Journal of Psychotherapy Integration

Psychological Flexibility, Attachment Style, and Personality

Organization: Correlations Between Constructs of Differing
Approaches
Joseph D. Salande and Raymond C. Hawkins, II
Online First Publication, April 18, 2016. http://dx.doi.org/10.1037/int0000037

CITATION
Salande, J. D., & Hawkins, R. C., II (2016, April 18). Psychological Flexibility, Attachment Style,
and Personality Organization: Correlations Between Constructs of Differing Approaches. Journal
of Psychotherapy Integration. Advance online publication. http://dx.doi.org/10.1037/int0000037
 Journal of Psychotherapy Integration © 2016 American Psychological Association
2016, Vol. 26, No. 2, 000 1053-0479/16/$12.00 http://dx.doi.org/10.1037/int0000037

Psychological Flexibility, Attachment Style, and Personality

Organization: Correlations Between Constructs
of Differing Approaches

Joseph D. Salande Raymond C. Hawkins II

Fielding Graduate University Fielding Graduate University and The University of
Texas at Austin
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Psychological flexibility is a theoretical construct associated with acceptance and

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commitment therapy, a “third wave” cognitive– behavioral therapy treatment focusing

on mindfulness and acceptance of aversive internal events. Psychological flexibility has
been thoroughly investigated in clinical and nonclinical populations. However, very
little research has been done pertaining to the possible relationships between psycho-
logical flexibility and attachment style. Similarly, there is no research investigating the
potential link between psychological flexibility and constructs associated with a psy-
chodynamic formulation of personality organization, particularly identity integration
and defensive operations. We hypothesized that psychological flexibility would be
negatively correlated with attachment anxiety and attachment avoidance, as well as
being negatively correlated with primitive defenses and identity diffusion. Our hypoth-
eses were largely confirmed, with several significant correlations found. Psychological
flexibility was negatively correlated with attachment anxiety, as well as being nega-
tively correlated with primitive defenses and identity diffusion. We discuss these
findings in terms of clinical practice and directions for future research.

Keywords: psychological flexibility, identity diffusion, defense mechanisms,

attachment, psychotherapy integration

There has been an increasing interest in the- the possible relationships among the theoreti-
oretical integration in terms of clinical strate- cally separate constructs of psychological flex-
gies, techniques, and interventions (Gaete & ibility (based on cognitive– behavioral princi-
Gaete, 2015; Wachtel, 2010). As such, there ples; Hayes, 2004), personality organization
exists a need for investigation into relationships (based psychodynamic theory; Kernberg,
between the key theoretical constructs of differ- 1984), and attachment style (based on develop-
ing approaches. The present work represents an mental and relationship research).
effort at exploring the integration of several
clinically relevant yet theoretically separate Behaviorism, Relational Frame Theory, and
constructs, each of which may lend complemen- Acceptance and Commitment Therapy
tary understanding to the value and utility of the
others for clinical research applications. The Acceptance and commitment therapy
focus of the present project is to explore (ACT) constitutes one of several “third wave”
cognitive– behavioral approaches, along with
dialectical behavioral therapy (DBT) and
other mindfulness-based approaches (Hof-
mann & Asmundson, 2008; Linehan, 1993).
Joseph D. Salande, School of Psychology, Fielding Grad-
uate University; Raymond C. Hawkins II, School of Psy- These approaches are termed “third wave” be-
chology, Fielding Graduate University and Psychology De- cause they represent the third, and most recent,
partment, The University of Texas at Austin. paradigm of behaviorism. The strict empiricism
We would like to thank Joseph Bush for his valuable of the original Watsonian behaviorism, the “first
contribution to this project.
Correspondence concerning this article should be ad-
wave,” as it were, reflected a concerted effort to
dressed to Joseph D. Salande, 609 Ember Dr., New Iberia, apply empirically informed interventions in the
LA 70560. E-mail: [email protected] treatment of mental illnesses, using the princi-
1
 2 SALANDE AND HAWKINS

ples of learning. The second “wave” in this Wegner et al. went on to link this cognitive
progression involved the integration of social phenomenon to the etiology of obsessive and
learning, as well as cognitive and emotive pro- intrusive thinking. The findings of Wegner et al.
cesses, into behavioral interventions. This “sec- have important implications for a variety of
ond wave” reflected an increasing body of em- cognitive and cognitive– behavioral therapy
pirical evidence, and the influence of cognitive (CBT) approaches.
psychology. “Third wave” treatments represent In addition to the “rebound effect” first re-
an increasingly nuanced understanding of be- ported by Wegner et al. (1987), their research
havior as functional and contextual, as well as implied, and subsequent studies confirmed, that
an appreciation of Buddhist traditions of medi- thought suppression is also associated with on-
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ation and mindfulness. going failure to suppress thoughts in the mo-

