Socially isolated, but not lonely in lockdown: Exploring the role of reflective functioning as a protective factor in the early days of the COVID-19 pandemic in Germany

INTRODUCTION

Loneliness is a pressing public mental health issue. So far, there has been a paucity of investigations focused on the individual differences modulating this subjective feeling in the face of difficult circumstances, e.g., the COVID-19 pandemic. As such, the present study aimed to investigate the role of mentalization; given that the construct comprises reflection abilities that might be particularly relevant to the pandemic's interpersonal challenges.

METHODS

A survey representative of the German population was conducted from May to June 2020 (N = 2503). We examined mentalization, operationalized as reflective functioning (RF) and measured using the Mentalization Questionnaire (MZQ), both as a protective factor against loneliness on its own and as a moderator of the association of social isolation with loneliness.

RESULTS

Of the overall sample, 822 (32.8 %) individuals reported social isolation. Worse RF was moderately associated with higher levels of loneliness (r = 0.433, p < .001). A linear regression model (controlling for sociodemographic characteristics and general personality pathology) confirmed this positive association, but also indicated an interaction effect of RF and social isolation in the statistical prediction of loneliness. Stratified models showed that RF was a comparatively weaker statistical predictor of loneliness among the socially isolated.

DISCUSSION

This representative population study expanded our knowledge about the factors shaping loneliness in the population. RF emerged as a potentially modifiable protective influence. Further research needs to clarify the mechanisms through which it mitigates loneliness.

LIMITATIONS

The cross-sectional design does not give insight into the temporal association of RF and loneliness.

The use of mentalization-based techniques in online psychodynamic child psychotherapy

Objective: Psychodynamic child psychotherapy is an evidence-based approach for a range of child mental health difficulties and needs to constantly adapt to meet the needs of children. This study is the first to investigate whether the use of mentalization-based interventions (i.e., a focus on promoting attention control, emotion regulation, and explicit mentalization) predicted a good therapeutic outcome in online psychodynamic child therapy sessions conducted during the COVID-19 pandemic. Methods: The sample included 51 Turkish children (Mage = 7.43, 49% girls) with mixed emotional and behavioral problems. Independent raters coded 203 sessions from different phases in each child's treatment using the Mentalization-Based Treatment for Children Adherence Scale (MBT-CAS). Results: Multilevel modeling analyses showed children with higher emotional lability benefited more from attention control interventions compared to those with lower emotional lability. Discussion: Interventions that focus on developing the basic building blocks of mentalizing may be effective components of therapeutic action for online delivery of psychodynamic child psychotherapy, especially for children with greater emotional lability.

Threat, safety, safeness and social safeness 30 years on: Fundamental dimensions and distinctions for mental health and well-being

In 1993, the British Journal of Clinical Psychology published my paper titled 'Defence and safety: Their function in social behaviour and psychopathology'. The paper highlights that to understand people's sensitivity to threat, we also need to understand their ability to identify what is safe. This paper offers an update on these concepts, highlighting distinctions that were implicit but not clearly defined at the time. Hence, the paper seeks to clarify distinctions between: (i) threat detection and response, (ii) safety and safety seeking, (iii) safeness and (iv) their social and non-social functions and forms. Threat detection and response are to prevent or minimize harm (e.g., run from a predator or fire). Safety checking relates to monitoring for the absence and avoidance of threat, while safety seeking links to the destination of the defensive behaviour (e.g., running home). Safety seeking also relates to maintaining vigilance to the appearance of potential harms and doing things believed to avoid harm. Threat-defending and safety checking and seeking are regulated primarily through evolved threat processing systems that monitor the nature, presence, controllability and/or absence of threat (e.g., amygdala and sympathetic nervous system). Safeness uses different monitoring systems via different psychophysiological systems (e.g., prefrontal cortex, parasympathetic system) for the presence of internal and external resources that support threat-coping, risk-taking, resource exploration. Creating brain states that recruit safeness processing can impact how standard evidence-based therapies (e.g., exposure, distress tolerance and reappraisal) are experienced and produce long-term change.

Alternation of psychological resilience may moderate mentalization toward mental health related to macro- and micro-brain function

OBJECTIVE

We aim to investigate the interplay between mentalization, brain microstructure, and psychological resilience as potential protective factors against mental illness.

METHOD

Four hundred and twenty-six participants (mean age 40.12±16.95; 202 males, 224 females), without psychiatric or neurological history, completed assessments: Dissociative Process Scale (DPS), Peace of Mind (PoM), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Resilience Scale for Adults (RSA), and Magnetic Resonance Imaging (MRI) structures with selected region of interests, and Diffusion Tensor Imaging (DTI) maps from various tracts in the right hemisphere and connection to the frontal areas, including anterior thalamic radiation (ATR), Cingulum (hippocampus) (CH), Corticospinal tract (CST), Superior longitudinal fasciculus (SLF), Inferior fronto-occipital fasciculus (IFOF), and Uncinate fasciculus (UF) were analyzed.

RESULTS

Two clusters, representing hypomentalization (HypoM) and hypermentalization (HyperM), were identified based on DPS, CPSS, and RFQ responses. One-way ANOVA showed no significant age or gender differences between clusters. The HypoM group exhibited lower PoM scores, higher BDI and BAI scores, and lower RSA scores (ps< 0.05). Structural brain metric comparison showed significant differences in GMV in the right caudal middle frontal gyrus (rcMFG), right superior frontal gyrus (rsFG) and right frontal pole (rFP) between groups. In addition, the HyperM individuals with a higher risk of depression and a higher ratio of intrapersonal to interpersonal factors of resilience were found with reduced GMV on the rcMFG. Additionally, analyses of DTI metrics revealed significant differences between two groups in rATR and rSLF in terms of fractional anisotropy (FA) values; rATR, rCST, rUF, rSLF, rCH and rIFF in terms of mean diffusivity (MD) values; and rATR, rCH, rCST, and rUF in terms of radial diffusivity (RD) (corrected p = 0.05). Moreover, the positive correlation between different domains of resilience and white matter (WM) integrity implied further enhancement of intrapersonal or interpersonal resilience factors that are different for people with different mentalization.

CONCLUSIONS

The findings underscore the importance of considering both intrapersonal and interpersonal factors in understanding the interactions between psychological resilience and mental health conditions relevant to brain mechanisms.

Management of the therapeutic relationship in a patient with Complex PTSD and Personality Disorder

Individuals diagnosed with Complex PTSD (C-PTSD) have experienced repeated and often prolonged traumatic events. From a therapeutic perspective this can lead to difficulties in emotion regulation within-session, challenges with patient-therapist attunement, and impaired coregulation of emotions during therapeutic interactions. As a result, frequent therapeutic alliance ruptures can emerge, which in turn pose challenges for symptom-focused work. We describe a case study involving a 38-year-old woman presenting with C-PTSD, dissociation, anxiety and borderline and dependent personality disorder traits. We explore how difficulties in attunement and emotion regulation during therapy were mostly attributable to (i) maladaptive ideas regarding the self and others; and (ii) difficulties in recognizing both her own mental states and those of her therapist. For instance, the patient believed that the therapist was distant and critical; which she held to be fact rather than reflective of a mental state. We show how the therapist addressed these difficulties, incorporating repair of the therapeutic alliance, which enabled a return to symptom focused work. The case description offers guidance on how to maintain a dual focus on therapeutic alliance alongside symptoms when treating C-PTSD (with or without comorbidity).

Engagement strategies in an assertive outreach context: a mixed-methods systematic review

BACKGROUND

Assertive outreach (AO) is a systematic approach to engage vulnerable patients with serious mental illness.

AIMS

This review aims to provide a comprehensive analysis of engagement strategies in relation to principles of the AO model to clarify effective components of AO, better understand engagement in an AO context, and consider encompassing change mechanisms.

METHODS

A systematic mixed-methods review was completed from 1806 to December 2022 (no pre-registration). Articles meeting the inclusion criteria were rated for methodological quality using the JBI scales and thematic synthesis using a meta-aggregative approach. Reporting was according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

RESULTS

Eighteen articles met the inclusion criteria. The literature was defined by three main themes: definition and perspectives of engagement; key principles of AO in relation to engagement; and additional principles and strategies enhancing engagement.

