There is Room for Even More Doublethink: The Perilous Status of Psychoanalytic Research

The opposition between psychoanalysis and systematic interdisciplinary research is to be regretted. The target article attempts to bridge the intellectual divide and for this aim as well as the intellectual adroitness shown it is to be celebrated. Much harder to understand is the high level of affect generated by the debate. Accusations of “doublethink” are helpful. The present paper, like the target paper it follows, attempts to develop an understanding of the position of those who are categorically opposed to interdisciplinary systematic research linked to psychoanalysis. Appreciating the perspective of those deeply opposed to such work could help to create a shared agenda from which our troubled discipline could benefit. This is predicated on the possibility of an open collegial dialogue which this journal was founded to create.     

The Developmental Roots of Borderline Personality Disorder in Early Attachment Relationships: A Theory and Some Evidence

The paper suggests a way of understanding borderline personality disorder in terms of the failure of a secure base. We begin with an account of optimal self-development in a secure attachment context, highlighting the importance of the caregiver's ability to help the small child think about his own and others' minds. This optimal self-development is crucial in developing the child's capacity for mentalization, which can enhance his resilience in the face of later trauma. We discuss the impact of attachment trauma in later development, arguing that the extent of this impact depends on how well early attachment relationships facilitated the capacity for mentalization. We identify some of the consequences for the representations of the internal world of a failure of mentalization that may follow trauma in individuals made vulnerable by genetic predisposition or disorganized early attachment. We link these features to the clinical presentation associated with borderline personality organization. Finally, some of the necessary characteristics of successful psychotherapeutic treatment of borderline personality disorder are briefly considered.     

Mentalization-Based Treatment

The concept of mentalizing has captured the interest and imagination of an astonishing range of people—from psychoanalysts to neuroscientists, from child development researchers to geneticists, from existential philosophers to phenomenologists—all of whom seem to have found it useful. According to the Thompson Reuter maintained Web of Science, the use of the term in titles and abstracts of scientific papers increased from 10 to 2,750 between 1991 and 2011. Clinicians in particular have enthusiastically embraced the idea, and have put it to innovative use in their practices. Mentalization-based treatment (MBT)—making mentalizing a core focus of therapy—was initially developed for the treatment of borderline personality disorder (BPD) in routine clinical services delivered in group and individual modalities. Therapy with mentalizing as a central component is currently being developed for treatment of numerous groups, including people with antisocial personality disorder, substance abuse, eating disorders, and at-risk mothers with infants and children (A. Bateman & Fonagy, 2011). It is also being used with families and adolescents, in schools, and in managing social groups (Asen & Fonagy, 2011; Fonagy et al., 2009; Twemlow, Fonagy, & Sacco, 2005a Twemlow, S. W., Fonagy, P. and Sacco, F. C. 2005a. A developmental approach to mentalizing communities: I. A model for social change. Bull. Menninger Clin, 69(4): 265–281. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar], 2005b). In this article, we focus on MBT in the treatment of BPD.     

Everyone Must Get a Turn: From Omnipotence to Respect for Otherness: Reply to Commentary

The authors conceptualize Davies's account of the difficult session with her patient Karen as a mentalization mismatch: an expectable failure on the analyst's part to understand the mental state of the patient. In response, the patient used projective identification to re-create the link to the analyst that was temporarily severed. They argue that the therapeutic impasse produced by Karen's successful externalization of a persecuting part of her self is more than repetition of a past relationship. It is the current experience of a disorganized self: a pervasive state for the borderline patient, and a temporary but no less disorganized state in the analyst.     

Genetics,Developmental Psychopathology,and Psychoanalytic Theory: The Case for Ending Our (Not So) Splendid Isolation

This paper considers the historical isolation of psychoanalysis from other scientific academic disciplines. The example of behavior genetics is used to illustrate the potential mutual benefit of cross-fertilization. Exploring links between the two disciplines makes it possible to debate antipsycho-analytic constructions in behavior genetics with greater vigor. At the same time, psychoanalysis, which studies subjectivity, is relevant to a discipline that naively explores the objective environment without considering the crucial mediation through the subjective world. Microbiology and genetics offer models of the mechanisms by which meaning generation and interpretive capacity might interface with the unfolding of genetic expression. Simultaneously, emerging psychoanalytic developmental models have provided an ontogenetic psychological framework that links development of this capacity to the infant-mother relationship. The paper concludes by stressing the need for a cadre of specialist psychoanalytic professionals dedicated to research as the precondition of any meaningful dialogue between psychoanalysis and any other discipline.     

Early Intervention and the Development of Self-Regulation

Self-regulation is the key mediator between genetic predisposition, early experience, and adult functioning. This paper argues that all the key mechanisms underpinning the enduring effects of early relationship experiences interface with individuals' capacity to control (a) their reaction to stress, (b) their capacity to maintain focused attention, and (c) their capacity to interpret mental states in themselves and others. These three mechanisms together function to assist the individual to work closely and collaboratively with other minds. The paper proposes a reformulation of attachment theory constructs in terms of the quality of interpersonal interpretive functioning and the interpersonal strategies adopted by individuals to maintain optimal psychological distance between themselves and others, given their particular level of interpretive capacity.     

The Talking Cure in the Cross Fire of Empiricism—The Struggle for the Hearts and Minds of Psychoanalytic Clinicians: Commentary on Papers by Lester Luborsky and Hans H. Strupp

I outline the arguments advanced by Lester Luborsky and Hans H. Strupp on the current controversy regarding empirically supported treatment (EST). I support Luborsky's criticisms of some current attempts to provide empirical support for psychoanalytic treatment, but, unable to endorse the conclusion that therapies are equally effective, I argue that substantial evidence does exist to guide clinicians, even if this evidence is not yet accessible through a mechanical process of review. I also suggest that Luborsky's “open verdict” on the length-of-treatment issue is too conservative: Longer psychoanalytic treatments have been repeatedly associated with superior outcomes across a range of measures. I agree with Strupp that the current emphasis on EST is probably motivated primarily by economic rather than ethical conditions. However, I criticize Strupp's largely negative treatment of the issue of treatment “manualization” and argue that, though manualization is a mixed blessing, only a clear, structured, and coherent framework that guides the therapeutic process can enable the therapist to withstand the interpersonal pressures inevitably generated in the consulting room. I conclude by arguing that there is a need for refinement of the concepts and methods by which outcomes are evaluated in order to help psychoanalysis and psychotherapy become a more specific family of treatments for particular conditions.