005: How and Why Humans 'Attach' (Attachment Theory) | Dr Cameron Gill

Please read disclaimer below or watch: https://youtu.be/pfVAn7Zp-_o

Description:
In this podcast, psychiatry registrars Dr Syl and Dr Cam explore attachment theory and reflect on how it influences their practice. We explore the strange situation experiment, the different attachment styles, the implications for relationships and how they relate to different personality disorders.

~
Newsletter: http://eepurl.com/iMHJp6
Buy me a coffee: https://www.buymeacoffee.com/DrSyl.AU
Thanks YouTube Members:  youtube.com/channel/UCiOBkubL46VQT9mPqrnJlrQ/join
Thanks Patreons: patreon.com/DrSyl
Insta: instagram.com/dr_window_syl/

PLEASE READ - DISCLAIMER
If you or someone you know is in immediate danger, please call a local emergency telephone number or go to the nearest emergency room. This channel is intended for general educational mental health content only. It is NOT a substitute for seeking professional mental health/health advice from your doctor or therapist. Interacting with my channel does NOT constitute a Doctor-Patient relationship. I do NOT represent any medical college or organisation. This content represents my PERSONAL views only.

Timestamps
00:00 - Introduction
01:40 - Exploring why humans attach
09:00 - The strange situation 
14:40 -The different attachment styles
55:20 - How attachment styles relate to clinical practice
01:01:07 - Attachment Style and Personality Disorders
01:38:00 - Wrapping up

Transcript

we covered attachment Theory the different types of attachment and how they map and relate to different

personality disorders we discussed both research but also some clinical experiences and map the discussion and

the content to our personal Reflections this was really one of those conversations where I just personally felt the time fly it was so interesting

and invigorating and I remember um looking at the recording clock thinking that maybe 30 minutes had passed and we

were already an hour and a half into the recording so let's get into it but of course before we begin a quick disclaimer both Cameron and I are doing

this podcast in our personal capacity the views we're sharing here are not that of any medical college or any

workplace we are not representing anyone but ourselves any advice that is shared is General in nature and does not

constitute personalized medical advice though I think it's wonderful when people comment and engage with my content there is no patient doctor the

relationship formed by engaging in this [Laughter] [Music]

content cam thank you so much for joining me on a podcast um we kind of

yeah my pleasure we're talking about talking about attachment and how that relates to lots of different things

because humans attach yep uh so I was thinking a good place to start is to is

to kind of address what is attachment like when when psychiatrists and psychologists and people who work in

mental health uh talk about attachment so some people that might feel like psychobabble you know I'm not attached

to anyone I mean so how do you think about attachment yeah that's um a really interesting question so attachment is

such a broad concept and it gets applied both in these really jar and heavy spaces but then we also have ideas of it

in our popular culture and it's been really strongly incorporated into that therapy speak stuff which which you know

is a whole topic for another day uh but fundamentally attachment is a pattern of

uh behaviors and beliefs that people have about themselves about

relationships and about the world around them and it's really been informed by

those earliest experiences um the ways that it informs beliefs about the self uh uh can stem

from how we're treated the way it informs our experi our beliefs about uh relationships and

others is like how those early relationships go um and the way it informs our beliefs about the universe

is like well what is this universe what is what does it mean to be alive and what do we experience in it so

attachment is to my view it is the most fundamental aspect that of like

understanding people wow you've added a whole new element to it so what so I I

really liked that you're talking about like a kind of intra personal attachment where you your how you relate to your

personal to yourself whatever that is and that's an interesting discussion your interpersonal attachment but then

that's a really interesting concept that's feeling so satisfying to hear how

you attach to meaning and the bigger existential questions of life and and what we're doing and um and I'm sure

that there are healthy ways to attach and less healthy ways to attach uh and

that different states of stress might bring out different ways of attaching absolutely so this is where uh it is

really important that I establish that I am I have a very workmanlike a very functional understanding of attachment

Theory I am not an attachment scholar uh and one of the advantages of that is there are definitely movements within

attachment theory that posit a much stronger categorization that if you

belong if you have one kind of attachment style or you belong in one category that is the only category to

which you belong and that informs everything uh but you know reality is much more complex and like clinically

what you see is that yeah people move in and out of different modes people you know might usually have to use the

jargon term for the healthy attachments atly secure attachment style but then when they go through some enormously

stressful experience so so for example you know the the death of a loved one people can sort of seem to shift into a

different attachment style one of the insecure attachment Styles so it's really important to reflect that

absolutely these are ways of being these are belief systems and we can move

between them even though we tend to have a pattern of having one that is more predominant than the others so so um why

do humans attach why is it so important that we have relationships with others really

really great question uh one of the I suppose the way that I approach

that is the reason humans attach is because we are mammals that are born at

an incredibly underdeveloped stage so you know we're not like sea turtles where we the egg gets buried in the sand

and then Mom uh am I allowed to swear in here sure I don't know but go for it sure mom

[ __ ] off and then we two months later later crawl out of the sand run the seagull Gauntlet and then we are

expected to thrive on our own right that's that's how sea turtles do uh we're also not like some other mammals

like giraffes you know giraffes Start Life by Falling six feet to the ground and then getting up and running right we

are fundamentally different from that humans are born you know apart from Mas

Aussie oie oie o oi oi we are born at one of the most underdeveloped stages in

the m Kingdom which means that you know a baby is actually physically incapable

of looking after itself a baby cannot feed itself it cannot clean itself it can barely regulate its own temperature

in fact it needs a lot of assistance to regulate its own temperature um and we are actually born at a stage where we

can't even differentiate between these different adverse experiences um from a baby's perspective you know for those

first couple of weeks of life and like any new parent can attest to this that at first babies cry all the time and you

can't work out why it's just like something bad is happening and I need to be looked after uh as to why then we

need this attachment it's because humans need to be looked after and so

attachment can be conceptualized as these adaptive responses to our primary

caregiver or our caregiving system in systems which don't have a single primary caregiver um and our EnV

environment to elicit the care that we need um there

are so I hold a view that it is a kind of manipulation that babies are trying to manipulate you into meeting their

needs because they can't do it themselves they need to be looked after and so they will respond to the

environment and the person who is providing that care in order to keep that care there yeah it's interesting so

um sounds like a baby might be a bit insec attached bit anxious well they're

not ready exactly to spend time on their own and and explore the world it sounds like they're pretty dependent oo that I

am going to disagree on that one because part of attachment is this idea that you

have even the capacity to do something babies can't move their own bloody legs of course they can't go out and explore

the world like we our early experiences in form our attachment but you wouldn't really say that you know a child that is

pre movement is has any kind of attachment style you might be able to see some

inklings of it but you can only really start assessing attachment um and when

uh they're actually capable of volitional movement and um some kind exactly um I'm sure that you're aware of

the strange situation test which is sort of like the foundation of a large part

of modern attachment theory developed by Mary anworth and it is such a

fundamental piece of the puzzle to understand how we

think of attachment you know I I let's talk about it let's go through it because it'll be really helpful to

inform when the next parts of uh the conversation around different attachment Styles absolutely yeah so uh this would

be this is where it's often more helpful uh to find a YouTube video that like goes through it because the strange

situation test it's this CH choreograph set of uh separations and reunions the

way that it looks is the you know it was developed in the 19 what 60s '70s uh in

the UK uh so it is usually the mother uh who because you know patriarchy and

misogyny exists but uh so it's the primary caregiver brings an infant between the ages of 12 and 18 months

usually to uh the center there will be a room that has been set up as the

observation room so it'll be full of toys and books and like chairs and like

you know it's a fun space to be in they try and make it somewhere that's very similar to like a playroom or a daycare

room uh and it'll either have you know some oneway glass or some cameras so that what's going on in there can be

observed without bub feeling observed um the way that the strange situation start

test starts is that the caregiver and Bub enter the space they explore it for

a bit um we watch how the caregiver and Bob uh respond to to one another and to

this new environment um then a stranger one of the people on the testing team a

stranger enters the room we see how Mom and Bub react sorry how the caregiver and Bub

react then we have the first separation which is the caregiver leaves the room

leaving bub in the room with the stranger and we see how does that is a

stress it is a stress if you if you end up watching one of these on YouTu YouTube one of the

things that people really notice is that for securely attached kids they get

incredibly distressed and it can feel actually quite cruel to be doing this

you know there's this element of well why are you putting a child through this it's important to remember that these