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According to Hayes (2004), who has been the ment (Lavy & van den Hout, 1990; Wenzlaff,
central figure in the creation and dissemination Wegner, & Roper, 1988). That is to say, thought
of ACT, third wave treatments, such as DBT, suppression leads to two related phenomena:
ACT, mindfulness-based therapy, and so forth, one in which suppressing a thought leads to its
are open to older clinical traditions, focus on “rebound” (subsequent spike in frequency of the
changing the function rather than the form of suppressed thought) as an aftereffect of attempts
mental or behavioral phenomena, and seek to at suppression, and another in which the active
establish a more flexible behavioral repertoire. suppressing of a thought increases the activa-
In its most practical sense, third wave treat- tion of that thought in the moment. It was also
ments address aspects of human experience, found that thought suppression is correlated
such as the acceptance of painful events, the with measures of obsessional thinking, depres-
role of values in our lives, spirituality, and re- sive affect, and anxious affect (Wegner & Zana-
lationships (Hayes, 2004). Related to these lines kos, 1994). If we look to the third wave CBT
of research and theory concerning mindfulness,
approaches that emphasize mindfulness, accep-
acceptance, and so forth, there are well-
tance, and so forth, it is clear that inherent to
documented paradoxical effects associated with
these approaches is the assumption that in trying
attempts at thought suppression.
to avoid some internal event (suppression,
In 1987, a landmark article describing two
studies on thought suppression (Wegner, Sc- avoidance, etc.), we become more deeply mired
heider, Carter, & White, 1987) was published. in it.
In these experiments, participants were asked to ACT is theoretically based on relational
articulate a stream of consciousness for 5 min; frame theory (RFT; Törneke, 2010), a theory of
one group was specifically asked to not think of language and cognition. RFT proposes that hu-
white bears and the other group was asked to man cognition and language are the result of the
think of white bears. Each group participated in ability to learn to relate events and stimuli that
two conditions; one was a suppression condi- are arbitrarily controlled by context. Core com-
tion and the other was an expression condition. ponents of RFT, such as mutual entailment,
Participants asked not to think of white bears combinatorial entailment, and transformation of
that were placed in the thought suppression stimulus functions, inform the functional con-
condition first showed much greater instances textualism of behavioral analysis as conceptu-
of thinking of white bears in a subsequent trial alized from an ACT perspective. Any event,
relative to those participants who were asked to internal or external, must be understood in
think of white bears in their first trial and then terms of its function. Efforts to alter one’s ex-
were subsequently asked not to. Wegner et al. perience of an event can only be addressed by
(1987) described this “rebound effect” as re- manipulating the context of such events, thus
flecting a paradox of thought suppression—that altering the contextual function of the event.
thought suppression leads to thoughts of the Wegner et al.’s (1987) findings on the paradox-
suppressed material. The findings of Wegner et ical effects of thought suppression preceded the
al.’s “white bear studies” demonstrated what advent of RFT, a theory of language and cog-
had been suspected for some time: that efforts to nition with strong behavioral influences, but
avoid thinking of something increases the like- these results make perfect sense when examined
lihood of thinking about that avoided thing. through the lens of RFT.
 FLEXIBILITY, ATTACHMENT STYLE, AND PERSONALITY 3

RFT posits that verbal units act as cognitive tight verbal relations that establish stimulus
structures that become related to one another functions through relational learning” (Hayes,
through experience, so that if one learns that 2004, p. 654). Mindfulness is a core concept in
a ⫽ b and b ⫽ c, then a ⫽ c (Törneke, 2010). ACT, as it is believed that mindful contact with
The participants in Wegner et al.’s (1987) study the present moment, free from evaluation or
were asked to suppress thoughts of white bears, judgment, decreases cognitive fusion and in-
and when put into that context, everything be- creases psychological flexibility.
comes implicitly associated with white bears. A key concept that differentiates ACT from
RFT is relevant here to the extent that it is the other CBT approaches is the emphasis on the
theoretical grounding for ACT, a premier third self as context. Related to the appreciation of
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wave approach. the self as context is the concept of the “tran-

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According to RFT and ACT, humans attempt scendent sense of self,” which involves foster-
to escape unpleasant events through a process ing a sense of self that is both removed from
termed experiential avoidance. Paradoxically, immediate experience and able to observe one’s
our efforts to avoid painful internal events re- immediate experience without being subject to
sults in increased cognitive and emotional con- it or the object of it (Hayes, 2004). Central to
tact with such internal events and subsequent the focus of the present project is that the “self
maladaptive functioning. Hence, experiential as context” component of ACT opens the door
avoidance entails pathological efforts to avoid to the exploration of psychological flexibility in
the form and frequency of distressing experi- terms of object relational and attachment pro-
ences and events (Hayes, 2004). The arbitrary cesses. To our knowledge, there has been no
control of our cognitive relational frames cre- exploration of the interface of these theoretical
ates a situation in which a human can experi- domains as of yet.
ence a painful event without direct contact with As the name acceptance and commitment
the painful event (e.g., for someone suffering therapy would imply, acceptance is very impor-
with obsessions of cleanliness, being physically tant to this model. Acceptance, which is in
clean does not actually prevent one from feeling essence an exposure-based intervention, en-
dirty). ACT emphasizes acceptance of unpleas- courages the experience of thoughts and feel-
ant events, altering the functional context of ings as what they are, and nothing more. In
such events, and thus changing the emotional other words, clients are led to experience and
experience of such events. accept their thoughts and feelings fully. Another
Along with experiential avoidance, cognitive feature unique to ACT is a focus on living with
fusion is another central component of ACT. a commitment to one’s values. In effect, ACT
Cognitive fusion refers to being trapped within interventions are geared toward these processes
maladaptive relational frames or cognitive (i.e., contact with the present moment, accep-
structures of verbal units, which keep individu- tance, defusion, self as context, values, and
als “stuck” in certain cognitive-emotional/ committed action), all of which are thought to
behavioral patterns. Along with attempting to increase psychological flexibility. Of all of the
decrease experiential avoidance, ACT also concepts central to ACT described here, one of
seeks to break the hold of cognitive fusion and the most theoretically fundamental constructs,
increase the flexibility of our psychological ex- and most relevant to this article, is that of psy-
perience. ACT typically entails “confronting the chological flexibility. Psychological flexibility
system,” an effort to address current strategies is, in essence, a model of psychological health,
that have been used to deal with whatever the with a growing body of evidence supporting its
presenting problems are. In ACT, it is proposed formulation as fundamental to adaptive func-
that it is attempts to control aversive thoughts tioning (Hayes, Luoma, Bond, Masuda, & Lil-
and feelings that keep the individual trapped in lis, 2006; Hayes et al., 2004). Psychological
their maladaptive cognitive and emotive states. flexibility shares some properties with other
Experiential avoidance refers to a systemic ex- constructs associated with healthful adaptation
amination of efforts to control automatic inter- to life’s challenges, such as the construct of
nal experiences, with such efforts at avoidance psychological resilience.
being behaviorally pathological in nature. Cog- There is indeed some conceptual similarity
nitive defusion refers to efforts to “erode the between the construct of psychological flexibil-
 4 SALANDE AND HAWKINS

