City University of New York, Dean's Office ... and slappin

1
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

2
Personality Disorders Institute (PDI)Joan and
Sanford I. Weill Medical College of Cornell
University

• Otto F. Kernberg, MD, Director
• John F. Clarkin, PhD, Co-Director
• 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.

3
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

4
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, Deans Office
• Research Foundation of the City University of New
  York
• Pennsylvania State University
• Social Science Research Institute

5
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.

6
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

7
Attachment and Psychotherapy

•  Bowlby also believed that attachment theory had
  particular relevance for psychotherapy.

8
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 therapists 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)

9
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

10
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

11
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.

12
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

13
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)

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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

15
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

16
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)

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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)

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Ainisfeld et al., 1990 Attachment Security in
SS (n 46)
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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)

20
Bateman Fonagy (1999)

• RCT of the effectiveness of 18 months of a
  non-manualized 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

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Bateman Fonagy (2008) Partial Hospital RCT
Patients at 5 yrs FU
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Partial Hospital RCT Patients at 5 yrs FU
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Partial Hospital RCT Attempting Suicide
N44 NNT (18 months)2.1 NNT (36 months)1.9 NNT
(60 months)2.1






p lt .05 p lt .01 p lt .001
Follow -up
Treatment
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Partial Hospital RCT Employment
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Partial Hospital RCT GAF Scores
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Assessment of Attachment

• Adult Attachment Interview
• Reflective Function

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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

28
Assessment of Coherence (George, Kaplan, Main,
1985)

• Coherence
• Qualitytruthful, i.e., evidence for what was
  presented
• Quantitysuccinct, and yet complete
• Relationrelevant to the topic at hand
• Mannerclear 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)

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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 ones own
  experience, whatever his or her attachment status.

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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 wouldnt
  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.

31
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 Im still
  upset, but it is almost exactly this time of year
  when the accident happened.

32
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
  Im 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.

33
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 thats how it
  appeared, sometimes you feel different inside
  from how things appear.)
• Recognizing developmental aspects of mental
  states (Its 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 (Im not sure if that makes sense,
  should I explain further?)

34
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

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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.

38
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.

39
Validity for RF

• Grienenberger, Kelly, Slade, 2005 found that
  mothers RF mediated the relationship between
  atypical maternal behaviors (e.g., affective
  communication errors, role/boundary confusion,
  intrusiveness) and attachment security in their
  infants.

40
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.

41
Wisconsin Card Sorting Task

• Measure of executive functioning,
• Specifically concept formation and the capacity
  shift attention (cognitive flexibility)

42
Relation of Reflective Function to Wisconsin Card
Sort Test
r -.47
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• 3078

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• 3078

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• 1367

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• 1637

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Relation of Reflective Function to Impulsivity on
Continuous Performance Test
r .35
54
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.

55
Attachment as a Moderator of Outcome

• Dozier, 1990
• Fs more cooperative with treatment
• Ds associated with less help seeking, less
  self-disclosure, 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.

56
Attachment as a Moderator of Outcome

• Fonagy et al., 1996
• Ds attachment predicted better outcomes than E

57
? in GAF between Admission and Discharge as a
Function of Attachment
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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.

59
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

60
Fonagy et al., 1995 Change in Security of
Attachment (n 35)
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Diamond et al., 2003 Change in Security of
Attachment (n 10)
62
Change in Coherence and RF as a Function of
Time Pre-Post Study
Coherence Paired t-test -2.86, p lt .02 RF
paired t-test -6.38, p lt .001 Levy et al., 2008
63
Stovall-McClough Cloitre, 2003 Change in
Unresolved Status (n 18)
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BPDRF-PDI RCTOverall 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)

65
BPDRF-PDI RCTOverall 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)

66
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

67
Transference Focused Psychotherapy

• Modified Psychoanalytic Psychotherapy
• Specifically for personality disorders
• Structured twice weekly outpatient treatment
• Based on Otto Kernbergs 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)

68
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

69
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 therapists 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.

70
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

71
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

72
Therapist Patient

• Sets frame via contract
  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

73
Levy, Critchfield, Clarkin, in preparation
74
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

75
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

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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

77
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!

78
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

79
Distribution of 5-Category Attachment Status Time
1
80
Change in Secure-Insecure Attachment Status as a
Function of Time
McNemars ?2 test was significant at the p .03
level.
81
Change in Coherence as a Function of Time and
Treatment
82
Change in Reflective Function as a Function of
Time and Treatment
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Change in Resolved-Unresolved Attachment Status
as a Function of Time
84
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

85
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, df1, plt.03) and SPT (Wilcoxon
  Statistic8.81, df1, lt.003).
• TFPltDBTSPT
• Severely Impaired RF Significantly more dropout
  in DBT than TFP (Wilcoxon Statistic3.82, df1,
  plt.05), while the differences between SPT and
  other treatments were non-significant.
• TFPltDBT, SPT ns

86
Dropout in Average RF Group
87
Dropout in Impaired RF group
88
Dropout in Severely Impaired Group
89
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)

90
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

91
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

92
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

93
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/a
  voidant)
• Angry preoccupied parent-blaming passages
  (hostile/controlling)

94
Clinical Observations

• Lyons-Ruths 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

95
Clinical Observations

• Psychic Equivalence
• Interview process or questions experienced as the
  equivalent of past traumatic experiences

96
Therapist RF and Patient RF

• We assessed RF in our therapist in the small
  pre-post study using a modified patient-therapist
  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

97
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

98
Clinical Illustration

• Occasional self-cutting
• 3 brief hospitalizations diagnosis Bipolar
  Disorder
• Background Middle daughter in highly educated
  family prestigious and dominant but tough
  father masters degree educated series of jobs
  destroyed by interpersonal relations not working
  for last few years

99
Clinical Illustration

• On the AAI
• CC/Ds2 (devaluing of attachment
  experiences/derogating)/E2 (angry/conflicted)
• RF -1

100
Clinical Illustration

• Treatment Controlling, dominant, dismissing
  therapists 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
• Patients reflection on relationship with father
  coincident with emergence of positive
  transference while re-establishing relations with
  men

101
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

102
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)

103
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

104
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.

105
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 ones attention or think
  differently about an event).
• Events remain in perspective and lose their
  re-traumatizing capacity.

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Thank You

• For more information please e-mail me at
  klevy_at_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