Attachment and mentalization in contemporary psychodynamic psychotherapy

Attachment and mentalization in contemporary psychodynamic psychotherapy

Attachment and mentalization in contemporary psychodynamic psychotherapy 3 Martin Debbane´1,2 1 Developmental Clinical Psychology Research Unit, Fac...

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Attachment and mentalization in contemporary psychodynamic psychotherapy


Martin Debbane´1,2 1 Developmental Clinical Psychology Research Unit, Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland, 2Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom

Attachment theory and mentalization theory resonate on many dimensions, and their concepts yield clinical utility for the practice of psychotherapy. As a cardinal point of contact, both theories lend central importance to the type of learning that takes place within relationships characterized by security and trust. These theories have evolved as forms of applied science linked to a common theoretical ancestor, psychoanalysis, with which they continue to entertain complex and often uneasy familial ties. The feuds between proponents of attachment theory and those of psychoanalysis have been described at length (Fonagy, 2001a), and the field of tension created has been characterized as being entrenched in “bad blood.” The mentalization-based approach was arguably born out of this field of tension in which psychoanalysis and attachment theories confronted each other (Fonagy & Campbell, 2015), a field of conflict that also contained the potential for development and creativity—specifically in the application of these theories to psychodynamic psychotherapy. In terms of positioning, the “in-betweenness” of mentalization theory has taken advantage of a space in which conceptual integration could emerge. Mentalization theory as applied to psychotherapy integrates a diverse set of principles originating from different theories, including psychoanalysis, attachment theory, developmental psychology, and cognitive neuroscience (Bateman & Fonagy, 2004, 2006). In order to contextualize the latest conceptual developments concerning mentalization in psychotherapy, this chapter will attempt to address some of the key questions that arise when we consider points of contact between attachment and mentalization theories. While mentalization is believed to be salient across all psychodynamic approaches to psychotherapy, mentalization-based treatment (MBT) will be referred to throughout the chapter as an exemplar of applied mentalization theory in contemporary psychodynamic practice. First, the concept of mentalizing in the context of psychotherapy will be defined, and its affiliation with attachment theory and its empirical foundations will be retraced. The second section will outline

Contemporary Psychodynamic Psychotherapy. DOI: © 2019 Elsevier Inc. All rights reserved.


Contemporary Psychodynamic Psychotherapy

the importance of how these two theories conceptualize the nature of psychopathology and the implicit views they share on the nature of therapeutic change. The final section will consider new developments in mentalization theory, reaching beyond its initial tenets and leaning toward an overall theory of psychotherapeutic communication that sheds new light on how we understand the therapeutic effects of psychodynamic psychotherapy.

Conceptual and empirical links between attachment theory and mentalization in dynamic psychotherapy From the perspective of mentalization theory, mentalizing—the suite of psychological processes devoted to thinking about the mental states underlying behaviors in self and others—constitutes a key ingredient driving change in psychotherapy (Bateman & Fonagy, 2006). Thus it was hypothesized that mentalization could be thought of as an active agent inducing therapeutic change in almost all psychotherapeutic models, ranging from psychodynamic to systemic, cognitive behavioral, humanistic, and person-centered approaches (Allen, Fonagy, & Bateman, 2008). As a time-limited psychodynamic therapy model, MBT places particular emphasis on mentalizing as both a process and an outcome of treatment. Moreover, a mentalization perspective, embodied in MBT, proposes a sophisticated developmental framework accounting for the maturational dependency of the child’s mentalizing capacity on the minds of its caregivers. This conceptualization provides key insights into the development of borderline personality disorder (BPD) while proposing a focused therapeutic method as a psychodynamic alternative to the classical psychoanalytic cure, which has often failed to provide therapeutic change in patients with BPD and has sometimes even provoked negative therapeutic reactions (Bateman & Fonagy, 2004). For the purpose of conciseness this chapter will examine the empirical foundation of mentalization in the psychotherapeutic context from three main areas of study: (1) research on attachment; (2) research on reflective functioning (RF); and (3) research on the developmental dynamics linking trauma, attachment insecurity, impairments in mentalization, and the development of BPD. Relying on attachment research using the strange situation procedure (SSP; Ainsworth, Blehar, Waters, & Wall, 1978), mentalization theory emphasizes the dyadic regulation of affect between the infant and its caregiver, which studies employing SSP have depicted so tangibly. Formulating a contemporary account of the Winnicottian transitional space (Winnicott, 1965, 1971) created by the mother infant dyadic communication, the mentalization-based framework stipulates that caregivers foster regulation of affect in children when the caregivers offer contingent, congruent, and marked responses in communicating (mirroring) their understanding of the child’s expressed affect (Fonagy, Gergely, Jurist, & Target, 2002). Indeed, from the perspective of mentalization theory, the parent child communication system provides a matrix upon which much therapeutic communication

