Page 90 - Personality disorders and insecure attachment among adolescents

as a whole demonstrated significant changes toward increased secure attachment in relation to reduced symptomatology. However, since this cohort study was not randomised, we cannot draw conclusions about a direct effect of the treatment itself on attachment. Nevertheless, this study suggests that insecure attachment in adolescents is likely to diminish during MBT. The results of this study provide hope concerning treatment and the future prospects of adolescents with insecure attachment. Our study showed that attachment insecurity is malleable, which is of substantial clinical relevance in a high-risk sample of adolescents with personality disorders and comorbidity. Changes towards secure attachment were accompanied by symptom reduction. Therefore, with regard to implications for prevention programs and clinical practice, our findings suggest that fostering attachment security may also improve outcomes as assessed by symptoms, or vice versa. On the other hand, the symptoms of the group that did not change in attachment also improved, although less so than of the group whose attachment became more secure. The question is what has influenced the change in attachment representations. The influence of social support of family and friends (van Harmelen et al., 2016) or age-related development may have played a role, since normal emotional maturation in adolescence is characterised by an interplay between progression and regression (Kaltiala-Heino & Eronen, 2015). If the treatment was of influence as well, the first hypothesis is that mentalization, as the process in group therapies in the program focusing on the adolescents’ subjective experience of themselves and others, and on the relationships with the group members and the therapists, stimulated a positive outcome (Bateman & Fonagy, 2008; Borelli, Compare, Snavely, & Decio, 2015; Rossouw & Fonagy, 2012). Mentalization was previously found to relate positively to secure attachment (Borelli et al., 2015; Fonagy et al., 1996; Reiner, Bakermans-Kranenburg, Van IJzendoorn, Fremmer-Bombik, & Beutel, 2016). Also, the continuous availability of MBT-trained nursing staff in this intensive psychotherapy program may have positively influenced the attachment of the participants (Reiner et al., 2016). The second hypothesis is that psychotherapy in a group with a group psychodynamic approach was especially relevant for adolescents possessing an insecure attachment (Yalom & Leszcz, 2005). On the other hand, it cannot be ignored that attachment security in 15.2% of the patients deteriorated, and that about one third of the group did not show a change. This is not surprising given the complexity of adolescence, the treatment context that requires the commitment of patients and their families, and that of the treatment team, and possible untoward life events occurring during treatment. The rates of deterioration as an outcome of psychotherapy range from 5% to 14% among adult patients and are thought to be even higher among children (Lambert, 2013). Moreover, we may consider whether a different kind of treatment would be more suited for this group of patients and whether personalised care could offer a solution. Further work is needed to fully understand the implications of the potential prolonged effects. 86