Adult attachment as a predictor and moderator of psychotherapy outcome: A meta-analysis.

Bowlby's attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Attachment patterns have been characterized as secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others). We update a previous meta-analysis to determine the association of patient attachment with psychotherapy outcome. Meta-analysis of 36 studies (3,158 patients) suggested that patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy may coincide with better treatment outcome. Finally, preliminary moderator analyses suggest that those who experience low pretreatment attachment security may find better treatment outcome in therapy that incorporates a focus on interpersonal interactions and close relationships. The article closes with research limitations, diversity considerations, and therapeutic practices.

Pseudosecure vs. individuated-secure client attachment to therapist: Implications for therapy process and outcome.

OBJECTIVE: We differentiated two hypothesized client subtypes: (a) Pseudosecure clients have high Client Attachment to Therapist Scale (CATS) Secure and high CATS Preoccupied scores, tend to idealize their therapist, and exhibit maladaptive dependency; (b) Individuated-secure clients combine high Secure with low Preoccupied scores and function more autonomously. Clients who, despite insecure attachment to others, "earn" individuated-secure attachment to their therapist benefit most from therapy. METHOD: We examined regression suppressor effects by reanalyzing raw data from four published studies. If pseudosecure attachment is present, when covariance between CATS Secure and Preoccupied scores is removed, residual Secure scores should be significantly better predictors of process/outcome indicators than raw Secure scores. RESULTS: Suppressor effects were observed in eight of nine analyses. Two were statistically significant. Earned individuated-secure attachment predicted improvement in interpersonal relationship symptoms, but only for clients with Avoidant pre-therapy attachment patterns. Finally, significant meta-analytic effect size estimates were obtained for CATS subscales, Secure r = .274 (95% CI = .177, .366), Avoidant, r = -.296 (95% CI = -.392, -193), and Preoccupied, r = -.192 (95% CI = -.289, -.092). CONCLUSIONS: Clients with pre-therapy Avoidant attachment who nevertheless "earn" individuated-secure attachment to their therapist appear to benefit more from therapy.

Frontolimbic neural circuit changes in emotional processing and inhibitory control associated with clinical improvement following transference-focused psychotherapy in borderline personality disorder.

AIMS: Borderline personality disorder (BPD) is characterized by self-regulation deficits, including impulsivity and affective lability. Transference-focused psychotherapy (TFP) is an evidence-based treatment proven to reduce symptoms across multiple cognitive-emotional domains in BPD. This pilot study aimed to investigate neural activation associated with, and predictive of, clinical improvement in emotional and behavioral regulation in BPD following TFP. METHODS: BPD subjects (n = 10) were scanned pre- and post-TFP treatment using a within-subjects design. A disorder-specific emotional-linguistic go/no-go functional magnetic resonance imaging paradigm was used to probe the interaction between negative emotional processing and inhibitory control. RESULTS: Analyses demonstrated significant treatment-related effects with relative increased dorsal prefrontal (dorsal anterior cingulate, dorsolateral prefrontal, and frontopolar cortices) activation, and relative decreased ventrolateral prefrontal cortex and hippocampal activation following treatment. Clinical improvement in constraint correlated positively with relative increased left dorsal anterior cingulate cortex activation. Clinical improvement in affective lability correlated positively with left posterior-medial orbitofrontal cortex/ventral striatum activation, and negatively with right amygdala/parahippocampal activation. Post-treatment improvements in constraint were predicted by pre-treatment right dorsal anterior cingulate cortex hypoactivation, and pre-treatment left posterior-medial orbitofrontal cortex/ventral striatum hypoactivation predicted improvements in affective lability. CONCLUSIONS: These preliminary findings demonstrate potential TFP-associated alterations in frontolimbic circuitry and begin to identify neural mechanisms associated with a psychodynamically oriented psychotherapy.

A meta-analysis of the relation between patient adult attachment style and the working alliance.

