Psychotherapy for severe personality disorder. Article did not do justice to available research data.
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Borderline Personality Disorder↗
Biomedical subjects
P Fonagy
Publications and source records attributed to P Fonagy.
The transgenerational transmission of holocaust trauma. Lessons learned from the analysis of an adolescent with obsessive-compulsive disorder.
This paper outlines an attachment-theory based model of transgenerational trauma inspired by the successful psychoanalytic treatment of a severely disturbed adolescent with obsessive-compulsive disorder who was the first child of the first daughter of a holocaust survivor. It is proposed that the transmission of specific traumatic ideas across generations may be mediated by a vulnerability to dissociative states established in the infant by frightened or frightening caregiving, which, in its turn, is trauma-related. Disorganized attachment behaviour in infancy may indicate an absence of self-organization, or a dissociative core self. This leaves the child susceptible to the internalization of sets of trauma-related ideation from the attachment figure, which remain unintegrated in the self-structure and cannot be reflected on or thought about. The disturbing effect of these ideas may be relatively easily addressed by a psychotherapeutic treatment approach that emphasizes the importance of mentalization and the role of playful engagement with feelings and beliefs rather than a classical insight-oriented, interpretive approach.
Adolescent↗
Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial.
OBJECTIVE: This study compared the effectiveness of psychoanalytically oriented partial hospitalization with standard psychiatric care for patients with borderline personality disorder. METHOD: Thirty-eight patients with borderline personality disorder, diagnosed according to standardized criteria, were allocated either to a partially hospitalized group or to a standard psychiatric care (control) group in a randomized controlled design. Treatment, which included individual and group psychoanalytic psychotherapy, was for a maximum of 18 months. Outcome measures included the frequency of suicide attempts and acts of self-harm, the number and duration of inpatient admissions, the use of psychotropic medication, and self-report measures of depression, anxiety, general symptom distress, interpersonal function, and social adjustment. Data analysis used repeated measures analysis of covariance and nonparametric tests of trend. RESULTS: Patients who were partially hospitalized showed a statistically significant decrease on all measures in contrast to the control group, which showed limited change or deterioration over the same period. An improvement in depressive symptoms, a decrease in suicidal and self-mutilatory acts, reduced inpatient days, and better social and interpersonal function began at 6 months and continued until the end of treatment at 18 months. CONCLUSIONS: Psychoanalytically oriented partial hospitalization is superior to standard psychiatric care for patients with borderline personality disorder. Replication is needed with larger groups, but these results suggest that partial hospitalization may offer an alternative to inpatient treatment.
Adult↗
Relation of theory and practice in psychodynamic therapy.
Explores the role of theory in psychodynamic practice. This article attempts to show that clinicians commonly labor under the illusion that practice is governed by the logic of theory, by deduction rather than by induction. With psychoanalytic theory and practice as an example, theory is shown to be logically independent of practice and technique. It is suggested that maintaining the illusion of a logical relation between the two can cause a petrification of practice and ultimately the downfall of a theoretical orientation. Further, the inductive use of clinical experience can generate an excessive number of irreconcilable theoretical ideas, which in turn explains the tendency of psychodynamic clinicians to eschew operationalization and rigorous theory building. The abandonment of the pretense of a logical relation, by contrast, could lead to a renewed excitement about the development of technique.
Freudian Theory↗
Psychoanalytic research and the IPA: history, present status and future potential.
This paper traces the chequered history of formal psychoanalytic research within the century-long development of psychoanalysis as theory and practice. It describes the official involvement of the American Psychoanalytic Association in the support of psychoanalytic research since 1970, and of the International Psychoanalytical Association since the 1980s. In the IPA, this has consisted of the introduction at the 1987 Montreal Congress of two half-day panels on formal psychoanalytic research; in the creation in 1991 of an annual IPA Research Conference held in March at University College London; and then the creation in 1996 of an annual ten-day IPA Summer School for neophyte psychoanalytic researchers, also at UCL in London. The paper then details the inauguration by the IPA, at the 1997 IPA Congress in Barcelona, of a mechanism for funding psychoanalytic research the Research Advisory Board (RAB), and the overwhelming--and totally unanticipated--worldwide response to the initial call for proposals in the autumn of 1997. Implications of this for psychoanalysis as a discipline are sketched.
