Attachment and Psychotherapy: Implications
from Empirical Research
Kenneth N. Levy, Ph.D.
Pennsylvania State University
and
Joan and Sanford I. Weill Medical College of Cornell
University
Early Development, Attachment, and Psychotherapy,
Copenhagen, Denmark,
November 20th-22nd , 2008
Personality Disorders Institute (PDI)
Joan and Sanford I. Weill Medical College of
Cornell University
• Otto F. Kernberg, MD,
Director
• John F. Clarkin, PhD, CoDirector
• Frank Yeomans, MD
• Armand Loranger, PhD
• Paulina Kernberg, MD
• Mark Lenzenweger, PhD
(Binghamton)
• Eve Caligor, MD
•
•
•
•
•
•
•
•
Ann Appelbaum, PhD
Monica Carsky, PhD
Catherine Haren, Psy.D.
Diana Diamond, PhD
(CUNY)
Pamela A. Foelsch, PhD
James Hull, PhD
Michael Stone, MD
Jill Delaney, M.S.W.
Laboratory for Research in Personality,
Psychopathology, and Psychotherapy
• City University of New
York
–
–
–
–
Kevin B. Meehan
Joseph S. Reynoso
Michal Weber
Komal Choksi
• Penn State
–
–
–
–
Lori N. Scott
Rachel H. Wasserman
Joseph E. Beeney
William D. Ellison
Funding and Support
• National Institute of Mental Health
• Borderline Personality Disorder Research Foundation
• National Association for Research in Schizophrenia and
Depression
• American Psychoanalytic Association
• International Psychoanalytic Association
• Köhler Foundation
• DeWitt Wallace Readers Digest Fund (Kernberg)
• Department of Psychiatry, Weill Medical College
• City University of New York, Dean’s Office
• Research Foundation of the City University of New York
• Pennsylvania State University
• Social Science Research Institute
Attachment and Psychotherapy
• Although Bowlby was a psychiatrist.
Psychoanalyst, and psychotherapist, much of the
research on attachment theory has been carried out
by developmental and social psychologists
focusing on normative aspects of attachment.
• From its inception, however, Bowlby
conceptualized attachment theory as relevant to
both normal and psychopathological development.
Attachment and Psychotherapy
• Bowlby believed that attachment insecurity,
although originally an adaptive set of
strategies designed to manage distress,
increases vulnerability to psychopathology,
and can be linked to specific types of
difficulties that arise.
• "the many forms of emotional distress and personality
disturbance, including anxiety, anger, depression, and
emotional detachment” (p. 5) which result from the
disruption of those bonds
Attachment and Psychotherapy
• Bowlby also believed that attachment
theory had particular relevance for
psychotherapy.
Bowlby on Attachment and
Psychotherapy
• The chief role of the therapist is “to provide
the patient with a temporary attachment
figure” (Bowlby, 1975, p. 191)
• the therapist’s first task is to “provide the
patient with a secure base from which to
explore both himself and also his relations
with all those with whom he has made or
might make, an affectional bond” (Bowlby,
1977; p. 421)
Bowlby: Five Key Tasks of
Psychotherapy
• Establishing a secure base
– which involves providing patients with a secure
base from which they can explore the painful
aspects of their life by being supportive and
caring;
• Exploring past attachments
– which involves helping patients explore past
and present relationships, including their
expectations, feelings, and behaviors;
Bowlby: Five Key Tasks of
Psychotherapy
• Exploring the therapeutic relationship,
– which involves helping the patient examine the
relationship with the therapist and how it may
relate to relationships or experiences outside of
therapy;
• Linking past experiences to present ones,
– which involves encouraging awareness of how
current relationship experiences may be related
to past ones;
Bowlby: Five Key Tasks of
Psychotherapy
• Revising internal working models
– which involves helping patients to feel, think,
and act in new ways that are unlike past
relationships.
Bowlby: Five Key Tasks of
Psychotherapy
• Revising internal working models
– which involves helping patients to feel, think,
and act in new ways that are unlike past
relationships.
• Providing a Safe Haven
– Which to go in times of distress
• Can be a representational
Bowlby: Five Key Tasks of
Psychotherapy
• Revising internal working models
– which involves helping patients to feel, think,
and act in new ways that are unlike past
relationships.
