Bridging the transmission gap: an end to an important mystery of attachment research?

The authors provide a context for this special section by arguing that the attachment relationships of infancy fulfil an evolutionary role in ensuring that the brain structures that come to subserve social cognition are appropriately organised and prepared to equip the individual for the collaborative existence with other people for which his or her brain was designed. Processes as fundamental as gene expression or changes in receptor densities can be seen as direct functions of the extent of understanding of mental states provided by the caregiving environment. If the attachment relationship is indeed a major organiser of brain development, it is even more important to understand the processes that underpin the transgenerational transmission of attachment patterns. The contributions of the papers in the special section to understanding the role of reflective function in the development of attachment and social cognition are reviewed, and the implications for the development of both theory and practice are explored.

The place of psychodynamic theory in developmental psychopathology.

Psychoanalysis ushered in this century. Will its influence on developmental psychopathology end in the next? The paper explores some critical obstacles in the way of psychodynamic research, including the fragmentation of psychoanalytic theory. the relative independence of theory from its clinical and empirical base, the predominance of inductive scientific logic, the polymorphous use of terms, the privacy of clinical data, the dominance of the reconstructionist stance, and the isolation of psychoanalysis from psychology and neurobiology. Notwithstanding these limitations, core psychoanalytic precepts are not only consistent with some of the most important advances of the last decade but may also be helpful in elaborating these new discoveries in the next century. Psychoanalysis is centered on the notion that complex, conflicting, unconscious representations of mental states constitute a key facet of normal and abnormal development. This notion retains its power, and deserves a prominent position among the major frames of reference to guide developmental science in the next century.

From sixty-two interviews on 'the worst and the best episode of your life'. Relationships between internal working models and a grammatical scale of subject-object affective connections.

The authors address the issue of inferring unconscious internal working models of interaction through language. After reviewing Main's seminal work of linguistic assessment through the 'adult attachment interview', they stress the idea of adults' internal working models (IWMs) as information-processing devices, which give moment-to-moment sensory orientation in the face of any past or present, animate or inanimate object. They propose that a selective perception of the objects could match expected with actual influence of objects on the subject's self, through very simple 'parallel-processed' categories of internal objects. They further hypothesise that the isomorphism between internal working models of interaction and grammatical connections between subjects and objects within a clause could be a key to tracking positive and negative images of self and other during discourse. An experiment is reported applying the authors' 'scale of subject/object affective connection' to the narratives of sixty-two subjects asked to write about the 'worst' and 'best' episodes of their lives. Participants had previously been classified using Hazan & Shaver's self-reported 'attachment types' (avoidant, anxious and secure) categorising individuals' general expectations in relation to others. The findings were that the subject/object distribution of positive and negative experience, through verbs defined for this purpose as either performative or state verbs, did significantly differ between groups. In addition, different groups tended, during the best episodes, significantly to invert the trend of positive/negative subject/object distribution shown during the worst episode. Results are discussed in terms of a psychoanalytic theory of improvement through co-operative elaboration of negative relational issues.

Attachment and borderline personality disorder. A theory and some evidence.

An attachment theory approach to severe personality disorder is described. Evidence is presented that suggests that representations of attachment relationships and attachment behaviors of patients with this diagnosis are commonly disorganized in character. It is argued that the capacity to develop mental representations of mental states in self and other (reflective function) develops in the context of attachment relationships and that disorganization of attachment undermines this process. Such disorganization can be associated with trauma but may also be linked to other biological and psychosocial deficits. Many of the clinical characteristics of patients with borderline personality disorder may be seen as consequences of disordered self-organization and a limited rudimentary capacity to think about behavior in mental state terms. The relevance of this model for the practice of psychotherapy with this group of patients is discussed.

Playing with reality: III. The persistence of dual psychic reality in borderline patients.