sorts of separations and reunions are part of normal life every time a parent

drops their child offer daycare that is a separation every time a parent leaves

the room so that they can go put on a a a wash in the washing machine that is a

separation and that is causing this distress and seeing how the child and

the caregiver respond to this distress really informs our understanding of what's going on and can provide us with

some tools for helping to change things um so to sort of come back to the

strange situation test we were at the point of um the caregiver left the room with child there with a stranger we see

what happens um we see how the child responds to The Stranger in this weird

situation then the caregiver re-enters the room we watch that reunion we watch

what happens how does the child respond um a securely attached child to use the

jargon um should be like as soon as the parent re-enters they should be crying

they should be running to the parent they should take a while to settle down but they should settle down they should

be able to be comforted by their parent and then after a bit get back to having fun in the

playroom uh while that reunion is happening The Stranger leaves the

room then the caregiver separates again leaving the child alone in the room how

does the child respond to this new situation this new very stressful situation like as we said before like

the human child cannot look after itself you know the toddler on the Savannah on

its own would die and fundamentally like evolutionarily kids

are aware of this so this is incredibly stressful for the child so then the stranger

re-enters how does the child respond to this um do they go to the stranger do

they shy away from the stranger what happens and then the final reunion is

the parent re-enters this whole any we watch again how does the child and the

parent respond in the situation um this whole choreograph thing takes

you know half an hour at the most like it's not that long um or at least

usually it's not that long it can take a lot longer and as we go through the attachment Styles um we can sort of talk

about well why what can make it take less time what can make it take more time and what does that tell us about

the bond that exists between the infant and the caregiver in their environment

well I think we we should talk about the the different kind of attachment Styles there because that that's um it's

interesting to well I was about to go into nature and nurture and how that that drives different temperaments and

uh and reactions but maybe it's good to start with with an understanding of some of the major attachment Styles um

actually think that we should talk a little bit about this nature nurture thing sure yeah what are your thoughts of the contributions I wouldn't be so

rude as to ask is it nature or nurture cuz i' probably get if you were to ask

well no if you were to ask a question like that you'll get the very boring answer of it's both that's right so

that's why it's better to ask well how do they interplay um and I would say

that the way that they interplay is that there are going to be factors around the infant that affect their attachment

there are going to be factors that belong to the caregiver that influence attachment and there are going to be factors that influence the environment

in which they live that strongly influence attachment so to give some easy examples um you

mentioned temperament uh there's a couple of they're not these are terms

that were developed in like I want to say the 70s or the 60s so they aren't the most PC terms okay um but it's

things like some kids are slow to warm up or like there's like these technical jargon terms for for temperamental

Styles um but fundamentally they're just these things that we have a lot of evidence of being inborn genetically

driven um patterns of uh how anxious somebody

is how easy it is for them to settle themselves and or be settled by others um and that is one ingredient into

attachment into the infants factors of attachment but there's also factors like does the child have an illness does the

child have epilepsy does the child have some other kind of physical illness that's going to affect them does the

child have a neurodevelopmental difference does the child have you know a developing autism spectrum dis order

or any of those factors can really influence have an impact on the Infant

factors to attachment then there's the caregivers factors you know one of the things that we know about Detachment is

that it is incredibly heritable in the sense that people with a certain

attachment style tend to uh have relationships with other people with the same attachment style and tend to have

children who develop that same attachment style it's something about this way of being in the world world is

you know it influences how we can then as you know it if it influences my relationships with others of course it's

going to influence my relationship with my child so there are these so a caregivers attachment style has a strong

impact on the attachment style bond that develops between the infant and the

caregiver as does uh things that are completely outside of the caregiver's control things like do they have an

illness whether that's a physical illness whether that's uh mental illness whether that's an addiction

there's so many things that sort of belong to the caregiver that can influence these attachment Styles and

then there's the environment so one of the things that we know is that people in uh who are oppressed people who are

in situations of immense deprivation that that uh really does shift your

attachment style one of the things that is Central to understanding attachment is the idea of having a secure and Safe

Haven and if you are living in a war zone then you then like the world is not

safe so you're not going to learn anything about having a secure and Safe Haven and that's going to have an impact

on your attachment um as does growing up without access to money without access

to food and a lot of these things are environmental factors so everything

influences attachment I'm sure we're about to well we're going to talk about the different styles but I'm just I'm

reminded of an important quote I heard where um a disorganized Detachment style

is an organized response to a disorganized up 100% right so it's it's

actually quite adaptive and always makes sense in the end when you dig down deep enough absolutely and and then that can

help with a bit of a therapeutic nihilism and empathy which sometimes can

happen yeah and I think that that idea that attachment is always adaptive is

actually really important to hold on to uh it's something that you know also plays into uh some of the

I think the approach for dialectical behavioral therapy has sort of one of

the axioms is that people are doing the best they can with the tools they have and similarly attachment is always an

Adaptive learned response to the environment in which the infant finds

itself that environment that includes its own factors uh the caregiver factors and the world around them so then cam

what are the kind of different attachment styles yeah so we're going to be talking a bit about sort of like the

attachment Styles as developed by uh Mary answorth who developed that strange

situation test we talked about they are so her research

found essentially four patterns um and

they are they sort of belong to two groups there is the secure attachment and then uh you I think it was oh which

which which Uh Russian author was it that said uh all happy families are

happy in the same way whereas unhappy families are unhappy in their own ways um there are there's like that yeah

there's know yeah there's only one kind of secure attachment but there are three

different insecure attachments um and they are called uh anxious avoidant or just

avoidant anxious ambivalent or just ambivalent and disorganized and the these are these

four patterns the secure the avoidant ambivalent and disorganized are all

based on how kids and their caregivers responded to the strange situation test

and so we sort of use the strange situation test to understand them but then we can also apply those patterns to

uh what that child is learning about themselves about relationships and about the world around them so there's these

different attachment styles that get observed when you're a child but does that mean that you know you're seeing

them as a child does that that they're destined to have that attachment style the rest of their life absolutely not so

attachment styles are not Destiny um there are certain associations with them

so you know we associate secure attachment styles with um with there's a lot of evidence that people with secure

attachment style are more likely to have better physical health better mental health um stronger

relationships uh that kind of thing and that people with insecure attachment Styles uh are more likely to have poorer

Health outcomes and poor relationship outcomes however it's not Destiny just because I'm securely attached doesn't

mean that I can't get schizophrenia just because I'm insecurely attached doesn't mean that I can't have an amazing life

and also we can see people shifting between these attachment Styles

and uh my personal philosophy when it comes to therapy is that all therapy is

a kind of reparenting and all of it is essentially trying to shift people from various insecure attachment Styles into

having a more secure attachment style and we do see that working

wow so why don't we explore what the different attachment styles are um what

what do you see in someone who's securely attached and and what about in the anxious attachments absolutely so a

securely attached person uh going through the strange situation test um

what you would see is that they enter this strange place and they're a bit they're weirded out by it um they're

finding it's a new new experience uh things that are new and unknown can be

quite frightening to young kids and so you often see them Clinging On when they first enter the space but then with a

little bit of time a little bit of encouragement they were able to start exploring they're able to start playing

with things maybe at first only with the parent but then they might see something across the room that they're really interested in they'll go and grab it and

bring it back they'll leave the parent exactly um and then they'll come back to

the parents they'll share in that Joy what you'll see as well is that in those

separations the child will get really distressed they'll get uh the child will

often be crying they'll um they'll show all the um they'll show their distress in all the ways that they

have a securely attached child will probably avoid the stranger in the

strange situation test they probably won't seek comfort from The Stranger um

they won't necessarily completely run away from the stranger because there's a bit of an implicit indic

when a parent has left a child alone in a room with somebody that the child is like well my parent would would not have

left me if this person was dangerous so surely it must be okay so they won't

necessarily completely stay away from the stranger but they might um and then on reunion when the parent comes back

into the room the child would go to them

the child will be crying and it will take some time for them to settle down

and the parent will be able to settle them the parent will be able to tolerate their distress will be able to sit with

them through that and get them out of it and get them to be playing or reading or

whatever it is that they do together so what this sort of shows is a

that the child sees the parent as being safe that while they are with that parent that

they are safe it's like this is a strange new place but I'm holding on to my onto my parent so I am I'm saying