ity and that of psychological resilience; how- Hummel, and Hoyer (2011) reporting that the
ever, there are also important differences that AAQ-II measures a unitary construct of psycho-
clearly differentiate the two. Both of these con- logical flexibility that is “correlated with other
structs are associated with healthy adaptation to variables largely consistent with predictions,
painful events or difficult circumstances. How- differentiated patients from healthy controls,
ever, the key difference lies in the context of the and showed preliminary indications of treat-
activating event. Psychological flexibility is a ment sensitivity” (p. 970).
cognitive property generally associated with Masuda et al. (2011) conducted two cross-
one’s attention to, and acceptance of, painful sectional studies examining the mediating effect
internal events (i.e., cognition and affect). On of psychological flexibility on self-concealment
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other hand, most conceptualizations of resil- and negative psychological outcomes. Using the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ience are associated with the effects of external 16-item version of the AAQ (AAQ-16: Bond &
events. For example, Zautra, Arewasikporn, and Bunce, 2003), as well as the Self-Concealment
Davis (2010) define resilience as “adaptive re- Scale (Larson & Chastain, 1990) and the Inter-
sponses to adversity” (p. 222). There may be personal Reactivity Index–Personal Distress
some value in future research exploring a pos- (Davis, 1983), Masuda et al. found that the links
sible relationship between flexibility and resil- between self-concealment and psychological
ience, as well as attempts to identify a common distress in interpersonal contexts, and self-
latent psychological variable among the two. concealment on general negative psychological
Psychological flexibility refers to “the ability outcomes, were mediated by psychological
to contact the present moment more fully as a flexibility. According to Masuda et al., “the
conscious human being, and to change or persist judgmental, avoidant, and behavior-interfering
in behavior when doing so serves valued ends” nature of SC may play an important role in its
(Hayes et al., 2006, p. 7). The six core processes link to negative psychological outcomes” (p.
of ACT we have described (i.e., contact with the 246).
present moment, acceptance, defusion, self as In an interesting study investigating psycho-
context, values, and committed action) are logical flexibility as measured by the AAQ-II,
thought to establish the psychological flexibility as well as alternative instruments measuring
of the individual. These processes, and thus cognitive fusion (i.e., the Cognitive Fusion
psychological flexibility, are measured with the Questionnaire and the Mindful Attention and
Acceptance and Action Questionnaire (AAQ; Awareness Questionnaire), Palladino et al.
Hayes et al., 2004). (2011) reported evidence in support of the con-
Hayes et al. (2004) examined 32 studies com- struct validity of psychological flexibility. More
paring the AAQ with various measures and relevant to the present discussion is Palladino et
outcomes, finding that measures of ACT pro- al.’s finding of greater psychological flexibility
cesses have a moderate relationship to several being related to higher life satisfaction. Al-
important psychological dimensions and out- though a complete review of all findings regard-
comes (as assessed by a variety of instruments ing psychological flexibility is beyond the scope
measuring depression, anxiety, adjustment, of the current discussion, the overall theme of
symptomatology, etc.). Notable instruments these findings point to psychological flexibility
used in these comparison studies have included as a construct central to psychological health
the Beck Depression Inventory (Beck, Rush, and well-being.
Shaw, & Emery, 1979; Beck, Steer, & Brown,
1996), the Brief Symptom Inventory (Derogatis Development and Attachment Style
& Melisaratos, 1983), and the Fear Question-
naire (Marks & Mathews, 1979; Oei, Moylan & Although there is a close relationship be-
Evans, 1991). tween attachment theory and psychodynamic
Although the AAQ is described in some lit- theories, particularly object-relations theory, at-
erature primarily as a measure of experiential tachment processes have garnered an increasing
avoidance (Hayes et al., 2004), it is actually amount of attention among theorists and re-
viewed, as a whole, as a measure of psycholog- searchers, irrespective of theoretical orientation.
ical flexibility. The AAQ has been revised (as According to Ainsworth (1969), “attachment
the AAQ-II), with Gloster, Klotsche, Chaker, refers to an affectional tie that one person (or
 FLEXIBILITY, ATTACHMENT STYLE, AND PERSONALITY 5

animal) forms to another specific individual . . . sions, and they showed the dominant role of
attachment is thus discriminating and specific” heritability in anxious attachment, and the role
(p. 971). The central themes of attachment the- of environment in avoidant attachment.
ory revolve around the nature and quality of the DeVito and Hopkins (2001) examined attach-
infant’s relational bond with the primary care- ment processes within the parent– child dyad for
giver. preschoolers, finding that insecure attachment
Attachment theory has emphasized the evo- (coercive) patterns, along with marital dissatis-
lutionarily adaptive value of attachment behav- faction and permissive parenting, were associ-
ior in human infants, as well as framing such ated with higher instances of disruptive behav-
theory in an empirically verifiable way (Ain- ior in preschoolers. Although these findings do
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sworth & Bowlby, 1991). Many researchers support the general philosophical assumptions
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since the time of Bowlby and Ainsworth have of both psychodynamic and attachment theoret-
investigated the link between attachment style, ical schools, the fact that the measurement of
presumably a function of the relationship be- variables was based on maternal self-report is
tween child and caregiver, and other various an important limitation pointed out by the au-
psychological and psychosocial domains. How- thors. It should also be mentioned that attach-
ever, there has been little, if any, investigation ment pattern (as occurring between mother and
into a possible link between attachment and child) is related to, yet distinct from, attachment
psychological flexibility. The possibility of such style (as occurring in close relationships).
a relationship is explored in the current project. In a fascinating study that speaks to the psy-
choanalytic roots of attachment theory, Mi-
Relevant Research Findings Regarding kulincer and Horesh (1999) found that “anx-
Attachment Style ious-ambivalent persons’ impression formation,
memory retrieval, and inferences about others
There exists a breadth of research findings reflected the projection of their actual-self traits;
regarding the connection between attachment avoidant persons’ responses reflected the pro-
style and processes and a variety of outcomes, jection of their unwanted-self-traits” (p. 1022).
dynamics, and psychological features. As men- The research methodology of this study was
tioned, attachment theory was designed to be unique, as the nature of the material would
ethologically and evolutionarily based, and necessitate; however, the novelty of the design
most importantly, an empirically verifiable con- makes is difficult to assume generalizability. On
struct. Researchers in a variety of areas were the other hand, the findings of Mikulincer and
relatively quick to take up the task of providing Horesh converge with and support previous ef-
empirical validation for the construct of attach- forts to link attachment with projective and so-
ment. For example Waters, Wippman, and cial– cognitive phenomenon. In this study ex-
Sroufe (1979) not only found empirical support amining the relationship between attachment
for the construct but also identified a link be- style and perception of others, it was found that
tween attachment and social competence in pre- attachment styles were influential in partici-
schoolers. pants’ impression formation, memory retrieval,
McCarthy and Maughan (2010), in investi- and inferences about others. Mikulincer and
gating the link between attachment and adult Horesh argue that these findings highlight the
romantic relationships in “high risk” women role of attachment in the experience of others,
(from poverty-stricken urban areas), found that and further differentiate anxious and avoidant
satisfaction with love relationships was associ- persons in terms of the qualities that guide their
ated with higher coherence of mind. These find- interactions with others.
ings suggest that insecure attachment is associ- Although the original conception of attach-
ated with problematic love relationships in ment included three primary categories (secure,
adulthood. Crawford et al. (2007) investigated anxious, and avoidant), this model has been
the link between anxious and avoidant attach- expanded upon and modified, most notably by
ment and personality disorders within twin Bartholomew and Horowitz (1991), who intro-
pairs. These investigators found that both anx- duced and validated a four-category model that
ious and avoidant attachment were associated has proven to be very useful for some lines of
with pathological personality features/dimen- research. These four categories of attachment
 6 SALANDE AND HAWKINS