This meta-analysis synthesizes research on the relation between patient adult attachment style and patient-rated working alliance. A random-effects model was used to calculate the mean weighted product-moment correlation (r) for 24 studies (12 published in peer-reviewed journals and 12 unpublished doctoral dissertations) of individual outpatient therapy with adults. The mean weighted r for attachment avoidance and alliance was -.137, p<.001, and the mean weighted r for attachment anxiety and alliance was -.121, p<.001. These findings suggest that therapists should attend to attachment in order to foster alliance and have additional implications for theory and future research.

The availability of dialectical behavior therapy in partial hospitalization and residential services for borderline personality disorder: An exploratory longitudinal study of the National Mental Health Services Survey from 2014 to 2021.

OBJECTIVE: Treatment guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment (American Psychiatric Association, 2010; National Health & Medical Research Council, 2013). However, the current literature suggests that evidence-based treatment for BPD may be difficult to access (Lohman et al., 2017). The present study aims to characterize the accessibility of dialectical behavioral therapy (DBT) in day-treatment and residential programs in the United States in the last 7 years and examines whether day-treatment and residential programs that accept state benefits (i.e., Medicaid) are significantly less likely to offer DBT. METHOD: Using mixed logistic regression, we examined trends in the National Mental Health Services Survey data from 2014 to 2021, a survey of U.S. mental health facilities which tracks whether facilities provide DBT. RESULTS: We found that the likelihood that a residential or day-hospital facility offers DBT has been growing over time at the national level (ORday-treatment = 1.07, SE = .03, z = 1.90, p = .05; ORresidential = 1.08, SE = .05, z = 1.77, p = .08). We also found significant variability in these trends at the state level. In addition, we found that facilities accepting state benefits were less likely to offer DBT (ORday-treatment = .66, SE = .021, z = -1.93, p = .05; ORresidential = .67, SE = .21, z = -1.91, p = .06). CONCLUSION: Consistent with previous literature, our study suggests that these programs are very scarce across the United States and difficult to access for those with Medicaid.guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment (American Psychiatric Association, 2010; National Health & Medical Research Council, 2013). However, the current literature suggests that evidence-based treatment for BPD may be difficult to access (Lohman et al., 2017). The present study aims to characterize the accessibility of dialectical behavioral therapy (DBT) in day-treatment and residential programs in the United States in the last 7 years and examines whether day-treatment and residential programs that accept state benefits (i.e., Medicaid) are significantly less likely to offer DBT. METHOD: Using mixed logistic regression, we examined trends in the National Mental Health Services Survey data from 2014 to 2021, a survey of U.S. mental health facilities which tracks whether facilities provide DBT. RESULTS: We found that the likelihood that a residential or day-hospital facility offers DBT has been growing over time at the national level (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mentalizing in and out of awareness: A meta-analytic review of implicit and explicit mentalizing.

BACKGROUND: Mentalizing, making sense of mental states, is hypothesized to have a central role in self-organization and social learning. Findings support this notion, but the extent of the association between mentalizing and various correlates has not been meta-analyzed. Furthermore, mentalizing presumably occurs with (explicit) and without (implicit) awareness but few studies have attempted to disentangle these aspects. We conducted a meta-analysis of implicit and explicit mentalizing in relation to the domains of attachment security, personality, affect, psychopathology, and functioning. METHODS: We searched for studies of adult mentalizing in PsycINFO and in related reviews. Overall, 511 studies (N = 78,733) met criteria and were analyzed using multi-level meta-analysis. RESULTS: Implicit (r = 0.19-0.29) and explicit (r = 0.26-0.40) mentalizing were moderately correlated with psychopathology, functioning, personality, affect, and attachment security. The correlations of implicit mentalizing were stronger with more objectively measured correlates (b = 0.02, p < .001) while the correlations of explicit mentalizing were not (b = -0.07, p = .21). CONCLUSIONS: Mentalizing is associated with better intra- and interpersonal functioning. Implicit mentalizing is more strongly associated with objectively measured correlates. These findings underscore the importance of an integrative approach considering both implicit and explicit mentalizing.

The impact of pathological narcissism on psychotherapy utilization, initial symptom severity, and early-treatment symptom change: a naturalistic investigation.

