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

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Copyright © Jessica Kingsley Publishers 2004
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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

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

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

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
-

high school, killing fifteen people, including themselves (Verlinden,
Hersen and Thomas 2000). The explosives they brought with them, had
they detonated, would have put the death toll into the hundreds. During
the attack, the boys excitedly discussed which of their classmates should be
allowed to live and who should be killed. They congratulated each other as
they fired at pupils at close range. Neither boy came from environments of
poverty or neighbourhood disorganization, neither experienced prejudice,
nor were they confronted with more media violence than expectable for
their group. While they did form an antisocial peer group (the ‘Trenchcoat
Mafia’), they did not experience academic failure, and isolated themselves
by their morbid behaviour, rather than experiencing social exclusion. Their
family lives appeared to be within the normal range. Eric’s brother was an
honours student and star football player, and his father was a decorated
pilot. Dylan’s parents were concerned about him, and despite evidence of
lack of supervision, there is no evidence of abuse, exposure to violence,
marital conflict or parental substance abuse. Eric had a psychiatric history of
major depression, but Dylan did not. Dylan was temperamentally difficult,
and both had a history of aggression, but there is no evidence of medical
complications, hyperactivity or substance abuse in their histories.
I do not wish to deny the importance of the above descriptive indicators
of violence but simply to say that the psychoanalytic perspective can offer a
key additional vector in our understanding of violent behaviour: the
intrapsychic. My own psychoanalytic interest in human violence has grown
out of the work I have done with borderline personality disordered patients,
some with a history of extreme violence. It is my contention that violent
individuals have an inadequate capacity to represent mental states – to
recognize that their own and others’ reactions are driven by thoughts,
feelings, beliefs and desires. I will try to show that this lack of a reflective
capacity results from the inadequate developmental integration of the two
primitive modes of experiencing the internal world. It is consequent upon

five increasingly complex levels of agency of the self: physical, social, teleo
-
logical, intentional and representational (Fonagy et al. 2002; Gergely
2001). We shall describe the normal developmental stages first, and then
speculate about the deviations in the development of the agentive self that
might constitute the psychological roots of violence.
The first level of physical agency involves an appreciation of the effects of
actions on bodies in space. The child begins to understand that he is a
physical entity with force that is the source of action, and that he is an agent
whose actions can bring about changes in bodies with which he has
immediate physical contact (Leslie 1994). Developing alongside this is the
child’s understanding of himself as a social agent. Babies engage from birth in
16 A MATTER OF SECURITY
interactions with their caregivers (Meltzoff and Moore 1977; Stern 1985;
Trevarthen 1979). In these exchanges the baby’s behaviour produces
effects on his caregivers’ behaviour and emotions. Early understanding of
the self as a social agent, therefore, involves at least knowing that one’s
communicative displays can produce effects at a distance, in the social en
-
vironment (Neisser 1988).
The types of causal relations that connect actions to their agents on the
one hand, and to the world on the other, go far beyond the level of physical
description, and we grow to understand much more about both of these
relations as we develop. Thus, around eight or nine months of age
(Tomasello 1999) infants begin to differentiate actions from their outcomes
and to think about actions as means to an end. This is the beginning of their
understanding of themselves as teleological agents (Csibra and Gergely
1998; Leslie 1994) who can choose the most efficient way to bring about a
goal from a range of alternatives. The limitation of this stage of experiencing
the agentive self is one of physicality. Experimental studies of infants

to the other previously, even when that desire was different from their own
preference. In contrast, 14-month-olds gave the experimenter the item they
themselves liked, basing their choice on their own preference, without
being able to consider the other’s relevant prior intention. The little ones
had assumed an identity between their experience of their own desire and
the likely experience of the other.
Around three- to- four years of age this understanding of agency in
terms of mental causation also begins to include the representation of so
called ‘epistemic mind states’ concerning knowledge about something
(such as beliefs; Wimmer and Perner 1983). At this stage, we can say that the
young child understands herself as a representational agent: that is, her inten-
tional mental states (desires and beliefs) are representational in nature
(Perner 1991; Wellman 1990).
Still later, perhaps as late as the sixth year, emerge related advances such
as the child’s ability to link memories of his intentional activities and experi-
ences into a coherent causal-temporal organization (Povinelli and Eddy
1995), leading to the establishment of the (temporally) ‘extended’ or
‘proper’ self (James 1890). Consider this simple variation on the famous
‘rouge’ studies of mirror self-recognition. A five-year-old child is videoed
playing with an experimenter. In the course of the play, the experimenter,
unbeknownst to the child, places a sticky label on him. The sticky label
remains on when the experimenter and child watch the video together. The
child, who has absolutely no difficulty recognizing himself, notices the
sticky label but fails to check if it is still on him. When asked to comment, he
says: ‘That child has a label on him’, and not: ‘In the video I have a label on
me’. A few months later, aged six, he clearly experiences himself as the same
person as the child on the video and immediately removes the sticky label
and smiles with the experimenter at the trick perpetrated on him. In other
words, the autobiographical self has come into being.
18 A MATTER OF SECURITY

