher rates of dissociative behavior, both in elementary school and in high school, as perceived by, like, teachers, using, this teacher report form and child behavior checklist. Also, participants who displayed disorganized attachment and infancy had self-reported more dissociative experiences as measured by the DES, which is the dissociative experiences scale, which is probably one of the best

scales of his dissociation going on. And that was at age 19. Yep, that's at age 19. Yeah. So here's some of the questions from that. So you're supposed to rank yourself from 0% never to 100% always and 10% increments. So some people have experiences of being in a familiar place, but finding it strange and unfamiliar. Select a number that shows the percentage of time this happens to you. Some people find that when they are watching television or a movie, they become so absorbed that the story that they are unaware of other events happening. around them. Select the number of the percentages of time this happens to you. Some people sometimes find that they become so involved in a fantasy or daydream that it feels as though

it is really happening to them. Select the number of times this happens to you. Some people find that they're sometimes able to ignore pain. So that's a way of that you're dissociating away from the pain. Some people find that they sometimes can sit staring off into space, thinking of nothing and not aware of the passing time. They find themselves, they're able to talk out loud to themselves. They find that they can act so differently compared with another situation where they feel almost as if they were different people. So in two different situations, they can act two very, very different ways. Wow.

So we'll put this on our blog, PDF that we'll put in the resource library if you want to go through and see how you score on this, the dissociative experience scale. But this is what's linked to disorganized attachment early on. Yeah, absolutely. And one of the books we read said actually that the only clear connections between infant attachment and adult psychopathology is between disorganized attachment. and dissociative symptoms in adolescence in early adulthood. So, yeah, definitely a major player in this discussion. And I think where this is helpful as clinicians is realizing then what they really need is attunement and they need that empathy and they need that connection.

And I think this is what allowed the different psychotherapies that have helped people with dissociation, help them because you have people who are attuning to their real self. So for example, in my men program, we don't attune to the illness. So we don't give a lot of energy to the illness narrative, the part of them that maybe they used to get connection through. So a lot of people who have a high rate of dissociation, they find ways of getting connection that are not really their experience, but it's a way of getting a pseudo-connection.

Like I'm going to show up to the ER and I'm having these psychogenic seizures and all of a sudden all these important people are giving me attention. And so it's like a kind of a pseudo attention mirroring, but it's not really who they are because who they are is like their strengths and their personhood. And so what we do is we give that a lot of energy. when we see something real, we give it a lot of energy. And sometimes when I'm talking to someone who's a high dissociation type person, the way that I know what's real is I look at their micro expressions. So this goes back to my therapeutic or my microexpression series, because you can see the real emotions.

And so that's worth mirroring. That's worth giving empathy to. When you see someone experience something real, right? Because micro expressions are 100% real. like that's a real emotion in their brain going off. If they flash anger, somewhere inside of them, they could be the most passive,

dependent person, but they flash anger, and therefore that's an experience of, that's a significant experience of maybe repressed anger or something that they feel angry about, but they can't just get access to. So like something like, like if we're just having a pleasant conversation

and then all of a sudden a patient like flashes and anger, micro expression? Are you saying like that might be like a sign of dissociation? Maybe they're dissociating from the anger. So you can have very polite people who learn very early on that for whatever reason it's better not to be angry. Especially, you know, in our culture, females are not allowed to be angry, you know, as much as boys. And so you can be sad, you can be fearful, but you can't be angry. And so there's this whole movement. and there's a whole series of books out there for women who have issues finding their anger. You know, how do you have boundaries?

You get in touch with your anger. How do you have a voice? You get in touch with your anger. How do you argue for a raise when you deserve a raise? You get in touch with your anger. And the anger is what gives you the courage to have the voice. But people, a lot of the times, think of anger as very pejorative, is a bad thing. I don't see it as a bad thing at all.

I see it flash on the face. and it's when someone's passionate about something, it flashes on the face, when they want to have a voice, when they want to have a boundary, when, you know, and then it's often directed at themselves. It's like the anger is directed at themselves,

and so they feel guilt, they feel shame for, I am bad rather than I should have a voice, right? And so maybe that's what's happening, by the way, by and large, in our culture and our society with the race wars going on. All of a sudden, you have a whole group of people whose anger has been suppressed. They weren't allowed to have anger.