• Providing a Safe Haven
– Which to go in times of distress
• Can be a representational
• Transference and countertransference
dynamics (multiple contradictory IWM)
Attachment and Psychotherapy
• There are a number of ways that Attachment and
Psychotherapy intersect
– Attachment theory based interventions
– Attachment organization as a moderator of outcome
(prognostic indicator)
– Attachment organization as a prescriptive indicator
– Psychotherapy process (therapist and patient in session
behaviors) as a function of attachment processes
– Attachment organization as a moderator of
psychotherapy process
– Change in attachment representations as outcome
Attachment Theory Based
Interventions
• Many treatments implicitly use principles
and techniques that are consistent with
attachment theory
– the establishment of a therapeutic alliance
– the exploration of past and/or relational
experiences, the updating of self-views
• Until recently, few psychotherapies have
been developed based directly on
attachment theory principles
Attachment Based Child
Interventions
• Baby Carrier Intervention (Ainisfeld et al., 1990)
• Home Visits (van den Boom, 1994)
• Intervention for high-risk pregnant women,
(Korfmacher, Adam, Ogawa, & Egeland,1997)
• Watch, Wait, and Wonder (Cohen, Muir et al., 1999)
• Toddler-Parent Psychotherapy (Cicchetti, Toth, Rogosch,
1999; Toth et al., 2006)
• Circle of Security (Marvin, Cooper, Hoffman, & Powell, 2002;
Hoffman et al., 2006)
Attachment Based Child
Interventions
• Video Feedback Positive Parenting (Zeijl eta l., 2006)
• Prenatal Home Visits (Heinicke et al., 2006)
• Parent-Child Psychotherapy (Lieberman & Van Horn,
2004; Lieberman, Ippen, & Van Horn, 2006)
Ainisfeld et al., 1990:
Attachment Security in SS
(n =46)
Attachment Based Adult
Interventions
• Interpersonal Psychotherapy (IPT; Klerman,
Weissman, Rounsaville, & Chevron, 1984)
• Mentalization Based Therapy (Bateman & Fonagy,
1999; 2001; 2008)
• Attachment Injury Resolution Model for
Couples based Emotion Focused
Psychotherapy (Johnson, 2004; Makinen & Johnson, 2006)
Bateman & Fonagy (1999)
• RCT of the effectiveness of 18 months of a nonmanualized psychoanalytically oriented day
hospitalization program compared with routine
general psychiatric care for patients with BPD
–
–
–
–
significant improvement in depressive symptoms
better social and interpersonal functioning
significant decrease in suicidal and self-injurious acts
number of inpatient days
• Note:
– TAU consisted of 2 hours of psychiatric care a month
vs. 30 hours a week of PHP
Bateman & Fonagy (2008) Partial Hospital RCT:
Patients at 5 yrs FU
MBT-PH
TAU
90
80
70
60
50
40
30
20
10
0
Meet criteria
(p<.0001)
No longer Subsequent Any suicide
on
treatment
attempt
medication
(p<.02)
(p<.001)
(p<.005)
No self harm
(p<.001)
Partial Hospital RCT: Patients at 5 yrs FU
MBT-PH
TAU
20
18
16
14
12
10
8
6
4
2
0
total
score(p<0.0001)
affective
disturbance
(p<.01)
cognitive
disturbance
(p<.08)
impulsivity score
(p<.001)
disturbed
relationship
(p<.0.0003)
Partial Hospital RCT: % Attempting Suicide
N=44
NNT (18 months)=2.1
NNT (36 months)=1.9
NNT (60 months)=2.1
100
90
80
*
70
*
***
***
60
**
50
**
40
Day Hospital
Control
30
20
10
0
Admission 12 months 24 months 36 months 48 months 60 months
Treatment
Follow -up
* p < .05
** p < .01
*** p < .001
Partial Hospital RCT: Employment
MBT-PH
TAU
80
Percent in Employment
70
60
50
40
30
20
10
0
Baseline
MidTreatment
End
Treatment
1 year FU
2 year FU
3 year FU
Partial Hospital RCT: GAF Scores
65
60
Mean GAF Score
55
50
MBT-PH
TAU
45
40
35
30
Baseline
End
treatment
18m FU
30 m FU
42 m FU
Assessment of Attachment
• Adult Attachment Interview
• Reflective Function
Adult Attachment Interview
• On the AAI individuals are asked to describe:
– Their parents generally, giving 5 adjectives with specific examples
to back up general descriptions
– How parents responded when they were upset, ill, or in distress
– The impact of early experience on current adult functioning
• The interview has the effect of “surprising the
unconscious”
• Provides numerous opportunities for the speaker to
elaborate upon, contradict or fail to support examples
• Can classify interviewees pattern of attachment as Secure,
Preoccupied, Dismissive, Unresolved, or Cannot Classify
Assessment of Coherence
(George, Kaplan, & Main, 1985)
• Coherence:
–
–
–
–
Quality—truthful, i.e., evidence for what was presented
Quantity—succinct, and yet complete
Relation—relevant to the topic at hand
Manner—clear and orderly
• Rated on 9 point scale, with 1= low coherence and 9 =
high coherence, and score of 5 = cut-off for secure
attachment
• Not related to IQ, or coherence of narrative discourse of
non-attachment experiences (e.g., work)
Reflective Function
• The social cognitive and affective process
of interpreting or making sense of behavior
in oneself and others in terms of intentional
mental states, such as desires, feelings, and
beliefs.