style are very similar to the original model, tioning, although the two constructs have not
though with greater differentiation among inse- been examined together, as the present study
cure attachment styles (secure, dismissing, pre- aims to do.
occupied, and fearful; Bartholomew & Horow-
itz, 1991). This model has proved influential, Measuring Attachment
despite its initial empirical support being based
on a relatively small and homogeneous sample. According to Rivas, Handler, and Sims
The current investigation does not classify par- (2009), the measurement of attachment has fol-
ticipants according to a particular model of at- lowed two separate traditions tapping different
tachment, but rather to establish the relation- aspects of the internal working model (IWM).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ships between attachment anxiety and On one hand, socially based self-report mea-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

avoidance and psychological flexibility. sures tap into conscious experiences of close-
Waters, Merrick, Treboux, Crowell, and Al- ness and relatedness with others and are “de-
bersheim (2000) performed a longitudinal study signed to assess aspects of the IWM that govern
in which individuals’ attachment styles were attachment-seeking processes for the adult in
assessed at 12 months and 21 years. Waters et close interpersonal relationships with other
al. found that 72% of individuals received the adults, such as romantic partners or close
same secure versus insecure classification at friendships” (p. 28). On the other hand, devel-
both assessments; they also found that 44% of opmentally based narrative measures are
those who experienced negative life changes in thought to tap into conscious and unconscious
childhood changed attachment classification, themes related to early childhood experiences.
whereas only 22% of participants who experi- The emphasis in these measures is relatedness
enced no such negative life changes had any and attachment between child and caregiver as
change in attachment classification (Waters et opposed to close adult relationships (Rivas et
al., 2000). Doron, Moulding, Kyrios, Nedeljk- al., 2009). For the purposes of the present study,
ovic, and Mikulincer (2009) explored possible we limit the remainder of this discussion to a
connections between attachment and cognitive specific self-report instrument, and its deriva-
patterns and symptomatology related to obses- tives, which enjoy particularly strong empirical
sive– compulsive disorder (OCD). Doron et al. support and high accessibility: the Experiences
(2009) found that, when controlling for depres- in Close Relationships–Revised (ECR-R; Fra-
sion, attachment was related to OCD-related ley, Waller, & Brennan, 2000).
cognitions, and “attachment insecurities, anxi- Ravitz, Maunder, Hunter, Sthankiya, and
ety or avoidance, predicted dysfunctional OCD- Lancee (2010), who conducted a systematic re-
related cognitions and OCD symptoms” (p. view of currently published assessment instru-
1039). In a study investigating thought suppres- ments, stated that the ECR “emerged from a
sion processes (particularly in the context of principal components analysis of 323 attach-
suppressing thoughts of one’s exclusive roman- ment items from 60 self-report measures of
tic partner leaving for a new partner) in indi- attachment, many of which were unpublished
viduals whose attachment style was categorized . . . analysis produced factors related to attach-
as dismissing-avoidant (expressing low levels ment anxiety and attachment avoidance” (p.
of attachment-related distress), Fraley and 427). This instrument has high reliability and
Shaver (1997) found that such individuals “are validity, and it has been used quite extensively
capable of suppressing the latent activation of in a variety of research contexts (Ravitz et al.,
their attachment system and are not simply con- 2010; Sibley, Fischer, & Liu, 2005).
cealing latent distress” (p. 1080). Sibley and Lui (2004) reported high internal
The findings reviewed here represent only a reliability of both factors of the ECR-R, mea-
small portion of the data that have been gener- sured by the Attachment Anxiety subscale (␣ ⫽
ated indicating the relevance of attachment pro- .9477) and Attachment Avoidance subscale
cesses to developmental, relational, social, cog- (␣ ⫽ .9344). The test–retest coefficients of the
nitive, and psychopathological domains. ECR-R have been found to range from .50 to
Attachment style, like psychological flexibility, .75 (Mikulincer & Shaver, 2007). However,
has been found to be related to a variety of other studies have established higher test–retest
measures of psychological and behavioral func- reliability (Kooiman, Klaassens, van Heloma
 FLEXIBILITY, ATTACHMENT STYLE, AND PERSONALITY 7

