1. Attachment and Psychotherapy: Implications from Empirical Research Kenneth N. Levy, Ph.D. Pennsylvania State University and Joan and Sanford I. Weill Medical College of Cornell University Early Development, Attachment, and Psychotherapy, Copenhagen, Denmark, November 20 th -22 nd, 2008

2. Personality Disorders Institute (PDI) Joan and Sanford I. Weill Medical College of Cornell University Otto F. Kernberg, MD, Director John F. Clarkin, PhD, Co- Director Frank Yeomans, MD Armand Loranger, PhD Paulina Kernberg, MD Mark Lenzenweger, PhD (Binghamton) Eve Caligor, MD Ann Appelbaum, PhD Monica Carsky, PhD Catherine Haren, Psy.D. Diana Diamond, PhD (CUNY) Pamela A. Foelsch, PhD James Hull, PhD Michael Stone, MD Jill Delaney, M.S.W.

3. Laboratory for Research in Personality, Psychopathology, and Psychotherapy City University of New York –Kevin B. Meehan –Joseph S. Reynoso –Michal Weber –Komal Choksi Penn State –Lori N. Scott –Rachel H. Wasserman –Joseph E. Beeney –William D. Ellison

4. Funding and Support National Institute of Mental Health Borderline Personality Disorder Research Foundation National Association for Research in Schizophrenia and Depression American Psychoanalytic Association International Psychoanalytic Association Köhler Foundation DeWitt Wallace Readers Digest Fund (Kernberg) Department of Psychiatry, Weill Medical College City University of New York, Dean’s Office Research Foundation of the City University of New York Pennsylvania State University Social Science Research Institute

5. Attachment and Psychotherapy Although Bowlby was a psychiatrist. Psychoanalyst, and psychotherapist, much of the research on attachment theory has been carried out by developmental and social psychologists focusing on normative aspects of attachment. From its inception, however, Bowlby conceptualized attachment theory as relevant to both normal and psychopathological development.

6. Attachment and Psychotherapy Bowlby believed that attachment insecurity, although originally an adaptive set of strategies designed to manage distress, increases vulnerability to psychopathology, and can be linked to specific types of difficulties that arise. "the many forms of emotional distress and personality disturbance, including anxiety, anger, depression, and emotional detachment” (p. 5) which result from the disruption of those bonds

7. Attachment and Psychotherapy Bowlby also believed that attachment theory had particular relevance for psychotherapy.

8. Bowlby on Attachment and Psychotherapy The chief role of the therapist is “to provide the patient with a temporary attachment figure” (Bowlby, 1975, p. 191) the therapist’s first task is to “provide the patient with a secure base from which to explore both himself and also his relations with all those with whom he has made or might make, an affectional bond” (Bowlby, 1977; p. 421)

9. Bowlby: Five Key Tasks of Psychotherapy Establishing a secure base –which involves providing patients with a secure base from which they can explore the painful aspects of their life by being supportive and caring; Exploring past attachments –which involves helping patients explore past and present relationships, including their expectations, feelings, and behaviors;

10. Bowlby: Five Key Tasks of Psychotherapy Exploring the therapeutic relationship, –which involves helping the patient examine the relationship with the therapist and how it may relate to relationships or experiences outside of therapy; Linking past experiences to present ones, –which involves encouraging awareness of how current relationship experiences may be related to past ones;

11. Bowlby: Five Key Tasks of Psychotherapy Revising internal working models –which involves helping patients to feel, think, and act in new ways that are unlike past relationships.

12. Bowlby: Five Key Tasks of Psychotherapy Revising internal working models –which involves helping patients to feel, think, and act in new ways that are unlike past relationships. Providing a Safe Haven –Which to go in times of distress Can be a representational

13. Bowlby: Five Key Tasks of Psychotherapy Revising internal working models –which involves helping patients to feel, think, and act in new ways that are unlike past relationships. Providing a Safe Haven –Which to go in times of distress Can be a representational Transference and countertransference dynamics (multiple contradictory IWM)

14. Attachment and Psychotherapy There are a number of ways that Attachment and Psychotherapy intersect –Attachment theory based interventions –Attachment organization as a moderator of outcome (prognostic indicator) –Attachment organization as a prescriptive indicator –Psychotherapy process (therapist and patient in session behaviors) as a function of attachment processes –Attachment organization as a moderator of psychotherapy process –Change in attachment representations as outcome

