Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder.

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.

Attachment and borderline personality disorder: implications for psychotherapy.

BACKGROUND: Psychopathology researchers and theorists have begun to understand fundamental aspects of borderline personality disorder (BPD) such as unstable and intense interpersonal relationships, feelings of emptiness, bursts of rage, chronic fears of abandonment, intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization. In the present study, we will examine self-reported attachment in a study group of well-characterized patients reliably diagnosed with BPD. SAMPLING AND METHODS: Ninety-nine outpatients reliably diagnosed with BPD using the International Personality Disorders Examination, completed a number of attachment measures including the Relationship Questionnaire, Relationship Style Questionnaire, and Experiences in Close Relationships inventory. RESULTS: Factor analysis revealed six factors that clustered into three groups corresponding to an avoidant attachment pattern, a preoccupied attachment pattern, and a fearfully preoccupied pattern. The preoccupied pattern showed more concern and behavioral reaction to real or imagined abandonments, whereas the avoidant group had higher ratings of inappropriate anger. The fearfully preoccupied group had higher ratings on identity disturbance, although only at the trend level. CONCLUSIONS: The psychometric properties and response characteristics of the ECR items suggest that the scales, keying, and domains are appropriate for assessment of attachment in BPD samples. The scales generally retain their factor structure and show a similar pattern of correlations and inter-relationships. Nevertheless, consistent with a developmental psychopathology model, there are some important differences in factor structure, indicating the need to look at both typical and atypical samples when constructing models of attachment. Further research is needed to delineate the prognostic and prescriptive significance of attachment patterns for treating patients with BPD.