Attachment and Psychotherapy: Implications from Empirical Research

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

3. 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 Laboratory for Research in Personality, Psychopathology, and Psychotherapy

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, Dean’s 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 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)

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)

14. 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)

17. 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)

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

19. 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

21. Bateman & Fonagy (2008) Partial Hospital RCT: Patients at 5 yrs FU

22. Partial Hospital RCT: Patients at 5 yrs FU

23. Partial Hospital RCT: % Attempting Suicide N=44 NNT (18 months)=2.1 NNT (36 months)=1.9 NNT (60 months)=2.1 * *** * *** ** ** * p < .05 ** p < .01 *** p < .001 Treatment Follow -up

24. Partial Hospital RCT: Employment

25. Partial Hospital RCT: GAF Scores

26. Assessment of Attachment • Adult Attachment Interview • Reflective Function

27. 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: • 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)

29. 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.

30. 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.”

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 I’m 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 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.”

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 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?”)

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

37. 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 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.

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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48. 1367

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