15. Attachment Theory Based Interventions Many treatments implicitly use principles and techniques that are consistent with attachment theory –the establishment of a therapeutic alliance –the exploration of past and/or relational experiences, the updating of self-views Until recently, few psychotherapies have been developed based directly on attachment theory principles

16. Attachment Based Child Interventions Baby Carrier Intervention (Ainisfeld et al., 1990) Home Visits (van den Boom, 1994) Intervention for high-risk pregnant women, (Korfmacher, Adam, Ogawa, & Egeland,1997) Watch, Wait, and Wonder (Cohen, Muir et al., 1999) Toddler-Parent Psychotherapy (Cicchetti, Toth, Rogosch, 1999; Toth et al., 2006) Circle of Security (Marvin, Cooper, Hoffman, & Powell, 2002; Hoffman et al., 2006)

17. Attachment Based Child Interventions Video Feedback Positive Parenting (Zeijl eta l., 2006) Prenatal Home Visits (Heinicke et al., 2006) Parent-Child Psychotherapy (Lieberman & Van Horn, 2004; Lieberman, Ippen, & Van Horn, 2006)

18. Ainisfeld et al., 1990: Attachment Security in SS (n =46)

19. Attachment Based Adult Interventions Interpersonal Psychotherapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984) Mentalization Based Therapy (Bateman & Fonagy, 1999; 2001; 2008) Attachment Injury Resolution Model for Couples based Emotion Focused Psychotherapy (Johnson, 2004; Makinen & Johnson, 2006)

20. Bateman & Fonagy (1999) RCT of the effectiveness of 18 months of a non- manualized psychoanalytically oriented day hospitalization program compared with routine general psychiatric care for patients with BPD –significant improvement in depressive symptoms –better social and interpersonal functioning –significant decrease in suicidal and self-injurious acts –number of inpatient days Note: –TAU consisted of 2 hours of psychiatric care a month vs. 30 hours a week of PHP

21. Bateman & Fonagy (2008) Partial Hospital RCT: Patients at 5 yrs FU

22. Partial Hospital RCT: Patients at 5 yrs FU

23. Partial Hospital RCT: % Attempting Suicide * * p <.05 ** p <.01 *** p <.001 * *** ** *** ** Follow -upTreatment N=44 NNT (18 months)=2.1 NNT (36 months)=1.9 NNT (60 months)=2.1

24. Partial Hospital RCT: Employment

25. Partial Hospital RCT: GAF Scores

26. Assessment of Attachment Adult Attachment Interview Reflective Function

27. Adult Attachment Interview On the AAI individuals are asked to describe: –Their parents generally, giving 5 adjectives with specific examples to back up general descriptions –How parents responded when they were upset, ill, or in distress –The impact of early experience on current adult functioning The interview has the effect of “surprising the unconscious” Provides numerous opportunities for the speaker to elaborate upon, contradict or fail to support examples Can classify interviewees pattern of attachment as Secure, Preoccupied, Dismissive, Unresolved, or Cannot Classify

28. Assessment of Coherence (George, Kaplan, & Main, 1985) Coherence: –Quality—truthful, i.e., evidence for what was presented –Quantity—succinct, and yet complete –Relation—relevant to the topic at hand –Manner—clear and orderly Rated on 9 point scale, with 1= low coherence and 9 = high coherence, and score of 5 = cut-off for secure attachment Not related to IQ, or coherence of narrative discourse of non-attachment experiences (e.g., work)

29. Reflective Function The social cognitive and affective process of interpreting or making sense of behavior in oneself and others in terms of intentional mental states, such as desires, feelings, and beliefs. The capacity to reflect upon one’s own experience, whatever his or her attachment status.

30. Aspects of Reflective Function The explicit effort to tease out mental states underlying behavior –Accurate attributions of mental states to others. As suggested by differentiated views of events “My mother was good if I were physically hurt, except if she was frightened, then she wouldn’t be able to cope.” –Recognition of diverse perspectives and points of view of the same event. “My mother had the habit of lifting her hand and slapping us, if we were naughty, or when she thought that we were naughty.”