This paper is a contribution towards understanding the difficulties of severely borderline patients as they are uncovered within the psychoanalytic process. The authors aim to extend a model from previous papers, bringing a developmental perspective to bear on self-representation and self-organisation. This model rests on an understanding of the child's experience of psychic reality in both normal and neurotic people. The authors explore the relevance of these developmental ideas in thinking about severe borderline and related disturbances seen in adult patients, from the point of view of both understanding the pathology and considering technique. Illustrations are given from a case that helped to prompt the formulation of these states in terms of persistent, pervasive distortions of the experience of psychic reality. There is then an attempt to elucidate the difficulties of borderline patients in tolerating both separation and intimacy, consideration of the way in which bodily experiences may be used as an equivalent of mental experience or contact, and a discussion of the impact of disturbances in the experience of psychic reality on the analytic process.

Outcome research on the psychosocial treatment of personality disorders.

This brief overview of outcome research on psychosocial treatment of personality disorders first examines difficulties in using existing classifications of abnormal personality. A summary is offered of uncontrolled investigations of the treatment of personality disorders, a few controlled studies, and literature on the impact of comorbid personality disorder on treatment of Axis I symptomatology. The conclusions take into account the particular challenges of these disorders in the current health care context.

[Aggression and the psychic self]. / Aggression und das psychische Selbst.

In this paper we explore the idea of aggression as a defence against threats to the psychological self. This aspect of the self allows reflection about people in psychological terms and develops, in the first three years of life, through appreciation of mental states in the other. When the object is unpredictable or hostile, recognition of this is painful to the child, and his reflective function will not be adequately established. The defences of aggression or avoidance will be invoked very frequently. In time, aggression may become an organising influence in the construction of the self; pathological destructiveness then takes the place of emotional relatedness and concern for the other. Psychoanalytic treatment no longer works primarily by addressing conflict. Instead, particularly through interpretations of transference and countertransference, the analyst recreates an intersubjective process which enhances the patient's reflective self, this time in the safety of a benign relationship.

Attachment and reflective function: their role in self-organization.

The paper traces the relationship between attachment processes and the development of the capacity to envision mental states in self and others. We suggest that the ability to mentalize, to represent behavior in terms of mental states, or to have "a theory of mind" is a key determinant of self-organization which is acquired in the context of the child's early social relationships. Evidence for an association between the quality of attachment relationship and reflective function in the parent and the child is reviewed and interpreted in the context of current models of theory of mind development. A model of the development of self-organization is proposed which has at its core the caregiver's ability to communicate understanding of the child's intentional stance. The implications of the model for pathological self-development are explored, with specific reference to the consequences of maltreatment.

Playing with reality: II. The development of psychic reality from a theoretical perspective.

In this paper the authors extend their examination of the child's perception of psychic reality, and the integration of the 'psychic equivalent' and 'pretend' modes into a reflective mode at around the oedipal stage. A model is presented of the elaboration of a core or psychological self through early object relationships, and they describe how the transition in modes of experiencing inner and outer reality fits in with this model. They then look at evidence from both developmental psychology and psycho-analytic thinking, and consider to what extent their thinking is compatible with these. They maintain that there is consistent empirical evidence supporting the model they have presented, and that it can be seen as complementing and extending previous psychoanalytic developmental theories.

Playing with reality: I. Theory of mind and the normal development of psychic reality.

The authors of this paper discuss changes in the child's perception of psychic reality during normal development, highlighting a major shift in the child's understanding of minds ('theory of mind') at the oedipal stage. They illustrate this transition with material from the analysis of a 4-year-old girl. They maintain that the very young child uses two forms of psychic reality, which they have called 'psychic equivalent' and 'pretend' modes, which differ primarily in the assumed relationship between internal and external realities. The integration of the dual modes into a singular reflective mode is normally completed by about the age of 4, with affect leading cognition: the child first understands that people have different feelings, then that they may have different thoughts about the same external reality. The authors describe normal psychological growth and neurotic pathology, in which the integration of these two modes of functioning has been only partly achieved.

The relation of attachment status, psychiatric classification, and response to psychotherapy.