parent caregiver could be a grandparent could be a foster parent whatever um so

it holds on to the caregiver uh CU they are safe in this uncertain

world but then they also demonstrate an ability to be able to go out into that

uncertain world to say oh uh there's something out there that I want I can go

and do that and when I do that I can be sure that my caregiver is still here

they can come back to them they also learned that uh when things go bad so on

those separations and separations are really quite traumatic for young children during those separations they

learn that uh I can feel bad but I can feel good again and when my caregiver

comes back they can help me feel good again and importantly the child also

learns by crying um and by going to their parent that

other people can help me feel better when I feel this bad my caregiver is

able to get me through this so you know what does that te what does that show us

about their understanding of themselves of relationships and the world around them because you know these are all

important key factors uh in terms of what the child learns about themselves through or what

we can see the child knows about themselves through this it's that I am capable of going out into the world I am

capable of being helped I am capable of asking for help and asking for help

works it shows you know their understanding of other people that other people can help me asking for help Works

uh and what it also shows us is that some people are safe some people I'm not

so sure of what it shows the child understands about the world around them is that you

know the world is a place where good things can happen if I go out into it it's also a place where bad things can

happen but it's a place where you know when bad things happen good things can

come after that I can be made whole again um it's a it's astonishing how

much you can read into like these quite simple interactions of just separating

and reuniting um but through that we can see so much or we can interpret so much

about what's going on with that child so uh I guess an important thing to not is a lot of

is unconscious for the child they're not wording um these thoughts and stuff I've

not yet met the 13-month-old who's a that um and uh and so when people feel

like uh you know I can't remember being a kid so why would anything like during

that phase affect me now it's it well there's a lot of things you can't remember that influence how you develop

of course absolutely yeah and the other thing to take away is that kids cry like

it's it's not abnormal and um and I think some parents feel a lot of Shame around it or um or Panic as well um and

and yeah just saying that is the tool of children I'm sure parents know this but for people who don't have kids it's you

know and they hear babies cry on a plane or whatever maybe this will help promote some empathy but that is their tool of

expressing their needs absolutely and it's the only tool they have for quite a long time yeah and you know we some of

us still use it in our adulthood as well I know I better or worse I know I do yeah yeah so um that's a yeah that's

been really insightful to hear about that kind of secure attachment response to that um

experiment I'm just wondering quickly does that still pass ethic Sports it's not that unethical but it's distressing

um do they still do the strange experiment absolutely so I've not personally been part of it but uh there

are definitely attachment centers mostly in larger places you know London New York that kind of thing uh where they

will sometimes bring people in to do a strange situation attachment assessment of a particular um of a particular CH uh

infant caregiver relationship and it's not for research purposes it is for clinical purposes right of course okay

uh and so what are the kind of findings you might see in someone who's got one of the anxious let's go through the different anxious attachment Styles so

maybe dependent is a good place to start next so depent uh anxious dependent is uh I'm

really glad actually that you brought that up so anxious dependent is part of the I think the adult attachment

interpretations rightor and so no it's a good it's something important that we actually discuss is that I am looking at

this from the child developmental perspective and then applying that to my adult practice which is different to the

sort of adult attachment styles that you can come across which have things like dependent um I actually don't know much

about those adult attachment Styles I I know I would say that my knowledge of the infant attachment is relatively deep

and that's what how I can use it in my practice and how I can apply it but yeah

i' actually don't know that much about the uh dependent yeah personalities and things what about the um avoidant

response would you there we go I can talk about I can talk about avoid until your legs fall off it's you're not going

to avoid it no I'm not going to avoid it just this once for you I feel really safe here that's why I can do this this

is good secure attachment exactly uh so the avoidant attachment style uh is the

second most common attachment style that we see in the west so the most common is secure about 2third of kids um or 2/3 of

adults too have a secure attachment style in uh the weird cultures the

Western educated industrialized Rich Democratic cultures um we see then that

the second most common is the uh avoidant or anxious avoidant attachment

style so what we see in the strange situation test uh with the anxious

avoidant attachment style is that externally it will actually be a much

more pleasant thing to watch so you know the parent and the kid will come in um

sometimes the parent will be they'll start exploring the environment together they'll be playing together um sometimes

kid will go off on their own like almost immediately and stop playing on their own and the parent will just will sit there and supervise um but it can be

something where you see this beautiful these beautiful interactions between the caregiver and the child or you can see

very minimal interactions uh where this attachment style really shows its strong

differentiation from the secure attachment style is in the separations so externally what we can see is that on

those separations the doesn't look that fast doesn't look that fuss so the child

will continue playing on their own um they might look around a bit but they

won't be too bothered by the fact that their caregiver isn't there and then on reunion when the parent re-enters the

room the child might not go to the parent the child might actually move

away from the caregiver stay away from them um and if they go to the caregiver

you know because sometimes they are so distressed that they can't deal with it on their own and so they go to the caregiver in a little bit of distress or

showing a little bit of distress they settle down incredibly quickly they get redirected really quickly um so

externally it looks like this child actually doesn't have anywhere near as much distress as the securely attached

child and look it was hypothesized early on that that was uh not a true

interpretation and then and proven beyond all doubt when they did uh some

ECG testing where they just put the ECG recording dots on the kids um when they

were doing these attachment assessments so as you can probably anticipate when you've got uh when you're more

distressed your heart rate goes up so securely attached kids soon as the parent left the room and they got really

upset their heart rate went up with these anxious avoidant attached kids

when the caregiver left and they look completely unfazed their heart rate

skyrocketed these kids were in intense distress but were not showing it and you

know they were settling down when the caregiver came back but it took a lot longer for them to settle

down and this is you know we talked about how this is an Adaptive response to something this is an Adaptive

response to a parent who is obviously safe who's obviously able to meet their needs but who isn't necessarily able to

meet the their emotional needs and importantly where crying and distress

does not actually work to communicate that I need help um the sort of

situations where we see this happening is in parents who themselves can't

handle the distress like their own distress or the distress of the infant so you know parents where you while the

child is crying they move back they step away they they separate elves from the

crying child and very quickly that child will learn oh no I I can't let you go

away you going away is how I'm you know the infant alone on the Savannah that's how I die crying is

fundamentally uh it's it's fundamentally punished by the system um and you know

obviously no one's doing this consciously this is all un it's no one's fault you know you don't choose your attachment style exactly um but it's all

about us noticing that oh for this relationship

system crying expressing distress doesn't work the impact that then has on the

developing child is like well one uh the child is learning I am I can

be safe I can go out into the world I can do things um my caregiver they're

going to be back and but when they're back if I cry if I ask for help it's not

going to make things better if anything one of the beliefs that they um that people can develop as part of an avoid

and attachment style is that asking for help just makes things worse um I'm not

sure uh if you've how do I want to put this uh one

of the things that I like to do when talking about attachment Styles is try and do broad Strokes of what does this

look like in terms of people's day-to-day experience es um I would say that male friendships are very

avoidantly attached so uh like I said a lot of the time you'll see these beautiful interactions where the child

and the parent are playing together um and that's what you tend to see with male friendships male male friends will

you know get together to you know play footy or play DND D or like do all these

things they do something together but they're never vulnerable they never tell one another what's going on inside

because they have learned that that doesn't work that that does not meet my

needs it also uh actually I don't think there is an

also though it does not meet my needs not to put a value judgment on it but I think there's a that I've had yeah that

it's really nice to show some vulnerability with friends and that um and hopefully that you if people are

wondering about whether they should ask their male friends uh for help or to express distress that maybe they'll

they'll be surprised because I think secretly a lot of us do want to kind of access um a deeper well I'm I'm well I'm

not potentially very avoidant if if you're avoidant maybe you don't want to kind of get there but uh I'm just having

memories come back of some interactions I've had with friends and uh and thinking about how yeah the nature of

the relationship was probably a bit more competitive and um and avoided uh but

actually was in crisis and in distress where you can get to a deeper connection C it's interesting how crisis and and

vulnerability can can actually augment improve relationships

sometimes absolutely it's an interesting reflection in a very real sense it is

like relationships can only grow when there's been some kind of a breach in them W um it's you know we're not like

you know a hous Made of Stone and wood like we are a living system we all know

that when you know that when bones break when they they can heal stronger if

they're set right if they're in a healing environment when they heal they are stronger and that's the same with