Forecasting↗
Process and outcome in mental health care delivery: a model approach to treatment evaluation.
In recent years, there has been a strong movement toward "evidence-based medicine," which has significantly affected approaches to the delivery of mental health care. The author highlights the cultural and socioeconomic context in which this trend has emerged. He also notes the resulting controversy over the emphasis on randomized controlled trials (RCTs). Although he does not reject the important role of such trials, he reviews some of their limitations and offers a rationale for the equally important role of naturalistic outcome studies. He concludes by introducing subsequent articles in the journal issue that describe a computerized, online approach for evaluating the effectiveness of mental health care delivery. This system, originally developed in the United Kingdom, has been adapted for use by The Menninger Clinic.
Cost-Benefit Analysis↗
What do adult attachment scales measure?
Research suggests that attachment patterns can be measured as early as 12 months of age and that in the absence of major environmental change, they persist into adulthood. Evolving from three traditions, a number of assessment tools have been developed to study adult attachment. They range from semiclinical interviews to brief questionnaires and explore different relationship domains, from retrospective accounts of childhood experience to current romantic relationships. After exploring the theoretical background of the study of adult attachment, the authors review the format and the psychometric properties of several measures. Studies that compare measures are described. The article concludes with a discussion of unresolved questions about adult attachment that emerge from various measurement perspectives.
Adult↗
[Aggression and the psychic 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.
Adolescent↗
An attachment theory approach to treatment of the difficult patient.
This article reviews the role of attachment in difficult-to-treat patients. It is suggested that difficulty often arises in the treatment of these patients because of their inadequate understanding of mental functioning in themselves and in others. The capacity to mentalize is seen as a function of early attachment relationships. Vulnerability introduced by insecure attachment is frequently compounded by a history of intense trauma, leading these patients to defensively inhibit their capacity to think about mental states in their abusers, which then generalizes to other attachment relationships. The clinical implications of this model are discussed.
Child↗
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.
Adult↗
Evaluating the effectiveness of interventions in child psychiatry.
OBJECTIVE: To review the nature of outcome measures used to evaluate psychosocial treatment in children. METHOD: Recent research findings that highlight the importance of outcome data and justify randomized controlled trials (RCTs) are reviewed. RESULTS: Outcome measures of child therapy can focus on changes in the child's symptoms, adaptation to the psychosocial environment, cognitive or emotional capacities, and changes in interaction with others. They can also assess service utilization, related costs, and the suffering of those associated with the child before and after treatment. RCTs remain the optimal methodology, notwithstanding current critiques. CONCLUSION: Studies assessing the effectiveness of psychosocial treatment must include a definition of various outcomes and use appropriate methodologies to measure them.
Adolescent↗
An emerging culture for psychoanalytic research?
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Education↗
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.
Borderline Personality Disorder↗
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.
Adolescent↗
Associations among attachment classifications of mothers, fathers, and their infants.
Associations are reported among classifications of Adult Attachment Interviews (AAIs) obtained from expectant parents and subsequent classifications of their infants in the Strange Situation Procedure (SSP). Mothers' AAIs predicted infant-mother SSPs (chi 2 = 41.87, N = 96, df = 9, p < or = .0001), and fathers' AAIs predicted infant-father SSPs (chi 2 = 18.94, N = 90, df = 6, p < or = .005). Associations between parents' AAIs and infant-parent SSPs were lessened by the failure to predict the insecure-resistant pattern with mother and the absence of this pattern with father. Counter to expectation, infant-father SSPs were associated with infant-mother SSPs (chi 2 = 3.78, N = 90, df = 1, p < or = .05), which could not be accounted for in terms of an overlap between parental AAIs. A secondary analysis of the data suggested that this dependency effect of SSPs may be explained by the influence of maternal AAIs upon child-father SSPs. Results are discussed in terms of intergenerational and relationship-specific influences upon attachment during infancy, the possible influence of infant temperament, and the relative influence of mother and father upon the child's evolving representations of attachments within the family.
Adult↗
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.
Adult↗