• The capacity to reflect upon one’s own
experience, whatever his or her attachment
status.
Aspects of Reflective Function
• The explicit effort to tease out mental states
underlying behavior
– Accurate attributions of mental states to others.
• As suggested by differentiated views of events
• “My mother was good if I were physically hurt, except if she
was frightened, then she wouldn’t be able to cope.”
– Recognition of diverse perspectives and points of view
of the same event.
• “My mother had the habit of lifting her hand and slapping us, if
we were naughty, or when she thought that we were naughty.”
Aspects of Reflective Function
• Recognizing the developmental aspects of
mental states
– Taking a developmental perspective
• “When we were little my father always seemed to have time for
us and we would have so much fun together, but then as we got
older he withdrew and had difficulty I think getting on with
teenagers.”
• Mental states in relation to the interviewer
– Acknowledging the separateness of minds
• “It must seem strange to you that I’m still upset, but it is almost
exactly this time of year when the accident happened.”
Aspects of Reflective Function
• Awareness of the nature of mental states:
– The opaqueness of mental states
• “I thought my mother felt resentful of us, but I’m not really
sure if she felt that way herself” would be regarded as
reflective whereas the statement, “One can never know what
someone else thinks” would not.
– Awareness of the defensive nature of certain mental
states:
• “You tend to blank things out that make you unhappy
sometimes.”
Reflective Function
(Fonagy, Target, Steele, Steele, 1998)
• The process of being able to reflect on experience and
interpreting behavior in terms of intentional mental states, such
as desires, feelings, and beliefs; represented by four dimensions:
–
Awareness of the nature of mental states (“Well I think he felt obligated
to do that because he felt guilty…”)
–
Explicit efforts to tease out mental states underlying behavior (“…or at
least that’s how it appeared, sometimes you feel different inside from
how things appear.”)
–
Recognizing developmental aspects of mental states (“It’s only as an
adult that I understand this, as a child I was confused why he did
that.”)
–
Recognition of mental states in relation to the interviewer (“I’m not
sure if that makes sense, should I explain further?”)
Reflective Function Scale
(Fonagy, Target, Steele, Steele, 1998)
-1 Negative
• Rejection, totally barren, grossly distorted, overly concrete,
unintegrated, or inappropriate RF
1 Disavowal, distorted/self-serving
3 Naive simplistic or over-analytic/hyperactive
5 Ordinary or inconsistent
• model of mind is fairly coherent, but somewhat one
dimensional or simplistic
7 Marked
9 Exceptional
• unusually complex, elaborate or original reasoning about
mental states
Correlation between Coherence and
RF
• In non-clinical samples = .73 *** (Fonagy
et al., 1991)
• In BPD sample pre-treatment = .48**
• In BPD sample post-treatment = .52**
•
Note: *** significant at the .001 level.
Validity for RF
• Fonagy et al (1995) found that RF mediated
the relationship between parental
attachment security and infant attachment
security in the SS.
– insecurely attached parents with high RF were
more likely to have securely attached babies
than insecurely attached parents with low RF.
Validity for RF
• Grienenberger, Kelly, & Slade, 2005 found
that mother’s RF mediated the relationship
between atypical maternal behaviors (e.g.,
affective communication errors,
role/boundary confusion, intrusiveness) and
attachment security in their infants.
Validity for RF
• Fonagy et al. (1996) found that among
patients reporting abuse, those who scored
low on RF were more likely to be diagnosed
with BPD compared to those who were
abused but scored high on RF.
