Attachment, Borderline, and Transference-Focused Therapy

Borderline Personality Disorder (BPD) is a condition in which people have significant difficulty with emotion regulation, instability of sense of self, and difficulty with interpersonal relations. The advocacy group National Alliance for Mental Illness reports that BPD affects 1.4 percent of the population, 75 percent women.

According to the DSM-5, BPD is associated with the following signs and symptoms:

• An intense fear of abandonment, even going to extreme measures to avoid real or imagined separation or rejection.
• A pattern of unstable intense relationships, such as idealizing someone one moment and then suddenly believing the person doesn't care enough or is cruel.
• Rapid changes in self-identity and self-image that include shifting goals and values, and seeing yourself as bad or as if you don't exist at all.
• Periods of stress-related paranoia and loss of contact with reality, lasting from a few minutes to a few hours.
• Impulsive and risky behavior, such as gambling, reckless driving, unsafe sex, spending sprees, binge eating or drug abuse, or sabotaging success by suddenly quitting a good job or ending a positive relationship.
• Suicidal threats or behavior or self-injury, often in response to the fear of separation or rejection.
• Wide mood swings lasting from a few hours to a few days, which can include intense happiness, irritability, shame or anxiety.
• Ongoing feelings of emptiness.
• Inappropriate, intense anger, such as frequently losing your temper, being sarcastic or bitter, or having physical fights.

While effective for many, therapy can be prolonged and challenging, complicated by stigma, misunderstanding, and the same issues which interfere with other relationships. Medication may help alleviate symptoms, but it is not sufficient alone for most.

Nature and Nurture

BPD appears to be caused by a combination of factors. A 2013 study found 55 percent of BPD is due to general genetic factors, with specific contributions for emotion regulation and intense, unstable interpersonal relations. A 2016 review highlights the emerging role of epigenetic factors, quantifying how environment interacts with biology.

In terms of environment, people with BPD report higher levels of neglect and trauma in childhood. A recent meta-analysis found that childhood adversity was almost 14 times higher in patients diagnosed with BPD.

Recent research shows that while BPD and cPTSD often occur together—especially at higher severity of BPD—they are distinct. For example, they share emotional instability, with disturbed relationships and suicidality reflective of BPD.

Attachment, Insecure

A key issue in BPD is attachment style. Attachment starts early in life. For most people, unless they are very vulnerable, a "good enough" environment will yield secure attachment. Those with BPD have an insecure attachment style, usually either dismissive or preoccupied, though in profound trauma there may be a blended "disorganized" attachment style.

Transference-Focused Therapy (TFT)

TFT is a psychoanalytically-based approach emphasizing interactions between patient and therapist to rectify destructive patterns by identifying and addressing them as they come up during therapy.

“Transference” is the psychoanalytic concept for importing our prior patterns of relationship (“internalized object relations”) into therapy, unwittingly projecting distorted negative perceptions onto others via crude defenses like splitting and projection. This happens in all relationships, but it is called "transference" when it takes place in therapy, and the analysis of transference is a hallmark of psychoanalysis.

TFT has been shown to be more effective than therapy as usual (Doering et al 2010), and to have a positive impact on attachment style while improving reflective function, critical for adaptive self-referential processing, and social function.

Treatment has been shown to improve structural problems in personality for BPD patients, replacing dysfunctional internal patterns ("internalized object relations") with more adaptive ones by learning from and internalizing therapeutic interactions. Patients are better able to tolerate challenging situations, navigating difficult interpersonal interactions with greater mutuality—avoiding splitting and projection which drive feelings of abandonment and misunderstanding, ensuring relationship ruptures without the possibility of repair.

How does TFT improve attachment?

In order to answer this question, researchers Fischer-Kern, Doering, Rentrop, Hörz-Sagstetter, and Buchheim (2020) performed additional analysis on data (Doering et al 2010) from 63 patients who completed a year of therapy, either TFT or treatment-as-usual by experienced community therapists (ECP). All participants completed the gold-standard measure of attachment, the Adult Attachment Inventory (AAI), in addition to the original study measures.

The AAI is administered by trained psychologists in a semi-structured format. Patients are asked to speak about their upbringing with a focus on caregiver relationships and difficult experiences. Responses are rated based on the coherence of the story told. Are there missing elements or gaps in memory? Do they stop in the middle of speaking, and resume somewhere else, seemingly unaware of the jump? That is coded as dismissive. Are there high levels of anger or worry, repetitiveness, or unresolved themes? These point toward preoccupied attachment.

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Findings

Analysis of AAI pre-treatment and after one year of TFT showed major transformation while at the same time continuity. Many of the patients no longer met BPD diagnostic criteria, with fewer and less severe symptoms. Personality organization shifted from stronger borderline traits to less severe, more ordinary neurotic traits.

Notably, participants no longer showed insecure attachment but had shifted to secure attachment as measured by the AAI. There were three paths to secure attachment. In the first two, patients shifted to security but kept similar tendencies, moving from insecure-preoccupied to secure with preoccupied tendencies, and insecure-dismissive to secure with dismissive tendencies.

The third path showed an interesting pattern: attachment style flipped, shifting from insecure-dismissed to secure with preoccupied tendencies. Perhaps efforts to counteract excessive disconnection demand a level of sustained attention. Research, for example, shows that deliberate rumination, but not excessive worry, is associated with post-traumatic growth.

Qualitative analysis of the AAI transcripts revealed marked changes (see below for excerpt). Preoccupied participants showed less anger and more emotional regulation, decreased defensiveness and greater integration and positivity recounting distressing childhood experiences. Dismissive participants told more connected narratives, with greater detail supplanting former vagueness, greater continuity and coherence, and increased proportionate inclusion of feelings such as sadness and guilt.

Considerations

This work extends understanding of what happens in effective treatment for BPD, and by extension—though this was not measured in this study—potentially elements of complex trauma. Relieving aspects of childhood adversity in a contained setting, along with greater understanding and opportunities for reparative experiences with the therapist as a more competent caregiver, also permits controlled exposure to developmental trauma to desensitize trigger reactions.

Transference Focused Therapy is based on psychoanalytic models of treatment in which perceptions of self-and-other are mapped out and processed within the treatment framework, allowing internal object relations and personality structure to re-organize through persistent effort and targeted attention on key problematic dynamics. This study shows how TFT rights attachment style in ways which therapy as usual does not.

Further research is needed to compare different treatments for BPD—including Dialectical-Behavioral Therapy (shown to be helpful in many conditions), Mentalization-Based Therapy and others (e.g. Schema-Based Therapy)—in controlled trials to look at long-term outcomes, understand overlap with trauma therapy, and provide information to guide personalized care.