This thesis explores the role of attachment in a group of violent, personality-disordered patients in a high secure hospital. The research examines the mental representation of attachment and the perception of parenting, as assessed by the Adult Attachment Interview and the Parental Bonding Instrument, in this patient group and examines whether these differ from those of non-violent psychiatric patients. A prospective study examines whether the attachment measures predict change across a range of outcomes for this group of violent, personality-disordered patients.
This thesis begins with a qualitative literature review on attachment and the development of psychopathology, focussing on attachment and psychiatric disorder in adulthood. The question as to whether particular attachment classifications are associated with specific psychiatric disorders is further investigated by a systematic review and meta-analyses. The meta-analytic results show that insecure attachment acts as a general vulnerability factor for the development of mental disorder.
The distribution of Adult Attachment Interview classifications in these violent, personality-disordered patients significantly differed from non-violent patients. In particular there was an over-representation of individuals with Dismissing and Cannot Classify states of mind and an under-representation of patients who were Unresolved for loss and trauma. Additionally the violent personality-disordered patients had an impaired capacity to mentalize as evidenced by their low level of reflective functioning; especially patients with Dismissing attachments. This deficit is seen as a critical mediating mechanism between Dismissing attachment states of mind and violent behaviour. No one attachment measure predicted change across the outcome measures. However patients with Dismissing and Cannot Classify attachment representations improved in terms of the frequency and severity of their violent and aggressive behaviour. Patients with Preoccupied states of mind made the least progress. The results suggest that these particular attachment states of mind are predictive of change in the violent behavioural trajectory of these patients
