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Luyten P, Campbell C, Moser M, Fonagy P. The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research. Clin Psychol Rev 2024; 108:102380. [PMID: 38262188 DOI: 10.1016/j.cpr.2024.102380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 12/20/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024]
Abstract
Mentalizing is the human capacity to understand actions of others and one's own behavior in terms of intentional mental states, such as feelings, wishes, goals and desires. Mentalizing is a transtheoretical and transdiagnostic concept that has been applied to understanding vulnerability to psychopathology and has attracted considerable research attention over the past decades. This paper reports on a pre-registered systematic review of evidence concerning the role of mentalizing as a moderator and mediator in psychological interventions in adults. Studies in adults were reviewed that address the following questions: (a) does pre-treatment mentalizing predict treatment outcome; (b) do changes in mentalizing across treatment predict outcome; (c) does adherence to the principles or protocol of mentalization-based treatment predict outcome; and (d) does strengthening in-session mentalizing impact the therapeutic process via improved alliance, alleviated symptoms, or improved interpersonal functioning? Results suggest that mentalizing might be a mediator of change in psychotherapy and may moderate treatment outcome. However, the relatively small number of studies (n = 33 papers based on 29 studies, totaling 3124 participants) that could be included in this review, and the heterogeneity of studies in terms of design, measures used, disorders included, and treatment modalities, precluded a formal meta-analysis and limited the ability to draw strong conclusions. Therefore, theoretical and methodological recommendations for future research to improve the quality of existing research in this area are formulated.
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Affiliation(s)
- Patrick Luyten
- Faculty of Psychology and Educational Sciences, KU Leuven, Tiensestraat 102, Pobox 3722, Leuven 3000, Belgium; Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK.
| | - Chloe Campbell
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
| | - Max Moser
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
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Keefe JR, Louka C, Moreno A, Spellun J, Zonana J, Milrod BL. Open Trial of Trauma-Focused Psychodynamic Psychotherapy for Posttraumatic Stress Disorder Among LGBTQ Individuals. Am J Psychother 2023; 76:115-123. [PMID: 37203147 DOI: 10.1176/appi.psychotherapy.20220037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals report higher rates of exposure to traumatic events and posttraumatic stress disorder (PTSD) compared with heterosexual and cisgender individuals. No treatment outcomes research has focused on PTSD in the LGBTQ population. Trauma-focused psychodynamic psychotherapy (TFPP) is a brief, manualized, attachment- and affect-focused psychotherapy for PTSD. TFPP explicitly incorporates broad identity-related and societal factors into its conceptualization of trauma and its consequences, which may be especially helpful for LGBTQ patients with minority stress who seek affirmative care. METHODS Fourteen LGBTQ patients with PTSD, assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), received 24 sessions of twice-weekly (12 weeks) TFPP via teletherapy provided by supervised early-career therapists inexperienced in the modality. Sessions were videotaped to monitor therapists' treatment adherence. Patients were assessed at baseline, week 5, termination (week 12), and 3 months posttreatment for PTSD symptoms (assessed with the CAPS-5) and secondary outcomes. RESULTS TFPP was well tolerated by patients, with 12 (86%) completing the intervention. CAPS-5-measured PTSD symptoms, including dissociation, significantly improved during treatment (mean decrease=-21.8, d=-1.98), and treatment gains were maintained at follow-up. Most patients experienced PTSD clinical response (N=10, 71%) or diagnostic remission (N=7, 50%). Patients generally experienced significant, concomitant improvements in complex PTSD symptoms, general anxiety, depression, and psychosocial functioning. Adherence to the intervention among therapists was high, with 93% of rated sessions meeting adherence standards. CONCLUSIONS TFPP shows promise in the treatment of PTSD among sexual and gender minority patients seeking LGBTQ-affirmative PTSD care.