The relation of patterns of attachment and psychiatric status was studied in 82 nonpsychotic inpatients and 85 case-matched controls using the Adult Attachment Interview (AAI). AAI transcripts rated (masked to case vs. control status and treatment) were classified using M. Main and R. Goldwyn's (1991) system. Psychiatric patients, diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) I and II structured interviews, were more likely to be classified as preoccupied and unresolved with respect to loss or abuse. On Axis I, anxiety was associated with unresolved status, and AAI scales were able to discriminate depression and eating disorder. On Axis II, borderline personality disorder (BPD) was linked to experience of severe trauma and lack of resolution with respect to it. BPD patients were also rated significantly lower on a scale measuring awareness of mental states. Preliminary outcome results suggest that individuals rated as dismissing on the AAI are more likely to show improvements in psychotherapy.

Predictors of outcome in child psychoanalysis: a retrospective study of 763 cases at the Anna Freud Centre.

Under Anna Freud's guidance, the Anna Freud Centre developed a rigorous approach to the collection of child psychoanalytic data. Material contained in detailed diagnostic assessments and weekly written reports of 763 cases treated in intensive and nonintensive therapy has now been subjected to systematic study. This is the first, retrospective stage of a major investigation of child psychoanalytic outcome, carried out in collaboration with Yale University Child Study Center, New Haven, CT. The main findings of the work are reviewed. The study showed child analysis to be particularly effective for seriously disturbed children under 12 years suffering from a variety of psychiatric disorders, particularly those which involve anxiety.

Understanding the violent patient: the use of the body and the role of the father.

We offer some thoughts about the roots of habitual violence in patients who are not part of the 'cycle of abuse'. We suggest that both self-harm and mindless assaults on others may reflect inadequate capacity to mentalise. Poor functioning of this capacity tends to lead to mental states being experienced as physical, in both the self and others, and the violence is seen as an attempt to obliterate intolerable psychic experience. This experience is felt to belong to somebody else, originally to mother or father. The problem can be traced back to a crucial stage of the development of the self when the child searches the face of his primary object for a representation of his own states of mind. Failure to find this forces him into pathological solutions to achieve an containing organisation. We explore the meaning of the gender difference in the direction of aggression, and the way in which the child has a second chance to foster a secure psychological self through his relation to the father, even when the mother has been unable to support this and to separate successfully. These issues and others of technique are explored in the treatment of a violent young man.

The efficacy of psychoanalysis for children: prediction of outcome in a developmental context.

OBJECTIVE: This is the third report from a chart review of 763 cases of child psychoanalysis and psychotherapy at the Anna Freud Centre. This paper examines the way in which the age of a child or adolescent at the time of treatment in psychoanalytic psychotherapy relates to the outcome of that treatment. METHOD: One hundred twenty-seven children were selected from each of three age bands (younger than 6 years, 6 to 12 years, and adolescents); they were matched on broad diagnostic grouping, gender, socioeconomic status, global adaptation (Children's Global Assessment Scale), and frequency of sessions. Outcome was indicated by diagnostic change and clinically significant change in adaptation. RESULTS: Younger children were more likely to show significant improvement. Children younger than 12 benefited from intensive (four or five times weekly) treatment more than from nonintensive (one or two times weekly) treatment; this was not true of adolescents. There were interactions between certain diagnostic categories, age, and outcome. Predictors of good and poor outcome were different for the three age groups, further highlighting the importance of a developmental perspective. CONCLUSIONS: Within the limitations of a retrospective design, this study suggests that in psychodynamic treatment, younger age is an advantage and developmental factors considerably affect the outcome of this form of therapy.

Efficacy of psychoanalysis for children with emotional disorders.

