Changes of attachment status among women with personality disorders undergoing inpatient treatment

Abstract

Background: Attachment has increasingly received attention in psychotherapy and has been used as a predictor of process and outcome. Studies investigating changes of attachment styles during psychotherapy are very rare. Method: Forty women with either borderline (BPD) or avoidant personality disorders (AVPD), treated as inpatients, were investigated using an attachment interview (interpersonal relations assessment (IRA)), and questionnaires to determine therapy outcome at the beginning and after seven weeks of therapy. The IRA uses similar questions as the adult attachment interview (AAI) and is used as the basis for the adult attachment prototype rating (AAPR), a procedure to assign individuals to prototypical categories of attachment. Results: The study showed that the therapy in general was effective. In contrast to other studies, we did not find many women classified as secure at the end of their therapy. Comparisons of pre-post-ratings revealed instead that clients within both subgroups received higher ratings for the avoidant prototypes at the end of therapy, indicating deactivation of attachment. Changes from ambivalent to avoidant attachment were linked with better outcome among women with borderline personality disorder (BPD). Conclusions: This study adds further evidence to the result that attachment styles do not change dramatically during a time-limited psychological treatment of personality disorder. Instead, the study showed that features of preoccupied/ambivalent attachment were less significant after seven weeks of therapy. For women with BPD, these changes were linked with a more favourable outcome which might reflect a more structured and deactivated attachment status as a result of inpatient therapy.

Changes in attachment representations during psychological therapy

“…The results of these two studies are in contrast to those obtained by Strauss et al (2011) in an inpatient sample using an interview measure. This may be due to the slightly shorter treatment duration used in the study by Strauss and colleagues and the additional complexity of this patient group (i.e., co-morbid borderline and avoidant personality disorder).…”

“…Nevertheless, these results need to be interpreted with caution because of the lack of control over confounding variables. Strauss, Mestel, and Kirchmann (2011) demonstrated significant reductions in attachment security and increases in attachment avoidance over a 7-week program for female inpatients with Borderline Personality Disorder and Avoidant Personality Disorder using the AAPR. These findings are perhaps not surprising, however, given the short treatment period in relation to the complexity of needs of the patient group.…”

Forgiveness in the Treatment of Borderline Personality Disorder: A Quasi‐Experimental Study

“…These results are consistent with previous research with BPD inpatients, which show that reductions in anxious attachment were more relevant to therapeutic outcomes than changes in avoidant attachment (Strauss, Mestel, & Kirchmann, 2011) and that anxious attachment and emotional dysregulation are particular struggles associated with BPD (Scott et al, 2013). The finding that anxious attachment was reduced in ways that affected psychiatric symptoms during DBT is noteworthy because attachment has not been part of DBT theory but is a central dimension of mentalization-based treatment, suggesting there may be potential for theoretical integration.…”

Avoidant personality disorder: current insights

“…A number of studies have confirmed the theorized relationship between AVPD and both anxious and avoidant strategies. 46 , 81 , 103 – 110 Using the four-category model of Bartholomew and Horowitz, 111 which posits that attachment may be classified into one of four groups determined by positive or negative views of the self and positive or negative views of others, some studies also identified a fearful attachment style in AVPD. 101 , 112 , 113 In the four-category model, the fearful attachment style may be the most disabling, since it is associated with negative views of both self and other.…”