Attachment and mentalization in contemporary psychodynamic psychotherapy


is modeled. While parental contingent mirroring involves adequate and sensitive timing of the parent’s response to the child’s emotional signals, the congruency of the parental response refers to the success the parent encounters when correctly identifying the category of affect dominating the child’s experience. Critical to parental success is the efficient transmission of the parent’s affective understanding through nonverbal and verbal communication with the child. Importantly, the parental response’s degree in marking (marked mirroring) is crucial to establish metacommunication, that is, to convey that the parent is communicating about the child’s emotion and not simply reacting to the child’s affective expression. Marked mirroring focuses the attentional lens of dyadic communication on learning about affect through reflectivity; it organizes the links between the trigger of affective arousal, the affective experience, its meaning for the child, and the consequence of affect on the child’s behavioral expression. The parental response already constitutes a rich and complex repertoire of communication that employs ostensive communication cues, such as eye contact and turn taking, that the child naturally decodes. Similarly, a therapist practicing from a mentalizing standpoint is encouraged to come into contact with the patient’s emotional expression through empathic validation (Bateman, O’Connell, Lorenzini, Gardner, & Fonagy, 2016), that is, through sensitively reflecting what the patient may be affectively experiencing. Through the careful monitoring of the patient’s emotional arousal in session, the therapist employs a spectrum of interventions designed to foster the process of mentalizing. The interventions of the therapist are to be used as an object to be edited, transformed by the patient to sustain the therapeutic process, and fuel further mentalizing. Therefore mentalizing involves at least two individuals implicated in affective regulation through communication about mental states (Luyten, 2014). Research on RF, which attempts to operationalize and measure the psychological processes that are captured by the term mentalization, constitutes the second line of empirical knowledge upon which a mentalizing perspective in psychotherapy is founded. Our understanding of this process in psychotherapy derives from the rich historical definitions of mentalization (Lecours & Bouchard, 1997). The brevity of this chapter unfortunately does not permit adequate tribute to the authors who contributed to this understanding before the birth of MBT—authors such as Pierre Marty and colleagues whose proposed definition of mentalization is still traceable today in Bateman and Fonagy’s MBT model (Debbane´, 2016). Discussion of RF (Fonagy, Target, Steele, & Steele, 1998) will occur within the confines of both conceptual and empirical research in MBT, delineating some key milestones and the questions they have raised. It may be argued that research on RF constitutes the cornerstone of a mentalization focus in psychodynamic psychotherapy. Indeed, in the first practical guides outlining the MBT method of psychotherapy (Bateman & Fonagy, 2004, 2006), the patient’s RF (capacity to mentalize self and others) was designated as the main target of treatment. RF is investigated as the process by which thinking about mental states in oneself and others contributes to understanding behaviors in the social domain, especially within interactions involving significant others (Bouchard et al., 2008).


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The measurement of RF is drawn from narrative material collected using the adult attachment interview (George, Kaplan, & Main, 1985). The RF scale (Fonagy, Steele, & Steele, 1991; Fonagy et al., 1998) provides the interview with more sensitivity to capture the adult’s awareness of mental states, and their employment of mental state information to understand themselves and others. Importantly, RF in parents is found as a key predictor of the child’s attachment status, linking parental mentalizing skills to the establishment of secure attachment relationships (Fonagy et al., 1991). It further supports the view that situates early attachment relationships as the initial playground in which the child learns about minds (Fonagy & Target, 1996). Research on RF lends support to mentalizing as playing a key developmental role in the establishment of secure attachment, which through a virtuous cycle further promotes the development of mentalizing. Most crucially, one’s capacity to develop reflective thinking depends, in part, on the way significant others have thought about our minds as children: . . . a fundamental need of every infant is to find his own mind, or intentional state, in the mind of the object. In Epilogue, Fonagy et al. (2002, p. 474)