– Thus, high RF seems to be a possible buffer
against the development of BPD in individuals
who have experienced abuse.
Wisconsin Card Sorting Task
• Measure of executive
functioning,
• Specifically concept
formation and the
capacity shift attention
(cognitive flexibility)
Relation of Reflective Function to
Wisconsin Card Sort Test
5.5
5.0
4.5
4.0
3.5
3.0
r = -.47
2.5
2.0
1.5
-.5
0.0
.5
1.0
WCST Failure to maintain set
1.5
2.0
2.5
3.0
3.5
3078
3078
1367
1637
Relation of Reflective Function to
Impulsivity on Continuous
Performance Test
5.5
5.0
4.5
4.0
3.5
r = .35
3.0
2.5
2.0
1.5
-4
-2
Impulsivity 4FN
0
2
4
6
8
Attachment Moderates
Likelihood of Being in
Psychotherapy
• Riggs et al. (2002) examined attachment and
history of psychotherapy in 120 middle-class
women.
– dismissing women ↓ report a history of
psychotherapy
– disorganized ↑ report a history of individual
psychotherapy
– secure women ↑ report a history of couples therapy.
Attachment as a Moderator of
Outcome
• Dozier, 1990
– Fs more cooperative with treatment
– Ds associated with less help seeking, less selfdisclosure, and poorer treatment use
• Dozier, Cue, & Barnett, 1994; Tyrrell et al., 1999
– Fs clinicians more likely to challenge patients’ own
strategies for relating
– insecure clinicians tended to mirror the patients
interpersonal style
– Better outcome when patient and therapist attachment
complementary vs. concordant.
Attachment as a Moderator of
Outcome
• Fonagy et al., 1996
– Ds attachment predicted better outcomes than E
GAF Score
∆ in GAF between Admission and
Discharge as a Function of
Attachment
45
40
35
30
25
20
15
10
5
0
36
41
36
31
25
20
F
E
Ds
Admission
Discharge
Attachment as a Prescriptive
Indicator
• McBride, Bagby, & Atkinson, 2006
– attachment security moderate treatment
outcomes in a RCT of CBT and IPT for MDD
– avoidant attachment predicted better response
to CBT than to IPT on all outcome measures,
but anxious attachment did not predict different
outcomes with the two treatments.
Attachment as an Outcome
•
•
•
•
•
•
•
Fonagy et al., 1995
Diamond et al., 2003; Levy et al., 2008
Stovall-McClough & Cloitre, 2003
Levy et al., 2006,
Makinen and Johnson , 2006;
Cicchetti et al., 1999; Toth et al., 2006
Hoffman et al., 2006
Fonagy et al., 1995: Change in
Security of Attachment (n =35)
Diamond et al., 2003: Change in
Security of Attachment (n =10)
Change in Coherence and RF as a
Function of Time: Pre-Post Study
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
4.4
3.58
3.05
2.7
Coherence
RF
Yr. Prior
Tx. Year
Coherence Paired t-test = -2.86, p < .02; RF paired t-test = -6.38, p < .001
Levy et al., 2008
Stovall-McClough & Cloitre,
2003: Change in Unresolved
Status (n =18)
BPDRF-PDI RCT
Overall Study Aims
 To assess the efficacy of Transference
Focused Psychotherapy (TFP) and
Supportive Psychotherapy (SPT)
compared with Dialectical Behavioral
Therapy (DBT) for patients with
Borderline Personality Disorder (Clarkin, Levy,
Lenzenweger, & Kernberg, 2004, Journal of Personality Disorders)
BPDRF-PDI RCT
Overall Study Aims and Design
 Examine efficacy of Transference Focused Psychotherapy
 Randomized 90 patients to one of three treatments: TFP,
DBT, and Supportive Psychotherapy (SPT)
 Experienced treatment cell leaders, experienced trained
therapists, supervised weekly
• Patients clinically referred, highly comorbid (77% hx of
MDD, 55% anxiety disorder, 33% eating disorder, and
38% substance use disorder), and highly traumatized (28%
severe sexual abuse and ~50% some sexual abuse)
(Clarkin, Levy et al., 2004; 2007; Levy et al., 2006)
Treatments
 Transference Focused Psychotherapy
– Uses a treatment contract to set the frame and assist in the
containment of acting out behaviors, stipulates a sequence of
treatment phases for interventions, emphasizes analysis of the
transference for the integration of disparate representational
models.