They were told to just get along, to be passive. And all of a sudden, now they can have a voice. And so there's the anger. It's right there. And you know what? I think they're entitled to feel angry. They're entitled to feel angry about a lot of injustices that they felt throughout their life. And I think we need to listen, right?

And so. So, yeah, it happens on me. multiple levels like that, right? Where it's like you have, but coming back to this four month old, this four month old is not mirrored, is not reflected upon. And therefore, they don't know what they feel. Yeah. And if they don't know what they feel, then they go into their adulthood, not knowing what

they feel and they're, they dissociate. When any emotion gets too strong, they dissociate. When any stress comes up, they just, they disociate. up, they dissociate, and it can look very different for men. Like in these boys, the boys work with conduct disorder, right? Right. Because they're boys. They're wired different. They have testosterone levels that are different. They have, they're acting out the level of disconnection. Maybe they're acting out to get connection. They're acting out to feel heard right away, where maybe it's different for different people. And, you know, there's a bell curve and a, you know, some, some people are

going to have, like, two standard deviations for their gender, one where and two standard deviations the other way. So it's not always the same. But in general, the study that we looked at with the early kids, it was the, it was the callous unemotional traits that they were looking at. That was the disorganized stuff. Right. All right. So let's talk a little bit more about what disorganized attachment looks like in adulthood. So we have the adult attachment interview in which you can sit down, you can talk with an adult, ask them about their life, and then you rate them based on their ways of talking about their childhood, their ways of talking about what's happened in their life. And so in this adult attachment interview, you have secure and insecure. And then on top of that,

you add on this sort of unresolved or disorganized marker. So you can be secure, unresolved, disorganized, or insecure, unresolved, disorganized. So what is unresolved, disorganized? Sure. So someone who would be classified as unresolved disorganized would display lapses in the monitoring of their reasoning or discourse, especially when discussing their experiences of loss and abuse. And these lapses include highly implausible statements regarding the causes and consequences

of traumatic attachment-related events and loss of memory for attachment-related traumas and confusion and silence around discussion of trauma or loss. Yeah. So maybe they're talking about something traumatic from their childhood and then they just go blank for like, you know, 20 seconds. or maybe they're missing big chunks of what actually happened in that traumatic situation. Or maybe there's confusion, you know, don't quite remember it. And it's like it's not making sense.

There's implausible statements, meaning, you know, like my dad was, my dad was an amazing man. And he also sexually abused me. And, you know, so it's like they're pairing sometimes things that don't really fit together, right? in the same spot. So they haven't really made sense of the situation. They don't have a, they don't have a cohesive narrative of the traumatic experience. And that's like similar to disorganized attachment in infancy.

Yeah. Yeah. And so just to go over like what is a secure, you know, a secure autonomous individual, this is someone who has a coherent description of early attachment relationships. They freely express emotions and discuss

concrete examples of both positive and negative early relationships. They view attachment-based relationships of being influential to their own personal development. And so, you know, I can always tell when someone's done

the work of some trauma in how they're able to tell the story. You know, maybe there's distress while they tell the story. It's usual to experience some distress. Also, you know, if the story is distressing and it's unresolved, maybe it's floating around in their unconscious where it's like in their dreams and it's in their, you know, it slips out, right? So that would be a way of me deciphering if this trauma is yet to be resolved. Right. And it's not just like

secure versus insecure. There's other types of adult attachment. like including dismissing and enmeshed slash preoccupied. But yeah, we're going to talk more in detail about like the long-term consequences of disorganized attachment and like what else it means besides just being characterized by something on the adult attachment interview. Yeah. Let's talk about personality disturbances. Like do these patients have personality disturbances?

The original pioneers of attachment theory believe that, yeah, attachment difficulties in early life predispose individuals for personality disturbances later in life. And disorganized behavior in infancy may shift to controlling behavior, which talks about can happen in childhood, but it can apparently extend into adulthood as well. And this study from 1999 talks about how individuals with disorganized attachment feel as though they're powerless. And as a result, they often see their peers as a potential threat. And behavior with peers shifts between extreme social withdrawal and extreme aggressive behaviors. Yeah. So powerless. Yeah.

