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.
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.