In other words, the capacity for RF develops, to a large extent, through the reflective function of caregivers. This is extended to the psychotherapeutic context, in that the therapist’s RF with regard to the patient’s mind is seen as foundational for the patient’s enhancement of mentalizing abilities. For this reason—the idea that mentalizing minds breed mentalizing minds—a focus on RF characterizes the focused approach of MBT in guiding the therapist to identify her or his own moments of loss of mentalizing as a key feature to the psychotherapeutic process. While sensitive to the concepts of transference and countertransference, MBT technique encourages the psychotherapist to attend to process rather than content in the therapeutic exchange and to react swiftly to interrupt nonmentalizing interactions in the heat of the session. Thus MBT explicitly demonstrates how RF as a threedimensional process (therapist RF, patient RF, therapist patient RF) lies at the heart of psychodynamic psychotherapy. From the perspective of mentalization theory a considerable degree of psychopathology—particularly that which pertains to self- and affect-regulation— may be traced to the thwarted development of mentalization. Both cross-sectional and longitudinal studies provide supporting evidence for the view that early trauma induces the establishment of insecure attachment in children, who are more likely to demonstrate developmental delays or impairments in mentalization (Berthelot et al., 2015; Ensink, Berthelot, Begin, Maheux, & Normandin, 2017). Prospective research observes that insecure attachment is linked to impaired mentalizing in adolescents, which itself mediates the association between early insecure attachment and adult development of borderline personality symptomatology (Carlson, Egeland, & Sroufe, 2009). With the advancement of neuroscientific research at the turn of the 21st century, attachment and mentalization researchers have increasingly emphasized the impact

Attachment and mentalization in contemporary psychodynamic psychotherapy


of trauma on stress regulation mechanisms (Debbane´ & Nolte, 2019; Nolte, Guiney, Fonagy, Mayes, & Luyten, 2011), that is, the neurobiological underpinnings relating to the HPA axis, together with interacting dopaminergic, oxytonergic, and serotonergic systems (Luyten & Fonagy, 2015; Mayes, 2000). Such an articulation between attachment, stress regulation, and mentalization confers on therapy the role of rejuvenating the regulatory function of mentalizing through assisting its development or strengthening depending on the degree of alteration. The neuroscience of emotion regulation thus further frames contemporary psychodynamic psychotherapy as a practice that increases patients’ capacities to self-regulate.

Shared assumptions on psychopathology and change Attachment and mentalization theories have historically participated in the nature/ nurture debate on the origins of psychopathology (Bowlby, 1988; Fonagy, 2001b), formulating critical arguments for the role of early relationships as key factors to mental health. As would be expected from theories that model human development by focusing on the social and emotional growth fostered in close relationships, attachment theory and mentalization theory put heavy emphasis on the impact of childhood experiences in developing psychopathology. The two theories converge in suggesting that their central construct represents a nonspecific risk/resilience factor for mental health (Fonagy, Steele, Steele, Higgitt, & Target, 1994; Mikulincer & Shaver, 2012). They both advance the idea that their central construct, whether mentalizing or attachment, contributes to developing psychopathology or mental health through (1) (dys)regulation of emotions, (2) (de)stabilization of self and other representations, and (3) (in)capability of developing high-quality interpersonal relationship (Fonagy et al., 2002; Mikulincer & Shaver, 2012). At the heart of their therapeutic propositions lies the necessity to primarily regulate arousal in order to positively influence the mental models the patient entertains about both self and others. Consistent with object relations models of therapy (Kernberg, Yeomans, Clarkin, & Levy, 2008), this focus on regulation of arousal is designed to enable psychotherapeutic work on representations or internal working models. Moreover, the linking of attachment and mentalizing as nonspecific factors in psychopathology has contributed to the creative development of psychodynamic psychotherapies for groups of patients who could not necessarily access services in which contemporary psychodynamic psychotherapy was delivered (Bevington, Fuggle, & Fonagy, 2015; Byrne et al., 2018; Debbane´ et al., 2016; Fuggle et al., 2015; Weijers et al., 2016). One important limitation to the nature of the links between attachment, mentalizing, and psychopathology is that the strength of these associations remains relatively low (Groh, Roisman, van Ijzendoorn, Bakermans-Kranenburg, & Fearon, 2012; Katznelson, 2014). Similarly, no clear causality relationships can be gleaned from the available associative studies (Mikulincer & Shaver, 2012). Furthermore, the