OBJECTIVE: This is the second report from a chart review of 763 cases of child psychoanalysis and psychotherapy at the Anna Freud Centre. METHOD: Three hundred fifty-two children and adolescents were identified who met DSM-III-R criteria for emotional disorders or who had sleep or somatoform symptoms with marked emotional disturbance. Two hundred fifty-four were treated in full psychoanalysis, the remainder one to three times per week, for an average of 2 years. Outcome was indicated by diagnostic change and by change in overall adaptation, measured by the Children's Global Assessment Scale (CGAS). RESULTS: Of those treated for at least 6 months, 72% showed reliable improvement in adaptation, 24% still had some diagnosis at termination, and 15% still had an emotional disorder. Simple phobias were most likely to remit, and depressed children were least likely to return to normal CGAS levels. Children younger than 11 years were considerably more likely to be well at the end of treatment. Intensive treatment generally led to greater improvements, independently of age and treatment length. Certain disorders, and more severe pathology, required intensive treatment; 50% of severe cases showed no improvement in psychotherapy. Thirty-one percent of variance in CGAS change could be predicted, and greater than 50% when diagnostic groupings were examined separately. CONCLUSION: Despite methodological limitations, the study identifies predictors of improvement (e.g., younger age, phobic symptoms, intensity and length of treatment) and shows that severe or pervasive pathology requires intensive analytic help.

The Emanuel Miller Memorial Lecture 1992. The theory and practice of resilience.

The aim of this paper is to identify a theoretical framework which may provide a meaningful context for developing practical interventions to build upon the concept of resilience. In so doing I shall briefly consider the importance of the concept, what is known about it, and then focus on a specific facet of the problem: intergenerational transmission of maladaptive relationship patterns and resilience to such a threat.

The efficacy of psychoanalysis for children with disruptive disorders.

OBJECTIVE: This paper describes a chart review of 763 cases of child psychoanalysis and psychotherapy at the Anna Freud Centre, and illustrates its usefulness by examining predictors of treatment outcome in children with disruptive disorders. METHOD: 135 children and adolescents with a principal diagnosis of disruptive disorder were individually matched with others suffering from emotional disorders. Outcome was indicated by diagnostic change and change in overall adaptation (clinically significant improvement or return to normal functioning). RESULTS: Improvement rates were significantly higher for the emotional than for the disruptive group. Within the disruptive group, significant improvement was more frequent among children with oppositional defiant disorder (56%) than those with attention deficit hyperactivity disorder (36%) or conduct disorder (23%). However, 31% of the children terminated treatment within 1 year. Of those disruptive children who remained in treatment more than 1 year, 69% were no longer diagnosable on termination. Fifty-eight percent of the variance in outcome ratings could be accounted for within this group. The crucial variables in predicting attrition and symptomatic improvement were found to be quite different in the disruptive and emotional groups. CONCLUSION: Although the study has several methodological limitations, it does suggest demographic, clinical, and diagnostic characteristics of those disruptive children most likely to benefit from intensive and nonintensive psychodynamic treatment.

Aggression and the psychological self.

In this paper we explore the idea of aggression as a defence against threats to the psychological self. This aspect of the self allows reflection about people in psychological terms and develops, in the first three years of life, through appreciation of mental states in the other. When the object is unpredictable or hostile, recognition of this is painful to the child, and his reflective function will not be adequately established. The defences of aggression or avoidance will be invoked very frequently. In time, aggression may become an organising influence in the construction of the self; pathological destructiveness then takes the place of emotional relatedness and concern for the other. Psychoanalytic treatment no longer works primarily by addressing conflict. Instead, particularly through interpretations of transference and countertransference, the analyst recreates an intersubjective process which enhances the patient's reflective self, this time in the safety of a benign relationship.

The roles of mental representations and mental processes in therapeutic action.

In this paper we describe two models of the psychoanalytic treatment of mental disturbance. The first describes the mechanism by which the patient is helped to recover threatening ideas and feelings which have been repudiated or distorted as a result of conflict and defense. The second points to the therapeutic effects of engaging previously inhibited mental processes within the psychoanalytic encounter. The two forms of therapeutic action imply two distinct means available to the individual to deal with psychological conflict. They highlight different aspects of the psychoanalytic process and technique in child and adult psychoanalysis.