CONCLUSION

Despite the heterogeneity in defining engagement, the relationship between AO professionals and patients emerged as crucial in the process of engagement. Subsequently, the four key principles of AO emerged as central to promoting engagement. Finally, we identified a number of additional principles that are considered crucial in the engagement process in AO. The review concludes with recommendations for future research and the implementation of AO in routine clinical care.

A Meta-Analysis of Interpersonal and Psychodynamic Psychotherapies for Posttraumatic Stress Disorder

OBJECTIVE

Established trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder (PTSD) have remission rates of approximately 30%-40%. Alternatively, interpersonal psychotherapy (IPT) and psychodynamic psychotherapy (PDT) focus on disrupted attachment, mentalization, and social connection in PTSD and may help some patients. The authors conducted a meta-analysis on these interpersonal and affect-oriented approaches to treating PTSD.

METHODS

Building on a prior meta-analysis, the authors searched for randomized controlled trials (RCTs) comparing IPT or PDT with other established PTSD treatments or control conditions for adults diagnosed as having PTSD. Random-effects meta-analyses were conducted to assess outcome effect sizes and dropout rates. RCTs were rated via the Randomized Controlled Trial Psychotherapy Quality Rating Scale.

RESULTS

Ten RCTs (eight of IPT) comparing IPT or PDT with control (k=7) or active treatment (k=4) conditions were identified, nine of which were of adequate quality. IPT (k=5) and PDT (k=2), when analyzed together, were superior to control conditions overall (g=-1.14, p=0.011 [as was IPT alone: g=-0.88, p=0.034]) and to waitlist (g=-1.49) and treatment-as-usual (g=-0.70) groups. Effect sizes, however, may have been inflated by outliers or publication bias. IPT (k=3) and PDT (k=1), when analyzed together, were equally efficacious compared with other active PTSD treatments (primarily exposure-based psychotherapies), as was IPT alone, and had lower dropout rates (relative risk=0.63, p=0.049 for IPT and PDT analyzed together; relative risk=0.61, p=0.098 for IPT alone).

CONCLUSIONS

Affect-focused therapies hold promise in the treatment of PTSD. IPT has demonstrated efficacy in multiple trials, whereas the evidence base for PDT is sparse.

Parental reflective functioning in mothers and fathers of preschoolers: Associations with adult attachment and parenting behavior

Parental reflective functioning (PRF) is considered a key parental competence. Since most research on PRF has focused on infancy or the first years of life, there is a gap in our understanding of PRF among parents of older children. Therefore, we investigated PRF in mothers and fathers with preschool-aged children, examining associations between PRF, parent's romantic attachment, and observed parenting behavior. The sample comprised 50 mothers, 40 fathers, and their 5-year-old children. PRF was assessed using the parental reflective functioning questionnaire (PRFQ), parental romantic attachment was assessed using the experiences in close relationships scale-revised (ECR-R), and parenting behavior was assessed during a parent-child free-play interaction with the coding interactive behavior (CIB) coding system. Results showed that mothers scored higher on the interest and curiosity scale than fathers, indicating that mothers show a more active interest and curiosity in their child's mental states. Further, higher levels of attachment anxiety in fathers were associated with higher levels of pre-mentalizing modes. In mothers, higher levels of attachment avoidance were associated with lower levels of interest and curiosity. Finally, and unexpectedly, higher levels of interest and curiosity in mothers were associated with less sensitivity during free play. In summary, the study found meaningful associations between mothers' and fathers' romantic attachment and their PRF indicating a spill-over of their attachment strategies into their relationship with their child. Further, the study results suggest that very high levels of interest and curiosity in mothers reflect hypermentalizing.

"I Do Not Know How You Feel and How I Feel About That": Mentalizing Impairments in Machado-Joseph Disease

Machado Joseph disease (MJD), also known as spinocerebellar ataxia type 3 (SCA3), is an autosomal dominant neurodegenerative disease. Mentalizing is the ability to think and understand the mental state of the other and of the self in terms of thoughts, feelings, and intentions. The aim of this study is to fill the gap in our understanding of mentalizing in MJD since there is currently very little and inconsistent research on MJD and mentalizing. A total of 18 Jews of Yemenite origin with clinically and genetically confirmed MJD, 5 pre-symptomatic MJD with a positive genetic test, and 17 Jews of Yemenite origin healthy controls, underwent a battery of tests consisting of reading the mind in the eyes (RME), Toronto Alexithymia Scale (TAS-20), and false belief test (FBt). The MJD group scored lower on the RME and FBt, and higher on TAS-20 test compared to control. A significant negative correlation was found between disease duration and RME score. All the pre-symptomatic participants scored within the normal clinical range in all tests. MJD patients demonstrated a widespread deficiency in the ability to mentalizing on a clinical level with autistic characteristics. These impairments may impact the patient's interpsychic experience and daily life interactions and have important clinical implication. Pre-symptomatic participants demonstrated normal mentalizing in all tests, suggesting that the mentalizing impairments do not precede the symptoms of ataxia and are part of the clinical picture of MJD.

Mothers with a history of trauma and their children: a systematic review of treatment interventions

Introduction

Mothers with a history of trauma frequently face significant challenges in their relationships with their children. Therefore, it is crucial for trauma-exposed mothers and their young children to receive adequate trauma-informed treatment. This review aimed to examine the effects of trauma-informed interventions on improving the mother-child relationship among mothers with a history of trauma and their young children under 6 years old.

Methods

The study analyzed 15 articles that met the eligibility criteria, encompassing a sample size of 1,321 mothers. The systematic GRADE approach was used to rate the certainty of evidence in this systematic review.

Results

The study found that while some interventions demonstrated small to large effects, the quality of evidence was only moderate. The most promising interventions were Parent-Child Interaction Therapy (PCIT), Child-Parent Psychotherapy (CPP), and Maternal Empowerment Program (MEP), which all included elements of psychotherapy, psychoeducation, and skills training.

Discussion

The study underscores the importance of understanding the needs of mother-child dyads affected by trauma and tailoring interventions to meet those needs. Overall, the literature suggests that interventions combining psychotherapeutic, psychoeducational, and skills-training components are most effective in improving mother and child-related outcomes for mothers with a history of trauma and their young children. The review provides recommendations for future research and emphasizes the importance of considering the mother-child relationship in trauma-informed interventions.

Mentalisation-based online intervention for psychologically distressed parents: protocol of a non-randomised feasibility trial of the Lighthouse Parenting Programme-Online (LPP-Online)

INTRODUCTION

Online-based interventions provide a low-threshold way to reach and support families. The mentalisation-based Lighthouse Parenting Programme is an established intervention aimed at preventing psychopathological development in children. The objective of this study is to examine the feasibility of an online adaptation of the Lighthouse Parenting Programme (LPP-Online), evaluating (a) recruitment capability, compliance, acceptability and satisfaction with the intervention; (b) the psychometric properties of and the acceptability regarding the adjunct psychological evaluation; and (c) the employed materials and resources. The study will also obtain a preliminary evaluation of participants' responses to the intervention.

METHOD AND ANALYSIS

In this monocentric, one-arm, non-randomised feasibility trial, n=30 psychologically distressed parents with children aged 0 to 14 years will participate in the LPP-Online for a duration of 8 weeks. The intervention consists of online group sessions and individual sessions, 38 smartphone-based ecological momentary interventions (EMI), and psychoeducational materials (website, booklet). At baseline (T0) and the end of the intervention (T1), parents complete self-report questionnaires as well as 7-day ecological momentary assessments (EMA) via smartphone. During the intervention, additional EMA are completed before and after the daily EMI. An interview regarding parents' subjective experience with the intervention will be conducted at T1. The feasibility of the intervention, the psychological evaluation and the resources will be examined using descriptive and qualitative analyses. The preliminary evaluation of the parents' response to the intervention will be conducted by analysing pre-post changes in questionnaire measures and the 7-day EMA as well as data of additional EMA completed before and after the daily EMI.