See their peers as a potential threat. so they go they may shift from extreme social withdrawal and extreme aggressive behavior right yeah and so this was kind of some of the early work this is like 21 years ago yeah talking about it and they also said that individuals with disorganized attachment may be perceived by peers as being like weird or annoying and often are subject to peer isolation and social rejection. Yeah. The second big thing that we've already talked about is dissociation.

So they've really linked this. There's dissociative symptoms in adulthood. It's important for clinicians to recognize because the incidence of abuse among people who experienced dissociation has been reported as high as 97%. So like there's... Wow. You know what? Okay. I remember this article is specifically talking about multiple personality disorder.

Oh, okay. And so, you know, that's multiple personality disorder is kind of like a, um, a high level of dissociation. I think I, I just kind of cluster them as like pretty bad dissociation and, you know, kind of more in the borderline personality disorder when I think of that group. Oh, so this, this 97% article was talking about how, like people with multiple personality disorder have high levels of dissociation oh okay yep and with high and high levels of trauma and so yeah i've seen stuff like the worst the trauma the the worst the dissociation is going to be essentially right yeah okay so let's keep you on one study suggested that disorganized attachment behaviors and childhood are phenotypically similar to dissociative states in in adulthood right so

So yeah, that's sort of like what we've talked about. For instance, in the middle of an approach behavior to the parent, the child may suddenly become immobile or unresponsive to the parent's call with a blind look and persist in this state for 30 seconds or more. And it sounds pretty similar to how people experience dissociation in adulthood. Is that right? Yeah. And, you know, since disorganized attachment in children is so strongly linked to unresolved,

adult attachment interview ratings in their parents, these observations hint at possibly an intergenerational transmission of dissociative mental states that is related to unresolved memories of past parental traumas. So this is one of the big kind of like takeaways. I'm just going to like, you know, if you were sort of floating off in your own dissociativeness as you listen to this, which could which could be pretty good. You know, I think it's normal, right, to kind of your mind drifts off when you're listening to something. I'm going to pull you back right now and I'm going to say there is an intergenerational transmission of trauma. So if the parent has unresolved adult attachment interview, which means that there's trauma there that's unresolved, they're more likely to have kids with disorganized attachment.

So the biggest, if you're planning on having kids and you have a lot of trauma in your background, the biggest gift that you could give them today is to work through your stuff in therapy. Okay? Because remember, some patients that I see when they talk about their trauma and they've done a lot of psychotherapy, it reports differently. They're not reporting it in the way where they're having drops in their memory. They're not having dissociative symptoms in the same way that someone who hasn't worked through their trauma, okay? So. So this is sort of like a second generation effect of, um, of trauma, this disorganized attachment. Yeah. You know, and it's like, um, there's a Jewish saying that the,

the sins of the parents go on to the third and fourth generation. And, you know, if you have, let's say, a father who sexually abuses the kid, right? And then the kid goes on and has disorganized, attachment style, and then that affects the kid that they have, that's, there you go, third generation. Right. And then, so this is where, like, you know, there's intergenerational trauma that is sometimes very, very hard to get out of. And I think about this with our discussion of racism.

You know, when you have a group of people that have been experiencing racism for 400 years, there's some intergenerational trauma there. And if you compare, I heard a conservative person say, well, if you look at people who just came from Africa, they score very differently on all these things compared to people who have been here for generations. And I'm like, yeah, because of the intergenerational trauma. Right. And how that is affecting them. And so I think that's like one of the missing pieces that maybe keeps people specifically like, you know, people who don't understand like why this is such a big deal. It keeps them from understanding it because they don't understand this piece of intergenerational trauma. Right. And it's like it's,

I mean, it's at the hands of the systemic racism. And it's like people who haven't been here for decades and decades have not been subject to that. And I mean, it's an interesting parallel that you draw between, I guess, like, trauma within, like, two people versus, like, systemic trauma, systemic racism. What I mean by systemic trauma is, like, trauma done to a whole group of people. Right, right. Progressively for, like, for years and years and years, right? Right.