Lugt, & Kamperman, 2013; Sibley et al., 2005). Object Relations and
Recently, Mastrotheodoros, Chen, and Motti- Psychological Functioning
Stefanidi (2015) described similarly high reli-
abilities in Greek and Chinese samples. Sibley The quality of one’s object relations is re-
et al. (2005) demonstrated the strong criterion flected in how one experiences the self and
validity of the ECR-R in a nonclinical sample others, especially in interpersonal relationships.
via analysis of subjective ratings of personal Internalized representations of the self and oth-
interactions with romantic partners. The ECR-R ers, and the relations among them (what is re-
was found to demonstrate good construct valid- ferred to as object relations), determine behav-
ity in a Dutch outpatient mental health popula- ior in interpersonal relationships, constitute the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tion, as well as demonstrating good test–retest basis of personality structure and dysfunction,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

reliability (Kooiman et al., 2013). There is a and are related to a number of other psycholog-
growing body of research supporting the use of ical factors. For example, Herbert, McCormack,
the ECR-R as a valid and reliable measure of and Callahan (2010) found that perceptions of
attachment in adults. both early attachment experiences and peer at-
tachment were predictive of later depressive
symptomatology.
Object Relations Theory and As mentioned earlier, there is a close, and
Personality Organization possibly overlapping, relationship between the
constructs involved in attachment theory and
Object relations theory represents the dominant object relations theory. In investigating quality
post-Freudian psychodynamic approach. Begin- of object relations and attachment as predictors
ning with the work of Melanie Klein (1952/1989), of the therapeutic alliance, G. Goldman and
and then greatly expanded upon by D. W. Winni- Anderson (2007) found a strong relationship
cott (Winnicott & Sutherland, 1952/1987), Hienz between these constructs. They also found cor-
Kohut (1972), and Otto Kernberg (1984), among relations between scores on the Working Alli-
others, object relations theory has also had a close ance Inventory, a measure of working, and the
relationship to attachment theory. As mentioned in Revised Adult Attachment Scale, with correla-
the previous discussion of attachment theory, it tions of .39, .30, and .19 for Sessions 1, 2, and
was John Bowlby (1958), an object-relations ori- 3, respectively. Significant correlations were
ented psychoanalyst, who was the first to speak of also found between working alliance scores and
attachment as its own domain of psychological several domains of the Bell Object Relations
phenomenon. Although modern object relations Inventory (BORTI), particularly the Insecure
theory has several iterations, depending on the Attachment scale of the BORTI being nega-
theoretical treatment of the “object,” “self,” and tively associated with WAS scores (r ⫽ ⫺.28),
relational dyads, there is nonetheless a core set of and the Alienation scale of the BORTI also
unifying assumptions. being negatively associated with WAS scores
Object relations theory is based on the prem- (r ⫽ ⫺.37). It was found that strength in these
ise that humans, through an interacting combi- constructs (attachment and object relations) in
nation of genetic/temperamental factors and combination predicted early therapeutic alliance
early childhood experiences with primary care- formation, though quality of object relations
givers, operate according to unconscious rela- alone did not (G. Goldman & Anderson, 2007).
tional themes that are a function of dyadic re- Personality organization, as measured by the
lations between internalized representations of Inventory of Personality Organization (Lenzen-
self and others (Kernberg, 1984). This uncon- weger, Clarkin, Kernberg, & Foelsch, 2001), is
scious constellation includes primitive (good vs. a reflection of one’s object relational function-
bad) representations of the self and other, with ing, in that it gauges the integration of internal-
healthy personality development thought to re- ized representations of the self and other by
flect the successful integration of these primi- assessing defensive operations, identity diffu-
tive representations, which in turn allows for sion, and reality testing. It may be the case that
stable and integrated experiences of the self and successful integration of internalized objects,
others in real life (Clarkin, Lenzenweger, Yeo- and nonpathological relations between these in-
mans, Levy, & Kernberg, 2007). ternalizations, is reflective of, or related to, psy-
 8 SALANDE AND HAWKINS

chological flexibility. The proposed study at- defenses. As this is a nonclinical sample, the
tempts to identify and explore the relationship researchers did not expect that participants with
between psychological flexibility and the inter- seriously disorganized personalities (such as
nalized-relational flexibility of one’s experience those scoring in the severely borderline or psy-
of self and others. chotic ranges) would be included. We also pre-
dicted that secure attachment would be associ-
Personality Organization Measurement ated with higher psychological flexibility, with
psychological flexibility manifesting a negative
The measurement of object relations has its association with both attachment anxiety and
roots in projective instruments, such as the Ror- attachment avoidance.
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schach and Thematic Apperception Test. How-

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ever, beginning with the Bell Object Relations Method

and Reality Testing Inventory, there have been
some quite successful efforts at measuring ob- In this correlational study, scale scores on the
ject relations through self-report instruments. AAQ-II, IPO, and ECR-R were analyzed for
For the purposes of the present study, we limit effects indicating correlations between the the-
our interest to the Inventory of Personality Or- oretically distinct, though functionally overlap-
ganization (IPO), a 38-item self-report measure ping, constructs of psychological flexibility,
of personality structure and organization (Len- personality organization, and attachment style.
zenweger et al., 2001). An online survey, containing the informed con-
The IPO assesses three separate scales re- sent form, demographic questions, and the three
flecting (a) reality testing, (b) primitive psycho- assessment instruments, was completed by each
logical defenses, and (c) identity diffusion. All participant. Participants were recruited through
three scales demonstrated adequate internal social networking.
consistency and good test-retest reliability in
predicting “increased negative affect, aggres- Participants
sive dyscontrol, and dysphoria as well as lower
levels of positive affect” (Lenzenweger et al., Fifty-five participants were recruited online
2001, p. 577). These three scales were found to via social networking and directed to a survey
support a two-factor model of the IPO (Reality website. The sample was Caucasian. This cul-
Testing vs. Primitive Defensive Operations/ tural homogeneity was not planned for, but
Identity Diffusion). The present study is partic- rather was incidental to the data collection.
ularly interested in the Primitive Defenses and Other demographic features (education, marital
Identity Diffusion scales. We hypothesized that status, etc.) were not measured in this study.
psychological flexibility would be negatively
correlated with identity diffusion and primitive Measures/Instrumentation
defenses. AAQ-II. The AAQ-II is a common instru-
ment for the measurement of psychological
The Current Study flexibility. The AAQ was originally developed
as a 32-item self-report measure of experiential
Each of the relevant constructs so far dis- avoidance; 16- and nine-item scales were sub-
cussed is well developed and supported by ideas sequently developed, all showing a very good fit
in theoretical isolation. However, in the interest to the theoretical ACT model as well as ade-
theoretical integration there is a need for efforts quate internal consistency, criterion-related,
to explore these constructs as they relate to one predictive, and convergent validity (Hayes et
another. What is the relationship among psy- al., 2004, 2006). This instrument was moder-
chological flexibility, attachment style, and the ately to highly correlated with measures of gen-
quality of object relations? We theorize that eral psychopathology at a significant level
high psychological flexibility as a cognitive fac- (Hayes et al., 2004). The AAQ’s test–retest
tor will be associated with a well-organized, reliability was .64. The findings of Hayes et al.
nonborderline personality organization, or that (2004) in this investigation of the AAQ sup-
psychological flexibility will be negatively as- ported a one-factor model of experiential avoid-
sociated with identity diffusion and primitive ance. Experiential avoidance represents the the-
 FLEXIBILITY, ATTACHMENT STYLE, AND PERSONALITY 9