ETHICS AND DISSEMINATION

Ethical approval of the study has been obtained from the local ethics board (Faculty of Behavioural and Cultural Studies, University of Heidelberg). Consent to participate will be obtained before starting the assessments. Results will be disseminated as publications in peer-reviewed scientific journals and at international conferences.

REGISTRATION DETAILS

German Clinical Trials Register (DRKS00027423), OSF (https://doi.org/10.17605/OSF.IO/942YW).

Trauma-related symptoms in adolescents: the differential roles of sexual abuse and mentalizing

Introduction

Major gaps remain in our knowledge regarding childhood sexual abuse (CSA) related symptoms in adolescent psychiatric inpatients, as well as potential resilience factors like mentalizing. CSA is a risk factor for the early emergence of borderline personality features, posttraumatic stress, and sexual concerns. Mentalizing, which involves the capacity to understand our reactions and that of others in psychological terms, is a resilience factor for self and interpersonal functioning. The aim of this study was to address knowledge gaps by examining the contributions of CSA and mentalizing in a latent factor composed of borderline personality features, posttraumatic stress, and sexual concerns in a sample of adolescent psychiatric inpatients. We hypothesized that CSA and mentalizing would independently explain the variance in this latent factor.

Method

Participants were 273 adolescents aged 12-17 recruited from an adolescent inpatient psychiatric clinic. They completed the Reflective Function Questionnaire for Youth (RFQ-Y), the Trauma Symptom Checklist for Children (TSCC), and the Borderline Personality Features Scale for Children (BPFS-C). CSA was assessed using the Child Attachment Interview (CAI), the Computerized Diagnostic Interview Schedule for Children (C-DISC), as well as the Childhood Trauma Questionnaire (CTQ).

Results

27.5% of adolescent psychiatric inpatients reported CSA. CSA and mentalizing were independently associated with a latent factor consisting of posttraumatic stress, borderline personality features, and sexual concerns. CSA explained 5.0% and RF explained 16.7% of the variance of the latent factor. When we consider both the unique and the shared contribution of CSA and mentalizing, the model explained 23.0% of the variance of this factor.

Discussion

CSA and mentalizing independently explained variance in a latent factor constituted of borderline personality features, posttraumatic stress, and sexual concerns. The direct effect of mentalizing was stronger and mentalizing explained comparatively more variance of trauma-related symptoms in adolescent psychiatric inpatients. The findings are consistent with the theory that mentalizing is an internal resilience factor in adolescent psychiatric inpatients. By implication, clinical interventions focused on promoting the development of mentalizing, such as Mentalization Based Treatment, may palliate mental health difficulties manifested by adolescent psychiatric inpatients including those associated with CSA.

Physical multimorbidity in psychiatric patients with personality disorders: Insights within the ICD-11 framework

OBJECTIVE

Recent research has revealed poor physical health among individuals with personality disorders (PDs). We aimed to compare chronic physical illnesses (CPI) and chronic physical multimorbidity (CPM) prevalence between the general population (GEP) and PD patients, and to explore the relationship between CPM and various aspects of PD, predominantly within the ICD-11 framework.

METHODS

This cross-sectional study included 126 PD patients and 126 matched controls from the GEP. Patients were evaluated for the ICD-11 PD severity and maladaptive personality domains, subjective emptiness, and reflective functioning. CPI was assessed using a standardized self-report questionnaire.

RESULTS

PD patients had a higher mean number of CPIs (2.05 vs. 1.02) and a more frequent CPM occurrence (49.2% vs. 26.2%) compared to the matched controls (p < .001). The ICD-11 PD severity (OR = 1.143, p = .007) and maladaptive domain Negative affectivity (OR = 4.845, p = .002), and poor reflective functioning (OR = 1.694, p = .007) were significant predictors of CPM, independent of sociodemographic, clinical and lifestyle factors. Negative affectivity showed the most robust effect on CPM, while smoking did not significantly mediate these relationships.

CONCLUSION

Our study found increased CPM burden in PD patients and a link between CPM and various PD aspects under the ICD-11 framework, highlighting the need for more integrated healthcare.

Childhood adversity and adolescent acting-out behaviors: the mediating role of mentalizing difficulties and epistemic vigilance

Childhood adversity is a well-established risk factor for adolescent acting-out behaviors such as self-harm, bingeing, substance abuse, and aggressive behavior. From a mentalizing perspective, acting-out behaviors are understood as resulting from a combination of impairments in mentalizing and epistemic vigilance that are a consequence of childhood adversity. Yet, few studies have investigated these assumptions. The current study investigated the potential mediating role of mentalizing impairments and epistemic vigilance in the relationship between childhood adversity and acting-out behaviors in adolescents, oversampled for risk status for psychopathology (N = 451, mean age = 15.40 years). Structural equation modeling showed a strong, direct relationship between childhood adversity and acting-out behaviors, confirming the importance of traumatic childhood experiences for adolescent acting-out behaviors. This relationship was partially mediated by both mentalizing difficulties and epistemic vigilance, explaining about 40% of the total variance. These results support the importance of focusing on strengthening mentalizing abilities and lowering epistemic hypervigilance in psychotherapeutic work with adolescents who have experienced childhood trauma.

Arts and psychomotor therapies in personality disorder treatment: An appropriate therapeutic entrance to personal development: A commentary

Personality disorders (PD) are based not just on maladaptive ideas about self and others, they also are grounded on embodied patterns of behaviors and reactions to interpersonal stressors. There is growing interest in working with the body and through the body so to address automatisms that lead to suffering and dysfunctional social action. In this issue of the Journal of Clinical Psychology: In-Session the use of art and psychomotor therapies for these patients was explored by seven different clinical perspectives. Patients described presented with different PD and associated symptoms. The arts and psychomotor therapies deployed in personality disorder treatment are: (visual) art therapy, music therapy, drama therapy, dance (movement) therapy, and psychomotor therapy making psychotherapeutic use of the different modalities: art, music, play, role-play, performance, improvisation, dance, body awareness and movement. Interventions provide kinesthetic, sensory, perceptual, and symbolic opportunities to invite alternative modes of meaning-making, accessing own needs and wishes, and communicating them to others. In this commentary we summarize some of the different topics covered by the clinical-based papers, including working mechanisms of arts and psychomotor therapies, the importance of bottom-up emotion regulation processes, how to treat trauma in the presence of a PD, how to integrate art and psychomotor therapies in a fine-grained formulation and how to understand the process of change. Although there is a need for more empirical research, we hope this issue makes a solid case that clinicians can effectively include art and psychomotor therapies when treating the full range of PD.

Mentalizing as a Predictor of Well-Being and Emotion Regulation: Longitudinal Evidence from a Community Sample of Young Adults

Background: In recent years, mentalizing - the capacity to understand one's own and others' intentional mental states in social contexts - has been considered to be a protective capacity that enables adaptive processing of stress-related emotional arousal, benefits general well-being and underpins adaptive emotion regulation. Objective: Several studies using cross-sectional research designs have demonstrated the potential health-promoting effect of mentalizing in non-clinical samples. However, longitudinal evidence is scarce. The present study aimed to investigate whether mentalizing predicts well-being and emotion regulation strategies in a non-clinical sample of mainly young adults using a prospective longitudinal design. Methods: In a prospective research design, 135 participants completed questionnaires assessing well-being, psychological symptom severity and mentalizing capacity at baseline (T1). Twelve months later (T2), emotion regulation strategies (suppression and cognitive reappraisal), well-being and psychological symptom severity were assessed by self-report. The data were analyzed using multivariate linear regression analysis. Results: Impairments in mentalizing were a significant negative predictor of well-being 12 months later. Furthermore, impairments in mentalizing positively predicted suppression of emotional states at T2. No association was found between deficits in mentalizing and cognitive reappraisal of emotional states over the course of 1 year. Conclusion: The findings indicate that mentalizing is longitudinally associated with mental health indicators in a non-clinical adult sample. Specifically, ineffective mentalizing was associated with impaired psychological well-being and a tendency to suppress intense emotional states over a period of 1 year. Future research should replicate these findings using multiple measurement timepoints to etablish causality.