our relationships it the strength of our relationship if if we kept things superficial and avoidant and always

happy gol lucky then there's not much depth or strength to that relationship and that relationship can be put down

anytime it's only when you have breaches in the expectations of that relationship you know we're colleagues but you know

you and I haven't sat down and had like a deep and meaningful about the awful things that have happened to us but if we were to do that then that would be a

breach in this kind of relationship we have and through that breach we would then you know I assume we would then

heal that relationship and through that we'd learn that oh no this person is someone I can be safe with and I can

share that in that's right yeah so in a superficial happy go-lucky just play

cricket on the weekends kind of relationship there's a lack of safety in showing vulnerability but as you show it

depending on the interaction of the two people you can get a DE a sense of safety and that that's that's a beautiful thing

absolutely so that's anxiously avoidant I'm going to avoid going any further

into that um pardon all these puns I'm in a mood um and so what where where's

the best next um attachment style to explore I think exploring the anxious ambivalent attachment style yeah so

which I think tends to I was I was going to try and Link that to dependence but I won't do that I think let's talk about

it as its own thing my understanding is that it is linked to the dependent one and it sounds like you have a bit more

understanding about those adult attachment Styles and so as we're talking through it I would love to hear the connections that you're making with

those because in my opinion you know it's these sorts of cross-disciplinary or like these aren't really two distinct

disciplines but it's through making these connections um between different areas that we can really broaden and

deepen our understanding just on that point um yeah Psychiatry is not just about meds by the way we're doing

Psychiatry training and we haven't talked about a single medicine in 45 minutes of talking exactly so just as a

shout out to people who just think we're pill pushes no that we're psychiatrists we're in training just to make that clear but

um exctly you and I both signed the same piece of paper that said I will not style myself a psychiatrist that's right

I love that oh goodness yet exactly um fingers crossed one more year for me

yeah yeah that's right so ambivalence ambivalent yeah importantly here uh

ambivalence means something different in the jargonistic term than it does in everyday Parlin so if I were to say to

my partner you know my partner said oh do you want to go out for um for Italian tonight and I said I'm ambivalent about

that that by the way why would you be y uh because Tai exists okay that is why

um and because I'm secretly trying to signal I want Tai anyway um so it's this thing of we in common Palance

ambivalence means H I don't care either way in Psychiatry and psychology ambivalence

means two strongly held opposing views so we when we are ambivalent about

something it might be because I you know for example if I'm ambivalent about you

know moving to Brisbane you know I have this strong positive there of oh my God

I hate every single winter in CA I freeze half to death and if I move to

Brisbane I will never be cold again and on the other hand all of my

family are here in CRA my I have such strong friends and communities here in

camra and I would not have that in Brisbane so I have this strong ambivalence about moving to Brisbane uh

which is why we use that term for this attachment style because we see two very

different modes of behavior in the ambivalent attachment style um but they

are united by something um so what we see in the ambivalent attachment style is the caregiver and the child will

enter the the playroom uh they'll be able to play together it'll look really beautiful it'll look superficially very

similar to the secure attachment style um the what we'll notice maybe is that

the child stays quite close to the parent like they don't necessarily go out as far to um or it takes longer for

them to go out to start playing with things and so we might get an inkling that there's an ambivalent attachment style going on here while they're still

in that first exploratory stage but it really becomes obvious on

the separations so no separations no it's the reunions

that becomes obvious so on the first separation um you'll see the child become distressed you know a child in

distress is a child in distress we're not going to say it looks more or less distressed than the securely attached child definitely more distressed than

the they look more distressed than the avoidantly attached attached child but like they look distressed on that reunion this is where

we have those two opposing points so you know some of the kids will run to

the parent and they will be inconsolably crying they will be crying harder

they'll be showing they'll often be showing more distress than they were before the reunion like when they were

isolated or with the stranger whe whether it was with the stranger or on their own they will be showing more

on reunion than they were in that moment of Separation uh and it will take

forever for the caregiver to settle them down the metaphor that gets used by a

lot of parents when there's an ambivalent attachment style between them and their child uh is that no matter how

much love I pour into this child it's like their cup doesn't have a bottom to

it just pouring right through and they can never feel better so what you see is these kids

you know one of the valencies one of the two options is that the kid will run to the parent and be inconsolably crying um

and almost impossible to settle down the other veilance the other option is that the kid on reunion will attack the

parent they will run up to the parent they'll be angry they will be kicking they will be punching they will be biting you see this

incredible um or you know if they're vocal they might start yelling they might start being expressing really

strong anger so whereas one of the valencies is this sadness this like I need you how could you do this to me the

other one the other me again yeah the other one is this

incredible like whether it's verbal or physical violence directed towards the

caregiver this is importantly they are the reason they've been lumped together

is that they are both responses to the same set of situations and it's you know

sometimes you'll have a kid that on one day will have the sad reaction and another day will have the anger reaction

sometimes you'll have kids that are always in one reaction mode and never in the other is it gendered do you do you

find that boys who externalize more or more violent and and and females and who are maybe bit more quiet will be more um

expressing distress so I would say that there is a strong socialization aspect

to it absolutely and that then plays into if we get opportunity to talk about how these attachment Styles and link to

personality disorders um that then really plays into a

well-known uh gender-based diagnostic difference in the personality disorders

yeah let's go there yeah but we'll we'll get that uh be patient

still so uh and the so what could possibly how could these two things this

you know inconsolable sadness and this incredible violence or anger how could they be addressing the same need um and

you know that's an exercise for the listen I'm curious um have you come across this like way of thinking about

it before do you have an answer ready for what they're responding to well I guess the way I would think

about it um I think kind of just learned about it through lectures um it hasn't

been uh that Forefront in my clinical

style I usually tend to uh think about how people relate to others and

themselves and the coping mechanisms that are used and think about the cop I mean this would take ages to go but I I

usually try and that that's where I'm at at the moment in my development it's really what coping mechanisms are used

um and each coping mechanism I say try and look at it on a spectrum um of

helpful and unhelpful and different states and stresses put people into using it in unhelpful more helpful ways

so so it's like your observing what is the person doing using some of those um

categories that we're taught about how you can analyze that and based on this pattern that you're seeing you can try

and infer some things about what might be some helpful things you can do to help shift somebody from using the less helpful to the more helpful coping

strategies yeah so I get just an example that's popping into my mind if someone um usually Retreats into fantasy um or

is and is withdrawn and avoidant um that can be maladaptive and unhelpful uh or

it can be if they're expressing their creativity that can be very helpful and a really wonderful way to explore this

is is asking them what are their strengths and depending on why they're presenting to hospital or why I'm seeing

them um trying to and that's a very supportive Psychotherapy thing to try and identify people's strengths and use

them to try and resolve whatever issues there but I guess here what I'm thinking

about is uh there's a coping mechanism of of uh aggression and and externalizing is um and that can be

uh avoid jargon but that can be transformed into something more helpful

in time like like exercise and um Sports and bits and Bobs uh and how to do that

I would consult my my colleagues do not point at me I'm not yet a psychiatrist I

have not styled myself a psychiatrist this whole time so that's right but yeah so that that would be how I kind of

think about it so how do they do the same thing yeah I guess they're trying to evoke a caregiver response though and

get some emotional needs met oh I got there okay you got that just got to ramble long enough and the answer will

be there somewhere that's my strategy the similarity between these two things that they are both unignorable right if

you have somebody who is latched on to you and balling their eyes out you can't ignore that if you have somebody who is

punching and kicking you you can't ignore that they it is meeting the need because would they have the environment

in which they are is one in which their caregiver is able to meet their emotional needs they're not like the

avoidant kids where they know that crying doesn't work their caregiver is able to meet their emotional needs some

of the time so this is uh something that we see you in a response to like I'm

trying to not to do anything to derogatory here right where uh sometimes when we talk about these it can feel

like we're really blaming parents but like everybody's doing the best they can with the tools they have uh but you know

for example if a parent has um let's go with multiple sclerosis um especially

there are kinds of multiple sclerosis where you'll have periods where you're really disabled by your illness and

periods where you're not as disabled by your illness and when you're not as disabled by your illness you can be an amazing parent who's you know playing

with the kids looking after them and interacting with them and that's amazing um but then when you're having a flare

up you can't do that you know you are in pain you are physically incapable of

looking after yourself that'll learn other people for some people with multiple sclerosis and this can then

