https://doi.org/10.4081/ripppo.2021.531
Mentalization, attachment, and defense mechanisms: a Psychodynamic Diagnostic Manual-2-oriented empirical investigation
Submitted: March 2, 2021
Accepted: March 17, 2021
Published: March 29, 2021
Accepted: March 17, 2021
Abstract Views: 52444
PDF: 2164
HTML: 209
HTML: 209
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Mentalizing capacities depends on the quality of primary attachment interactions with caregivers who thinks of the child as a subject with mental states. Operationalized as reflective functioning, mentalization is crucial for regulating emotions and developing of a coherent sense of identity, for interacting with individuals making sense to own and others mental states, and for distinguishing internal and external realities without distortions. Although the clinical literature on interplay between mentalization, attachment, and emotional regulation is rich, the empirical research is limited. This study sought to explore connections between reflective functioning, attachment styles, and implicit emotion regulation, operationalized as defense mechanisms, in a group of depressive patients. Twenty-eight patients were interviewed using the adult attachment interview (AAI) and diagnosed using the Psychodynamic Chart-2 of the Psychodynamic Diagnostic Manual, Second Edition. The reflective functioning scale and the defense mechanisms rating scale Q-sort were applied to AAI transcriptions to assess reflective functioning and defensive profile. Patients with secure attachment showed significantly higher levels in reflective functioning and overall defensive functioning as compared to those with insecure attachment. Good reflective functioning and secure attachment correlated with mature defenses and specific defensive mechanisms that serve in better regulating affective states. Overall, the relationship between mentalization, attachment and emotion regulation lay the foundations for the delineation of defensive profiles associated with attachment patterns and reflective functioning in depressive patients. The systematic assessment of these psychological dimensions with gold-standard tools may help in tailoring personalized therapeutic interventions and promoting more effective treatments.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. doi: https://doi.org/10.1176/appi.books.9780890425596.744053
Antonsen, B. T., Johansen, M. S., Rø, F. G., Kvarstein, E. H., & Wilberg, T. (2016). Is reflective functioning associated with clinical symptoms and long-term course in patients with personality disorders?. Comprehensive Psychiatry, 64, 46-58. doi: https://doi.org/10.1016/j.comppsych.2015.05.016
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226-244. doi: https://doi.org/10.1037/0022-3514.61.2.226
Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford, UK: Oxford University Press. doi: https://doi.org/10.1093/med:psych/9780199680375.001.0001
Besharat, M. A., & Khajavi, Z. (2013). The relationship between attachment styles and alexithymia: mediating role of defense mechanisms. Asian Journal of Psychiatry, 6(6), 571-576. doi: https://doi.org/10.1016/j.ajp.2013.09.003
Boldrini, T., Lo Buglio, G., Giovanardi, G., Lingiardi, V., & Salcuni, S. (2020). Defense mechanisms in adolescents at high risk of developing psychosis: An empirical investigation. Research in Psychotherapy: Psychopathology, Process and Outcome, 23(1). doi: https://doi.org/10.4081/ripppo.2020.456
Bouchard, M., Target, M., Lecours, S., Fonagy, P., Tremblay, L., Schachter, A., & Stein, H. (2008). Mentalization in adult attachment narratives: reflective functioning, mental states, and affect elaboration compared. Psychoanalytic Psychology, 25 (1), 47-66. doi: https://doi.org/10.1037/0736-9735.25.1.47.
Bowlby, J. (1969). Attachment and Loss: vol. I. Attachment. New York, NY: Basic Books.
Bowlby, J. (1973). Attachment and loss: vol. II Separation, anxiety and anger. New York, NY: Basic Books.
Bowlby, J. (1980). Attachment and Loss. Vol. 3: Loss, Sadness and Depression. New York, NY: Basic Books.