mechanism which they call the contingency detection module. This mechanism
enables the infant to analyse the probability of causal links between his
actions and stimulus events. Watson (1994, 1995) proposed that one of the
primary functions of the contingency detection module is self-detection.
While our own actions produce effects that are necessarily perfectly
THE DEVELOPMENTAL ROOTS OF VIOLENCE IN THE FAILURE OF MENTALIZATION 19
response-contingent (e.g. watching our hands as we move them), stimuli
from the external world typically correspond less perfectly to our actions.
Detecting how far the stimuli we perceive depend on our actions may be the
original criterion that enables us to distinguish ourselves from the external
world. Our bodies are by far the most action-contingent aspects of our en
-
vironments.
Numerous studies have demonstrated that young infants are highly
sensitive to the relationship between their physical actions and consequent
stimuli (e.g. Bahrick and Watson 1985; Field 1979; Lewis, Allessandri and
Sullivan 1990; Lewis and Brooks-Gunn 1979; Papousek and Papousek
1974; Rochat and Morgan 1995; Watson 1972, 1994). For example,
Watson (1972) has shown that two-month-olds increase their rate of leg
kicking when it results in the movement of a mobile, but not when they
experience a similar, but non-contingent event. Sensitivity to contingency
thus explains how we learn that we are physical agents whose actions bring
about changes in the environment.
In a seminal study Bahrick and Watson (1985; see also Rochat and
Morgan 1995; Schmuckler 1996) have demonstrated that infants can use
their perception of perfect contingency between actions and their conse-
quences for self-detection and self-orientation as early as three months of
age. In a series of experiments, five- and three-month-old infants were
seated on a high-chair in front of two monitors so that they could kick
freely. One monitor showed a live image of the child’s moving legs,

kind of responses that are characteristic of children’s caregivers. This
change re-orients the infant after three months, away from self-exploration
(perfect contingencies) and towards the exploration and representation of the
social world, beginning with the parents, who provide stimuli that are highly
but not perfectly contingent on her responses. Just as the early contingency
detector alerts the infant to aspects of her own body by identifying parts of
the world that move simultaneously with her actions, the detection of
high-but-imperfect contingencies directs attention to the reactions of
others and begins the process of helping her define delimiters to her subjec-
tive experience. How might this happen?
EARLY UNDERSTANDING OF THE SELF AS A SOCIAL AGENT
A large body of evidence indicates that from the beginning of life babies can
tell people apart (Stern 1985). From a very early age they are sensitive to
facial expressions (Fantz 1963; Morton and Johnson 1991); they get used
to their mothers’ voice in utero and recognize it after birth (DeCasper and
Fifer 1980); and can imitate facial gestures from birth (Meltzoff and Moore
1977, 1989). Young babies’ interactions with their caregivers have a
‘protoconversational’ turn-taking structure (Beebe et al. 1985; Brazelton,
Kowslowski and Main 1974; Brazelton and Tronick 1980; Jaffe et al. 2001;
Stern 1985; Trevarthen 1979; Tronick 1989). The currently dominant
biosocial view of emotional development holds that mother and infant are
THE DEVELOPMENTAL ROOTS OF VIOLENCE IN THE FAILURE OF MENTALIZATION 21
engaged in affective communication from the beginning of life (Bowlby
1969; Brazelton et al. 1974; Hobson 1993; Sander 1970; Stern 1977,
1985; Trevarthen 1979; Tronick 1989) in which the mother plays a vital
role in modulating the infant’s emotional states to make them more man
-
ageable.
Mothers are generally very good at telling what their babies are feeling,
and sensitive mothers tend to attune their responses to modulate their chil

22 A MATTER OF SECURITY
mother’s empathic expression by developing a secondary representation of
his emotional state, with the mother’s empathic face as the signifier and his
own emotional arousal as the signified. The mother’s expression tempers
emotion to the extent that it is separate and different from the primary
experience, although crucially it is not recognized as the mother’s experi
-
ence, but as an organizer of a self-state. It is this ‘inter-subjectivity’ which is
the bedrock of the intimate connection between attachment and self-
regulation.
If the mother’s mirroring is to effectively modulate her baby’s emotions,
and provide the beginnings of a symbolic system by means of which the
capacity for self-regulation can be further extended, it is important that, as
well as accurately reflecting the emotion the child is feeling, she signals in
some way that what he is seeing is a reflection of his own feelings; other-
wise it is possible that he will misattribute the feeling to his mother.
Misattributing the expressed emotion would be especially problematic in
cases where the mother is reflecting the infant’s negative emotion states, say,
fear or anger. If the child thinks that the mother has the feelings she is dis-
playing, then his own negative emotion state, instead of being regulated in a
downward direction, is likely to escalate, as the sight of a fearful or angry
parent is clearly cause for alarm.
This attribution problem is solved by a specific perceptual feature of the
parent’s mirroring displays, which, following Gergely and Watson, we refer
to as their ‘markedness’. Marking is typically achieved by producing an exag-
gerated version of the parent’s realistic emotion expression, similar to the
marked ‘as if ’ manner of emotion displays that are characteristically
produced in pretend play. To be sensitive to markedness the child moves
away from interpreting reality ‘as is’ and imposes an alternative construction
upon it. This constitutes a move away from the immediacy of physical

accurate but unmarked parental mirroring in infancy might play an
important causal role in establishing projective identification as the
dominant form of emotional experience in personality development charac-
teristic of some violent individuals.
In infancy the contingent responding of the attachment figure is thus far
more than the provision of reassurance about a protective presence. It is the
principal means by which we acquire an understanding of our own internal
states, which is an intermediate step in the acquisition of an understanding
of others as psychological entities. In the first year, the infant only has
primary awareness of being in a particular, internal, emotional state. Such
awareness is non-causal or epiphenomenal in that it is not put to any func
-
tional use by the system. It is in the process of social biofeedback that these
internal experiences are more closely attended to and evolve a functional
role (a signal value) and a role in modulating or inhibiting action. Thus it is
the primary attachment relationship that can ensure the move from primary
awareness of internal states to a functional awareness. In functional
awareness a concept corresponding to the feeling of anger (the idea of anger
rather than the experience of anger) may be used to simulate and so to infer the
24 A MATTER OF SECURITY