lead to the child learning oh but you

you helped me but last Wednesday you cuddled me yeah exactly you did that why

aren't you doing that today I need you I still need you what they've kind of learned and you

can also see this in the way that they don't go out and explore the environment when they enter it is they don't know

that if I go out there that my caregiver will still be here and even if my

caregiver's here I don't know if they'll be able to look after me if they'll be

paying attention to me so the ambivalent response is one in which uh a child has

learned that they can't do things on their own they can be looked after other

people can help in fact it's only other people that can help and the only way to

keep people helping are these is to have this big unignorable response so uh

disorganized attachment so what can you tell us about that disorganized attachment

is the is different from secure anxious

ambivalent and anxious avoidant in a very important way so one of the things that's unified the other three that we've talked about so far is that the

parent is fundamentally meeting the child's needs that the parent is safe

the child feel knows that good things can happen you know whether that's you know and I cannot possibly leave my

attachment figure in case they're not there again or whether it's because and my attachment figure can't really help with that but I can make good things

happen those are responses to parents who are you know fundamentally safe for their child the disorganized attachment

style is what we see in instances where you know there's not that safety

with whether that's because the parent is not safe the parent is the one harming the child whether that's because

they live in a situation in an environment that is so overwhelmingly dangerous that the child could not

possibly learn safety um if the child doesn't have that secure

base then everything else that we've been using all the tools that we've been

using to look at how these children act in this strange situation they don't apply the reason that the it's called

the disorganized attack style is because unlike those other kids where like we can actually pretty well predict how

they're going to act like on that first separation reunion based on that we can say okay we we're pretty sure we know

which way this is going to go and then those predictions are usually pretty accurate kids with a disorganized attachment style they don't act in the

ways that we anticipate unpredictable it's unpredictable it's disorganized and that's because they

don't have that fundamental sense of safety what you can then see though is

because as we were talking about you know kids need to be looked after these

kids are still trying to elicit care and that's one of the reasons why it's so important that we have the stranger in

the strange situation test I'm not sure if you've had this experience but when I was during my child adolescent term uh

we had a very young child come in um so he was six years old uh he'd been

brought in due to some uh essentially significant care of

burnout uh in the context of his violence at home so one we already know

there's something weird going on when a a six-year-old child is being violent

specifically there was a lot of violence towards family pets we know something is going wrong in that household when a

child is being violent towards animals and the first time I met this child so it was in a in the hospital

room I you know usually I'm not sure if you've ever interviewed or like assessed a child that young as part of your

medical training usually you walk into the hospital room the child will be

terrified of you and stay away and like hide behind the caregiver within 30 seconds of me

sitting down in the chair next to the bed this child was trying to crawl into my lap this child was Desperately

Seeking an attachment figure anybody who could meet his needs because

fundamentally he had didn't have a safe attachment figure and that's one of the things that

we see in the disorganized attachment uh system it's not the only thing that we

see you can have it like people can have a disorganized attachment style and not be seeking other attachment figures

because perhaps they have never had a safe attachment figure and so it is you

know what they have been taught by the universe is that no it is not possible

for people to be safe I I am alone the world is a dangerous

place that makes the disorganized well the disorganized attachment style is

fundamentally different from the other attachment Styles it's one of the reasons why it is

more strongly associated with um physical and mental ill health than the other attachment

Styles uh and it is importantly not

Destiny you can have a disorganized attachment style and have wonderful

fulfilling relationships be healthy you can start off life having a disorganized attachment style and have that change

over the course of your life um just because we we often talk about these

things as if they are these like you know written in stone at the you know beg your pardon like written in stone at

a certain point of a child's life that you know from this point on on yay they shall be miserable but no that's not the

case um however it is really important that we acknowledge that now these are kids who have gotten off to a really

rough start in life and their responses are them desperately trying to adapt to

it so now we've got a sense of how

different children and attachment Styles how different children will respond to stress to response to caregivers leaving

and coming back how does that map into your clinical practice when you're mostly seeing adults that's a great

question for me it's about understanding then based on my assessment of okay how

does this person act in their relationships because importantly you know these attachment Styles they were

developed during the um like the 50s 60s 7s during the peak of the behaviorist

movement so this is a a period of psychological science where we were really responding to and rejecting the

internal World stuff that um the psychoanal psychoanalysts had put forward uh and so all of this is stuff

that we can externally View and based on our observations of somebody we can

infer certain beliefs and so that's what I use it for

I when I talk to people about you know themselves their relationships

especially with sort of really strong figures in their life whether that's a partner whether that's a parent Grand

parent whoever try and work out what's going on in those relationships and based on that

try and you know roughly put them into one of the buckets and based on that I can then

infer some of these beliefs and then I can start questioning okay well what

does this person does this person hold beliefs like you know I can do things by

myself or I can't do things by myself um does this person hold belief that oh this

my uh attachment figures are if they leave they might never come back you

know and through that understanding that can then shape me into working well how can I help this person move from

these uh patterns of behavior which as we've said many times were adaptive they

were learned because of that early environment but they are no longer in that environment how do we help them

shift to a pattern of behavior that is adaptive for their current environment

or that you know is sort of more in vo commers uh objectively adaptive and that

can help shift their environment to one which is you know more strongly associated with health and

well-being that's a great uh question how how do you do that just in a quick

uh one minute do you mind just oh absolutely like obviously it's it's super challenging and I'm just my mind's

going to um repetition compulsion which is this concept um around how people who have had

traumatic upbringings find themselves in traumatic situations yes um and it's

it's it's also a concept of the experience of post-traumatic stress where disorder where your brain without

you choosing will trigger flashbacks and bring you back to extremely traumatic environments and that it's a compulsion

you don't choose it it just happens and it and it can be um yeah that's and the

repetition part of it is just the fact that it is unrelenting unrelenting and and

horrific and um so I'm imagining you know someone in in who started off

with um in disorganized attachment Style with troubles in their early attachments

um how do you help someone like that uh in a way reintegrate healthily uh if for

lack of a better word yeah so this was actually part of the framing that I used

in consultation with my supervisor for my long term Psychotherapy case uh

where you based on your assessment of somebody's or based on my assessment of

my person's attachment style I then worked out with my supervisor okay so

what behaviors do I need to model and what behaviors do I need to encourage in

this person in order to help move them towards that more secure attachment style so to take the example of a

disorganized attachment Style you know the thing that we fundamentally need to help them with is the belief

that it is possible to have a safe and predictable attachment figure and

consistent exactly because they've not had that so this is where it becomes really important

to uh so for example if I was providing Psychotherapy for a person with a

disorganized attachment style I would say you know I have a an appointment slot for them every single week uh and I

would have to be never late never change the room have a really predictable run of the session um so for example every

time they come in the first thing we talk about is all we always set an agenda and we always follow that agenda

we always finish the session at the time we finish we always start the session at the time we start uh and through this

and importantly I am always safe for them I don't try to hurt them I don't

you know a lot of the rules in our profession if anybody here has ever looked at the

uh uh rnz cp's uh ethics statements and

that kind of thing there's a lot of stuff in there that is you know it's a rule that's been put in there for a

reason uh I do not have sex with my patient I do not actively seek to harm

my patient there was a case hold a very firm frame exactly you

and try not to breach it and as a tangent I'd be interested in knowing how you hold how you end your sessions on

time all the time because like that can be very challenging for a lot of early career therapists and and doctors ending

on time when someone's there's one more crisis you know oh gosh yeah the um to

bring back to like patterns that we see in people the uh the classic pattern that you will see in patients who have

an avoidant attachment style is that in the last 5 minutes of the session that is when they will bring up

the big issue it's like you know everything's been going fine you've had a great chat you've really maybe done a bit of CBT stuff in there it's been

great you've set the homework cool just W feeling like it's wrapping up um and yeah I self H for the first time last

night for the first time in two years last night I was like well what do they call that the doorway

the um the doorway issue as they're going through the doorway exactly the

kind of throwaway comment that has all the mhm oh we can't talk about it I got

to go exactly and that's because they have this idea this belief that sharing

that vulnerability isn't safe won't work and if they mention it earlier in the

session you'll have to talk about it you'll have to confront it and that will be bad and a lot of people in avoidant

attachment style have this belief that my distress hurts other people and so I can't share that with anybody else but

they also know that like I'm here to talk about this stuff so so it's uh often what you can notice is from the