So it's, like, not only, yeah, I mean, it's like, it's really sad that there's so many young black men in jail. Yeah. Because if you dig into how traumatic jail is right now, it is horrible. It is absolutely horrible. The rape rate is worse for males in jail than it is for females outside of jail. Not to negate how bad rape is for females, but there's more rape that's going on in jails, male-on-male rape, than there is going on outside of jails. That's just how big the problem is.

And so you can imagine going through a system now for, for years early in your childhood. And then when you come out, it's like, how do you get a job? No one wants, you know, someone with a bad background check to do a job. And so it's like really hard to get a job. So it's like you have a whole group of people who are going to have a really hard time for many years to come, even when they get out. So it just gives me fired up because the more I read about it, the more it just pains me,

Especially when, you know, it's not just like it's one side of the aisle, like Democrats or Republicans. Like for the past like 20 or so years, like the jail population has been steadily increasing across the board. Yeah. And for both sides, both sides have been putting in policies that have made it worse. And so, you know, now here we are. Okay. Yeah. I hope now is now is the time that things are going to change.

I mean, there's a lot that has to be done. Well, I think first of all, understanding, right? Especially as mental health professionals, being able to have empathy, especially for people who are coming out of jail, who are struggling with their mental health, who have trauma, men have a lot of trauma. They don't seek health care as much as women. You know, my clinic is not full of men with trauma.

It just isn't. But a lot of times those are the ones, there's a whole group of people that are just silently suffering and their trauma appears in different ways. And sometimes it's that callous unemotional stuff, right? Right. And sometimes it's more acting out more than it is internally suicidal or depressed. So I think as a group of mental health professionals, I think we uniquely are the people that can make a big impact here

because empathy goes a long, long ways and helping like what other ways are there to resolve trauma and then to help someone integrate to the point that on the adult attachment interview they're no longer

going to be unresolved, disorganized. So I really think it's therapy and that's really not in the dialogue, and I think it needs to be in the dialogue more. So something we're going to talk about. Absolutely.

Yeah, therapies can change the attachment pattern, which seems like a tough thing to do, but we'll talk about it more. Okay, so borderline personality disorder. Yes, so dissociation can be a symptom of borderline personality disorder, and so with a strong connection between disorganized disorganized, disorganized, attachment and dissociation, a lot of times like borderline personality disorder gets thrown into the discussion. I tend to think of this borderline personality disorder and the episodes of borderline personality disorder as you have, you have like this episode of dissociation, which is prolonged sometimes

for weeks and it's really hard to break out of it's different than mania because you, if someone's hospitalized with borderline personality disorder, usually within a couple of days, they can snap out of the deep funk that they were in with some good medication. The other thing is borderline personality disorder responds well to treatment where there's prolonged deep connection with those that are treating them. So if you look at mentalization, transference focus therapy, dialectical behavioral therapy, you have prolonged contact with therapists. In mentalization-based therapy, you had partial that went on

for like a year. And we need insurance funding for that kind of treatment. Right. It's like it's a fight and it makes it unfun for me as a provider. If I have to fight with the insurance companies after 20 days or after 10 days instead of being able to get them the treatment that will actually help them. Exactly. Yeah. Okay. So let's talk about like what you actually found in the research for the link here. Sure. So in 2000, there was a longitudinal study that said disorganized attachment and infancy can predict symptoms of borderline personality disorder at age 28. But a study four years later in 2013 said that disorganized

attachment and infancy does not predict borderline symptoms later in life, but it's rather disorganized attachment in middle childhood that is predictive of borderline symptoms. And you know, that's a little hopeful, actually. if you think about it because really what that's saying yeah it's saying that that the early that something can happen between the age of like two to six which reverses the course for some of these kids like we like we found in that other study it was only the kids who had disorganized attachment and they were reported due to something being really wrong at that age of like you know that early, like youth age, right, that had the issues, right? So there's something that can reverse,