The impact of pathological narcissism on psychotherapy has seldom been investigated empirically, despite extensive clinical theory proposing that highly narcissistic individuals should be reluctant to engage in treatment and derive smaller benefits from therapy. In this study, we investigate the relationship between scores on the Pathological Narcissism Inventory (PNI; Pincus et al., 2009), which assesses both narcissistic grandiosity and narcissistic vulnerability, and clinical variables in a sample of outpatients (N=60) at a community mental health center. Results indicated that grandiosity, but not vulnerability, was negatively related to the use of adjunctive services and positively predicted client-initiated termination of psychotherapy. In addition, grandiosity and vulnerability were related to initial levels of different symptoms in multilevel models using a subsample (n=41) but not generally related to the linear rate of symptom change in early psychotherapy. The results highlight the clinical utility of assessing pathological narcissism in a real-world psychotherapeutic context.

Introduction: attachment theory and psychotherapy.

In this introduction to the JCLP: In Session 69(11) issue on attachment theory and psychotherapy, the key points of attachment theory (Bowlby, , , 1981) and its relevance to psychotherapy are briefly described. The aim of this issue is to provide case illustrations of how an attachment theory perspective and principles can expand our understanding of psychotherapy practice.

Investigating gender-based differential item functioning on the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD): An item response theory analysis.

The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a popular screening tool for identifying people who may have borderline personality disorder (BPD). However, because women are more frequently diagnosed with the disorder than men, it is possible that the MSI-BPD differs in its ability to identify BPD as a function of gender identity. Using item response theory (IRT), we sought to determine if components of the MSI-BPD would demonstrate differential item functioning (DIF), such that one gender identity would be more likely to endorse certain items. Twenty-two thousand thirty-five college undergraduates (14,305 women) aged 18-55 years (M = 18.77, SD = 1.75) were assessed using the MSI-BPD as part of a subject pool screening between 2008 and 2019. The MSI-BPD contains 10 items that are measured dichotomously, and the authors recommend a cut-off of 7 of 10 items endorsed to maximize sensitivity and specificity to BPD. Results suggested that a two-parameter model was the best fit to the data and that unidimensionality and local independence assumptions were met. The following items demonstrated DIF: self-harm/suicidality, affective lability, abandonment, impulsivity, and anger. At equal levels of the latent construct of BPD, women were more likely to endorse self-harm/suicidality, affective lability, and abandonment. Women were more likely to endorse impulsivity at higher levels of BPD, and men were more likely to endorse anger at lower levels of BPD. Ultimately, the effect sizes of these differences were small, however, and likely do not impact the individual's overall outcome on the measure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reflective functioning and its potential to moderate the efficacy of manualized psychodynamic therapies versus other treatments for borderline personality disorder.

BACKGROUND: Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive factor for TFP's effects. METHOD: A total of 194 patients with BPD were randomized across two clinical trials to receive TFP (n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). A mixed-effects model was used to examine whether baseline RF interacted with treatment condition to predict slopes of change in the Brief Symptom Inventory, the shared symptom outcome between trials. Moderation of changes in RF was also examined. RESULTS: Treatment interacted with baseline RF to predict BSI slopes (p = .011). In TFP/SPT, RF did not predict outcomes, ß = -0.00, p = .973, while higher RF was associated with relatively better outcomes in DBT/eTAU, ß = -0.54, p < .001. Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF (p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all. DISCUSSION: Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders.

Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.

Psychometric evaluation of a Visual Interpersonal Analog Scale.

Interpersonal theory organizes social behavior along dominant (vs. submissive) and warm (vs. cold) dimensions. There is a growing interest in assessing these behaviors in naturalistic settings to maximize ecological validity and to study dynamic social processes. Studies that have assessed interpersonal behavior in daily life have primarily relied on behavioral checklists. Although checklists have advantages, they are discrepant with techniques used to capture constructs typically assessed alongside warmth and dominance, such as affect, which typically rely on adjective descriptors. Further, these checklists are distinct from the methodologies used at the dispositional level, such as personality inventories, which rarely rely on behavioral checklists. The present study evaluates the psychometric performance of interpersonal adjectives presented on a visual analog scale in five different samples. Validity of the Visual Interpersonal Analog scale (VIAS) approach to momentary assessment was evaluated by comparing its performance with an interpersonal behavior checklist and by examining associations among the VIAS Warmth and Dominance scales and other momentary and dispositional constructs. Results were generally consistent with an existing interpersonal behavior checklist at the within-person level but diverged somewhat at the dispositional level. Across the five samples, the VIAS generally performed as hypothesized at both the within- and between-person levels. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder.