therapist side is this whole time there's like oh the session isn't quite feeling normal like there's this like

undercurrent of tension but like everything's running okay and then there's like this big release of tension

when they actually bring up the thing they've been wanting to talk about this whole time but their beliefs their

desire to share their desire to be vulnerable is in direct oppos opposition to their deeply held belief that I

cannot be vulnerable uh and then they resolve that tension by mentioning the

thing when it's too late to share it bam out the door it's like

well that's a um beautiful example of how important

counter transference monitoring is that feeling that something's just not right here abely and then both there's the

comment and and oh well got to end so that yeah that's insightful yeah um and

we were talking about that because was like oh the the strong frame how do you finish on time that is a skill that I am

slowly developing I am a classic nice to know I'm not the only one oh God yeah um

it is so important to it's one of the reasons why these days I every time I see a patient even

if it's somebody that I've seen you know dozens of times I will set an agenda I

will in the first couple of minutes of the session say cool these are things I want to talk about you know uh catch up

how the meds going make some plans uh what do you want to talk about oh you want to talk about a medical certificate

brilliant so we will do these four things and then I've got a rough idea of what it is that we're going to talk

about and that's what we talk about uh of course you do have to be adaptive

if something comes up during you know the catchup over the last couple of weeks that is that deserves time you do

have to be able to give it that time but yeah it is just all about for me at least having an agenda and trying to

stick to it and making sure that there is a clock on the wall above and behind

your patient so that you can every so often un you looking at your watch awful

terrible eyes drifting up to the ceiling that's fine yeah I think I I agree

strongly with that and the value of agenda of an agenda when you're running a clinic and you need a whole time of course um CL Psychiatry way um you don't

necessarily have like booked patients you just have it people you need to see I've found it more helpful to um for

initial assessments to not have an agenda to just let um the

patient if if they're not to avoidant flow through everything they've wanted to say and haven't had a chance to say

and usually one of the things I've been trying and have failed about 100% of the

time is to just ask one question and then be quiet for 10 minutes but I I can't handle the the

awkward stairs like say something so usually I can sometimes get to five minutes and that's pretty good for me

who talks too much I mean I have a YouTube Chanel so but really a lot of silence is something um the people I'm

seeing haven't really had an opportunity to to have and explore especially with

doctors yeah there was an interesting study I heard about um and I've only heard about it in conversation so feel

free to prove me wrong but it it's It Feels Right based on my clinical experience they they it was an ed study

and um doctors would either stand or sit for 3 minutes always 3 minutes they had

a little buzzer or timer in their pocket and then patients were asked how long did the doctor spend with you and if so

patients would say one minute if the doctor stood and would say about 5 to 10

minutes if the if the doctor sat don't know why my brain went there but that is a strong argument to just always sit

Absol absolutely yeah no we ey line yeah it's the ey line it's the change in the

power Dynamic um CU one of the things that I I think it's really wonderful that you try and be as free flowing as

you can and as responsive as you can in your interviews one of the things that I would encourage is you know there is

information we need to get and it can sometimes feel really arbitrary to the patient like you know you've been

talking about for example what you what you they're going through right now but as part of a full psychiatric assessment

you do need to understand stuff about you know their you know what was their earliest childhood like you know what

was the pregnancy um that that they were part of like what was their earliest experiences at school like you need to

know about the drug use you know everything a comprehensive psychiatric assessment is very invasive and if you

don't know what goes into it it can also be really bizarre like where are these questions coming from so that's one of

the reasons why I can sometimes find it Well I have found it really helpful to provide just a little bit of scaffolding

right and and sign posting exactly yeah that's that's I think that's yeah that's very true as well yeah you don't want to

go from talking about you know how someone fractured their need and then going straight into childhood yeah

whatever and tell me in only positive words everything you can about your mother you know love that stuff um only

positive words well so a big part of um every Psychiatry

registrar's clinical life is um working PE with people who have uh you know

severe mental illnesses like like schizophrenia but also have comorbidity or just um what we call personality

disorders and uh It's Tricky there's lots of different personality disorders

and they influence how people attach and relate to others and I was wondering if um you could help kind of Link what

we've talked about in attachment to some of the things we see in in different

personality disorders maybe we can run through the different disorders to to start with yep I think that's a really

good idea and I think it's one of the reasons why I think the attachment framework is so important to talk about

in relation to personality disorders is because if you don't look at things

through one of these sorts of lenses personality disorders can seem really arbitrary

um it can seem like just a bizarre list of unrelated symptoms like why why are these the symptoms of borderline

personality disorder why is you know you can I think there was a study showing that you know you it's possible for two

people to have borderline personality disorder and have no symptoms in common right this this why is this the same

entity uh and which by the way is why I find it more helpful to to think about

coping mechanisms rather than labeling a personality to

absolutely yeah it ends up actually being more about well that's as you said it's

actually super non-descriptive and usually gives us a bit of prejudice and

bias as to what to expect U which might not always be fair yeah to the patient

so um yeah sorry please go on absolutely so it's in a sense it's super n

descriptive however they are real and distinct clinical entities and I think

that relating them to attachment can help them to feel less arbitrary and

less bizarre and out of left field um so you and I are both um being educated

within a system that is largely based on the DSM uh not the ICD what are we up to

11 uh and as much as there's a movement in the DSM towards a factor model of

personality I think they're going with a six Factor model that they've developed on their own rather than the you know big five uh that is used in personality

psychology uh at the moment we use these clinical entities and so in the DSM they

split into sort of three clusters um so cluster a personality

disorders which you know what let's I think I've got them let's bring them up

just so we don't say anything fact incorrect I think it's skitso skito typal and avoidant is my um

my guess but let's we'll bring him up just to make sure we're not saying anything so you've mentioned skitso

schizotypal the other one is paranoid paranoid yeah so avoiding is not in a cluster a whoops correct I did have that

memorized before my exams good on you it's slipped there yeah look as with most forms of rot memorization it was

there for the day well it just not doesn't come into your mind when you're reviewing a patient is this a cluster a

or cluster c those are letters it doesn't exactly but knowing if someone is

schizotypal in their thinking or paranoid in their personality that that is quite helpful absolutely so B we and

then cluster B then we've got BPD borderline personality disorder yep uh

narcissistic personality disorder antisocial personality disorder and um

histrionic personality disorder that's the one we always forget it's interesting feels gendered it feels very

gendered there's this you know but you know hisonic girls you represent um

there's this really bizarre uh phenomenon that I've noticed within Psychiatry is that um there are

some of these diagnoses that we feel very comfortable making we feel very comfortable making the diagnosis of borderline personality disorder uh we

feel very uncomfortable diagnosing narcissistic or histrionic personality disorders and anal or okay no good point

probably more comfortable with antisocial especially because we often use antisocial personality to in contexts where uh we are trying

to understand some behaviors um that we don't necessarily want to take ownership

of in within the mental health lens so it's this really interesting thing though where like you know yes

borderline personality disorder people with borderline personality disorder experience enormous stigma within the

Healthcare System but there's an I would argue a much greater stigma within the Healthcare System against other cluster

personality disorders that's interesting but regardless uh then the cluster C oh

up to me again um so void dependent yep yep and it's the one that's uh yeah

what's a hint give me a hint uh there is a very different disorder that people

label this Behavior as uh I'll give you the first letter o

oh yes yes okay sorry I do know about obsessive compulsive personality disorder egos syonic mhm there we go so

uh to so let's start with the cluster a

ones because to be honest those are the ones that we see the least often but they're kind of interesting um so

paranoid personality disorder we often don't talk about it but according to hopkinsmedicine.org which I choose to

trust in this instance uh it's a personality disorder in which people have uh a very uh mistrusting of others

um they're constantly looking out for how they're being judged how they're being uh abused how they're being

misused um they uh often see themselves

as the target of other people's anger and there's this fundamental idea

that they are in danger which maps on really well with

the disorganized attachment style these are people who have a an experience that

the world is harmful and is going to get them and then that translates to these

beliefs that other people are talking behind my back other people are trying to hurt me and that's where we uh create

this clinical entity of paranoid personality disorder the skit typle personality

disorder which we sometimes refer to as uh being similar to schizophrenia but

like schizophrenia light so these are people who can have quite I haven't heard of that schizophrenia light wow

yeah it's uh people with schizotypal personality disorder will have uh sort

of beliefs that are a bit bizarre very idiosyncratic they might have some uh

like perceptual experiences that are not quite normal but don't quite meet the

the definition of a hallucination it's mystical it's Fantastical it's high very

deeply spiritual yeah what what does idiosyncratic mean sorry idiosyncratic is uh very

individual um so if I have an idiosyncratic belief it's a belief that only I have that other people even that