oretical inverse of psychological flexibility, our contexts. This instrument, the Relationship
variable of interest; as such, the AAQ is essen- Structures Questionnaire of the ECR–R, was
tially a measure of psychological flexibility found to be a valid and reliable measure of
(Hayes et al., 2006). attachment in a sample of 21,000 participants
The AAQ-II (Bond et al., 2011) was devel- (Fraley et al., 2000). We hypothesized that psy-
oped as shorter, revised measure of experimen- chological flexibility would be negatively cor-
tal avoidance and psychological flexibility. related both with attachment anxiety and attach-
Bond et al. (2011) report a mean alpha coeffi- ment avoidance.
cient of .84 for the AAQ-II. The test–retest The present study utilized the ECR-R (Fraley
reliability of the AAQ-II was .81 at 3 months et al., 2000) because of its psychometric prop-
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and .79 at 12 months. According to Bond et al., erties, as well as its brevity, ease of administra-
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“The AAQ-II also demonstrates appropriate tion and scoring, and highly accessible format.
discriminant validity. The AAQ-II appears to This measure assesses one’s experience in the
measure the same concept as the AAQ-I (r ⫽ contexts of close relationships. The ECR-R, like
.97) but with better psychometric consistency” its predecessors, accesses a two-factor solution
(p. 676). of attachment processes: Anxiety and Avoid-
IPO. Though there are several measures ance (Fraley et al., 2000). These two factors
that have been designed for the assessment of accounted for 69% of variability across rela-
psychodynamic formulations of personality or- tional domains and displayed high reliability
ganization, many involve significant invest- (.85 for anxiety and .88 for avoidance; Fraley et
ments in terms of expertise and training in their al., 2000). Its brevity and the ease in adminis-
administration, scoring, and interpretation. The tration and scoring of the ECR-R are assets that
IPO represents a sensible selection for the pres- set it apart from other popular measures of
ent research for several reasons. The IPO is both attachment, and made it ideal for the present
brief and a self-report measure, which sets it study.
apart from other methods of assessment that
access similar constructs. The IPO enjoys good Procedures
reliability and validity in differentiating levels
of personality organization (Lenzenweger et al., After completing an informed consent page
2001). and answering demographic questions, each
The two-factor structure of the IPO (primitive participant completed the AAQ-II, IPO, and
psychological defenses and identity diffusion) ECR-R. Upon completion of the questionnaires,
is consistent with Kernberg’s (1984) model of the participants were given the e-mail address of
personality structure. Of particular relevance to the researcher, in case they subsequently had
this project are the Defenses scale and Identity questions or concerns. Scores on all measures
Diffusion scale. This instrument has good psy- were analyzed for correlations with SPSS Ver-
chometric properties in both clinical and non- sion 22 software.
clinical samples (Lenzenweger et al., 2001).
The only appreciable limitation of this instru- Results
ment is that it has yet to be studied in terms of
its scales’ long-term stabilities. Because of its Nineteen cases were deleted because of in-
empirical support, brevity, and ease of admin- complete data. Spearman’s rho was selected as
istration and scoring, and overall accessibility, the correlation statistic because of its suitability
it was the most appropriate instrument for as- for correlational analysis of non-normally dis-
sessing personality organization in the current tributed data (Field, 2009). The hypotheses
context. were generally supported through Spearman’s
ECR-R. An item response theory analysis rho correlational analysis (see Table 1). There
conducted by Fraley et al. (2000), which led to was a significant negative correlation found be-
the ECR-R, indicated that the “ECR scales had tween psychological flexibility, as measured by
the best psychometric properties” (p. 362) of the the AAQ-II and the IPO variable of primitive
attachment instruments investigated. The pro- defenses, r ⫽ ⫺.46, p ⬍ .001. There was an
posed study used an alternative to the ECR-R, even more robust significant negative correla-
which measures attachment across relational tion found between AAQ-II psychological flex-
 10 SALANDE AND HAWKINS

Table 1
Spearman ␳ Correlations Between the AAQ-II, IPO, and ECR-R
Psychological Primitive Identity Attachment Attachment
Measured Constructs Flexibility Defenses Diffusion Anxiety Avoidance
Psychological Flexibility 1.00 ⫺.458ⴱⴱ ⫺.585ⴱⴱ ⫺.385ⴱ ⫺.163
Primitive Defenses ⫺.458ⴱⴱ 1.000 .784ⴱⴱ .444ⴱ .387ⴱ
Identity Diffusion ⫺.585ⴱⴱ .784ⴱⴱ 1.000 .437ⴱ .381ⴱ
Attachment Anxiety ⫺.385ⴱ .444ⴱ .437ⴱ 1.000 .629ⴱⴱ
Attachment Avoidance ⫺.163 .387ⴱ .381ⴱ .629ⴱⴱ 1.000
Note. Psychological Flexibility ⫽ Acceptance and Action Questionnaire—II; Primitive Defenses ⫽ Inventory of Person-
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ality Organization; Identity Diffusion ⫽ Inventory of Personality Organization; Attachment Anxiety ⫽ Experiences in
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Close Relationships—Revised; Attachment Avoidance ⫽ Experiences in Close Relationships—Revised.