it's not a death sentence to have someone who looks a little bit disorganized in infancy. And it's the disorganized behavior in middle childhood that was predictive of BPD because that's closer. Because if it hasn't been resolved yet, it's probably not going to be resolved in that family structure. And this, I may just go on a little bit of a sort of public health digression right here. Yeah. It is not wise to penalize parents in any way if their kid seems to have disorganized attachment. So unlike abuse, like if the kids being sexually abused, you want to get that kid out of that household, right? Whereas with disorganized attachment, that doesn't necessarily, mean you should remove that child. And there were some early sort of people pioneering who thought

that that was the case, that this is the big issue, you should remove them from the household, and that had some huge backfires and bad things. So we do not think that that should be done. And when we get into part two, we will talk about the treatments that are out there for helping the parent connect with their child. And that's, that's exciting too, because as providers, if we are able to screen this, are able to see this issue, we can get them into treatments that are effective. And yeah, and I think that's a good point because, I mean, like we'll talk about later, like maltreatment is a very strong predictor for disorganized detachment. But it's not always what's going on. It's not always what's going on.

Right. Yep. So you're not always going to see like physical abuse. You're not always going to see sexual abuse in a kid that's disorganized. Yeah. But sometimes you will. Sometimes you will. Okay.

So this study. Right. So the security of the infant's attachment behavior was not a significant predictor of the borderline symptoms. Thus, the quality of maternal caregiving behavior and infancy provided stronger prediction of later borderline symptoms than the assessment of the infant's behavior alone. And among children who displayed combinations of disorganized and controlling behavior at age 8, 43.5 percent displayed borderline traits in adolescence. So maybe we should define that.

So disorganized and controlling behavior, so that's like punitive, caregiving, disorganized. You want to talk more about that? So there's controlling punitive behavior, which is represented by attempts to assert authority over the parent, like the child attempts to assert authority over the parent using harsh commands or belittling comments. And this particular like controlling punitive behavior, so just organized controlling child behavior at age eight contributed independently to the prediction of borderline symptoms in adolescence. Okay. And this is like as opposed to, I guess there's also control and caregiving behavior in which the child would direct the parents' activities by guiding, encouraging, or structuring the parent. Both of these have role reversal, right?

So it's so important as the parent to be the parent. I've read so many parenting books and some of them are so bad. They're just like, allow the child to just freely express themselves and never have any discipline. No, children need discipline. they didn't need to have boundaries. They need to know you're in control. They, you know, in the first sort of this controlling punitive behavior, the child is ruling the roost.

The child at age eight is literally in control of the household. And then this controlling caregiving behavior, the child is the therapist. They're the encourager. They're adding structure to this. They're dysfunctional parent. And that's also a very bad dyad, right? It's a bad diet. Yeah.

And then the disorganized controlling child. That one as well. Right. Oh, and the disorganized controlling behaviors. That's the type of behavior that would predict borderline symptoms. Yeah. Anything else on that? No.

I think that's good. Yeah. I think this is really helpful to kind of really open up this topic and help us understand it and kind of understand how some people are then going to, you know, present to us later with more of the borderline symptoms. Yeah. We're going to talk about this study, the Lions Ruth 2013 study? Sure, yeah.

Is that the same study, right? This one and this one? It is, yeah, same study. Okay. So they also say that there are separate subtypes, these separate subtypes of disorganized attachment during infancy are distinct in their ability to predict later suicidality. and overall borderline symptoms.

So the pseudo-secure subtype of disorganized attachment was a specific predictor of suicidality at age 20, but not of overall borderline symptoms. Right. And suicidality can be a symptom of borderline per size order. Right. And you can, and interesting in the study, they controlled for depression,

which might, I think, have complicated the analysis because if you're controlling for something that's going to be very, very associated with the thing, then you can almost like over control. So because so many patients that I see with borderline per seizing disorder have depression, if you control for depression, you may eliminate the connection with borderline personized disorder. Does that make sense? So the study found severity of abuse was associated with borderline person high disorder, which was also interesting.