I've shared environments with don't hold okay it's quite a contained within yourself yeah exactly it's not like

Catholicism or you know a major religion it would be like your own little spirituality or something and you know

some other time we can have a chat about the intersection between uh religion

spirituality and Psychiatry because that's a personal area of interest of mine next podcast that I find that

interesting as well yeah that right so that's the the schizotypal personality who and and I guess the mechanisms that

they're using to manage stress is really um is is kind of using fantasy and and

ways of explaining like not that there's any and the the key thing is there's no it's not right or wrong to have the

these beliefs or not it's about if they're adaptive or malale adaptive so AB Absol you know people can absolutely

believe in crystals and their powers and that's completely fine if it crosses a threshold where um you know

that where you holding a crystal cures your cancer and so you're avoiding medical treatment well then that might

be going into a dangerous area exactly look we're not here to talk about

personality disorders in and of themselves today if we were then we would always be talking about Criterion zero which is is this interfering with

somebody's ability to live their life to have relationships to be happy if it's not doing that then it doesn't meet

criteria on zero and they're fine yeah yeah so schizotypal personality disorder

uh people with this disorder they live in a world that is fundamentally different from that that of other

people's their version of reality is very different from the version of reality that the rest of us share and

that's a whole other discussion by the way um but it's that difference that I think is

really telling because even though you might not necessarily see the disorganization in their uh in their

relationships it's showing that their fundamental belief is so different from other peoples because they don't have

that shared fundamental belief in Safety and Security it's that lack

of uh that shared understanding that then allows their model of reality to drift and be

very different from that of other people's hence disorganized attachment style is most strongly correlated with

the sket typal personality disorder I I would have thought it was

avoidant um but maybe that's more maybe that's more skitso we'll get to that

yeah but that that makes sense that it's disorganized yeah oh interesting and you know you then brought up skitso

personality disorder the final of the three cluster a it would be great if this was also disorganized attachment

but sadly you know the entities within the Clusters are great clinical entities

I don't think the Clusters necessarily have the same strength to them so uh this is one of those

frustrating times where the although the root word schizo which is used in

schizophrenia schizo typle and schizoid is the same Greek word meaning like a

split uh in schizotypal that means it's they're refering they are using schizo

to refer to schizophrenia so it's like schizophrenia whereas in skitso it is referring to a split from other people

so a schizoid personality disorder is or somebody with schizoid personality disorder is somebody who holds himself

apart from others has no interest in relationships with others uh sometimes

we can almost map it onto like we can try and look at as like oh they got a lot of the negative symp symptoms of

schizophrenia but realistically it is just like they have no interest in um relationships with others and they're

okay with that um and this is where the avoidant attachment style comes in

because these are people who have fundamentally learned that other people can't help like they're just it's not

helpful for me to have these relationships depend on others to depend on others they will let you down every

time that's one often one of the beliefs that are held by people skid personality disorder and as I'm going to say I'm a

broken record on record on this uh that is a belief that has come from experience they have learned that

because people have let them down in the past whether they are consciously aware of it or not you know we can infer a lot

about their life through the beliefs that they hold at at the time of review

right so that's the cluster A's we''ve got uh paranoid and schizotypal personality disorders being linked with

disorganized attachment and skizo personality disorder being linked with avoidant attachment M then we've got our

cluster B uh so borderline personality

disorder and antisocial personality disorder are have been linked for a long

time uh one of the things that we mentioned earlier was you know when you asked about this gender difference in

externalizing versus internalizing behaviors um there was a fantastic study that was done on psychiatrists I want to

say in the 80s I could be wrong here where they had little vignettes little

like you know single paragraph patient summaries of like you know uh let's say

70y old comes in after a big fight exactly and just describes you know some

basic factors of them and you what is the most appropriate diagnosis for this patient and what they found was that if

they had the same vignette but used masculine pronouns um for one of these particular

vignettes and if they used masculine pronouns the psychiat he him that kind of thing the psychiatrist would usually

diagnose antisocial personality disorder the exact same vignette using feminine

pronouns she her would be diagnosed with borderline personality disorder y so

there is a sexist lens that is being applied by psychiatrists to these

disorders I also would ask arue that there is a socialized

gender uh impact on the expression of them

so you mentioned before that you there is a lot of evidence that uh women tend

to be more internalizing men tend to be more externalizing and for uh those who

haven't come across those terms it's sort of like internalizing is uh having sort of anxious beliefs you know self

harm things of like I am a direct negative energy

inwards I'm I'm upset am I going to scream and attack outwardly and occupy

space mhm which I'm doing right now very masculine or am I going to withdraw and

say what's wrong with me and look within and attack uh and feel anxious and feel the tension in my body and internalize

that that energy that's a really way to sum it up yeah uh and I it seems pretty clear look at this

confusion that's held by psychiatrists that antisocial personality disorder and Borderland personality disorder are very

similar one might argue that they are in fact two valencies of an ambivalent

attachment style so whoa nice that's a nice insight there we go uh sometimes

I'm not just a pretty face it's this idea that uh people with uh borderline

personality disorder and antis personality disorder they've tended to come to these behaviors and beliefs um

as a result of that inconsistent care that's one of the reasons you know we talked about how uh people with an

ambivalent attachment style they do seek out their caregiver they still want that help um and but every time it's a crisis

that's one of the things that then drives the help-seeking behavior that we

see in people with Borderland personality disorder and antisocial personality disorder they are people who

come to emergency departments requesting help they see doctors they see

psychologists and it's one of the things that then drives some of the stigma held

by medical professionals against people with these disorders which is that it

feels like no matter how what no matter what I do to help this person nothing works I talked before yeah the cup with

a hole in it exactly can't fill it and when you if somebody has chosen to

become a healthc care professional uh usually at least partially they get some satisfaction out of helping people and

which means that they get immense dissatisfaction out of not being able to help

somebody this is also uh so that's when there's a lot of internalizing behaviors that's one of the things that really

drives that dissatisfaction and then when there's the externalizing behaviors what can then drive some of that

dissatisfaction and some of that stigma is you I don't know about but you Sil but I

have personally been assaulted by patients in the context of them having a personality disorder um we have

colleagues who have been assaulted by patients and it is something which is uh

it demonstrates that that person was in immense distress like in my instance it was a

patient that I had seen before and had had positive interactions with before but on that particular day that

particular time that particular situation they were in was one in which they could not handle how they were

feeling at any any other way but to externalize and it was honestly very

helpful for me to consider it on this view that it wasn't that they were attacking me like why are they attacking

me I'm trying to help them it's like well this is the only way they have to

feel that they can get help and have that help stay it doesn't make it okay it doesn't

make it you know it doesn't change uh the fact that it was a really difficult experience for me but I was definitely

able to move through it better by Framing it in this way in a much more compassionate way than just like oh

they're a bad person who hits people because that's not a helpful way to think about anybody wow thanks for sharing that Cam and I think that's

really useful for um any Healthcare professional who's been in these

instances the other thing is that when someone is seeing you they're usually at

their worst absolutely theyve they've tried their adaptive helpful strategies

that hasn't worked and now they're in the hospital sometimes because the police have brought them in or someone else has

said that it's time and they're feeling yeah so um I'm fortunate enough to have

never been assaulted yet um plenty of close calls and um uh but yeah it's one

of the reasons that usually uh in 90% of my reviews the first question is how are you doing at the moment uh and you know

because when I I was more Junior I would start off by saying so this is what I understand so far and then I would speak

for a minute not knowing at all what the person is thinking and and them definitely thinking look at this bloody

doctor who thinks he knows everything that I've gone through he's got no idea and you know

what so that that yeah so it's interesting how the that and by the way

that did generate a a conflict and this person did um get upset so it's

interesting how these really uh difficult situations do change our practice absolutely that's thank you for

sharing that Insight around understanding coping mechanisms and stress helps you

empathize that absolutely does not change whether you call police or whether someone is liable or not um