 Dialectical Behavior Therapy (DBT)
– emphasizes a balance between acceptance and change, skills
training in the context of validation
 Supportive Psychodynamic Psychotherapy (SPT)
– eschews transference interpretation and places primary emphasis on
strengthening adaptive defenses; forming an alliance, providing
reassurance and advice
Transference Focused
Psychotherapy
•
•
•
•
•
Modified Psychoanalytic Psychotherapy
Specifically for personality disorders
Structured twice weekly outpatient treatment
Based on Otto Kernberg’s Object Relations Model
Primary goal:
– reduce symptomatology and self-destructive behavior
through integration of representations of both self and
other (resolution of identity diffusion or stated
differently the accomplishment of identity
consolidation)
Overview of the TFP Treatment
Model
• During the first year of treatment, TFP focuses on
a hierarchy of issues:
– Begins with a treatment contract
• the containment of suicidal and self-destructive behaviors
• the various ways of interfering with the treatment
– In session, therapist follows dominant affect
– Identifies and explicates recapitulation of dominant
object relational patterns, as they are experienced and
expressed in the here-and-now of the relationship with
the therapist (conceptualized as a transference
relationship).
– Not about reconstructing childhood experience
Therapeutic Techniques
• Clarification
– Of the patients subjective experience
• Confrontation
– Tactfully pointing out discrepancies between what the
patient is saying at one time and another or between what
they are saying and doing or saying and expressing
• Transference Interpretation
– The therapist’s timely, clear, and tactful interpretations of
the dominant, affect-laden themes and patient enactments
in the here and now of the transference, are hypothesized
to integrate polarized self- and object representations.
Proposed Mechanisms of
Therapeutic Change
• Integration of self concept
• Integration of concept of significant
others
• Integration of previously dissociated or
split off affect states with the result
that affective experiences become
enriched and modulated
Increased Differentiation and
Integration
• Ability to think more
flexibly and
benevolently
• Impaired
representations
become transformed
through new
experiences
• Relationships:
– infused with less aggression
– greater capacity for
intimacy,
– increased coherence of
identity,
– reduction in self-destructive
behaviors,
– general improvement in
functioning
Therapist
Sets frame via contract
Patient
Experiences safe haven to express self
↓
Expression of affect includes actions and
interactions based on implicit OR dyads
Observes the action without judging or reacting
Tries to understand/explicate the OR underlying the actions, using
1 – Clarification
2 - Confrontation
3 – Interpretation
Increases reflection
(these appeal for reflection &
address obstacles to it)
Further reflection, with
Progress toward
increased contextualization
integration
Increased modulation of affects
Telephone Inquires
(n = 337)
(294 clinical referrals, 28 nonclinical, 15 not known)
Declined Interview
(n = 130)
Interviewed
(n = 207)
Did Not Meet Criteria
(n = 98)
Reason
Did not meet BPD Criteria
Age
Substance Dependent
Concurrent Treatment
IQ
Bipolar Disorder
Eating Disorder
Psychotic Disorder
Scheduling Conflict
Dropped out
n
30
21
9
6
3
8
4
8
1
8
Met Criteria
Offered Randomizing
(n = 109)
Refused Randomization
(n = 19)
Randomized
(n = 90)
Loss of Eligibility
(n = 0)
Levy, Critchfield, & Clarkin, in preparation
TFP
DBT
SPT
(n = 31)
(n = 30)
(n = 29)
Treatment Cell Leaders
• Treatment cell leaders were very experienced in
the modality that they were supervising
• Many years of experience practicing in their
respective treatments
• Many years supervising in their respective
treatments
• Acknowledged as nationally known experts
• Published on their treatments
Therapists
• In each condition:
– Chosen by treatment cell leader
– Experienced practitioner in respective modality
– Supervised weekly and monitored for
adherence and competence
– Generally senior therapists, although ranged
from recent graduates to those with 30 years of
experience
Patient Demographic
Characteristics
• 90 Patients (83 Women and 7 Men)
• Mean Age = 30.9 (S.D. = 7.85)
• Marital status:
–
7 (7.7%) Married, 11 (12.2%) Living with partner, 40 (44.4%) Divorced, 21 (23.3%) In
relationship
• Education:
– 4-year college degree (any college)
32.2% (63.3%)
• Employment:
– Employed (fulltime)
•
64.4% (33.3%)
Ethnicity/Race:
– 67.8% Caucasian, 10.0% African-American, 8.9% Hispanic, 5.6% Asian, 3.3 %
mixed ethnicity/race, 4.4% other
Patients Represented a Seriously
Disturbed Cohort
• All clinically referred
• Highly comorbid (77% hx of MDD, 55% anxiety
disorder, 33% eating disorder, and 38% substance
use disorder)
• Highly traumatized (28% severe sexual abuse and
~50% some sexual abuse)
• A third of the patients began cutting by age 12
• Not selected based on intelligence or
analyzability!