And so I tend to think that when I look at this and I look at some of the linkages between the disrupted maternal communication, there was an effect size of that of 0.45, there was a connection with this to organize controlling behavior in mid-childhood. with borderline per size disorder, there's this childhood abuse

and the severity of the abuse is associated with borderline per se disorder, the symptoms of borderline per size disorder. So all of these things are kind of pointing to they're linked, but you might not get the classic picture of borderline per seizsor always. So the other thing that I would add here is sometimes you have the psychosomatic borderline per seizsor,

which is not going to, it's not going to, come up in the normal screenings for borderline precise order. They may have the suicidality, but they're going to use the medical system to get their psychological needs met, to get their attachment needs met. And so they may have this controlling punitive behavior where they are using something to maintain control in the household, but it won't be maybe yelling. Maybe it'll be the medical illness, which allows them to have control. Interesting. Yeah. I like this study. I think it's worth reading. If you guys listening are interested in this stuff, check out the link in this PDF that we're going to have in the resource library.

And you can dive into this further. There's a lot of stuff in this article that we're not going to be able to completely hammer out. So I think it's worth reading. Sure. And that's the Lions Ruth 2013 study. I actually tried to get her to come on to the podcast, but she's very busy. So it's unfortunate. Yeah. If you change your mind, we'll have you come back. Yeah.

You know, there's another graph here we have on what types of attachment lead to or associated with borderline personality disorder. And for someone with borderline personality disorder, a large percentage of them will have the disorganized attachment. A very strong percentage. There's a very, the other part that's a smaller group is an insecure attachment. So they're either disorganized or insecure. They're not securely organized in their attachment style. I'm looking at this figure one here from this 2019 article. Right.

Yeah. It's like the disorganized attachment pattern in the BPD group is. just, yeah, off the charts. Really high. So there's the odds in this one study, Curly 2019, the odds ratio for disorganized attachment among BPD participants

was almost eight times that are participants without BPD. And the BPD group was significantly more likely to have less secure attachment than the other diagnoses group. Almost like I don't see any. Yeah. So in this, in summary,

disorganized attachment behaviors outside of infancy may be predictive of BPD features later in life. Also, adults with borderline presizer are very likely to have comorbid disorganized attachment patterns. While we know that many therapies that are beneficial for BPD, like dialectical behavioral therapy, mentalization-based therapy, transfer and focus therapy. You know, those types of therapies are helpful for someone with borderline per size disorder. And I think why they're helpful is because of some of the stuff that's going on in the therapies. For example, in DBT, classic DBT,

the therapists have a countertransference process group weekly to go over their own conflicts with, you know, handling the emotions that come up in themselves. So they learn how to process the stuff that's coming up so that it's not overwhelming for them. In mentalization, transfer and focus therapy, they're really focusing on the emotions, attuning, finding out what's going on in the person and looking at the interpersonal, what's going on between them and their client. Okay.

So I see it as, like, I see it as. like we don't need to invent a new therapy to solve this. What we need to do is we need to better understand why the therapies that currently do solve this actually work. And I think there's a lot of evidence that points to therapeutic alliance, connection, the longevity of that connection, and maintaining that despite maybe strong affects, you know imagine if the patient is really a four-month-old who wants to be attuned to there's part of them that is that four-month-old that was never attuned to and so there's the

fear there's the anger there's a hostility can you contain that you know as a therapist it's very hard to actually contain that yeah i can imagine and so your reaction to it if you're not imagining what might be going on in this human, in this person that's struggling, that maybe wasn't attuned to, it may be really hard to have empathy. Your empathy may get fatigued, and sometimes my empathy gets fatigued. And when that happens, I need supervision. I need someone to empathize with my distress. And that's how we are able to continue to help people, is then we get to go back our empathy can be recalibrated, renewed, and we can continue to connect with this person who needs that mirroring.

That needs that long-term mirroring and connection. Well, I think I want to leave it here for today. Sounds like a plan. This is going to be like a lot of stuff. This may be a part two or a part three to get through this. I don't know. It's fun though. I'm really glad Annabelle that you joined us.

I'm glad that you've worked hard on this. Yeah, I really appreciate it. You've done a lot of really good work here. Thanks. It was a lot of fun to do with this kind of digging into this topic. It was really cool. So can't wait to talk about it more. There's so much more to go.

Okay. Thank you guys for tuning in. I wish you have a great day. I hope this has been helpful. And I wish you well.