exactly and the consequences so I guess yes so BPD and

um antisocial personality disorder two valencies of vience mhm narcissism and

and hisonic I shouldn't say narcissism I should be specific narcissistic personality disorder and histrionic

personality disorder yeah what do you make of those so histrionic I find very easy to map onto amb yeah the ambivalent

attachment style as well hyic personality disorder is uh sort of

expressed usually in people who are very uh flamboyant who there's a sense of

theatricality to them it all often feels that's a great word theatricality it's like it's the uh the

root of the term is like I think hisonic is is the same roote as the word actor right and it is this sense of when

you're seeing them that like oh it feels like they're performing emotions at me it does it often feels like there's uh

no substance behind what they're saying or what they're expressing um and essentially that is based in this belief

that the only way to get care is to be going through a crisis it's to have this these big emotions and so it however I

think it whereas in borderline and antisocial personality disorders often there is this um sense

of how to put it there's often a a sense of authenticity to the distress like

you're seeing somebody and they have no way of dealing with what they're feeling other than to express exactly what

they're feeling in this moment uh people with hyic personality disorder the same

is true however the sense you get is that

they aren't actually feeling the emotion and so there's a sense of there's a a

disconnection between the conscious expression and the internal state so one

of the things that makes me a bad attachment theorist is that I personally believe that you know as much as these

are you know rough Sor as much as these are categories they are rough categories

with fuzzy borders where somebody can be you know have characteristics of one but

not the other and like it sort of tells you a bit that maybe their primary caregiver was predictable in some ways

but unpredictable in others you know that kind of thing and so I would say that histrionic personality disorder uh is one where somebody has

some avoidant characteristics where they have learned to distance themselves from

their internal experiences but has some ambivalent characteristics where they know that to keep people close they need

to be bigger and Larger than Life they can't be an authentic version of

themselves that's bringing up this what we what we were talking about at the very start around how attachments not

just about relating to other the self absolutely and I wonder can you have an avoidant attachment with yourself but an

ambivalent attachment with others and that's what this is kind of sounding like that um that uh really connecting

with your authentic self and emotions is uh hasn't been safe and being vulnerable

authentically hasn't been safe and so one has to um put this unconsciously

this demonstration and act out what they feel they're meant to look like or act

out as a yeah and yeah that's I haven't kind of pondered um I personality sort

of much but that is really interesting it's a that's a really insightful way to think about I haven't thought about it in those terms of the sort of different

parts of the attachment having different styles but I think that is quite a useful way to think about things um and

fundamentally I'm all about how can we use these theories to better our

understanding of ourselves and of our patients and to inform our care um I'm don't have any particular attachment

a to like you know theoretical Purity or you know the academic side of things um

then narcissistic personality disorder is probably one that I struggle

a little bit more to attach to these um sty attachment Styles but probably

closest to an avoidant attachment style what we often see with narcissistic personality disorder and I've only

treated a couple of patients where I would say that they meet that the criteria for that illness um is that the

it's often driven by a strong sense of shame that there is something fundamentally deeply wrong with them and

so around this fundamental belief they construct this thin shell of you know

being very different to that so one particular uh case that I can think of was a patient where look they were a

daily cannabis user um but one things that they were very clear with when they

saw me was but I'm not a junkie I'm not one of those people who you know just does drugs all the time and doesn't do

anything else I'm not a junkie and there's that thing where you know the lady does protest too much to

me thinks like when somebody is uh saying these things which puts

them above others and better than those disgusting dogs who do drugs all the

time that's probably actually the dis the dis the disgusting

dog who does drugs all the time might be a Bel they hold about themselves and so

it's a distancing from uncomfortable thoughts but a very superficial one um

it the only way that people with a narcissistic personality disorder are able to maintain a sense of positive regard for themselves is to really

distance themselves as much as they consciously can from their actual beliefs so I think it is an attach sorry

it is related to the avoidant attachment Style but I'll be perfectly honest it is one which I do struggle to use this

framework to understand um but it's also one which I think people do tend to

intuitively get a lot more people seem to get narcissistic personality disorder in a way that they don't get the other

personality disorders so maybe it's less important to be able to use this framework for it it's interesting when

we we talk about a lot of you know sty attachment Styles and defense mechanisms

coping mechanisms that actually occur pre- language and we're

trying to find words to describe it absolutely someone saying you know those

junky dogs um and it being said a couple too many times for it to feel natural

yeah it feels like that's a projective um defense and that yeah that there's probably a deep-seated fear that um that

might be something in their mind that they might be a junkie and and that it can be a safe and and that might be a

really useful therapeutic thing to one day explore is that it's safe to explore

how you see yourself with me absolutely

yeah well that's cluster B that's cluster B and last but not least our cluster sees uh so there's avoidant

dependent and ocpd MH why don't we start with ocpd because these These are people

who are extremely um the word fastidious and they they really need all their

books in the perfect order and that draw is perfectly organized and it and it generates a significant amount of

distress when things are not um running as they should yeah uh which I'm every

you know it's pretty common to hear Healthcare professionals being like Oh that's just you know I'm a bit ocpd um

but Criterion zero it's about how it's affecting relationships are you breaking up with your partner because you know

the socks were left out in the wrong place sorry excuse the extreme examples but um yeah and uh and and so how would

that map two different attachment Stars I think that what I would there's a very

telling uh I forget which of the lettered or numbered criteria it is in

ocpd uh in the DSM which states that it's a person who has very high

standards for themselves and others and who really struggle to

delegate somebody who cannot allow or trust other people to do things because

other people do things wrong if I ask somebody else to do something it won't work it's not going to help

fundamentally this is based on an avoidant attachment view of the world

one in which I'm the only one who can be relied upon nobody else is reliable I've

got the the only way I can have control over an environment in which I feel distress is by controlling it down to

the last you know atom in my environment and that's where this obsessive compulsive personality frame can come

from Wow and then um then there's anxious personality sorry there's

avoidant personality disorder yeah I'm really hoping it's avoidant attachment

style almost certain I am almost certain that the avoidant Personality Disorder so people with this disorder are very

sensitive to rejection they avoid situations with any possible conf conflict this reaction is fear

driven uh they become disturbed by their own social isolation withdrawal and

inability to form close interpersonal relationships yeah it's pretty avoidant like it's unlike the schizoid

personality disorder where somebody has separated themselves from others but seems to be okay with that they seem to

be happy with that somebody with an avoidant personality disorder uh is

aware that they don't like being this way and that's a really want connection

but it's too painful exactly there's this fear-driven belief that

vulnerability and connection will hurt me or hurt somebody else so they keep on ending these relationships and they keep

on skating off any kind of depth to the relationship so that's the avoidant personality and then I think we're up to

the last um last one dependent personality disorder which if I was I'm going to guess first then you can

correct but I think that would map most towards an ambivalent style where um

it's you're going to use whatever tools you've got to manage to maintain the relationship and um and that can be

dangerous if the relationship is dangerous it's something we SE unfortunately in in a lot of unhealthy

relationships um but is that right is that where you would map it definitely and it's you know part of that

ambivalent attachment style that we talked about was in that strange situation test they're not able to go out on their own to explore the the

space without the caregiver beg your pardon one of the features of dependent personality disorder is an inability to

make decisions even quite trivial decisions on your own a belief that no I'm actually not good enough to do this

on my own I can't do it on my own I need what do they think I need their opinion exactly what I'm going to do is wrong

yeah let's get someone else on this exactly wow oh that was very satisfying look uh

I'm I certainly I feel like I also learned a lot in going through it with you it's one of the wonderful things

about peer-to-peer discussions is that we all have different backgrounds and

different ways of looking at things like there are probably times that you can tell on that it felt a little bit rehearsed because I really love sharing

attachment Theory with um a lot of the medical students who come on placement in order to help them understand

personality disorders and remember them for the exam that they will have to take

and then they can forget about it don't care afterwards but uh but what they'll never forget is the insights they got

into themselves when they heard that for the first time because you know everyone

who works in mental health is slightly looking into themselves when they're looking into others oh gosh

absolutely but yeah I really appreciated you know some of the things that you asked or the connections that you made

were ones that I'd never considered so I really appreciated that that's awesome thank you so much Cam and um I look

forward to our next chat around uh I think we're going to cover religion and

um spirituality and um how that interplays into Psychiatry so that's going to be an awesome chat as well

thank you looking forward to it