Various conceptualizations of subtypes, levels, and dimensions of narcissism and narcissistic personality disorder (NPD) are considered with a particular focus on overt grandiose presentations and covert vulnerable presentations. Evidence supporting this distinction and clinical vignettes to illustrate it are presented as well as their implications for clinical work with NPD patients. The research and clinical evidence points to the conclusion that these broad categorical subtypes are better conceptualized as dimensions on which individual patients vary on relative levels, thus suggesting that grandiose and vulnerable presentations represent two sides of the same coin. A case example and clinical implications are provided and discussed.

Development and criterion validity of a computerized text analysis measure of reflective functioning.

The Reflective Functioning scale (RF) is a narrative-based assessment of the capacity to coherently conceptualize one's own and others' subjective motivations, emotions, beliefs, and desires. We report the preliminary results of an effort to develop a computerized text analysis version (CRF) of the RF assessment system. A sample of 113 clinical and non-clinical Adult Attachment Interviews (AAI) were utilized to develop the CRF measure. Using the Marker Approach (Mergenthaler & Bucci, 1999), 54 linguistic markers of high RF language were identified. The associations between CRF and RF were significant in both a clinical sample of patients diagnosed with Borderline Personality Disorder (BPD) (Spearman rho=.57, p<.0001) and a non-clinical sample of adults (Spearman rho=.57, p=.002). These results suggest that a CRF rating scale is feasible, has preliminary criterion validity, and, therefore, has potential to facilitate the efficient assessment of RF.

Construct Validity of a Measure of Affective Communication in Psychotherapy.

The present study evaluates the psychometric properties of a therapist measure for evaluating the affective communication created between the patient and therapist during the initial stages of treatment. The Affective Communication Questionnaire (ACQ) was administered to a sample of 81 therapists, each rating a single patient, and principal component analysis indicated the measure has coherent dimensions with strong internal consistency. The construct validity of the ACQ was then established in a sample of 16 therapists rating 73 patients diagnosed with Borderline Personality Disorder (BPD). The measure was found to have a strong relationship to the related constructs of transference, countertransference, and affect experience in predicted directions. The measure also was found to have a modest relationship to independent assessments of patient functioning; most notably more negative affect was significantly related to more odd/eccentric (cluster A) and less anxious/fearful (cluster C) personality disorder symptoms, and greater narrative coherence. Differences in affective communication as a function of treatment type were also evaluated. The clinical and research implications of the findings are discussed.

Chronic feelings of emptiness in a large undergraduate sample: Starting to fill the void.

Chronic emptiness in borderline personality disorder (BPD) has received little empirical attention. We sought to examine basic properties of a single chronic emptiness item, including prevalence, reliability, validity, the relation of the emptiness item to other BPD criteria, and measures of personality. Undergraduates enrolled in psychology courses over 12 years' time completed the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) (N = 22,217). Subsets of participants completed the International Personality Disorder Examination-Screening Questionnaire (IPDE-SQ) (N = 2732), The Revised NEO Personality Inventory (Anxiety, Angry Hostility, Depression, Positive Emotions [reversed], and Impulsivity facets) (N = 10,506), and the Depression Anxiety Stress Scales (DASS) (N = 1110) as validity indicators; 10.0% of respondents endorsed emptiness. Reliability indices suggested moderate levels of reliability between two emptiness items (r(2730) = 0.61, p < 0.001). Among BPD criteria, emptiness and identity disturbance correlated most strongly (r(22,215) = 0.81, p < 0.001). MSI emptiness was more correlated with depression on the NEO (r(10,504) = 0.43, p < 0.001) and DASS (r(1108) = 0.51, p < 0.001) than other facets of negative affect. Emptiness was more correlated with greater borderline pathology than any other MSI-BPD item (Sample 1, rtet = 0.87; Sample 2, rtet = 0.86). This criterion warrants further study and attention, especially related to assessment of BPD.