TFP Outcome
• Primary Outcome Variables
– Significant improvement in TFP and DBT; but not in
Supportive:
• Suicidality
– Significant improvement in TFP and SPT
• Anger and Impulsivity
– Significant improvement only in TFP group:
• Assault
• Secondary Outcome Variables
– Significant improvement in all three groups:
• Depression, Anxiety, Social Relations, GAF
– Significant improvement only in TFP group:
• Irritability
Distribution of 5-Category
Attachment Status Time 1
100%
80%
60%
40%
20%
30%
15%
5%
0%
Time 1
32%
18%
Secure
Preoccupied
Dismissing
Unresolved
Cannnot Classify
Change in Secure-Insecure
Attachment Status as a Function
of Time
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
95%
85%
Secure
Insecure
15%
5%
Time 1
Time 2
McNemar’s 2 test was significant at the p = .03 level.
Change in Coherence as a
Function of Time and Treatment
4.5
4.3
4.1
3.9
3.7
3.5
3.3
3.1
2.9
2.7
2.5
TFP
DBT
SPT
Coherence T1
Coherence T2
Change in Reflective Function as
a Function of Time and
Treatment
4.5
4.3
4.1
3.9
3.7
3.5
3.3
3.1
2.9
2.7
2.5
TFP
DBT
SPT
RF Time 1
RF Time 2
Change in Resolved-Unresolved
Attachment Status as a Function
of Time
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
79%
67%
Resolved
Unresolved
33%
21%
Time 1
Time 2
Dropout as a Function of Treatment
Condition and Reflective Function
• Survival Analysis
– Treatment Condition and RF as covariates
• Is there differential dropout across
treatments as a function of RF?
– e.g., are patients with low RF retained better in
certain treatments?
• RF at three levels:
– Severely Impaired, Impaired, Average
Survival analysis on the Dropout
criterion with Tx Condition and RF
• RF moderates relationship between Treatment Condition
and Dropout
– Average: When RF was within the average range, there were no
significant differences across treatments with respect to dropout
• TFP = SPT = DBT
– Impaired: Significantly more dropout for individuals in DBT than
TFP (Wilcoxon Statistic=.4.61, df=1, p<.03) and SPT (Wilcoxon
Statistic=8.81, df=1, <.003).
• TFP<DBT=SPT
– Severely Impaired RF: Significantly more dropout in DBT than
TFP (Wilcoxon Statistic=3.82, df=1, p<.05), while the differences
between SPT and other treatments were non-significant.
• TFP<DBT, SPT ns
Dropout in Average RF Group
Dropout in Impaired RF group
Dropout in Severely Impaired Group
Specific Aspects of TFP that may
Increase Mentalizing
• Focus on the object relation dyads
– Explore mental state of other and self
– The nature of mental states
– Reduces rigidity about knowledge of other
peoples minds
– Model and encourage patient to think about
mental states
– Move beyond empathizing by also offering a
different, yet experientially appropriate
representation (contingent and marked)
Specific Aspects of TFP that may
Increase Mentalizing
• Clarification
– Initiates self-exploration
– Identifies differences in perspective
• Confrontation
– Bids for self-reflection
– Brings into awareness disparate information
and illustrates the defensive nature of certain
mental states
Specific Aspects of TFP that may
Increase Mentalizing
• The Transference Interpretation
– timely, clear, and tactful interpretations of the
dominant, affect-laden themes and patient
enactments in the here and now of the transference
• Mentalization emotion-laden content
• Awareness of the defensive nature of certain mental
states
• Assists patient in elaborating on emotional state that
may have led to the enactment
• are hypothesized to integrate polarized representations
of self and others
Clinical Observations
• Cannot Classify
– E/Ds
• Derogations in angry preoccupied passages
– Pseudo Secures (F/E/Ds or Ud/F)
• Mildly coherent in the provision of believable episodic
memories, but may show below threshold idealization,
derogation, lack of recall, passivity, or angry preoccupation
• however, episodic memories are often belied by a self-serving
quality with positive wrap-ups, lack of true valuing of
relationships, and show little evidence compassion, affection,
forgiveness, or freshness characteristic of secure narratives
Clinical Observations
• Cannot Classify
– Time 1 CCs that move to E or D at Time 2
– Time 1 Es or Ds that move to CC at Time 2
• E classifiable transcripts with split representations
– E1/E2
• passive, self-blaming passages (helpless/passive/avoidant)
• Angry preoccupied parent-blaming passages
(hostile/controlling)
Clinical Observations
• Lyons-Ruth’s Hostile/Helpless distinction
• Severe Splitting
– Rapid oscillations of object relation dyads
– Splitting between caregiver
– Mention of trauma at beginning of interview or
during five adjectives but no mention of it later
in interview when topic is brought up by
interviewer
– Idealization or denigration of interviewer
Clinical Observations
• Psychic Equivalence
– Interview process or questions experienced as
the equivalent of past traumatic experiences
Therapist RF and Patient RF
• We assessed RF in our therapist in the small
pre-post study using a modified patienttherapist AAI.