31. Aspects of Reflective Function Recognizing the developmental aspects of mental states –Taking a developmental perspective “ When we were little my father always seemed to have time for us and we would have so much fun together, but then as we got older he withdrew and had difficulty I think getting on with teenagers. ” Mental states in relation to the interviewer –Acknowledging the separateness of minds “ It must seem strange to you that I ’ m still upset, but it is almost exactly this time of year when the accident happened. ”

32. Aspects of Reflective Function Awareness of the nature of mental states: –The opaqueness of mental states “I thought my mother felt resentful of us, but I’m not really sure if she felt that way herself” would be regarded as reflective whereas the statement, “One can never know what someone else thinks” would not. –Awareness of the defensive nature of certain mental states: “You tend to blank things out that make you unhappy sometimes.”

33. Reflective Function (Fonagy, Target, Steele, Steele, 1998) The process of being able to reflect on experience and interpreting behavior in terms of intentional mental states, such as desires, feelings, and beliefs; represented by four dimensions: –Awareness of the nature of mental states (“Well I think he felt obligated to do that because he felt guilty…”) –Explicit efforts to tease out mental states underlying behavior (“…or at least that’s how it appeared, sometimes you feel different inside from how things appear.”) –Recognizing developmental aspects of mental states (“It’s only as an adult that I understand this, as a child I was confused why he did that.”) –Recognition of mental states in relation to the interviewer (“I’m not sure if that makes sense, should I explain further?”)

34. Reflective Function Scale (Fonagy, Target, Steele, Steele, 1998) -1 Negative Rejection, totally barren, grossly distorted, overly concrete, unintegrated, or inappropriate RF 1 Disavowal, distorted/self-serving 3 N aive simplistic or over-analytic/hyperactive 5 Ordinary or inconsistent model of mind is fairly coherent, but somewhat one dimensional or simplistic 7 Marked 9 Exceptional unusually complex, elaborate or original reasoning about mental states

37. Correlation between Coherence and RF In non-clinical samples =.73 *** (Fonagy et al., 1991) In BPD sample pre-treatment =.48** In BPD sample post-treatment =.52** Note: *** significant at the.001 level.

38. Validity for RF Fonagy et al (1995) found that RF mediated the relationship between parental attachment security and infant attachment security in the SS. –insecurely attached parents with high RF were more likely to have securely attached babies than insecurely attached parents with low RF.

39. Validity for RF Grienenberger, Kelly, & Slade, 2005 found that mother’s RF mediated the relationship between atypical maternal behaviors (e.g., affective communication errors, role/boundary confusion, intrusiveness) and attachment security in their infants.

40. Validity for RF Fonagy et al. (1996) found that among patients reporting abuse, those who scored low on RF were more likely to be diagnosed with BPD compared to those who were abused but scored high on RF. –Thus, high RF seems to be a possible buffer against the development of BPD in individuals who have experienced abuse.

41. Wisconsin Card Sorting Task Measure of executive functioning, Specifically concept formation and the capacity shift attention (cognitive flexibility)

42. Relation of Reflective Function to Wisconsin Card Sort Test r = -.47

44. 3078

48. 1367

50. 1637

53. Relation of Reflective Function to Impulsivity on Continuous Performance Test r =.35

54. Attachment Moderates Likelihood of Being in Psychotherapy Riggs et al. (2002) examined attachment and history of psychotherapy in 120 middle-class women. –dismissing women ↓ report a history of psychotherapy –disorganized ↑ report a history of individual psychotherapy –secure women ↑ report a history of couples therapy.

55. Attachment as a Moderator of Outcome Dozier, 1990 –Fs more cooperative with treatment –Ds associated with less help seeking, less self- disclosure, and poorer treatment use Dozier, Cue, & Barnett, 1994; Tyrrell et al., 1999 –Fs clinicians more likely to challenge patients’ own strategies for relating –insecure clinicians tended to mirror the patients interpersonal style –Better outcome when patient and therapist attachment complementary vs. concordant.

56. Attachment as a Moderator of Outcome Fonagy et al., 1996 –Ds attachment predicted better outcomes than E

57. ∆ in GAF between Admission and Discharge as a Function of Attachment

58. Attachment as a Prescriptive Indicator McBride, Bagby, & Atkinson, 2006 –attachment security moderate treatment outcomes in a RCT of CBT and IPT for MDD –avoidant attachment predicted better response to CBT than to IPT on all outcome measures, but anxious attachment did not predict different outcomes with the two treatments.