Attachment and its vicissitudes in borderline personality disorder.

This article reviews the recent literature on attachment and attachment-related constructs in borderline personality disorder, with attention given to how recent findings in this area may inform understanding of the mechanisms underlying the etiology, maintenance, and treatment of the disorder. Most findings on this topic have stemmed from three major areas of research, each of which is reviewed in this article: 1) developmental psychopathology studies; 2) experimental psychopathology studies, particularly those using a neuroscience approach; and 3) treatment studies that have examined variables relevant to attachment. Overall, these findings suggest that attachment and related constructs may factor greatly into the underlying psychopathology of borderline personality disorder and may significantly impact the process and outcome of psychotherapy for the disorder. These findings are discussed as they relate to existing theories and ongoing debates in the field, and the implications for future research and clinical practice are highlighted.

Attachment style.

Attachment theory, developed by Bowlby to explain human bonding, has profound implications for conducting and adapting psychotherapy. We summarize the prevailing definitions and measures of attachment style. We review the results of three meta-analyses examining the association between attachment anxiety, avoidance, and security and psychotherapy outcome. Fourteen studies were synthesized, which included 19 separate therapy cohorts with a combined sample size of 1,467. Attachment anxiety showed a d of -.46 with posttherapy outcome, while attachment security showed a d of.37 association with outcome. Attachment avoidance was uncorrelated with outcome. The age and gender composition of the samples moderated the relation between attachment security and outcome: samples with a higher proportion of female clients and a higher mean age showed a smaller relation between security and outcome. We discuss the practice implications of these findings and related research on the link between attachment and the therapy relationship.

In-session reflective functioning in psychotherapies for borderline personality disorder: The emotion regulatory role of reflective functioning.

OBJECTIVE: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory effect on emotional arousal in treatments for BPD. METHOD: Early-, middle- and late-phase videotaped sessions from a randomized-controlled trial of transference-focused psychotherapy (TFP; n = 30), dialectical behavior therapy (DBT; n = 29), and supportive psychodynamic therapy (SPT; n = 29) were segmented to therapist and patient talk-turns. Therapist talk-turns were rated as asking patients to consider mental state (bids for RF) or not. Patient talk-turns were rated for RF and acoustically encoded for arousal. RESULTS: Bids were twice as common in TFP compared to DBT and SPT. Across treatments, therapist bids for RF predicted better RF, which, in turn, predicted lower emotional arousal. CONCLUSIONS: Asking patients to consider mental states has a down-regulatory effect on patients' arousal in psychotherapies for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The roles of attachment and emotion dysregulation in the association between childhood maltreatment and PTSD in an inner-city sample.

BACKGROUND: Most people will experience a traumatic event in their lifetime, but only a subset (<10%) will develop posttraumatic stress disorder (PTSD). OBJECTIVE: To facilitate prevention and intervention of PTSD, it is important to understand how risk and resilience factors interact with one another to explain individual differences in risk for PTSD, especially in underprivileged groups, who often experience greater burden of trauma and PTSD. METHOD: The current study utilized multiple and moderated regression to examine the relation between childhood maltreatment and adulthood PTSD risk in the context of various attachment patterns and emotion dysregulation in a sample (n = 856) of mostly low-income, African American participants. RESULTS: Moderation analysis indicated that the strongest association between self-reported childhood maltreatment and PTSD symptoms was manifest in participants reporting the highest levels of both attachment anxiety and attachment avoidance (b = 0.22, 95% CI [0.15, 0.29], p < .001), whereas, among those low on both these dimensions (i.e., more securely attached participants), there was no significant association between childhood maltreatment and current PTSD (b = 0.07, 95% CI [-0.01, 0.14], p = .07). Separately, multiple regression predicting current PTSD symptoms revealed an effect size for the two attachment dimensions similar to that of emotion dysregulation, while controlling for childhood maltreatment. CONCLUSIONS: These findings suggest more secure attachment may buffer against the deleterious effects of childhood maltreatment, and both attachment difficulties and emotion dysregulation serve as robust correlates of adulthood PTSD.