• Therapist RF re: patient generally high
• However, it did vary within therapist as a
function of patient (but not patient RF!)
• Therapist tended to have lower RF with
their Ds patients
Clinical Illustration
• Single, 32 year old, unemployed female
• Many unsuccessful treatments
• Over a number of years, increasingly
isolated in her apartment, gaining weight,
rarely bathing
• Poor interpersonal relations rationalized
because of her ethnic background
• No sexual relations ever, except 1 attempt
by boyfriend leading to formal rape charges
Clinical Illustration
• Occasional self-cutting
• 3 brief hospitalizations; diagnosis Bipolar
Disorder
• Background: Middle daughter in highly
educated family; prestigious and dominant
but tough father; master’s degree educated;
series of jobs destroyed by interpersonal
relations; not working for last few years
Clinical Illustration
• On the AAI:
– CC/Ds2 (devaluing of attachment
experiences/derogating)/E2 (angry/conflicted)
– RF = -1
Clinical Illustration
• Treatment: Controlling, dominant, dismissing therapist’s
comments
• Condition for treatment: back to work, accepted after
prolonged struggle
• Interpretation of relationship between hostile, grandiose,
arrogant object and victim threatened with abandonment
• Generalization of this relationship to all interpersonal
conflicts interpreted consistently
• Patient’s reflection on relationship with father coincident
with emergence of positive transference while reestablishing relations with men
Clinical Illustration
• At the completion of one-year of treatment
– Interested in apparently appropriate men;
however, relationships often unrequited
– Volunteering in a occupational area that she
thought she might be interested
– Taking non-matriculated graduate classes
– Independent study evaluations: advance from
Reflective Functioning score of -1 to 6 by end
of first year of therapy
– Medication: low dose of Neurontin at
beginning, tapered off during year of treatment
Clinical Illustration
• At one-year follow-up
– Effective improvement in work and
interpersonal relations
– Good sexual relations with stable boyfriend
– Attending graduate school in area consistent
with interests and capacities
– Occasional struggles with feelings during times
of stress (she had a cancer scare)
Clinical Illustration
• At three-year follow-up
– Continued improvement in work and
interpersonal relations
• Married; good sexual relations; trying to get
pregnant
• Working in high-level job consistent with her
interests and intellectual capacities
– Medication free
– Affect: generally happy
Mentalization, Mindfulness, and
Integrated Representation
• Slightly difference foci.
• Very similar in their hypothesized
relationship to attentional control and
affective instability.
• Allows appropriate distance (as opposed to
defensive distance) from events, thoughts,
and feelings.
Mentalization, Mindfulness, and
Integrated Representation
• Thoughts, feelings, and events are not seen
concretely or experienced literally as a rigid
reality, but are experienced implicitly and
sometimes explicitly as symbolic representations
of experience, which one has some control over
(i.E., One can shift one’s attention or think
differently about an event).
• Events remain in perspective and lose their retraumatizing capacity.
Thank You
For more information please e-mail me at klevy@psu.edu and
visit the Laboratory for Personality, Psychopathology, and
Psychotherapy website at http://levylab.psych.psu.edu
Also visit the Personality Disorders Institute website at
www.borderlinedisorders.com