ⴱ
p ⬍ .01. ⴱⴱ p ⬍ .001.

ibility and IPO identity diffusion scores, r ⫽ aimed at increasing psychological flexibility
⫺.59, p ⬍ .001. There was also a significant within the context of interpersonal patterns and
relationship between AAQ-II scores and attach- relational dynamics.
ment anxiety, r ⫽ ⫺.38, p ⬍ .01. In contradic- The results of this research might serve to
tion to we hypotheses, there was no significant guide ACT-oriented clinicians in their therapeu-
relationship between AAQ-II scores and attach- tic assessment and treatment planning, in that it
ment avoidance, r ⫽ ⫺.16, p ⫽ .235. appears that psychological inflexibility is asso-
Additionally there was a significant posi- ciated with an anxious attachment style, poorer
tive correlation between primitive defenses identity integration, and more primitive de-
and attachment anxiety, r ⫽ .44, p ⬍ .01. The fensive operations. Although assessing these
positive relationship between attachment constructs as informing case formulation and
avoidance and primitive defenses was also treatment is not typical of an ACT approach,
significant, r ⫽ .39, p ⬍ .01 (one-tailed). we propose that there is value to integrating
Identity diffusion was significantly positively these interpersonal and intrapersonal con-
correlated with attachment anxiety, r ⫽ .44, structs into ACT and other mindfulness-based
p ⬍ .01. Identity diffusion was also signifi- models of treatment. Psychological flexibility
cantly positively associated with attachment does not exist in isolation of our attachment
avoidance, r ⫽ .38, p ⬍ .01.
orientation, so it makes sense to consider their
interactive in vivo effects (e.g., one’s psycho-
Discussion logical flexibility in relational contexts) in
These results support our hypotheses that conceptualizing a case from a theoretically
psychological flexibility would be negatively integrative approach.
associated with primitive defenses and identity Similarly, the results of this research may be
diffusion, as well as negatively associated with of interest to relational, attachment-oriented,
attachment anxiety. Although we expected that and psychodynamic clinicians interested in the-
attachment avoidance would also be signifi- oretical integration involving ACT or other
cantly associated with psychological flexibility, mindfulness approaches. Again, a clinician op-
this hypothesized relationship did not attain sta- erating from a traditional psychodynamic or
tistical significance. We also discovered other relational approach is not typically interested in
significant relationships, with attachment anxi- assessing mindfulness as part of their overall
ety being positively associated with both iden- case formulation. However, psychodynamic
tity diffusion and primitive defenses. It appears and attachment-oriented clinicians interested in
that the construct of psychological flexibility is theoretical integration involving mindfulness,
related to the constructs of attachment anxiety, acceptance, and so forth may benefit from this
identity diffusion, and primitive defenses. This and further research examining the relationships
could have implications for integrationist clini- between personality organization, attachment
cians, for example, in the use of interventions style, and mindfulness.
 FLEXIBILITY, ATTACHMENT STYLE, AND PERSONALITY 11

Implications flexibility, mindfulness, and other key ACT el-

ements.
As the art and science of psychotherapy con- The study described here is a beginning effort
tinues to develop, the interest in theoretical inte- in the task of exploring how the tools of ACT
gration appears to continue as well. We propose can be applied to a psychodynamic treatment in
that the integration of cognitive– behavioral and which attachment is a key consideration. Al-
psychodynamic conceptualizations and practices though an effort to describe strategies and in-
represents a fundamental integrationist paradigm. terventions that achieve this integration is be-
In particular, we argue that ACT theoretical prin- yond the scope of this article, it is hoped that the
ciples and techniques can be integrated into a data gathered here will shed some light on the
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psychodynamic or relational psychotherapy with theoretical ground that we share, as well as

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relative ease and to great benefit to the client. This encouraging future research on the integration
integration would ideally occur at both a technical of ACT with psychodynamic psychotherapy.
and a theoretical level. As Gaete and Gaete (2015) Strategically sound and technically profi-
point out, much technical integration and eclectic cient integration of psychotherapeutic princi-
assimilation occur in practice without a sufficient ples from differing schools of thought can
theoretical application of the supposedly inte- only be achieved with a thorough knowledge
grated perspectives. base and skill set in each respective approach
To be sure, much work is to be done as it to be integrated. Owen (2009) describes one
relates to successfully theoretically integrating such model with the “Intentionality model,”
ACT with psychodynamic psychotherapy, and which proposes an integration of cognitive–
we hope that the current work modestly contrib- behavioral and psychodynamic interventions
utes to that end. Gaete and Gaete (2015) offered based on the shared ubiquitous themes of
three criteria for adequate theoretical integra- emotion rationality, shared social mores, and
tion: (a) conceptual conservation, by which the behavior. The integration of techniques that
key theoretical tenants of the integrated per- facilitate change of internationalities across
spectives are carefully preserved; (b) coherence, domains of psychological and behavioral
in that the integrating theories are not contra- experience is thus linked to strategies and
dictory; and (c) validity, in that each of the tactics that come from differing theoretical
integrated theories and associated techniques domains. Owen’s model encourages the utili-
are validly formulated and applied according to zation of empirically supported techniques for
the state of knowledge of such theories and the treatment of mood and anxiety issues,
techniques. We think that ACT and the psy- while reserving a space in therapeutic milieu
chodynamic perspective are able to be inte- for an exploration of the therapeutic relation-
grated, in part, because Gaete and Gaete’s con- ship, attachment processes, patterns of related-
ditions are thought to be attainable in such ness, and the gaining of deeper understanding of
integration. It is possible to integrate an ACT the self and other. Owen’s intentionality
formulation into an overall psychodynamic for- model represents a movement toward the
mulation without necessarily violating the key skillful integration of seemingly opposing
theoretical assumptions of either. This integra- schools of thought.
tion of ACT and psychodynamics is achievable Stricker (2013) describes the successful in-
with an intact theoretical and pragmatic coher- tegration of cognitive and psychodynamic
ence. In addition, the interventions of each ap- perspectives in a four-part model consisting
proach, when carefully carried out by trained of an exploration of the multiple selves, ther-
professionals, have demonstrated validity in apeutic rupture and repair, corrective emo-
isolation. tional experience, and utilization of home-
Although others have recommended the inte- work. Incidentally, Stricker (2006) had
gration of psychodynamic and CBT techniques, previously discussed the utility of homework
we are unaware of efforts to integrate ACT (typically associated with cognitive and CBT
practices into a psychodynamic approach, or treatments) in psychodynamic psychotherapy.
vice versa. Similarly, there seems to be a pau- In this model, which Stricker (2013) eluci-
city of literature concerning the relationship be- dates in a case he presents, there is technical
tween attachment security and psychological integration in terms of clinical intervention,
 12 SALANDE AND HAWKINS