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contributions of these concepts to our understanding of psychopathology has been muddled by the overlap they have with other concepts such as empathy, mindfulness, psychological mindedness, object relations, compassion, and the like (ChoiKain & Gunderson, 2008). Currently, while significant progress has been made through the application of attachment and mentalization theories to psychodynamic therapies, the lack of specificity and important overlap between these approaches and others could potentially limit advancement if the “Dodo bird verdict” would represent their ultimate contribution. Recently, significant attention and attempts to understand the overlap between contemporary constructs have been put forward in psychotherapy research, using the term common factors (Wampold, 2015). Most psychotherapists and clinical researchers today will admit to shared transtheoretical elements between different models of psychotherapy, the best known being the so-called therapeutic alliance (Arnow & Steidtmann, 2014). The impact of common factors is commonly found to be double that of the specific techniques linked to specialized psychotherapy models (Wampold, 2015), notwithstanding the significant impact of placebo in psychotherapy (Baskin, Tierney, Minami, & Wampold, 2003). From this perspective, attachment-based or mentalization-based perspectives do not necessarily hold the key to the city of therapeutic change. What is perhaps more troubling to clinicians is being confronted with research suggesting that the largest portion of their therapeutic impact with their patients relies on extratherapeutic factors (Wampold, 2015). These factors have to do with the contextual variables within which any psychotherapy takes place. Few concrete psychodynamic applications addressing these factors have been proposed to date (Asen & Fonagy, 2017). To summarize, attachment and mentalization theories conceptualize their key constructs as central to risk/resilience in the manifestation of psychopathology and propose intervention models that specifically aim to work on mechanisms that will sustain emotion regulation and foster work on self and other representations. This nonspecific approach to psychopathology and therapeutic change is both useful and limited. It is useful in the application of psychodynamic therapy for severe and also hard-to-reach clinical needs, but it may be limited because it does not necessarily address other areas of potential gains in psychotherapy, such as extratherapeutic factors. To account for these limitations, a series of developments in mentalization theory have recently undertaken to reframe the nature of therapeutic communication (Fonagy & Allison, 2014; Fonagy, Luyten, & Allison, 2015), proposing a novel model for thinking about therapeutic effects in psychodynamic psychotherapy.

From regulation therapy to learning from experience: beyond the therapeutic relationship Initial formulations of the mentalization perspective on psychotherapy stated that therapeutic change, no matter what therapeutic approach was used, could be linked to each technique’s effect on the patient’s ability to mentalize. Bateman and

