Concepts of separation-individuation (Mahler, Pine, & Bergman, 1975) and intersubjectivity (Stern, 1985) were operationalized in order to develop a methodology for assessing changes in self-and object representations that occur over the course of long-term, psychoanalytically oriented inpatient treatment. Adolescent and young adult patients were asked at admission and every 6 months thereafter until the end of treatment to describe their mother, father, therapist, and themselves. In addition to this Object Representation Inventory (ORI), some patients were also administered a Rorschach both at admission and discharge. The Rorschach data were analyzed based on a separation-individuation scale originally developed by Coonerty (1986) which we revised to include more mature levels of separation-individuation. A parallel scale was also developed to evaluate responses obtained from the ORI. Results indicate that toward the end of :reatment, representations of self and other show a clearer sense of boundaries and separateness, as well as a greater degree of empathic relatedness. Four case studies are presented to illustrate these changes.

The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.

We investigated attachment representations and the capacity for mentalization in a sample of adult female borderline patients with and without comorbid narcissistic personality disorder (NPD). Participants were 22 borderline patients diagnosed with comorbid NPD (NPD/BPD) and 129 BPD patients without NPD (BPD) from 2 randomized clinical trials. Attachment and mentalization were assessed on the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1996). Results showed that as expected, compared with the BPD group, the NPD/BPD group was significantly more likely to be categorized as either dismissing or cannot classify on the AAI, whereas the BPD group was more likely to be classified as either preoccupied or unresolved for loss and abuse than was the NPD/BPD group. Both groups of patients scored low on mentalizing, and there were no significant differences between the groups, indicating that both NPD/BPD and BPD individuals showed deficits in this capacity. The clinical implications of the group differences in AAI classification are discussed with a focus on how understanding the attachment representations of NPD/BPD patients helps to illuminate their complex, contradictory mental states.

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While all patients become more concrete in their psychological functioning in areas of conflict, especially in the setting of transference regression, in the treatment of patients with severe personality pathology this process poses a particular clinical challenge. In the psychoanalytic psychotherapy of patients with severe personality pathology in general, and borderline personality disorder in particular, the interpretive process serves multiple functions. This process comprises a series of steps or phases that can be viewed as moving the patient further away from a single, poorly elaborated, and concrete experience in the transference, which dominates and floods subjectivity, and toward more fully elaborated, complex, stable, and integrated representations of the analyst and of what he or she evokes in the patient's internal world.

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