whereas the overall organizing theoretical quite well, is found in schema therapy
perspective is psychodynamic. (Young, 1999). Schema therapy, although
Stricker (2013) emphasizes the role of the mostly similar to CBT in orientation, incor-
therapeutic relationship as a predictor of treat- porates attachment theory, Gestalt psychol-
ment outcome, using it to ground his integra- ogy, object relations and other psychoanalytic
tion. The present authors would concur with the traditions, and constructivist psychology
position that a good theoretical or technical (Young, Klosko, & Weishaar, 2003) in the
integration would consider the therapeutic rela- treatment of characterological, as well as
tionship integral to success. We propose that the mood and anxiety, issues.
integration of ACT techniques may serve a pos- The cultivation of mindfulness and the devel-
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itive influence in the development of a good opment of psychological flexibility, and other
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working alliance. Research by R. E. Goldman, key components of ACT, share something spe-
Hilsenroth, Owen, and Gold (2013) suggests cial with the psychodynamic approach. The
that the integration of CBT interventions do psychodynamic therapist seeks to improve
no disrupt the therapeutic relationship, which healthy relatedness and facilitate the develop-
is so integral to relational and psychodynamic ment of healthy defensive operations. The ACT
treatments. Goldman et al. (2013) examined therapist seeks to improve the client’s mindful-
the integration of CBT techniques into psy- ness and contact with the present moment as
chodynamic treatment and found that the in- well as seeking to help the client avoid experi-
tegration of CBT techniques, such as offering ential avoidance. In both approaches, the ther-
clients specific information regarding symp- apist is not trying to restructure what the client
toms and rational for treatment, contributed thinks or feels, but rather how the client expe-
positively to positive dimensions of the ther- riences internal events, as well as how the client
apeutic alliance.
experiences others and the social context around
Kholmogorova and Garanian (1997) pointed
them.
to the movement in behaviorism toward recog-
What the integration of ACT and psychody-
nizing the role of internal behavior. Similarly,
namics would look like would really depend on
the cognitive tradition has relied on theories of
the education and training of the clinician; how-
automatic information processing and stable
cognitive schemata. These intellectual trends ever, several methods of integration appear vi-
illustrate, at the very least, some theoretical able. The creative and useful tools of ACT can
common ground between these approaches and be used to address symptoms that require im-
psychoanalysis—the common ground being an mediate attention, and psychodynamic inter-
implicit interest in the internal and noncon- ventions can be used in the long term to help
scious determinants of behavior (Kholmogo- the client improve in a characterological
rova & Garanian, 1997). sense. Alternatively, the approach of ACT
Kholmogorova and Garanian (1997) go on to (particularly of mindfulness and acceptance)
present and integrative model in which cogni- can be a key to helping clients explore, un-
tive therapy processes are utilized the first stage derstand, and change maladaptive relational
of treatment, which addresses immediate behav- patterns that plague their lives—a mode of
ior and prepares the client for more intensive integration that is more theoretical than tech-
dynamic work by improving their self-under- nical. Yet another iteration of this integration
standing of internal psychological factors. Es- would be the use of psychodynamic principles
sential to this model is the structured approach strictly as a theoretical backdrop to help the
to addressing behavior and symptoms with cog- therapist understand clients in their full in-
nitive interventions, which also lays the psycho- trapersonal and interpersonal context, while
logical groundwork for deep exploratory and adhering largely to the ACT model proper.
relational work, all with the final goal of the Yet another iteration of the integration would
creation of new behavioral repertoires (Kholm- be represented in a therapist using psychody-
ogorova & Garanian, 1997). namic interventions (such as interpretation of
A good example of an integrated treatment, transference) sparingly and only when in the
one which integrates multiple approaches service of overall ACT intervention approach.
 FLEXIBILITY, ATTACHMENT STYLE, AND PERSONALITY 13

Limitations interventions. Further research could investigate

the effects of mindful-based interventions on
There are several limitations of this study. personality organization and attachment orien-
These include the small sample size as well as tation.
not including a clinical population. Logistical
restrictions limited our data collection, resulting Conclusion
in a rather modest sample size. The sample size
was of sufficient size so as to achieve acceptable Psychological flexibility, and its inverse con-
statistical power, but further study with larger struct— experiential avoidance, have previ-
populations is needed. Furthermore, this would ously demonstrated associations with mea-
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allow for analysis of gender differences, age sures of mental health, functioning, and so
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differences, and so forth. A number of statistical forth. The results of this study extend the
and methodological limitations exist in this body of research supporting psychological
project that should also be considered. These flexibility as a relevant psychological con-
include the lack of counterbalancing of mea- struct. For psychotherapists integrating inter-
sures to control for order effects, reliance on personal and psychodynamic modalities with
self-report measures without the support of ACT, these results might help to clarify the
other criterion variables, as well as the possibil- relationships between personality organiza-
ity of common method variance inflating corre- tion, attachment, and psychological flexibil-
lations. The original intent of this research was ity. Often, clients present with complicated
to provide a basic pilot study on the associations personal histories, current circumstances, in-
between psychological flexibility, personality terpersonal patterns, and symptomatic com-
organization, and attachment style, with the plaints. We think that it would be useful for
hope that its findings would give some indica- integrationist psychotherapists to be aware of
tion of the potential for this line of research. The the relationships that exist between the theo-
results of the present study merit a replication retically distinct constructs of personality or-
with a larger sample size and more sophisticated ganization, attachment, and psychological
methodology. flexibility.
This study utilized a self-report question-
naire, the IPO, to assess the constructs of iden-
tity integration and defenses. These constructs, References
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