Calati, R., Oasi, O., De Ronchi, D., & Serretti, A. (2010). The use of the defense style questionnaire in major depressive and panic disorders: A comprehensive meta-analysis. Psychology and Psychotherapy, 83, 1-13. doi: https://doi.org/10.1348/147608309X464206
Carrère, S., & Bowie, B. H. (2012). Like parent, like child: Parent and child emotion dysregulation. Archives of Psychiatric Nursing, 26(3), e23-e30. doi: https://doi.org/10.1016/j.apnu.2011.12.008
Ciocca, G., Rossi, R., Collazzoni, A., Gorea, F., Vallaj, B., Stratta, P., Longo, L., Limoncin, E., Mollaioli, D., Gibertoni, D., Santarnecchi, E., Pacitti, F., Niolu, C., Siracusano, A., Jannini, E. A., & Di Lorenzo, G. (2020). The impact of attachment styles and defense mechanisms on psychological distress in a non-clinical young adult sample: A path analysis. Journal of Affective Disorders, 273, 384-390. doi: https://doi.org/10.1016/j.jad.2020.05.014
Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58(4), 644-663. doi: https://doi.org/10.1037/0022-3514.58.4.644
Conversano, C., & Di Giuseppe, M. (2021). Psychological factors as determinants of chronic conditions: Clinical and psychodynamic advances. Frontiers in Psychology, 12, 635708. doi: https://doi.org/10.3389/fpsyg.2021.635708
Cramer, P., & Kelly, F. D. (2010). Attachment style and defense mechanisms in parents who abuse their children. The Journal of Nervous and Mental Disease, 198(9), 619-627. doi: https://doi.org/10.1097/NMD.0b013e3181ef3ee1
Di Giuseppe, M., Ciacchini. R., Piarulli, A., Nepa, G., & Conversano, C. (2019). Mindfulness disposition and defense style as positive responses to psychology distress in oncology professionals. European Journal of Oncology Nursing, 40, 104-110. doi: https://doi.org/10.1016/j.ejon.2019.04.003
Di Giuseppe, M., Gennaro, A., Lingiardi, V., & Perry, J.C. (2019). The role of defense mechanisms in emerging personality disorders in clinical adolescents. Psychiatry, 82, 128-142. doi: https://doi.org/10.1080/00332747.2019.1579595
Di Giuseppe, M., Perry, J. C., Lucchesi, M., Michelini, M., Vitiello, S., Piantanida, A., Fabiani, M., Maffei, S., & Conversano, C. (2020). Preliminary reliability and validity of the DMRS-SR-30, a novel self-report based on the Defense Mechanisms Rating Scales. Frontiers in Psychiatry, 11, 870. doi: https://doi.org/10.3389/fpsyt.2020.00870.
Di Giuseppe, M., Perry, J.C., Petraglia, J., Janzen, J., & Lingiardi, V. (2014). Development of a Q-sort version of the defense mechanisms rating scales (DMRS-Q) for clinical use. Journal of Clinical Psychology, 70, 452-465. doi: https://doi.org/10.1002/jclp.22089
Di Giuseppe, M., Prout, T. A., Fabiani, M., & Kui, T. (2020). Defensive profile of parents of children with externalizing problems receiving Regulation-Focused Psychotherapy for Children (RFP-C): A pilot study. Mediterranean Journal of Clinical Psychology, 8(2). doi: https://doi.org/10.6092/2282-1619/mjcp-2515.
Eagle, M. N. (2013). Intersections: Psychoanalysis and psychological science.Attachment and psychoanalysis: Theory, research, and clinical implications. New York, NY: Guilford Press.
Fischer-Kern, M., Buchheim, A., Hörz, S., Schuster, P., Doering, S., Kapusta, N. D., Taubner, S., Tmej, A., Rentrop, M., Buchheim, P., & Fonagy, P. (2010). The relationship between personality organization, reflective functioning, and psychiatric classification in borderline personality disorder. Psychoanalytic Psychology, 27(4), 395-409. doi: https://doi.org/10.1037/a0020862
Fonagy, P., & Target, M. (1997). Attachment and reflective function: their role in self-organization. Development and psychopathology, 9(4), 679-700. doi: https://doi.org/10.1017/s0954579497001399
Fonagy, P., Gergely, G., Jurist, E., Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. Other Press, New York.
Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2019). Mentalizing, epistemic trust and the phenomenology of psychotherapy. Psychopathology, 52(2), 94-103. doi: https://doi.org/10.1159/000501526
Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development, 62(5), 891-905. doi: https://doi.org/10.2307/1131141
Fonagy, P., Steele, M., Steele, H., Higgitt, A., & Target, M. (1994). The Emanuel Miller Memorial Lecture 1992. The theory and practice of resilience. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 35(2), 231-257. doi: https://doi.org/10.1111/j.1469-7610.1994.tb01160.x
Fonagy, P., & Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues, 8(1), 87-114. doi: https://doi.org/10.1080/10481889809539235.
Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual: version 5 for application to adult attachment interviews. (Unpublished manual) University College London.
George, C., Kaplan, N., & Main, M. (1996). Adult Attachment Interview (3rd ed.). Unpublished manuscript, Department of Psychology, University of California, Berkley.
Gordon, R. M., & Bornstein, R. F. (2015). Brief manual for the Psychodiagnostic Chart-2 (PDC-2). Retrieved from: https://www.academia.edu/14475535/Brief_Manual_for_the_Psychodiagnostic_Chart-2_PDC-_
Gross, J. J., & Thompson, R. A. (2007). Emotion Regulation: Conceptual Foundations. In J. J. Gross (Ed.), Handbook of Emotion Regulation (pp. 3-24). New York, NY: Guilford Press.
Gyurak, A., Gross, J. J., & Etkin, A. (2011). Explicit and implicit emotion regulation: a dual-process framework. Cognition & Emotion, 25(3), 400-412. doi: https://doi.org/10.1080/02699931.2010.544160
Hayden, M. C., Müllauer, P. K., Beyer, K. J., Gaugeler, R., Senft, B., Dehoust, M. C., & Adreas, S. (2021). Increasing mentalization to reduce maladaptive defense in patients with mental disorders. Frontiers in Psychology, 12, 637915. doi: https://doi.org/10.3389/fpsyt.2021.637915
Hershenberg, R., Davila, J., Yoneda, A., Starr, L. R., Miller, M. R., Stroud, C. B., & Feinstein, B. A. (2011). What I like about you: The association between adolescent attachment security and emotional behavior in a relationship promoting context. Journal of Adolescence, 34(5), 1017-1024. doi: https://doi.org/10.1016/j.adolescence.2010.11.006
Hesse, E. (2008). The Adult Attachment Interview: Protocol, method of analysis, and empirical studies. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed., pp. 552-598). New York, NY: Guilford Press.
Hilsenroth, M. J., Callahan, K. L., & Eudell, E. M. (2003). Further reliability, convergent and discriminant validity of overall defensive functioning. The Journal of Nervous and Mental Disease, 191(11), 730-737. doi: https://doi.org/10.1097/01.nmd.0000095125.92493.e8
Hilsenroth, M. J., Katz, M., & Tanzilli, A. (2018). Psychotherapy research and the Psychodynamic Diagnostic Manual (PDM-2). Psychoanalytic Psychology, 35(3), 320-327. doi: https://doi.org/10.1037/pap0000207
Hoglend, P., & Perry, J. C. (1998). Defensive functioning predicts improvement in treated major depressive episodes. The Journal of Nervous and Mental Disease 186(4), 238-243.
Hörz-Sagstetter, S., Mertens, W., Isphording, S., Buchheim, A., & Taubner, S. (2015). Changes in reflective functioning during psychoanalytic psychotherapies. Journal of the American Psychoanalytic Association, 63(3), 481-509. doi: https://doi.org/10.1177/0003065115591977
Katznelson, H. (2014). Reflective functioning: a review. Clinical Psychology Review, 34 (2), 107-117. doi: https://doi.org/10.1016/j.cpr.2013.12.003.