Emotion Regulation in Families: Exploring the Link between Parent-Child Alexithymia and Child Post-Traumatic Stress Symptoms Amidst the COVID-19 Pandemic

The COVID-19 pandemic comprises a mass trauma for children and families, and children may face particular vulnerability to post-traumatic stress symptoms (PTSS) through processes of parent and child emotional dysregulation, such as alexithymia. With 88 U.S. children (Mage = 9.94 years; 54.5% female; 59.1% White) and their parents/caregivers (68.2% female; 59.1% White), a path model was tested in which child alexithymia symptoms partially mediated the association between parent alexithymia symptoms and child COVID-19-related posttraumatic stress symptoms (PTSS). We also tested an alternative model in which child alexithymia symptoms moderated the association between parent alexithymia symptoms and child PTSS. The hypothesized mediation model was supported (β = 0.15, SE = 0.05, 95% CI: [0.07, 0.25], p < 0.001), whereas the hypothesized moderator model was not (β = 0.06, p = 0.44). Findings highlight the importance of parents' emotional understanding and regulation for child mental health during mass traumas such as pandemics.

A preliminary validation of PMQ-A four-factor questionnaire measuring parental mentalizing

The present study describes the construction and preliminary validation of a new parental mentalizing scale, PMQ. Based on theory, we hypothesized that one higher-order parental mentalizing factor would comprise four dimensions of parental mentalizing: (1) Parental self-mentalizing (SELF), (2) Parental child-mentalizing (CHILD), (3) Effort (E), and (4) Curiosity (C). After modifying the content of one factor (Effort > Lack of Effort, LE), four-factor structure with one higher-order factor was confirmed in data collected from parents of children aged two to 6 years through social media and email lists (N = 321, 10% male). All factors loaded significantly on the higher-order factor, with acceptable internal consistencies. Next, PMQ factors were compared with the factors of a previously validated questionnaire, parental reflective functioning questionnaire (PRFQ). The PMQ and PRFQ factors were consistently and significantly correlated, indicating the validity of the PMQ as a measure of parental mentalization ability. The continuation of PMQ validation is discussed.

The pattern theory of compassion

Concepts of empathy, sympathy and compassion are often confused in a variety of literatures. This article proposes a pattern-theoretic approach to distinguishing compassion from empathy and sympathy. Drawing on psychology, Western philosophy, affective neuroscience, and contemplative science, we clarify the nature of compassion as a specific pattern of dynamically related factors that include physiological, cognitive, and affective processes, relational/intersubjective processes, and motivational/action tendencies. We also show that the dynamic nature of the compassion pattern is reflected in neuroscientific findings, as well as in compassion practice. The pattern theory of compassion allows us to make several clear distinctions between compassion, empathy, and sympathy.

The dark side of personality functioning: associations between antisocial cognitions, personality functioning (AMPD), empathy and mentalisation

Introduction

With the introduction of the new psychiatric diagnostic manuals, personality functioning has gained new prominence. Several studies have reported consistent findings that individual showing high levels of antisocial features are associated with alterations in interpersonal functioning domains such as empathy and mentalisation. The focus of the current study (N = 198) is to examine antisocial cognitions, as measured by the Scrambled Sentences Task (SST), and to what extent this approach can help to better understand the relationship between antisocial traits and personality functioning/empathy.

Method

We implemented a hypothesis-driven approach using logistic regression and a data-driven approach using machine learning to examine distinct but related measures of personality functioning as predictors of antisocial cognitions.

Results

Antisocial cognitions were associated with low interpersonal functioning as expected, but only when not adjusting for antisocial traits, which accounted for almost all the association. The data-driven analysis revealed that individual items assessing empathic concern in personality functioning scales (as opposed to the whole scores) explained low antisocial cognitions even when adjusting for antisocial traits.

Discussion

Antisocial cognitions appear to be associated to two distinct traits, the antisocial and a specific type of personality functioning. This finding is discussed in terms of the possible distinction between two motivational forces: to harm others/prioritize one's advantage, and to help suffering others.

A time to reflect: deviations from the balanced time perspective are associated with hypomentalization

Introduction

Poor mentalization, or lack of capacity to reflect on self and others in terms mental states, thoughts, and feelings, and time perspective biases were both related to mental disorders and lower wellbeing in separate studies. Expanding one prior study, we examined the relationship of mentalization and time perspective, including a measure known as deviations from the balanced time perspective (DBTP) that summarizes time perspective biases across the past, present, and future time frames.

Method

A convenience sample of 258 participants responded to a version of the Reflective Functioning Questionnaire (RFQ-8) and a six-dimensional version of the Zimbardo Time Perspective Inventory (S-ZTPI). Given recent evidence that the original two-factor structure of the RFQ may need to be reconsidered, we used confirmatory factor analyses (CFA) to compare alternative models for RFQ as a first step.

Results

In line with several recent studies, the CFA favored a unitary model of RFQ-8 reflecting hypomentalization (or uncertainty). The total score showed significant associations with Past Negative, Present Fatalistic, and Future Negative dimensions of S-ZTPI, while hypomentalization was negatively associated with Future Positive. Of major interest, DBTP and hypomentalization showed a strong positive correlation (r = 0.64 for latent constructs; r = 0.62 in an adjusted model).

Conclusion

Deviations from the balanced time perspective were substantially related to hypomentalization. Further research is required to examine the generalizability of the finding (e.g., to measures of mentalization focused on others) and to provide a better understanding of the theoretical basis of the link. Potentially shared associations in development (e.g., attachment style) and mindfulness, that may influence both time perspective and mentalization is of interest in this regard.

The Social Shapes Test as a Self-Administered, Online Measure of Social Intelligence: Two Studies with Typically Developing Adults and Adults with Autism Spectrum Disorder

The Social Shapes Test (SST) is a measure of social intelligence which does not use human faces or rely on extensive verbal ability. The SST has shown promising validity among adults without autism spectrum disorder (ASD), but it is uncertain whether it is suitable for adults with ASD. We find measurement invariance between adults with (n = 229) or without ASD (n = 1,049) on the 23-item SST. We also find that adults without ASD score higher on the SST than adults with ASD (d = 0.21). We also provide two, 14-item versions which demonstrated good parallel test-retest reliability and are positively related to scores on the Frith-Happé task. The SST is suitable for remote, online research studies.

The parent's and the child's internal working models of each other moderate cascades from child difficulty to socialization outcomes: Preliminary evidence for dual moderation?

Infants' difficulty, typically characterized as proneness to negative emotionality, is commonly considered a risk for future maladaptive developmental trajectories, mostly because it often foreshadows increased parental power assertion, typically linked to future negative child outcomes. However, growing evidence of divergent developmental paths that unfold from infant difficulty has invigorated research on causes of such multifinality. Kochanska et al. (2019) proposed that parent and child Internal Working Models (IWMs) of each other are key, with the parent's IWM of the child moderating the link between child difficulty and parental power assertion, and the child's IWM of the parent moderating the link between power assertion and child outcomes. In Children and Parents Study (200 community mothers, fathers, and children), child difficulty was observed at 8 months, parents' power assertion at 16 months, and children's outcomes rated by parents at age 3. Parents' IWMs were assessed with a mentalization measure at 8 months and children's IWMs were coded from semi-projective narratives at age 3. The cascade from infant difficulty to maternal power assertion to negative child outcomes was present only when both the mother's and the child's IWMs of each other were negative. We did not support the model for father-child dyads.