59. Attachment as an Outcome Fonagy et al., 1995 Diamond et al., 2003; Levy et al., 2008 Stovall-McClough & Cloitre, 2003 Levy et al., 2006, Makinen and Johnson, 2006; Cicchetti et al., 1999; Toth et al., 2006 Hoffman et al., 2006

60. Fonagy et al., 1995: Change in Security of Attachment (n =35)

61. Diamond et al., 2003: Change in Security of Attachment (n =10)

62. Change in Coherence and RF as a Function of Time: Pre-Post Study Coherence Paired t-test = -2.86, p <.02; RF paired t-test = -6.38, p <.001 Levy et al., 2008

63. Stovall-McClough & Cloitre, 2003: Change in Unresolved Status (n =18)

64. BPDRF-PDI RCT Overall Study Aims  To assess the efficacy of Transference Focused Psychotherapy (TFP) and Supportive Psychotherapy (SPT) compared with Dialectical Behavioral Therapy (DBT) for patients with Borderline Personality Disorder (Clarkin, Levy, Lenzenweger, & Kernberg, 2004, Journal of Personality Disorders)

65. BPDRF-PDI RCT Overall Study Aims and Design  Examine efficacy of Transference Focused Psychotherapy  Randomized 90 patients to one of three treatments: TFP, DBT, and Supportive Psychotherapy (SPT)  Experienced treatment cell leaders, experienced trained therapists, supervised weekly Patients clinically referred, highly comorbid (77% hx of MDD, 55% anxiety disorder, 33% eating disorder, and 38% substance use disorder), and highly traumatized (28% severe sexual abuse and ~50% some sexual abuse) (Clarkin, Levy et al., 2004; 2007; Levy et al., 2006)

66. Treatments  Transference Focused Psychotherapy –Uses a treatment contract to set the frame and assist in the containment of acting out behaviors, stipulates a sequence of treatment phases for interventions, emphasizes analysis of the transference for the integration of disparate representational models.  Dialectical Behavior Therapy (DBT) –emphasizes a balance between acceptance and change, skills training in the context of validation  Supportive Psychodynamic Psychotherapy (SPT) –eschews transference interpretation and places primary emphasis on strengthening adaptive defenses; forming an alliance, providing reassurance and advice

67. Transference Focused Psychotherapy Modified Psychoanalytic Psychotherapy Specifically for personality disorders Structured twice weekly outpatient treatment Based on Otto Kernberg’s Object Relations Model Primary goal: –reduce symptomatology and self-destructive behavior through integration of representations of both self and other (resolution of identity diffusion or stated differently the accomplishment of identity consolidation)

68. Overview of the TFP Treatment Model During the first year of treatment, TFP focuses on a hierarchy of issues: –Begins with a treatment contract the containment of suicidal and self-destructive behaviors the various ways of interfering with the treatment –In session, therapist follows dominant affect –Identifies and explicates recapitulation of dominant object relational patterns, as they are experienced and expressed in the here-and-now of the relationship with the therapist (conceptualized as a transference relationship). –Not about reconstructing childhood experience

69. Therapeutic Techniques Clarification –Of the patients subjective experience Confrontation –Tactfully pointing out discrepancies between what the patient is saying at one time and another or between what they are saying and doing or saying and expressing Transference Interpretation –The therapist’s timely, clear, and tactful interpretations of the dominant, affect-laden themes and patient enactments in the here and now of the transference, are hypothesized to integrate polarized self- and object representations.

70. Proposed Mechanisms of Therapeutic Change Integration of self concept Integration of concept of significant others Integration of previously dissociated or split off affect states with the result that affective experiences become enriched and modulated

71. Increased Differentiation and Integration Ability to think more flexibly and benevolently Impaired representations become transformed through new experiences Relationships: –infused with less aggression –greater capacity for intimacy, –increased coherence of identity, –reduction in self-destructive behaviors, –general improvement in functioning

72. Therapist Patient Sets frame via contract Experiences safe haven to express self ↓ Expression of affect includes actions and interactions based on implicit OR dyads Observes the action without judging or reacting Tries to understand/explicate the OR underlying the actions, using 1 – Clarification 2 - Confrontation 3 – Interpretation Increases reflection (these appeal for reflection & address obstacles to it) Further reflection, with Progress toward increased contextualization integration Increased modulation of affects

73. Telephone Inquires (n = 337) (294 clinical referrals, 28 non- clinical, 15 not known) Declined Interview (n = 130) Interviewed (n = 207) Refused Randomization (n = 19) Randomized (n = 90) TFP (n = 31) DBT (n = 30) SPT (n = 29) Met Criteria Offered Randomizing (n = 109) Loss of Eligibility (n = 0) Did Not Meet Criteria (n = 98) Reasonn Did not meet BPD Criteria30 Age21 Substance Dependent9 Concurrent Treatment6 IQ3 Bipolar Disorder8 Eating Disorder4 Psychotic Disorder8 Scheduling Conflict1 Dropped out8 Levy, Critchfield, & Clarkin, in preparation