Kobak, R., & Bosmans, G. (2019). Attachment and psychopathology: a dynamic model of the insecure cycle. Current Opinion in Psychology, 25, 76-80. doi: https://doi.org/10.1016/j.copsyc.2018.02.018
Laczkovics, C., Fonzo, G., Bendixsen, B., Shpigel, E., Lee, I., Skala, K., Prunas, A., Gross, J., Steiner, A., & Huemer, J. (2018). Defense mechanism is predicted by attachment and mediates the maladaptive influence of insecure attachment on adolescent mental health. Current Psychology 39, 1388-1396. doi: https://doi.org/10.1007/s12144-018-9839-1.
Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., & Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74(6), 1027-1040. doi: https://doi.org/10.1037/0022-006X.74.6.1027
Lingiardi, V., & Bornstein, R. F. (2017). Profile of mental functioning - M axis. In V. Lingiardi & N. McWilliams (Eds.), Psychodynamic diagnostic manual (2nd ed.). (pp. 75-133). New York, NY: Guilford Press.
Lingiardi, V., Lonati, C., Delucchi, F., Fossati, A., Vanzulli, L., & Maffei, C. (1999). Defense mechanisms and personality disorders. The Journal of Nervous and Mental Disease, 187(4), 224-228. doi: https://doi.org/10.1097/00005053-199904000-00005
Lingiardi, V., McWilliams, N., Bornstein, R. F., Gazzillo, F., & Gordon, R. M. (2015). The Psychodynamic Diagnostic Manual Version 2 (PDM-2): Assessing patients for improved clinical practice and research. Psychoanalytic Psychology, 32(1), 94-115. doi: https://doi.org/10.1037/a0038546
Maffei, C., Fossati, A., Lingiardi, V., Madeddu, F., Borellini, C., & Petrachi, M. (1995). Personality maladjustment, defenses, and psychopathological symptoms in nonclinical subjects. Journal of Personality Disorders, 9(4), 330-345. doi: https://doi.org/10.1521/pedi.1995.9.4.330
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development, 50, 66-104. doi: https://doi.org/10.2307/3333827
Malik, S., Wells, A., & Wittkowski, A. (2015). Emotion regulation as a mediator in the relationship between attachment and depressive symptomatology: A systematic review. Journal of Affective Disorders, 172, 428-444. doi: https://doi.org/10.1016/j.jad.2014.10.007
Martino, G., Caputo, A., Schwarz, P., Bellone, F., Fries, W., Quattropani, M. C., & Vicario, C. M. (2020). Alexithymia and inflammatory bowel disease: A systematic review. Frontiers in Psychology, 11, 1763. doi: https://doi.org/10.3389/fpsyg.2020.01763
McMahon, C., Barnett, B., Kowalenko, N., & Tennant, C. (2005). Psychological factors associated with persistent postnatal depression: past and current relationships, defense styles and the mediating role of insecure attachment style. Journal of Affective Disorders, 84(1), 15-24. doi: https://doi.org/10.1016/j.jad.2004.05.005
Mikulincer, M. (1995). Attachment style and the mental representation of the self. Journal of Personality and Social Psychology, 69(6), 1203-1215. doi: https://doi.org/10.1037/0022-3514.69.6.1203
Mikulincer, M., & Horesh, N. (1999). Adult attachment style and the perception of others: The role of projective mechanisms. Journal of Personality and Social Psychology 76, 1022-1034. doi: https://doi.org/10.1037//0022-3514.76.6.1022
Mikulincer, M., & Shaver, P.R. (2018). Attachment theory as a framework for studying relationship dynamics and functioning. In A. L. Vangelisti & D. Perlman (Eds.), The Cambridge handbook of personal relationships (p. 175-185). Cambridge University Press. doi: https://doi.org/10.1017/9781316417867.015