Offline and online parental mentalizing in mothers with symptoms of postpartum depression: Examining the association between self-reported parental reflective functioning and interactional mind-mindedness

Mentalizing is, to a certain extent, considered context specific. However, research on the association between parents' abilities to reflect upon their infant's mental states outside social interaction (offline) versus during ongoing parent-infant interaction (online) is currently limited. This study investigated the association between self-reported offline and online mentalizing in a sample of primarily ethnically Danish mothers (N = 142), with symptoms of postpartum depression, and their 1-11-month-old infants. Offline mentalizing was assessed with the Parental Reflective Functioning Questionnaire-Infant Version (PRFQ-I) and online mentalizing was assessed with interactional mind-mindedness. Ordinal logistic regressions showed that a higher score on the PRFQ-I prementalizing subscale was negatively related to number of overall mind-related comments and appropriate mind-related comments produced by mothers during interaction with their infant. Our results indicate partial overlaps between self-reported parental reflective functioning and mind-mindedness, that is, that particularly offline maladaptive mentalizing is associated with lower levels of mentalizing during interaction in mothers with symptoms of depression. Post-hoc examination of the interaction effect of postpartum depression showed that this association was only evident in mothers with medium to high levels of depression. Findings and implications are discussed.

Push and Pull: Role of Therapist Mentalizing in Navigating Therapeutic Distance

In the relational playground of psychotherapy, negotiating therapeutic distance is crucial for the process as well as the outcome of treatment. The challenge of navigating this closeness and distance may be accentuated during emotionally charged interactions in therapy. Therapist and client may get locked in complementary, rigid positions, leading to either submission or resistance to the others' demands. The therapist's ability to respond appropriately to these pushes and pulls is supported by their ability to mentalize, which is their ability to attend to and understand their own states of mind while being aware of others' states of mind. Therapists are expected to maintain a mentalizing stance throughout and despite the relevance and impact of therapist mentalization, there is relatively less research, training, or practice-related guidance on how to maintain this balance. We use case illustrations to demonstrate therapeutic interactions that can trigger non-mentalizing for the therapist and reflect on ways of recognizing and addressing these patterns related to closeness and distance. We also share recommendations for reflective practice and supervision, training as well as research on therapist mentalization.

Transdiagnostic factors in the COVID-19 pandemic: Examining the role of childhood abuse and neglect in establishing latent profiles of risk and resilience

BACKGROUND

Ample studies have focused on the negative consequences of COVID-19 on mental well-being, but fewer have explored the specific role of childhood abuse and neglect in the context of risk and resilience during this unprecedented crisis.

OBJECTIVE

We aimed to identify distinct profiles of individuals based on their experiences of childhood abuse and neglect, coping strategies, and psycho-social transdiagnostic risk and protective factors, using a person-centered approach.

PARTICIPANTS AND SETTING

A convenience sample of 914 Israelis completed self-report questionnaires during the second wave of COVID-19.

METHODS

Latent Profile Analysis was employed based on levels of childhood abuse and neglect, coping strategies, and established factors underpinning risk and resilience in mental health: dissociation, self-criticism, self-efficacy, self-compassion, attachment insecurity, psychological resilience, mentalizing, distress disclosure, psychopathology, and relationship satisfaction. Profiles were compared in COVID-19-related distress and well-being using ANOVAs.

RESULTS

A four-profile solution was found to be optimal for describing individuals with different profiles of risk and resilience: "risk" (5.1 %)-individuals with meaningfully high levels of childhood abuse and neglect and dissociation; "vulnerable" (14.2 %)-individuals high in risk factors and low in protective factors; "moderately resilient" (47.6 %)-those with moderate levels of protective and risk factors; "highly resilient" (33.1 %)-individuals high in protective factors and low in risk factors; groups differed in mental well-being and COVID-19-related distress.

CONCLUSIONS

Results highlight the importance of childhood abuse and neglect in differentiating between the two distinct profiles of at-risk individuals. Implications for risk assessment and treatment in the context of potential traumatic stress are discussed.

Construct Validity and Measurement Invariance of the Difficulties in Emotion Regulation Scale - Short Form (DERS-SF): Further Evidence From Community and Student Samples

The current study aimed to evaluate the psychometric properties of the Difficulties in Emotion Regulation Scale-Short Form (DERS-SF) in Iran, including testing its measurement invariance across sexes, as well as community and student populations. Two samples were recruited: a community sample of 583 participants (58.7% female; Mage = 33.55) and a university student sample of 409 participants (67.2% female; Mage = 24.48). Besides the DERS-SF, participants completed a battery of instruments online, measuring mentalizing capacity and borderline personality features. Confirmatory factor analyses supported the tenability of the five-factor model, excluding the awareness subscale. Except for the awareness subscale, acceptable to excellent internal consistencies were found for the DERS-SF and its subscales. The awareness-excluded DERS-SF was significantly and strongly associated with relevant constructs (|rs| = .49 to .59). This study also found evidence for configural, metric, and scalar invariance of the DERS-SF across sexes and community and student populations. Our findings extended the evidence for the validity and reliability of the DERS-SF and its awareness-excluded version by administering it in Iranian samples and supporting its cross-cultural applicability.

Mentalizing in psychotherapeutic processes of patients with eating disorders

Background

Improvement in the capacity to mentalize (i.e., reflective functioning/RF) is considered both, an outcome variable as well as a possible change mechanism in psychotherapy. We explored variables related to (in-session) RF in patients with an eating disorder (ED) treated in a pilot study on a Mentalization-Based Treatment (MBT) - oriented day hospital program. The research questions were secondary and focused on the psychotherapeutic process: What average RF does the group of patients show in sessions and does it change over the course of a single session? Are differences found between sections in which ED symptomatology is discussed and those in which it is not? Does RF increase after MBT-type interventions?

Methods

1232 interaction segments from 77 therapy sessions of 19 patients with EDs were rated for RF by reliable raters using the In-Session RF Scale. Additionally, content (ED symptomatology yes/no) and certain MBT interventions were coded. Statistical analysis was performed by mixed models.

Results

Patients showed a rather low RF, which increased on average over the course of a session. If ED symptomatology was discussed, this was associated with significantly lower RF, while MBT-type interventions led to a significant increase in RF.

Conclusions

Results suggest that in-session mentalizing can be stimulated by MBT-typical interventions. RF seems to be more impaired when disorder-specific issues are addressed. Further studies have to show if improving a patient´s ability to mentalize their own symptoms is related to better outcomes.

Brain Activation for Social Cognition and Emotion Processing Tasks in Borderline Personality Disorder: A Meta-Analysis of Neuroimaging Studies

The present meta-analysis summarizes brain activation for social cognition and emotion-processing tasks in borderline personality disorder (BPD). We carried out two meta-analyses to elaborate on commonalities and potential differences between the two types of tasks. In the first meta-analysis, we implemented a more liberal strategy for task selection (including social and emotional content). The results confirmed previously reported hyperactivations in patients with BPD in the bilateral amygdala and prefrontal cortex and hypoactivations in bilateral inferior frontal gyri. When applying a stricter approach to task selection, focusing narrowly on social cognition tasks, we only found activation in prefrontal areas, particularly in the anterior cingulate and ventromedial prefrontal cortex. We review the role of these areas in social cognition in healthy adults, suggesting that the observed BPD hyperactivations may reflect an overreliance on self-related thought in social cognition.

Psychometric evaluation of the Parental Reflective Functioning Questionnaire in Polish mothers

Parental reflective functioning (PRF) refers to a parent's capacity to reflect on and understand the inner mental states of their child, their own mental states with regard to their child, and how these mental states may influence their behavior and interactions. This capacity has been shown to foster secure attachment in children and their socio-emotional development. The present study examined the psychometric properties of the Polish translation of the Parental Reflective Functioning Questionnaire (PRFQ), a brief screening measure of PRF, in a large community sample of Polish mothers of children aged 0-5 years (N = 979). Confirmatory factor analysis supported the hypothesized three-factor structure of the PRFQ, which consists of three subscales: prementalizing modes, certainty about mental states, and interest and curiosity in mental states. However, item loadings suggested that the 15-item version fitted the data better than the original 18-item version. These three PRFQ subscales exhibited satisfactory and moderate six-month test-retest reliability. They also correlated in theoretically expected ways with several criterion measures such as maternal attachment, maternal parenting stress, parental role restriction, depression severity, and borderline symptoms. In conclusion, this study is the first to provide preliminary evidence for the reliability and validity of the PRFQ as a measure of parental reflective functioning in Polish mothers.