74. Treatment Cell Leaders Treatment cell leaders were very experienced in the modality that they were supervising Many years of experience practicing in their respective treatments Many years supervising in their respective treatments Acknowledged as nationally known experts Published on their treatments

75. Therapists In each condition: –Chosen by treatment cell leader –Experienced practitioner in respective modality –Supervised weekly and monitored for adherence and competence –Generally senior therapists, although ranged from recent graduates to those with 30 years of experience

76. Patient Demographic Characteristics 90 Patients (83 Women and 7 Men) Mean Age = 30.9 (S.D. = 7.85) Marital status: –7 (7.7%) Married, 11 (12.2%) Living with partner, 40 (44.4%) Divorced, 21 (23.3%) In relationship Education: –4-year college degree (any college)32.2% (63.3%) Employment: –Employed (fulltime)64.4% (33.3%) Ethnicity/Race: –67.8% Caucasian, 10.0% African-American, 8.9% Hispanic, 5.6% Asian, 3.3 % mixed ethnicity/race, 4.4% other

77. Patients Represented a Seriously Disturbed Cohort All clinically referred Highly comorbid (77% hx of MDD, 55% anxiety disorder, 33% eating disorder, and 38% substance use disorder) Highly traumatized (28% severe sexual abuse and ~50% some sexual abuse) A third of the patients began cutting by age 12 Not selected based on intelligence or analyzability!

78. TFP Outcome Primary Outcome Variables –Significant improvement in TFP and DBT; but not in Supportive: Suicidality –Significant improvement in TFP and SPT Anger and Impulsivity –Significant improvement only in TFP group: Assault Secondary Outcome Variables –Significant improvement in all three groups: Depression, Anxiety, Social Relations, GAF –Significant improvement only in TFP group: Irritability

79. Distribution of 5-Category Attachment Status Time 1

80. Change in Secure-Insecure Attachment Status as a Function of Time McNemar’s  2 test was significant at the p =.03 level.

81. Change in Coherence as a Function of Time and Treatment

82. Change in Reflective Function as a Function of Time and Treatment

83. Change in Resolved-Unresolved Attachment Status as a Function of Time

84. Dropout as a Function of Treatment Condition and Reflective Function Survival Analysis –Treatment Condition and RF as covariates Is there differential dropout across treatments as a function of RF? –e.g., are patients with low RF retained better in certain treatments? RF at three levels: –Severely Impaired, Impaired, Average

85. Survival analysis on the Dropout criterion with Tx Condition and RF RF moderates relationship between Treatment Condition and Dropout –Average: When RF was within the average range, there were no significant differences across treatments with respect to dropout TFP = SPT = DBT –Impaired: Significantly more dropout for individuals in DBT than TFP (Wilcoxon Statistic=.4.61, df=1, p<.03) and SPT (Wilcoxon Statistic=8.81, df=1, <.003). TFP<DBT=SPT –Severely Impaired RF: Significantly more dropout in DBT than TFP (Wilcoxon Statistic=3.82, df=1, p<.05), while the differences between SPT and other treatments were non-significant. TFP<DBT, SPT ns

86. Dropout in Average RF Group

87. Dropout in Impaired RF group

88. Dropout in Severely Impaired Group

89. Specific Aspects of TFP that may Increase Mentalizing Focus on the object relation dyads –Explore mental state of other and self –The nature of mental states –Reduces rigidity about knowledge of other peoples minds –Model and encourage patient to think about mental states –Move beyond empathizing by also offering a different, yet experientially appropriate representation (contingent and marked)

90. Specific Aspects of TFP that may Increase Mentalizing Clarification –Initiates self-exploration –Identifies differences in perspective Confrontation –Bids for self-reflection –Brings into awareness disparate information and illustrates the defensive nature of certain mental states

91. Specific Aspects of TFP that may Increase Mentalizing The Transference Interpretation –timely, clear, and tactful interpretations of the dominant, affect-laden themes and patient enactments in the here and now of the transference Mentalization emotion-laden content Awareness of the defensive nature of certain mental states Assists patient in elaborating on emotional state that may have led to the enactment are hypothesized to integrate polarized representations of self and others