Attachment and mentalization in contemporary psychodynamic psychotherapy


Fonagy (2004, 2006) proposed a unified, transtheoretical perspective of therapeutic gain around the notion of mentalization while suggesting with a hint of impertinence that mentalization-based therapies offered the model to follow to help patients recover and deepen their mentalizing capacity. More recently, these authors have proposed a reformulation of the link between mentalization and therapeutic gain, shifting its conceptual framework from a mentalization-centered approach to an integrative articulation of the specific and general factors of evidenced-based psychotherapeutic approaches (Fonagy & Allison, 2014; Fonagy et al., 2015). This recent evolution introduces three additional notions: epistemic trust, the transmission of cultural knowledge through natural pedagogy, and psychotherapeutic communication systems. As surveyed in the first two sections of this chapter, one of the key characteristics of the attachment relationship is to provide an interpersonal context within which the child (and, in psychotherapy, the patient) can learn to identify and represent mental states specific to self and others and to regulate emotions and to “play” with psychic reality, all of which promote robust social cognition, self-regulation, and resilience (Fonagy et al., 1994; Fonagy & Target, 1996). More recent elaborations on the role of early attachment relationships examine the characteristics of communication within the early attachment relationship, specifically those characteristics that foster the internalization of cultural knowledge (Csibra & Gergely, 2009; Fonagy & Allison, 2014). Fonagy, Luyten, Allison, and Campbell (2017a,b) propose that the context of attachment serves not only to promote the capacity to mentalize, but also to generate a particular type of trust, epistemic trust, opening the way to receptivity and the process of. The key value of internalization processes is to extend beyond the confines of the privileged relationship with a parent (or a therapist) into the interpersonal and social spheres in the child’s (or patient’s) life. Epistemic trust refers to the individual’s propensity to consider new information as trustworthy, relevant to oneself, and generalizable to other contexts. If epistemic trust is essential to the therapeutic effect, how can therapists approach the question of their credibility in the eyes of patients who suffer from personality disorders, which have evolved in environments that are hostile to mental states, conferring on these patients rigid, inflexible, and chronic epistemic vigilance? Mentalization theory approaches this question through the prism of the patient’s subjective experience. A therapist’s only hope to restore a certain degree of epistemic trust is by engaging with the patient’s subjective experience. This commitment and dedication to trying to understand the patient’s subjectivity are likely to lead the patient to reconsider his or her perception of himself or herself and others and the patient’s relationships to others as opportunities to discover useful and satisfying elements to his or her life. To rekindle epistemic trust, the therapist’s primary interest and focus are directed more toward a process that can revive the patient’s ability to learn from his or her experience with the world around the patient (Bion, 1962). To resituate the place of mentalization in the therapeutic effect, Fonagy et al. (2015) hypothesized that mechanisms of therapeutic change are underpinned by three systems of therapeutic communication that, cumulatively, contribute to


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therapeutic gains during treatment and beyond. Each of these systems of therapeutic communication is seen as contributing to patients having the experience of their subjectivity being contained and understood. This in turn leads to feelings of confidence that such experiences exist outside the consulting room, thereby extending the effects of psychotherapy to the extratherapeutic domain.

Communication System I: Content relevance and the establishment of epistemic trust The first system of therapeutic communication refers to the formulation of mental health and disease proposed and conveyed by a given model of psychotherapy. Thus the generic proposition of a therapy model can potentially yield a subjective impression of being understood by or in the approach in question. Therapeutic orientations each communicate, in an ostensive manner (Csibra & Gergely, 2009), a representation of the functioning of psychological suffering that is sufficiently generic for it to be read by the candidate for therapy. In the experience of this reading, the future patient can feel a kind of congruent and marked mirroring conveyed by the generic message offered by the therapeutic orientation. Through this metacommunication, the encounter with a model is likely to stimulate a hope of change in the future patient or in the patient beginning a therapy. Moreover, such metacommunication informs the patient of the ability and potential effectiveness of the approach to solve a set of psychological problems and suffering. Therefore at the first level of psychotherapeutic communication, each psychotherapy model generates for the future or new patient a subjective feeling of being understood by the explanatory framework in question and a hope of evolving beyond one’s current state. For patients entering psychodynamic psychotherapy, the generic mechanism of contemplating underlying motivations, thoughts, and feelings—conveyed implicitly and explicitly to the patient—provides the initial basis for the establishment or reestablishment of epistemic trust. The patient’s openness to discovery and new knowledge at this level paves the way for the second communication system that specifically targets the capacity to mentalize.

Communication System II: The reemergence of robust mentalization Upon initiation of a treatment that proposes ways in which the patient might feel recognized and understood, the second communication system emerges in the specificity of the interactions between patient and therapist. From the standpoint of mentalization theory, the key to therapeutic efficacy is the therapist’s understanding of the subjective experience of the patient. Thus the therapist will more likely communicate about highly relevant content to the patient’s experience of self and others. For the patient, this essential experience of having one’s own subjectivity received, accepted, and understood by the therapist revives the ability to mentalize (Fonagy, 2002). Experiencing a therapy as consistent with one’s current needs, accompanied

