Patient-therapist attachment in the treatment of borderline personality disorder

Abstract

The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.

Change in Attachment and Reflective Function in Borderline Patients with and without Comorbid Narcissistic Personality Disorder in Transference Focused Psychotherapy

“…This shift in primary attachment status from disorganized to organized after one year is consistent with recent research findings on change in AAI classification from insecure to secure, and from disorganized to organized after one year of psychodynamic treatment (Diamond et al, 2003;Gerber, 2004;Buchheim et al, 2012). In one study, for example, Gerber (2004) used the AAI to track the shifts in attachment representations over the course of treatment of 25 young adults with severe personality disorders, who were sequentially assigned to psychoanalysis or psychodynamic psychotherapy at the Anna Freud Center.…”

“…Borderline personality disorder has been associated primarily with the preoccupied and unresolved (disorganized) attachment categories (Patrick, Hobson, Castle, Howard & Maughan, 1994;Fonagy et al, 1996 Clarkin, & Levy, 2003;Levy et al, 2006;Bakersman-Kranenburg & van IJzendoorn, 2009), and secondarily with dismissing and cannot classify attachment status (Barone, 2003;Levy et al, 2006). By contrast, narcissistic disorders have been associated primarily with dismissing-avoidant attachment status (Rosenstein & Horowitz, 1996;Blatt & Levy, 2003;Westen, Nakash, Tomas, & Bradley, 2006), using both interview and self-report measures of attachment.…”

“…TFP involves a stepwise interpretive process modified for more severely disturbed patients, one that is designed to increase the patient's capacity to cognitively represent and contain his or her affective experience, which in turn leads to improvements in reflective function or mentalization, or the capacity to symbolically manage and reflect upon his or her experience in the transference (Levy et al, 2006;Caligor et al, 2009). Another way to think about this process in terms of attachment theory and research is that the treatment situation in TFP, with its dyadic intimacy and intensity, activates primary internal working models of attachment-which in the case of more severely disturbed patients are likely to be insecure, multiple, Downloaded by [RMIT University] at 05:48 09 September 2014 contradictory, and conflictual in nature (Diamond et al, 2003;Fonagy & Bateman, 2005)-with the goal of moving the patient toward increased attachment security.…”

Construct validity of a measure of affective communication in psychotherapy.

“…It may be the case that such sexuality is both alluring and unnerving to therapists, leaving them simultaneously feeling enlivened by and trying to defensively disengage from such feelings (see the case of “Nicole” in Diamond, Stovall-McClough, Clarkin, & Levy, 2003 for a clinical illustration of this process). Future research attempting to replicate these findings on a non-personality disordered sample would be needed to further explore this question.…”

Attachment mental states and inferred pathways of development in borderline personality disorder: a study using the Adult Attachment Interview

“…If one looks only at past AAI studies of individuals with BPD, we find they represent 200 (or 2%) of the 10,000 AAI classifications reviewed by Bakermans-Kranenburg and van IJzendoorn (2009). Ten studies to date have considered the specific links between attachment and BPD utilizing the AAI (Barone, 2003;Barone, Borellini, Madeddu, & Maffei, 2000;Diamond, Stovall-McClough, Clarkin, & Levy, 2003;Fonagy, Leigh, Steele, Steele, Kennedy, Matoon, et al, 1996;Levy, Mehan, Kelly, Reynoso, Weber, Clarkin, et al, 2006;Lyons-Ruth, Melnick, Patrick, & Hobson, 2007;Patrick, Hobson, Castle, Howard, & Maughan, 1994;Rosenstein & Horowitz, 1996;Stalker & Davies, 1995;Stovall-McClough & Cloitre, 2003;van IJzendoorn, Feldbruggen, Derks, de Ruiter, Verhagen, Philipse, et al, 1997). While these studies do have some of the common methodological shortcomings mentioned above (often relying on small samples from in and out-patient sources, and various diagnostic criteria), they share the merit of having used the AAI, a highly reliable assessment method which allows more conclusive inquiry into the developmental issues implied in the disorder.…”