92. Clinical Observations Cannot Classify –E/Ds Derogations in angry preoccupied passages –Pseudo Secures (F/E/Ds or Ud/F) Mildly coherent in the provision of believable episodic memories, but may show below threshold idealization, derogation, lack of recall, passivity, or angry preoccupation however, episodic memories are often belied by a self-serving quality with positive wrap-ups, lack of true valuing of relationships, and show little evidence compassion, affection, forgiveness, or freshness characteristic of secure narratives

93. Clinical Observations Cannot Classify –Time 1 CCs that move to E or D at Time 2 –Time 1 Es or Ds that move to CC at Time 2 E classifiable transcripts with split representations –E1/E2 passive, self-blaming passages (helpless/passive/avoidant) Angry preoccupied parent-blaming passages (hostile/controlling)

94. Clinical Observations Lyons-Ruth’s Hostile/Helpless distinction Severe Splitting –Rapid oscillations of object relation dyads –Splitting between caregiver –Mention of trauma at beginning of interview or during five adjectives but no mention of it later in interview when topic is brought up by interviewer –Idealization or denigration of interviewer

95. Clinical Observations Psychic Equivalence –Interview process or questions experienced as the equivalent of past traumatic experiences

96. Therapist RF and Patient RF We assessed RF in our therapist in the small pre-post study using a modified patient- therapist AAI. Therapist RF re: patient generally high However, it did vary within therapist as a function of patient (but not patient RF!) Therapist tended to have lower RF with their Ds patients

97. Clinical Illustration Single, 32 year old, unemployed female Many unsuccessful treatments Over a number of years, increasingly isolated in her apartment, gaining weight, rarely bathing Poor interpersonal relations rationalized because of her ethnic background No sexual relations ever, except 1 attempt by boyfriend leading to formal rape charges

98. Clinical Illustration Occasional self-cutting 3 brief hospitalizations; diagnosis Bipolar Disorder Background: Middle daughter in highly educated family; prestigious and dominant but tough father; master’s degree educated; series of jobs destroyed by interpersonal relations; not working for last few years

99. Clinical Illustration On the AAI: –CC/Ds2 (devaluing of attachment experiences/derogating)/E2 (angry/conflicted) –RF = -1

100. Clinical Illustration Treatment: Controlling, dominant, dismissing therapist’s comments Condition for treatment: back to work, accepted after prolonged struggle Interpretation of relationship between hostile, grandiose, arrogant object and victim threatened with abandonment Generalization of this relationship to all interpersonal conflicts interpreted consistently Patient’s reflection on relationship with father coincident with emergence of positive transference while re- establishing relations with men

101. Clinical Illustration At the completion of one-year of treatment –Interested in apparently appropriate men; however, relationships often unrequited –Volunteering in a occupational area that she thought she might be interested –Taking non-matriculated graduate classes –Independent study evaluations: advance from Reflective Functioning score of -1 to 6 by end of first year of therapy –Medication: low dose of Neurontin at beginning, tapered off during year of treatment

102. Clinical Illustration At one-year follow-up –Effective improvement in work and interpersonal relations –Good sexual relations with stable boyfriend –Attending graduate school in area consistent with interests and capacities –Occasional struggles with feelings during times of stress (she had a cancer scare)

103. Clinical Illustration At three-year follow-up –Continued improvement in work and interpersonal relations Married; good sexual relations; trying to get pregnant Working in high-level job consistent with her interests and intellectual capacities –Medication free –Affect: generally happy

104. Mentalization, Mindfulness, and Integrated Representation Slightly difference foci. Very similar in their hypothesized relationship to attentional control and affective instability. Allows appropriate distance (as opposed to defensive distance) from events, thoughts, and feelings.

105. Mentalization, Mindfulness, and Integrated Representation Thoughts, feelings, and events are not seen concretely or experienced literally as a rigid reality, but are experienced implicitly and sometimes explicitly as symbolic representations of experience, which one has some control over (i.E., One can shift one’s attention or think differently about an event). Events remain in perspective and lose their re- traumatizing capacity.

106. Thank You For more information please e-mail me at klevy@psu.edu and visit the Laboratory for Personality, Psychopathology, and Psychotherapy website at http://levylab.psych.psu.eduklevy@psu.eduhttp://levylab.psych.psu.edu Also visit the Personality Disorders Institute website at www.borderlinedisorders.com www.borderlinedisorders.com