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Affiliation(s)
- John R Keefe
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe, Milrod); Department of Psychiatry, Weill Cornell Medical College, New York City (Keefe, Moreno, Spellun, Zonana, Milrod); Department of Psychiatry, New York-Presbyterian/Weill Cornell Medical Center, New York City (Louka); Silver Hill Hospital, New Canaan, Connecticut (Zonana)
| | - Charalambia Louka
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe, Milrod); Department of Psychiatry, Weill Cornell Medical College, New York City (Keefe, Moreno, Spellun, Zonana, Milrod); Department of Psychiatry, New York-Presbyterian/Weill Cornell Medical Center, New York City (Louka); Silver Hill Hospital, New Canaan, Connecticut (Zonana)
| | - Andrew Moreno
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe, Milrod); Department of Psychiatry, Weill Cornell Medical College, New York City (Keefe, Moreno, Spellun, Zonana, Milrod); Department of Psychiatry, New York-Presbyterian/Weill Cornell Medical Center, New York City (Louka); Silver Hill Hospital, New Canaan, Connecticut (Zonana)
| | - Jessica Spellun
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe, Milrod); Department of Psychiatry, Weill Cornell Medical College, New York City (Keefe, Moreno, Spellun, Zonana, Milrod); Department of Psychiatry, New York-Presbyterian/Weill Cornell Medical Center, New York City (Louka); Silver Hill Hospital, New Canaan, Connecticut (Zonana)
| | - Jess Zonana
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe, Milrod); Department of Psychiatry, Weill Cornell Medical College, New York City (Keefe, Moreno, Spellun, Zonana, Milrod); Department of Psychiatry, New York-Presbyterian/Weill Cornell Medical Center, New York City (Louka); Silver Hill Hospital, New Canaan, Connecticut (Zonana)
| | - Barbara L Milrod
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York City (Keefe, Milrod); Department of Psychiatry, Weill Cornell Medical College, New York City (Keefe, Moreno, Spellun, Zonana, Milrod); Department of Psychiatry, New York-Presbyterian/Weill Cornell Medical Center, New York City (Louka); Silver Hill Hospital, New Canaan, Connecticut (Zonana)
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Antichi L, Giannini M, Loscalzo Y. Interpretation in psychodynamic psychotherapy: A systematic review. PSYCHODYNAMIC PRACTICE 2022. [DOI: 10.1080/14753634.2022.2046140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Lorenzo Antichi
- Department of Health Sciences (DSS), University of Florence, Florence, Italy
| | - Marco Giannini
- Department of Health Sciences (DSS), University of Florence, Florence, Italy
| | - Yura Loscalzo
- Department of Health Sciences (DSS), University of Florence, Florence, Italy
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Ohse L, Burian R, Hahn E, Burian H, Ta TMT, Diefenbacher A, Böge K. Process-outcome associations in an interdisciplinary treatment for chronic pain and comorbid mental disorders based on Acceptance and Commitment Therapy. PAIN MEDICINE 2021; 22:2615-2626. [PMID: 33755159 DOI: 10.1093/pm/pnab102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Numerous studies support the effectiveness of Acceptance and Commitment Therapy (ACT) for chronic pain, yet little research has been conducted about its underlying mechanisms of change, especially regarding patients with comorbid mental disorders. The present investigation addressed this issue by examining associations of processes targeted by ACT (pain acceptance, mindfulness, psychological flexibility) and clinical outcomes (pain intensity, somatic symptoms, physical health, mental health, depression, general anxiety). SUBJECTS Participants were 109 patients who attended an ACT-based interdisciplinary treatment program for chronic pain and comorbid mental disorders in a routine care psychiatric day hospital. METHODS Pre- to post-treatment differences in processes and outcomes were examined with Wilcoxon signed-rank tests and effect size r. Associations between changes in processes and changes in outcomes were analyzed with correlation and multiple regression analyses. RESULTS Pre- to post-treatment effect sizes were mostly moderate to large (r between |0.21| and |0.62|). Associations between changes in processes and changes in outcomes were moderate to large for both, bivariate correlations (r between |0.30| and |0.54|) and shared variances accounting for all three processes combined (R2 between 0.21 and 0.29). CONCLUSION The present investigation suggests that changes in pain acceptance, mindfulness and psychological flexibility are meaningfully associated with changes in clinical outcomes. It provides evidence on particular process-outcome associations that had not been investigated in this way before. The focus on comorbid mental disorders informs clinicians about a population of chronic pain patients that often has a severe course of illness and has seldom been studied.