The (cost-)effectiveness of early intervention (MBT-early) versus standard protocolized treatment (CBT) for emerging borderline personality disorder in adolescents (the EARLY study): a study protocol for a randomized controlled trial

BACKGROUND

Although clinical guidelines prioritize the treatment of depression and anxiety in young persons, there is accumulating evidence that the presence of symptoms of borderline personality disorder (BPD) is associated with the limited effectiveness of these standard treatments. These findings stress the need for interventions addressing early-stage BPD in young people with presenting symptoms of anxiety and depressive disorders. The aim of this study is to investigate the (cost-)effectiveness of an early intervention programme for BPD (MBT-early) compared to first-choice psychological treatment for depression and anxiety according to Dutch treatment guidelines (CBT), in adolescents with either depression, anxiety, or both, in combination with early-stage BPD.

METHODS

This study is a multi-centre randomized controlled trial. A total of 132 adolescents, presenting with either depression, anxiety, or both and significant BPD features will be randomized to either MBT-early or CBT. The severity of BPD, symptoms of depression and anxiety, personality, social and academic functioning, and quality of life will be assessed at baseline, end of treatment, and at 12-, 18-, and 24-month follow-up, along with medical costs and costs of productivity losses for cost-effectiveness analyses.

DISCUSSION

This study will provide an empirical evaluation of the potential surplus value of early intervention in young people for whom treatment oriented at common mental disorders like anxiety and depression may be insufficient given their underlying personality problems.

TRIAL REGISTRATION

Netherlands Trial Register, NL9569. Registered on June 15, 2021.

The Brief Version of the Mentalization Scale (MentS-12): Evidence-Based Assessment of Mentalizing Capacity

Recognizing the need for a concise self-report measure of mentalizing capacity, we developed a 12-item iteration of the well-established Mentalization Scale (MentS). Using college student and community samples of Serbian adults (N = 566), we performed a precise selection of items and then examined the psychometric attributes of the shortened scale (MentS-12). The new scale maintains the original three-dimensional structure: self-related mentalization, other-related mentalization, and motivation to mentalize. MentS-12 proves to be both reliable and structurally consistent. To improve its utility in therapeutic contexts, we determined clinical change thresholds for both the complete and abbreviated forms. We hope that its feasibility stimulates the integration of the MentS-12 in longitudinal research projects and real-world clinical settings.

Emotional self-knowledge profiles and relationships with mental health indicators support value in 'knowing thyself'

"Know thyself" may be indicated by a balanced high pairing of two emotional self-knowledge indicators: attention to emotions and emotional clarity. Closely associated but often evaluated separately, emotional clarity is consistently, inversely associated with psychopathology, while evidence regarding attention to emotions is less consistent. Variables of high/low emotional clarity and attention to emotions yielded four emotional self-knowledge profiles which were analyzed for associations with mental health indicators (depression and anxiety symptoms, self-esteem, self-schema, resiliency, transcendence) in n = 264 adolescents. Here we report regression models which show that compared with neither, both high (attention + clarity) show higher positive self-schema (B = 2.83, p = 0.004), more resiliency (B = 2.76, p = 0.015) and higher transcendence (B = 82.4, p < 0.001), while high attention only is associated with lower self-esteem (B = - 3.38, p < 0.001) and more symptoms (B = 5.82, p < 0.001 for depression; B = 9.37, p < 0.001 for anxiety). High attention only is associated with most severe impairment all indicators excepting transcendence. Profiles including high clarity suggest protective effects, and 'implicit' versus 'explicit' emotional awareness are discussed. Balanced vs. imbalanced emotional self-awareness profiles dissimilarly affect mental health, which have implications for treatment and policy.

The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders

BACKGROUND

The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression.

METHODS

A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires.

RESULTS

Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression.

CONCLUSIONS

These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Observer-based and computerized measures of the patient's mentalization in psychotherapy: A scoping review

OBJECTIVE

In recent decades, mentalizing has found its permanent place both in therapeutic practice and in psychotherapy research. Inconsistent results and null results are often found. Therefore, the different methodological approaches should be examined in more detail. A scoping review was conducted to provide an overview of the approaches that measure the patient's mentalizing ability based on therapy sessions or in the course of psychotherapy.

METHOD

For the scoping review, a literature search was conducted in four databases. A total of 3217 records were identified.

RESULTS

We included 84 publications from 43 independent studies. Most studies used the Reflective Functioning Scale and applied the scale to therapy sessions or the Adult Attachment Interview. The other identified approaches used a computerized text analysis measure or clinician-report measures. Mostly good psychometric properties of the measures were reported. The Reflective Functioning Scale applied to the Adult Attachment Interview was the only measure that proved to be sensitive to change.

CONCLUSION

More economical variants to the time-consuming Reflective Functioning Scale applied to the Adult Attachment Interview are being developed continuously. In some cases, there is no standardized approach, or the measures are used only sporadically and require further and more comprehensive psychometric evaluations.

Is insufficient introspection a reason to terminate residency training? - Scrutinising introspection among residents who disputed dismissal

INTRODUCTION

Insufficient introspection as part of the 4I's model of medical professionalism (introspection, integrity, interaction, and involvement) is considered an important impediment in trainees. How insufficient introspection relates to decisions to terminate residency training remains unclear. Insights into this subject provide opportunities to improve the training of medical professionals.

METHODS

We analysed the Dutch Conciliation Board decisions regarding residents dismissed from training between 2011 and 2020. We selected the decisions on residents deemed 'insufficient' regarding introspection as part of the CanMEDS professional domain and compared their characteristics with the decisions about residents without reported insufficiencies on introspection.

RESULTS

Of the 120 decisions, 86 dismissed residents were unable to fulfil the requirements of the CanMEDS professional domain. Insufficient introspection was the most prominent insufficiency (73/86). These 73 decisions described more residents' insufficiencies in CanMEDS competency domains compared to the rest of the decisions (3.8 vs. 2.7 p < 0.001), without significant differences regarding gender or years of training.

CONCLUSIONS

Insufficient introspection in residents correlates with competency shortcomings programme directors reported in dismissal disputes. The 4I's model facilitates recognition and description of unprofessional behaviours, opening avenues for assessing and developing residents' introspection, but further research is needed for effective implementation in medical education.

Attachment Orientations: Associations with Romantic Partners' Self-Regulation and Dyadic Coping

The ability to effectively cope with stress is impacted by early relationship experiences and, thus, is related to attachment security. We examined how different forms of attachment insecurity (namely, attachment anxiety and attachment avoidance) impact romantic partners' capacity for coping with stress individually (via self-regulation) and together (via dyadic coping) in a community sample of 261 heterosexual couples. We also explored links between these coping strategies and measures of well-being. Multiple regression analyses in this cross-sectional, self-report study indicated that attachment avoidance, but not anxiety, was linked to less effective dyadic coping. In men, this was also the case for partner's attachment avoidance. Attachment anxiety, but not avoidance, was related to self-regulation problems for women, while in men, both facets of attachment insecurity were negatively associated with self-regulation. Individual and dyadic coping strategies each uniquely contributed to individuals' well-being and satisfaction with life. Relationship interventions and counseling processes might benefit from sensitizing clients for biographical influences on their coping strategies.

Elevated depression and anxiety predict future patterns of individualistic and collectivistic cultural values: A cross-lagged longitudinal network analysis

BACKGROUND

Specific components of independent and interdependent self-construal have been associated with psychopathology. However, most studies on this topic have been cross-sectional, precluding causal inferences. We used contemporaneous and temporal cross-lagged network analysis to establish weak causal effects in understanding the association between self-construal and psychopathology components.

METHODS

Middle-aged and older community-dwelling adults (n = 3294) participated in the Midlife Development in the United States study across two time-points, spaced nine years apart. Six self-construal (interdependence: connection to others, commitment to others, receptiveness to influence; independence: behavioral consistency, sense of difference from others, self-reliance) and three psychopathology nodes (major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder (PD) symptom severity) were examined. All network analyses controlled for age, sex, race, and number of chronic illnesses as covariates.