Müller, C., Kaufhold, J., Overbeck, G., & Grabhorn, R. (2006). The importance of reflective functioning to the diagnosis of psychic structure. Psychology and Psychotherapy, 79, 485-494. doi: https://doi.org/10.1348/147608305x68048
Nazzaro, M.P., Boldrini, T., Tanzilli, A., Muzi, L., Giovanardi, G., & Lingiardi, V. (2017). Does reflective functioning mediate the relationship between attachment and personality?. Psychiatry Research, 256, 169-175. doi: https://doi.org/10.1016/j.psychres.2017.06.045
Oasi, O., Buonarrivo, L., Codazzi, A., Passalacqua, M., Risso Ricci, G. M., Straccamore, F., & Bezzi, R. (2017). Assessing personality change with Blatt’s anaclitic and introjective configurations and Shedler-Westen Assessment Procedure profiles: Two case studies in psychodynamic treatment. Research in Psychotherapy: Psychopathology, Process and Outcome, 20(1). doi: https://doi.org/10.4081/ripppo.2017.231
Olson, T. R., Perry, J. C., Janzen, J. I., Petraglia, J., & Presniak, M. D. (2011). Addressing and interpreting defense mechanisms in psychotherapy: General considerations. Psychiatry, 74(2), 142-165. doi: https://doi.org/10.1521/psyc.2011.74.2.142
Perry, J. C. (1990). Defense mechanism rating scales (5th ed.). Boston, MA: The Cambridge Hospital.
Perry, J.C. (2014). Anomalies and specific functions in the clinical identification of defense mechanisms, Journal of Clinical Psychology, 70, 406-418. doi: https://doi.org/10.1002/jclp.22085.
Perry, J.C., Presniak, M.D., & Olson, T.R. (2013). Defense mechanisms in schizotypal, borderline, antisocial, and narcissistic personality disorders. Psychiatry,76(1), 32-52. doi: https://doi.org/10.1521/psyc.2013.76.1.32
Prunas, A., Di Pierro, R., Huemer, J, & Tagini, A. (2019). Defense mechanisms, remembered parental caregiving, and adult attachment style. Psychoanalytic Psychology, 36, 64-72. doi: https://doi.org/10.1037/pap0000158
Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment and Human Development, 7(3), 283-298. doi: https://doi.org/10.1080/14616730500245880.
Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. L., & Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with childhood mal- treatment histories: links to sensitive parenting and infant attachment security. Attachment and Human Development, 16 (5), 515-533. doi: https://doi.org/10.1080/14616734.2014.935452.
Taubner, S., Hörz, S., Fischer-Kern, M., Doering, S., Buchheim, A., & Zimmermann, J. (2013). Internal structure of the Reflective Functioning Scale. Psychological Assessment. 25 (1), 127-135. doi: https://doi.org/10.1037/a0029138.
Taubner, S., White, L. O., Zimmermann, J., Fonagy, P., & Nolte, T. (2013). Attachment-related mentalization moderates the relationship between psychopathic traits and proactive aggression in adolescence. Journal of Abnormal Child Psychology, 41, 929-938. doi: https://doi.org/10.1007/s10802-013-9736-x
Vaillant, G. E. (1992). Ego mechanisms of defense: A guide for clinicians and researchers. Washington: American Psychiatric Press.
How to Cite
Tanzilli, A., Di Giuseppe, M. ., Giovanardi, G., Boldrini, T., Caviglia, G., Conversano, C., & Lingiardi, V. (2021). Mentalization, attachment, and defense mechanisms: a Psychodynamic Diagnostic Manual-2-oriented empirical investigation. Research in Psychotherapy: Psychopathology, Process and Outcome, 24(1). https://doi.org/10.4081/ripppo.2021.531
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.