Attachment and mentalization in contemporary psychodynamic psychotherapy


by a person (the therapist) committed to understanding one’s subjective experience, is the essence of the second communication system. This process regenerates mentalizing or, more precisely, the desire to understand others. As the patient increasingly feels understood and represented in the mind of the therapist, the patient may become curious about the therapist’s mind, seeking to understand how it works and in turn how others’ perspectives are mentally generated. This process of mutual and differentiated understanding thus constitutes a therapeutic communication from which mentalizing emerges and is strengthened. Mentalization theory recasts the activities and communications within psychodynamic psychotherapy as primarily facilitating a mentalizing process between therapist and patient, thereby stimulating and enhancing the patient’s compromised RF. This process, however, cannot be limited to the walls of the consulting room. Rather, the mentalizing process engendered in psychodynamic therapy—and explicitly targeted in MBT—is seen as stimulating and sustaining the patient’s epistemic confidence in the world beyond the therapy session. Through the reactivation of epistemic trust, mentalization leads to a central aspect of the third system of communication: that of the desire and capacity to learn from experience (Bion, 1962) in the social world.

Communication System III: Reemergence of the ability to learn in the social world beyond the therapeutic relationship In Systems I and II the psychotherapeutic process builds on the sustained experience of the patient’s subjectivity being thought about and reflected upon by the therapist. It is hypothesized that this experience contributes to opening a wider path that could be referred to as an epistemic highway: the possibility of internalizing, on the basis of experience outside the consultation room, new knowledge that is both relevant to oneself and generalizable to the world. The experience of being carefully thought about and understood can potentially break open rigid and inflexible beliefs that keep the patient stuck in complex yet circular inferences (Rudrauf & Debbane´, 2018). This experience is theorized to propel the individual beyond the confines of the privileged therapy relationship, making the uncertainty and the unknown of any trajectory of human life tolerable or even desirable. While this evolution is partly driven by the therapeutic process, the patient’s environment is critical in the development and generalization of processes revitalized by psychotherapy. When the patient reengages with social and interpersonal interactions, he or she gains further increased understanding. This new understanding, bolstered by epistemic confidence, regenerates the patient’s agency within these interactions and reinforces a desire to draw from them as sources of knowledge and satisfaction that, until then, were inaccessible. The third system of communication initiates a third virtuous circle: the increased mentalization of the social world, where interpersonal relationships increase the patient’s understanding of the functioning of his or her environment. This in turn sensitizes the patient to complementary sources of support and meaningful relationships that may maintain the patient’s subjectivity in mind, that may engage the


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patient in socially constructive ways, and that may afford an increase in suspended time in which vigilance gives way to epistemic trust. In a world characterized by demands, change, and fundamentally unpredictable events, curiosity and openness to experience represent the currencies that critically engage with sources of potential learning. The systems of communication framework proposed by mentalization theory suggests that the reemergence of the ability to learn from one’s experience—fostered through the mentalizing process of communication between therapist and patient— lies at the heart of lasting psychotherapeutic success. Beyond the walls of the consultation room, epistemic trust supports the individual in his or her personal and social development, facilitating new or renewed understanding of how things work naturally in complex interpersonal and social systems. Thus in addition to promoting mentalization within the therapy itself, psychodynamic therapy is seen as helping the patient to increasingly move toward relationships in which he or she can find his or her mind and apprehend new sources of knowledge from interpersonal experiences.

Conclusion This chapter surveyed recent developments in attachment and mentalization theories as they pertain to understanding psychopathology and the processes of psychodynamic psychotherapy. In its integrative effort to conceptualize contemporary psychodynamic psychotherapy—and through the formulation of a specific MBT model—mentalization theory emphasizes the regulation of affect, security of therapy relationship, and understanding of subjective experience as central to the therapeutic endeavor. Moreover, a mentalization perspective reframes therapeutic gains within the broader context of socioemotional communication and experience. The systems of communication framework proposed in mentalization theory regards psychotherapy as a means for strengthening self-regulation through clinical practices that facilitate increased learning from experience outside the consultation room. Thus recent conceptual developments point to the importance of understanding how generalization processes infuse the patient’s mind to seek out experiences of learning from one’s environment. In this way, mentalization theory underlines the limitations of the strictly dyadic framework that characterizes most psychotherapy models, considering extratherapeutic factors that require further conceptualization, testing, and innovation in the future of psychodynamic psychotherapy.

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Attachment and mentalization in contemporary psychodynamic psychotherapy


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