RESULTS

Contemporaneous and temporal networks yielded relations between elevated MDD and PD and increased receptiveness to influence. Heightened GAD symptom severity was associated with future increased difference from others and decreased connection to others, commitment to others, and receptiveness to influence. Higher MDD, GAD, and PD severity were associated with future lower self-reliance. Network comparison tests revealed no consistent network differences across sex and race.

LIMITATIONS

DSM-III-R measures of MDD, GAD, and PD were used. Results may not generalize to culturally diverse racial groups.

CONCLUSIONS

Changes in self-construal may result from increased MDD, GAD, and PD severity. Findings suggest the importance of targeting common mental health symptoms to positively influence how individuals view the self and others in various social contexts.

Emotional impacts of racial discrimination on caregiver-child dyads: Can mentalizing-focused parenting groups buffer against racism-related stress?

Black and Latinx caregivers face high risk for parenting stress and racism-related stress due to experiences of racial discrimination (RD). This study aimed to explore the associations between RD, parenting stress, and psychological distress in caregiver-child dyads, as well as the impact of a mentalizing-focused group intervention on caregivers' experiences of RD distress. Ethnoracially minoritized caregivers of children aged 5-17 years old participated in a non-randomized clinical trial (N = 70). They received either a 12-session mentalizing-focused group parenting intervention or treatment-as-usual in outpatient psychiatry. We assessed self-reported frequency and distress related to RD, parenting stress, and psychological distress at baseline (T1) and post-intervention (T2). Caregiver- and self-reported child psychological distress were also measured. The results showed that greater RD frequency and greater RD distress separately predicted higher overall parenting stress and parental role-related distress. Greater RD distress was linked to increased psychological distress in caregivers. Similarly, greater RD frequency and distress among caregivers were associated with higher caregiver-reported, but not self-reported, child psychological distress. No significant changes in RD distress were observed between T1 and T2 for either of the treatment groups. These findings highlight the exacerbating role of RD on parenting stress and psychological distress among ethnoracially minoritized caregivers and their children.

Childhood maltreatment and mentalizing capacity: A meta-analysis

BACKGROUND

The protective role of mentalizing capacity against the adverse effects of childhood maltreatment (CM) is acknowledged; however, empirical studies have yielded diverse conclusions regarding the relationship between childhood maltreatment and mentalizing capacity.

OBJECTIVE

This meta-analytic review aims to comprehensively summarize and quantify the association between childhood maltreatment and mentalizing capacity.

PARTICIPANTS AND SETTING

A total of 23 studies involving 3910 participants were included in the analysis.

METHODS

Systematic searches across eight bibliographic databases identified peer-reviewed publications describing empirical studies on the interplay between CM and mentalizing capacity. Effect sizes (r) were synthesized using random-effects models. A moderated effects analysis was conducted on five variables: participant gender, age group, mental health status, mentalizing capacity measurement, and childhood maltreatment measurement.

RESULTS

The findings showed a significant moderate negative correlation between childhood maltreatment and mentalizing capacity (r = -0.21, 95 % CI = [-0.26, -0.15]). This suggests that heightened severity of childhood maltreatment corresponds to lower mentalizing capacity. Moreover, the strength of this correlation was influenced by participant gender, age group, mental health status, mentalizing capacity measurement, and CM measurement.

CONCLUSIONS

The controversy surrounding the link between CM and mentalizing capacity gains clarity when considering significant moderating variables. The pooled effect provides a preliminary definition of the magnitude and direction of this correlation.

Mentalizing in and out of awareness: A meta-analytic review of implicit and explicit mentalizing

BACKGROUND

Mentalizing, making sense of mental states, is hypothesized to have a central role in self-organization and social learning. Findings support this notion, but the extent of the association between mentalizing and various correlates has not been meta-analyzed. Furthermore, mentalizing presumably occurs with (explicit) and without (implicit) awareness but few studies have attempted to disentangle these aspects. We conducted a meta-analysis of implicit and explicit mentalizing in relation to the domains of attachment security, personality, affect, psychopathology, and functioning.

METHODS

We searched for studies of adult mentalizing in PsycINFO and in related reviews. Overall, 511 studies (N = 78,733) met criteria and were analyzed using multi-level meta-analysis.

RESULTS

Implicit (r = 0.19-0.29) and explicit (r = 0.26-0.40) mentalizing were moderately correlated with psychopathology, functioning, personality, affect, and attachment security. The correlations of implicit mentalizing were stronger with more objectively measured correlates (b = 0.02, p < .001) while the correlations of explicit mentalizing were not (b = -0.07, p = .21).

CONCLUSIONS

Mentalizing is associated with better intra- and interpersonal functioning. Implicit mentalizing is more strongly associated with objectively measured correlates. These findings underscore the importance of an integrative approach considering both implicit and explicit mentalizing.

The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research

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.

Taking stock to move forward: Where the field of developmental psychopathology might be heading

In this paper, dedicated to Dante Cicchetti's contributions and enduring influence, we explore the prospective directions of developmental psychopathology. Our focus centers on key domains where Cicchetti's significant achievements have continually shaped our evolving thinking about psychological development. These domains include (a) the concepts of equifinality and multifinality, along with the challenges in predicting developmental trajectories, (b) the imperative to integrate wider sociocultural viewpoints into developmental psychopathology frameworks, (c) the interplay of genetic and environmental influences in developmental courses, (d) the significance of mental state language, and (e) the progress, or its absence, in the development of prevention and intervention tactics for children, adolescents, and their caregivers. While many of our forecasts regarding the future of developmental psychopathology may not materialize, we maintain optimistic that the essential ideas presented will influence the research agenda in this field and contribute to its growth over the next fifty years.

Dutch dismissal practices: characteristics, consequences, and contrasts in residents' case law in community-based practice versus hospital-based specialties

BACKGROUND

In the Netherlands, 2 to 10% of the residents terminate training prematurely. Infrequently, termination of training is by dismissal. Incidentally, residents may disagree, dispute and challenge these decisions from the programme directors. Resident dismissal is always a difficult decision, most commonly made after, repeated assessments, and triangulation of the resulting assessment data and one or more remediation attempts. Nevertheless, the underlying reasons for dismissal and the policies for remediation and dismissal may differ between training programmes. Such differences may however impact the chance of remediation success, the chance of dismissal and subsequent residents' appeals.

METHOD

We included a total of 70 residents from two groups (community-based and hospital-based specialties) during 10 years of appeals. Subsequently, we compared these groups on factors potentially associated with the outcome of the conciliation board decision regarding the residents' dismissal. We focused herein on remediation strategies applied, and reasons reported to dismiss residents.

RESULTS

In both groups, the most alleged reason to dismiss residents was lack of trainability, > 97%. This was related to deficiencies in professionalism in community-based practice and medical expertise in hospital-based specialties respectively. A reason less frequently mentioned was endangerment of patient care, < 26%. However, none of these residents accused of endangerment, actually jeopardized the patients' health, probably due to the vigilance of their supervisors. Remediation strategies varied between the two groups, whereas hospital-based specialties preferred formal remediation plans in contrast to community-based practice. A multitude of remediation strategies per competency (medical expertise, professionalism, communication, management) were applied and described in these law cases.

DISCUSSION

Residents' appeals in community-based practice were significantly less likely to succeed compared to hospital-based specialties. Hypothesised explanatory factors underlying these differences include community-based practices' more prominent attention to the longitudinal assessment of professionalism, the presence of regular quarterly progress meetings, precise documentation of deficiencies, and discretion over the timing of dismissal in contrast to dismissal in the hospital-based specialties which is only formally possible during scheduled formal summative assessment meetings.

