Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74(6), 1027-1040

Department of Psychiatry, Cornell University, Итак, New York, United States
Journal of Consulting and Clinical Psychology (Impact Factor: 4.85). 01/2007; 74(6):1027-40. DOI: 10.1037/0022-006X.74.6.1027
Source: PubMed


Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment components responsible for effecting these changes, and examine the long-term outcome of these changes.

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    • "BPD patients are particularly likely to fall back on automatic mentalizing at moments of intense emotional arousal (e.g., in attachment contexts, challenging interpersonal situations, feelings of shame, guilt, anger, or inadequacy), often with severe impairments in social cognition as a consequence (e.g., being overly distrustful or trustful, being idealizing or overly denigrating). The dramatically reduced capacity of BPD patients for reflective functioning (Fonagy et al., 1996) that is necessary for controlled mentalizing has been shown to be reversible by psychotherapy (Levy et al., 2006). The task of the therapist, then, is to help slow down the patient's thinking and move them to a more reflective, explicit form of mentalizing that requires more conscious, verbal attention; all without generating a process of pseudo-reflection or hypermentalizing (Sharp et al., 2011, 2013). "
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    ABSTRACT: The role of mentalizing in relation to borderline personality disorder (BPD) is examined with a view to achieving improved levels of mentalizing in BPD patients as a therapeutic target. The article seeks to explain why mentalizing works as a treatment target for BPD, and suggests that a mentalizing approach to BPD may be at the core of any successful intervention. (PsycINFO Database Record
    Personality Disorders: Theory, Research, and Treatment 10/2015; 6(4):380-392. DOI:10.1037/per0000113 · 3.54 Impact Factor
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    • "One study (Levy et al. 2006) revealed a relationship between changes in RF and changes in attachment representation from disorganized to organized attachment patterns. Since RF and attachment were assessed from the same interview, it remains unclear if RF changes lead to changes in attachment or vice versa. "
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    ABSTRACT: This study examines how reflective functioning (RF) can be assessed in analytic sessions and throughout psychoanalytic psychotherapy. The goals are to replicate in part a study by Josephs and colleagues (2004) by applying the RF Scale to analytic sessions and to study fluctuations of RF within each session. Additionally, RF based on sessions was compared with the RF ratings based on the Adult Attachment Interview (AAI) during the course of two psychoanalytic psychotherapies with a duration of 240 hours. RF changes based on 10 sessions per patient, assessed at baseline and after 80, 160, and 240 hours of therapy, and RF changes based on AAI ratings measured at baseline and after 240 hours of therapy, and in one case at follow-up, were related to changes of symptoms and attachment classifications over time. Results showed that in both cases RF fluctuated within sessions. The average RF rating per session increased over the course of treatment, while the AAI-based RF rating needed longer to increase. Rather good correspondence was found between session-based RF ratings and independent AAI-based RF ratings. In both cases, changes in RF over time were compared to changes in attachment classification based on the AAI and to symptomatic change. Better correspondence between symptomatic and attachment changes was found with the AAI-based RF rating. It was tentatively interpreted that session-based RF ratings may represent a state of RF that is strongly influenced by the therapist-patient interaction, whereas AAI-based RF can be considered to have more trait characteristics. © 2015 by the American Psychoanalytic Association.
    Journal of the American Psychoanalytic Association 07/2015; 63(3):481-509. DOI:10.1177/0003065115591977 · 0.79 Impact Factor
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    • "In terms of empirical evidence, there is evidence of improvement in both narrative coherence and reflective function in people with borderline personality disorder as a function of transference-focused therapy and mentalization-based therapies (MBT), which are attachment-informed treatments for people with borderline personality disorder, incorporating many of the key processes and strategies described above (Fonagy & Bateman, 2006; Levy et al., 2006). The former study did, however, find limited evidence of change in patients' unresolved/resolved status with respect to trauma and loss as a result of therapy, despite the high levels of loss and trauma in the group. "
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    ABSTRACT: We aimed to provide an integrated overview of the key goals and strategies of an attachment-informed psychotherapy by summarizing the literature describing the clinical implications of attachment theory for psychological therapy for adults. We carried out a narrative thematic review of 58 texts from a diverse range of therapeutic schools, until we agreed that we had reached a saturation of themes. We identified six key themes: Changing internal working models; the therapeutic relationship and creating a secure base; formulating and processing relationship experiences; countertransference; separation, termination and boundary issues; and working with different attachment styles or patterns. We discuss empirical evidence in relation to each theme and highlight areas for research. Attachment theory provides a useful framework to inform psychological therapy with adults, but there is a pressing need for further research to empirically demonstrate the 'added value' of an attachment perspective. Attachment theory should be used to inform individual psychological therapy in adulthood. From the outset of their careers, therapists should receive training and supervision to enhance their awareness of their own and their clients' attachment experiences and how these play out during therapy. There is a need for greater empirical research to investigate whether the degree to which therapists formulate and meet clients' attachment needs influences outcomes. © 2015 The British Psychological Society.
    07/2015; DOI:10.1111/papt.12063
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