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Affiliation(s)
- Ludwig Ohse
- Department of Psychiatry, Psychotherapy and Psychosomatics, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstraße 79, 10365, Berlin, Germany.,Psychologische Hochschule Berlin, Am Köllnischen Park 2, 10179, Berlin, Germany
| | - Ronald Burian
- Department of Psychiatry, Psychotherapy and Psychosomatics, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstraße 79, 10365, Berlin, Germany
| | - Eric Hahn
- Department of Psychiatry, Psychotherapy and Psychosomatics, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstraße 79, 10365, Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Hannah Burian
- Department of Psychiatry, Psychotherapy and Psychosomatics, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstraße 79, 10365, Berlin, Germany
| | - Thi Minh Tam Ta
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Albert Diefenbacher
- Department of Psychiatry, Psychotherapy and Psychosomatics, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Herzbergstraße 79, 10365, Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Kerem Böge
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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Contemporary Psychodynamic Approaches to Treating Anxiety: Theory, Research, and Practice. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1191:451-464. [PMID: 32002941 DOI: 10.1007/978-981-32-9705-0_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Psychodynamic theory is founded on the idea that much, if not most, of human behavior is influenced by forces and experiences that lie outside of conscious awareness. It posits that despite what we may or may not recognize about our lived experience, an essential connection exists between unconscious processes and everyday psychological functioning. By extension, psychodynamic theory presumes that unconscious conflicts are pathognomonic of anxiety disorders and anxiety symptoms more generally. At the same time, the term "psychodynamic" refers not only to that which occurs within one's mind but also what happens between people and within families, groups, and systems. A comprehensive psychodynamic treatment of anxiety attempts to take into account these multiple domains of experience and functioning (including biological and genetic considerations) and applies a specific therapeutic approach to working with patients based in part on clinical techniques first developed by Sigmund Freud 100 years ago.
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Keefe JR, Huque ZM, DeRubeis RJ, Barber JP, Milrod BL, Chambless DL. In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy. Psychotherapy (Chic) 2019; 56:514-525. [PMID: 30869969 DOI: 10.1037/pst0000215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In panic-focused psychodynamic psychotherapy (PFPP), exploration and interpretation of avoided and conflicted emotions and fantasies surrounding anxiety are thought to promote panic-specific reflective functioning (PSRF), which drives panic disorder improvements. Patient emotional expression within a session may be a marker of engaged processing and experiencing of affectively charged material. Degree of in-session expressed emotion, indicating both verbal and nonverbal emotions, was examined across three early therapy sessions for prediction of subsequent outcomes. We further investigated whether personality disorder traits, theorized to relate to constricted (obsessive-compulsive) or heightened (borderline) emotions, moderated this relationship. Emotional expression in Sessions 2, 5, and 10 of a 24-session PFPP protocol was assessed by blinded observers in 44 patients randomized to PFPP in a two-site randomized controlled trial of psychotherapies for panic disorder. Robust regressions were conducted to examine the relationship between average emotional expression across the measured sessions and symptom and PSRF changes subsequent to the sampled sessions, as well as moderation by personality disorder criteria, controlling for early outcomes. Higher levels of emotional expression across the early sessions predicted greater subsequent symptom and PSRF improvement. Elevations in expression of grief/sadness drove the symptomatic finding. Patients meeting more borderline criteria experienced a smaller and potentially negative relationship between emotional expression and symptom improvement. Emotional expression in PFPP may be an indicator of positive therapy process for patients without comorbid borderline personality traits, predicting prospective improvements in both a key mediator (PSRF) and symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Reich J, Schatzberg A, Delucchi K. Empirical evidence of the effect of personality pathology on the outcome of panic disorder. J Psychiatr Res 2018; 107:42-47. [PMID: 30316085 DOI: 10.1016/j.jpsychires.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/01/2018] [Accepted: 10/04/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment resistant disorders are a significant clinical problem. Impediments to good outcome need to be identified and addressed. Personality pathology has been hypothesized to be one such factor in panic disorder. There is no consensus as to the effects of personality pathology on the outcome of panic disorder. This study examined empirical evidence. The hypothesis was that personality pathology would cause poorer outcome of panic disorder. METHODS A literature search was conducted that winnowed 2627 articles down to 27 based on 1) longitudinal design; 2) validated measures of personality; 3) validated outcome measures; and 4) the presence of effect size or data to calculate effect size. All effect sizes were translated into odds ratios (ORs) for ease of comparison. RESULTS An overall median OR of 2.7 was found, indicating personality pathology negatively affected outcome. This finding persisted even when adjusted for baseline severity of illness. The effects were found for both clinical outcomes (OR = 2.7) and for social adjustment (OR = 2.9). There was a tendency for more dropouts in the personality pathology group. More highly structured drug therapy regimens and highly structured psychotherapy seemed to partially mitigate this outcome. CONCLUSION The negative effect of personality pathology was confirmed in well-designed longitudinal studies. This was not related to initial clinical severity. Clinical implications are that patients with personality pathology require the therapist to stick more closely to treatment protocols and to mitigate the tendency of these patients to drop out of treatment.
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Affiliation(s)
- James Reich
- Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA; Department of Psychiatry & Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Alan Schatzberg
- Department of Psychiatry & Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Kevin Delucchi
- Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA
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