Capacity of Generative AI to Interpret Human Emotions From Visual and Textual Data: Pilot Evaluation Study

BACKGROUND

Mentalization, which is integral to human cognitive processes, pertains to the interpretation of one's own and others' mental states, including emotions, beliefs, and intentions. With the advent of artificial intelligence (AI) and the prominence of large language models in mental health applications, questions persist about their aptitude in emotional comprehension. The prior iteration of the large language model from OpenAI, ChatGPT-3.5, demonstrated an advanced capacity to interpret emotions from textual data, surpassing human benchmarks. Given the introduction of ChatGPT-4, with its enhanced visual processing capabilities, and considering Google Bard's existing visual functionalities, a rigorous assessment of their proficiency in visual mentalizing is warranted.

OBJECTIVE

The aim of the research was to critically evaluate the capabilities of ChatGPT-4 and Google Bard with regard to their competence in discerning visual mentalizing indicators as contrasted with their textual-based mentalizing abilities.

METHODS

The Reading the Mind in the Eyes Test developed by Baron-Cohen and colleagues was used to assess the models' proficiency in interpreting visual emotional indicators. Simultaneously, the Levels of Emotional Awareness Scale was used to evaluate the large language models' aptitude in textual mentalizing. Collating data from both tests provided a holistic view of the mentalizing capabilities of ChatGPT-4 and Bard.

RESULTS

ChatGPT-4, displaying a pronounced ability in emotion recognition, secured scores of 26 and 27 in 2 distinct evaluations, significantly deviating from a random response paradigm (P<.001). These scores align with established benchmarks from the broader human demographic. Notably, ChatGPT-4 exhibited consistent responses, with no discernible biases pertaining to the sex of the model or the nature of the emotion. In contrast, Google Bard's performance aligned with random response patterns, securing scores of 10 and 12 and rendering further detailed analysis redundant. In the domain of textual analysis, both ChatGPT and Bard surpassed established benchmarks from the general population, with their performances being remarkably congruent.

CONCLUSIONS

ChatGPT-4 proved its efficacy in the domain of visual mentalizing, aligning closely with human performance standards. Although both models displayed commendable acumen in textual emotion interpretation, Bard's capabilities in visual emotion interpretation necessitate further scrutiny and potential refinement. This study stresses the criticality of ethical AI development for emotional recognition, highlighting the need for inclusive data, collaboration with patients and mental health experts, and stringent governmental oversight to ensure transparency and protect patient privacy.

A short version of the reflective functioning questionnaire: Validation in a greek sample

This study aims to validate the Greek version of the 54-item Reflective Functioning Questionnaire (RFQ), a measure designed to assess an individual's capacity for understanding themselves and others based on internal mental states. This capacity, also known as Reflective Functioning (RF) or mentalizing, is believed to play a significant role in both typical and atypical development. The validation process examined the factor structure of the RFQ and its relationship with a variety of psychosocial and clinical constructs that have theoretical and empirical links to RF. Additionally, this research investigated the factor structure's invariance across gender and age groups to determine the robustness of the instrument. A unique contribution of this work lies in examining the application of the RFQ to attachment classifications through the use of cluster analysis. The sample consisted of 875 Greek adults from the general community with a mean age of 28.5 and a median age of 22. Participants completed the Greek RFQ along with a series of self-report questionnaires assessing psychosocial constructs, including attachment, epistemic trust, emotion regulation, and psychological mindedness, as well as clinical variables such as anxiety, depression, and borderline personality traits. Our findings suggest that a shorter, 31-item version of the questionnaire provides a robust three-factor structure across a non-clinical Greek adult population. The three identified subscales are (a) excessive certainty, (b) interest/curiosity, and (c) uncertainty/confusion, all demonstrating satisfactory reliability and construct validity. The uncertainty subscale was found to be associated with insecure attachment styles, epistemic mistrust and credulity, emotional suppression, and low psychological mindedness. In contrast, the certainty and curiosity subscales were linked to secure attachment, epistemic trust, emotion reappraisal, and psychological mindedness. Uncertainty was further shown to differ significantly across probable clinical and non-clinical groups, as distinguished by cut-off scores for anxiety, depression, and borderline personality disorder (BPD). However, the certainty and interest/curiosity subscales only varied between the two BPD groups. Our results provide the first evidence supporting the use of a 31-item version of the RFQ with three validated subscales to reliably assess reflective functioning in the Greek population, demonstrating stronger psychometric properties compared to other RFQ versions reported in previous studies. Findings suggest that impaired mentalizing capacity, as measured by the RFQ, is linked to insecure attachment, epistemic mistrust and credulity, poor emotion regulation, and low psychological mindedness, and potentially plays a role in adult mental health symptoms.

Emotional arousal and reflective functioning among parents participating in attachment-based family therapy for LGBTQ+ young adults and their nonaccepting parents

OBJECTIVE

Parents' rejection of their LGBTQ + young adults can have a negative impact on their young adult's psychological welfare, and on the young adult-parent relationship. Parents' ability to reflect on their child's pain and unmet needs is thought to evoke empathy and compassion, and reduce rejection. Empirical and clinical evidence suggest that parents' level of reflective functioning (RF) is impacted by their level of emotional arousal (EA). This study examined the association between parents' EA and RF within the context of attachment-based family therapy for nonaccepting parents and their LGBTQ+ young adults.

METHODS

43 therapy sessions drawn from six different cases were coded for parental RF and EA, based on 30-second segments. This generated a total of 343 observations for analyses.

RESULTS

Hierarchal linear modeling revealed that parents' level of RF was a function of their concomitant EA, with moderate levels of arousal predicting the highest RF levels.

CONCLUSION

Moderate EA may facilitate optimal parental reflective functioning. With nonaccepting parents, who typically present for treatment with high levels of maladaptive fear and shame, therapists would do well to assess their level of arousal and, when indicated, employ downregulating interventions before inviting them to reflect on their young adult's experience and needs.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

A four-year multi-wave prospective study on the role of parental reflective functioning and parenting stress in the development of socio-emotional problems in internationally adopted children

Parental reflective functioning (PRF) plays a protective role in the development of children with histories of early adversity, including adopted children. This is the first study to investigate the developmental trajectories of PRF and children's socio-emotional problems in the first 4 years after international adoption (N = 48 families, mean age (T1) = 20.7 months) and to examine the mediating role of parenting stress in the relation between PRF and child socio-emotional problems. Multilevel modeling indicated that age at adoption and parent gender moderated the development of PRF and child socio-emotional problems. Moreover, decreases in PRF were associated with more socio-emotional problems in the children. These relations were mediated by parenting stress, and particularly feelings of incompetence and marital dissatisfaction.

The significance of parental mentalizing for four-year-old children's solitary pretend play

BACKGROUND

Pretend play is a signature behavior of early childhood and is considered to reflect the child's emerging symbolic function, enabling the interpretation of social signals, language development, and emotion understanding. While theory links parental mentalizing with children's pretend play, only a few studies have investigated this association. These studies are limited to infancy and early toddlerhood, and child pretend play is assessed during play with an adult (social play). Based on the assumption that child solitary pretend play reflects the child's 'baseline' pretend play ability, in this study, we investigated children's pretend play at its peak, i.e., during the preschool age, without the facilitation of another player. The overall objective was to investigate if parental mentalizing increases pretend play complexity in children.

METHODS

The sample consisted 99 Danish mothers and their 4-year-old children. Employing a cross-sectional design, we hypothesized that parental mental state language, as an indicator of 'online' mentalizing during interaction with the child, is a mechanism through which 'offline' mentalizing, measured as parental reflective functioning, is associated with child solitary pretend play. Child pretend play complexity was observed and coded with an adapted version of the 12-Step Play Scale. Maternal offline mentalizing was assessed with the Parental Reflective Functioning Questionnaire, and maternal online mentalizing was assessed by coding the mothers' mental state language during interaction with the child using a modified version of the mind-mindedness coding scheme.

RESULTS

While there was no direct effect of maternal offline reflective functioning on child pretend play, online mental state language mediated the link between offline maternal reflective functioning and child pretend play.

CONCLUSIONS

These results provide support for the theoretically assumed link between parental mentalizing and children's capacity for pretend play. Furthermore, our study contributes to the literature on parental mentalization, suggesting that parental mentalizing facilitates child development only if the parent can translate this ability into 'mentalizing in action'.